ADHD Flashcards
Patients with ADHD have been found to have lower levels of the neurotransmitters [2]
Patients with ADHD have been found to have lower levels of the neurotransmitters noradrenaline and dopmaine.
Describe the aetiology for ADHD [3]
Genetic Factors
- FHx
Environmental Influences
* Prenatal exposure to tobacco smoke, alcohol or drugs increases the risk of developing ADHD.
* Premature birth and low birth weight
* Early childhood exposure to lead or other environmental toxins
Neurobiological Abnormalities:
- Areas implicated include prefrontal cortex, basal ganglia, corpus callosum and cerebellum, where functional imaging studies suggest that these structural changes may result in altered connectivity between different brain regions.
Describe the clinical features of ADHD [3]
Hyperactivity
- constant motion, exhibiting behaviours such as fidgeting, inability to sit still, excessive talking or running about excessively when it’s not appropriate.
Impulsivity:
- hasty actions without forethought or regard for consequences.
- This can lead to risky behaviours or difficulties with social interactions.
- e.g. interrupting conversations, intruding upon others’ activities and making decisions without considering potential outcomes.
Inattentiveness
- difficulty sustaining attention during tasks or play activities.
- They may appear not to listen when spoken to directly, frequently lose items necessary for tasks and have trouble organising activities.
NB: Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.
Inattention symptoms:
≥6 of the following symptoms need to be present: [+]
Careless mistakes:
- fails to give close attention to detail or makes careless mistakes in schoolwork, at work, or during other activities.
Difficulty sustaining attention in tasks or play activities (e.g., difficulty remaining focused during lectures, conversations, or lengthy reading).
Difficulty listening:
- doesn’t seem to listen when spoken to directly (e.g. mind seems elsewhere even in the absence of any obvious distraction).
Doesn’t follow instructions and fails to finish schoolwork chores or duties in the workplace
- (e.g. starts tasks but quickly loses focus and is easily sidetracked).
Difficulty organising and prioritising tasks and activities
- e.g. difficulty managing sequential tasks, difficulty keeping belongings in order, messy and disorganised work, poor time management, failure to meet deadlines
Disliking tasks requiring sustained concentration:
- often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork, preparing reports, completing lengthy forms).
Loses things necessary for tasks or activities
- (e.g. school materials, pencils, books, wallet, keys).
Easily distracted by irrelevant stimuli or own thoughts.
Forgetful in daily activities (e.g. doing chores, running errands, returning calls, paying bills, keeping appointments).
Lecture:
What might a description of someone with ADHD be like with regards to their behaviour w inattention? [+]
- Performs worse in exams than academically able to do
- Messy bedroom / desk
- Homework at last minute
- Misses appointments (even in really important items)
- Lose lost items - but when looking, don’t pay attention to really look
Describe the emotional ups and downs see in ADHD? [4]
Really excitable
Quick to anger / frustrate
Perfectionism
Ripping things up
Low self esteem
ADHD Dx:
- Hyperactivity and impulsivity symptoms - ≥6 of the following symptoms need to be present [+]
Fidgety:
- often fidgets with or taps hands or feet, squirms in seat.
Unable to sit still:
- often leaves seat in situations when remaining seated is expected (e.g. in classroom or workplace).
Runs about or climbs in situations where it is inappropriate
- In adolescents or adults, this may be limited to feeling restless.
Noisy:
- often unable to play or engage in leisure activities quietly.
“On the go” or acting restlessly as if “driven by a motor”
- (e.g. unable or uncomfortable sitting still for extended periods such as in restaurants, in class, or in meetings).
Talks excessively.
Blurts out answers before the question has been completed
- (e.g., can’t wait turn in the conversation, completing other sentences).
Difficulty waiting their turn
- (e.g. waiting in line).
Interrupts or intrudes on others
- (e.g. butts into others’ conversations, games, or activities, may start using other people’s things without asking or receiving permission, may intrude into or take over what others are doing).
How does ADHD present differently from childhood to adolescence to adulthood [3]
Childhood: The classic triad of hyperactivity, impulsivity and inattention is most evident at this stage.
Adolescence: While hyperactive behaviours generally decrease during adolescence, problems with attention and impulsivity may continue. Adolescents may also display risk-taking behaviours.
Adulthood: Inattentiveness often persists into adulthood, while hyperactivity tends to decrease. Adults may experience difficulties with time management, goal setting, employment and relationships.
What are the three recognised subtype of ADHD? [3]
There are three recognised subtypes of ADHD:
* predominantly inattentive presentation;
* predominantly hyperactive-impulsive presentation;
* combined presentation.
The subtype diagnosis depends on the predominant symptom pattern for the past six months.
ADHD is a clinical diagnosis and is based on [3]
A detailed clinical assessment: focus on the symptoms of ADHD and their impact across different settings.
A full developmental and psychiatric history.
Observer reports and assessments of the person’s mental state: often from parents and school.
NB: The diagnosis of ADHD is always made in secondary care.
Describe how you manage ADHD [+]
Non-pharmacological intervention:
* Offer parent-training/education programmes as first-line treatment for parents or carers of children under 6 years with ADHD.
* Establishing a healthy diet and exercise can offer significant improvement in symptoms. Keeping a food diary may suggest a link between certain foods, such as food colourings, and behaviour. Elimination of these triggers should be done with the assistance of a dietician
* School-based interventions such as individualised educational programmes or behavioural interventions may be beneficial.
Pharmacological intervention:
- Methylphenidate is usually the first-line medication for children and young people. Dexamfetamine or atomoxetine can be considered if response to methylphenidate is inadequate.
- Lisdexamfetamine or atomoxetine could be used as first line treatment in adults with ADHD.
Monitoring:
- Patient should have regular follow-up to monitor effectiveness and side-effects of medication along with ongoing need for other support.
What are the pharmacological interventions for ADHD?
- in children [3]
- in adults [2]
Methylphenidate is usually the first-line medication for children and young people. Dexamfetamine or atomoxetine can be considered if response to methylphenidate is inadequate.
Lisdexamfetamine or atomoxetine could be used as first line treatment in adults with ADHD.
Which drug is aka Ritalin? [1]
Methylphenidate
Describe the pharmacological treatment ladder for children for ADHD [3]
First line - METHYLPHENIDATE
- If no improvement after 6 weeks move on
Second line - LISDEXAMFETAMINE
- If good response but can’t tolerate long reaction - move onto DEXAMFETAMINE
- If can’t tolerate or non benefit to Lis..
ATOMOXETINE / GUANFACINE
Describe the pharmacological treatment ladder for adults for with ADHD [3]
1st line: LISDEXAMFETAMINE or METHYLPHENIDATE
- IF NO IMPROVEMENT AFTER 6-WEEK TRIAL OF ADEQUATE DOSE, SWITCH TO ALTERNATIVE 1ST LINE
2nd line: METHYLPHENIDATE or LISDEXAMFETAMINE
- If good response to LISDEXAMFETAMINE but cant’ tolerate long reaction move onto DEXAMFETAMINE
- If can’t tolerate METHYLPHENIDATE..
3rd line: ATOMOXETINE
A formal referral to cardiology before starting ADHD medication should be considered in the which circumstances? [3]
There is a history of cardiac pathology (history of congenital heart disease or previous cardiac surgery).
There are symptoms suggestive of cardiac pathology (hypertension, shortness of breath or fainting on exertion, cardiac-sounding chest pain, signs of heart failure, heart murmur on chest auscultation, palpitations).
There is a history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease.
Describe how you do a medication review for ADHD medications [3]
Measure height:
- every 6 months in children and young people (not applicable in adults)
Measure weight:
- in children < 10 years, measure weight every 3 months.
- In children >10 years and young people, measure weight at 3 months and 6 months after initiation, and then every 6 months.
- In children and young people plot the height and weight on a growth chart. In adults measure weight every 6 months.
Check heart rate and blood pressure:
- before and after each dose change and every 6 months.
- If tachycardia (>120bpm) or hypertension, consider dose reduction and referral to an appropriate specialist.
If the individual cannot tolerate the side effects of stimulant medication or there is an unsatisfactory response to two different stimulants, non-stimulant medication may be considered.
What are these and what are their MoA? [2]
Atomoxetine:
- selective noradrenaline reuptake inhibitor (SNRI)
Guanfacine:
- alpha-2a agonist
Uncommon but severe adverse effects to warn patients and their parents about for atomoxetine are [2]
- Atomoxetine is cautioned in those with [].
include increased suicidal ideation and liver dysfunction.
- Atomoxetine is cautioned in those with cardiovascular disease.
Lecture:
What are examples of environmental modifications that can give for a patient with ADHD? [+]
Structure and routine:
- helps to flow from one task to the next
Checklists:
- Helpful for complex tasks
- Breaks down tasks and organisation
Cueing:
- E.g. hand signal or tap on shoulder to get back on track
Minimise visualise and auditory hallucinatiosn
Different options for sitting at desk
Focus tools - fidget toys. Increases capacity to pay attention
Movement breaks
Appropriate chores (dishes)
Support for writing activities +/- extra time
What risk do you need to also ask about when giving stimulant treatment for ADHD? [1]
**Screen for FH of sudden cardiac death in < 40 year olds **
- ask about chest pain / palpiations when starting tx
How would you describe pharm. management of ADHD to people with ADHD? [1]
Not a treatment - they just help to manage some traits that cause problems in the world we live in
- e.g. attention
