ADHD 2 Flashcards
1
Q
ADHD and Hearing or vision problems
A
A differential dx and/or comorbid condition;
- Sensory deficits need to be ruled out first
- You must be sure that the child can see and hear normally
2
Q
Misc. ADHD Differential dx/comorbid conditions (5)
A
- Anxiety
a. Can mimic inattention
b. Difficulty with concentration - Sleep Problems
- Bereavement
a. Loss of significant family member or friend
b. Losses in terms of parental separation or divorce, deployment of parent in military
c. Breakup with friend - Language Impairment
a. Negative or expressive language impairment may be frustrated and inattentive as a result of being unable to express themselves - Developmental Problems
a. Overall intellectual or social limitations less able to control their impulses and to maintain focus - Substance Abuse - Self-medication with alcohol, nicotine or other drug
3
Q
ADHD and Depression (5)
A
- Co-occur with ADHD
- Look for marked sleep disturbances
- Disturbed appetite
- Low mood in adolescent
- Child may not be as obvious
4
Q
ADHD and exposure to adverse childhood events (6)
A
- Child with recent witness to or experience of traumatic event
- Natural disaster
- Separation of parents
- Parental divorce
- Neglect or physical, emotional, or sexual abuse
- PTSD may resemble ADHD in that hypervigilance can mimic hyperactivity, dissociation may mimic inattention
5
Q
ADHD and physical illness as dif dx or comorbid (5)
A
- Hypoglycemia
- Hyperglycemia
Inattention and impulsivity could be due to
i. Thyroid disease
ii. Bronchodilator
iii. Endocrine tumor such as pheochromocytoma
6
Q
ADHD and ODD
A
Conduct or oppositional defiant disorder
a. Disruptive behavior or aggression
b. Common to see aggressive and more behavioral problems with academic underachievement
7
Q
ADHD and Tourette Syndrome (3)
A
a. Repetitive movement disorder
b. Stimulant meds may worsen tics
c. Tailor treatment to child’s most pressing symptoms
8
Q
ADHD and Learning Problems or Disability (9)
A
- History of speech delay
- Difficulty in understanding despite normal hearing and vision
- Difficulty following directions
- Struggled with reading, math concepts in comparison to peers
- Frustrated parents with academic performance
- Underachiever
- Lazy in school
- Other family member have learning problems
- Inattention in school
9
Q
Findings that suggest learning disability (3)
A
- Percentiles are low ≤ 15 or markedly less than one would expect based on intelligence
- Grades are low or scattered
- Percentiles on IQ tests are significantly higher than measures of academic achievement
10
Q
ADHD Medical Differential Dx (9)
A
a. Seizure Disorder (e.g., Absence, Complex-Partial)
b. Chronic Otitis Media
c. Hyperthyroidism
d. Sleep Apnea
e. Drug-Induced Inattentional Syndrome
f. Head Injury
g. Hepatic Illness
h. Toxic Exposure (e.g., lead)
i. Narcolepsy
11
Q
AAP Clinical Practice Guidelines (8)
A
- Initiate evaluation of child with symptoms
- Confirm patient meets the DSM V criteria in more than one setting
- Assess for comorbidities
- Recognize ADHD is a chronic disease—follow principle for chronic care and medical home
- Treatment recommendations vary with age with younger children needed parent and/or teacher based therapy with an attempt to avoid meds
- Middle and high school ages—meds are first line
- PCP can titrate medication for maximum benefit and minimum adverse effects
- Meds are last choice for preschool children
12
Q
Behavioral Difficulties that you will hear in the Office (6)
A
- Parent-child relationship problems
- Cognitive and emotional problems
- Difficulties with transitioning
- Peer problems
- Problems with time
- Problems with sleep
70% OF CHILDREN WITH ADHD HAVE ANOTHER DISORDER SO YOU SHOULD NOT ONLY FOCUS CORE SYMPTOM
13
Q
ADHD Rule of 1/3rds (3)
A
1/3 → complete resolution
1/3 → continued inattention, some impulsivity
1/3 → early ODD/CD, poor academic achievement, substance abuse, antisocial adults
14
Q
ADHD Age Related Changes (4)
A
- Preschool (3-5 y/o) – hyperactive/impulsive
- School age (6-12 y/o) – combination symptoms
- Adolescence (13-18 y/o) – more inattention w/ restlessness
- Adult (18+) – largely inattention w/periodic impulsivity
15
Q
Ulterior Motives in Seeking and ADHD Diagnosis (8)
A
- Test accommodations (SATs !!)
- Improved grades (cognitive enhancement)
- Weight loss –> Teens – misuse / diversion
- Rush to clinical judgment
- Over-reliance on direct observation failure to gather info from multiple informants
- Failure to adequately
- Consider the differential diagnosis
- Failure to adequately assess for common or suggested co-morbidities
16
Q
ADHD Behavioral Interventions (11)
A
- Psychoeducation about ADHD
- Structure/routines
- Clear rules/expectations
- Attending/rewards
- Planned ignoring
- Effective commands
- Time out/loss of privileges
- Point/token systems
- Daily school-home report card
- Intensive summer treatment programs
- Fidget cube for those who cannot stop fidgeting with hands
17
Q
ADHD Alternative Treatments (3)
A
- Omega 3, best evidence
- B6
- Magnesium
18
Q
Psychoeducation Prior to Prescribing (6)
A
Parents need to
- Understand that mental health problems are common and not their fault
- If you are planning to offer medication, let the parent understand that treatment of mental health disorders are like treating any health problem (normalization)
- If there is a family member that has the same diagnosis and responded well to treatment, review their experience and offer hope
- If there is a family member who has the same but not responded well treatment, there may be difference
- Common disorders are common—ADHD, anxiety and depression is common
- When there are several options available, presenting a menu of options can allow for individualization
19
Q
Plan before initiating pharmacological treatments
A
- Identify the treatment goals
- Discuss of adverse medication effects
i. Risks, benefits, and alternatives to proposed treatment
ii. Changing side effect profiles
iii. Prolonged QT with citalopram
iv. Review pre-existing medication regime and make sure no interactions are present
v. Limit the total numbers of medication
20
Q
Plan once pharmacological treatment has been initiated (5)
A
- Give treatments a chance to work
- Use of standardized tool to monitor pharmacological effects
- Use of standard tool to monitor for suicidal risk in SSRI and in antiepileptic drugs
- Waiting for more severe symptoms to appear is not a good option
- Metabolic screening is indicated for patients on antipsychotic drugs
21
Q
Basic Principles of Psychotherapeutic Interventions and Techniques (15)
A
- Psychiatric medications should be one part of the treatment plan.
- The medication approaches to mental illness needs to address the chronic nature of some mental health problems and therefore cannot be used alone.
- The side effects and efficacy of each class of drugs in pediatric and adolescent drugs need to be considered.
- In general, children may need higher doses due to the faster metabolism, the kidney clearance and increased liver size in relationship to the body surface area.
- Problem solving strategies, behavioral strategies, psychoeducation, and support are part of the treatment
- When prescribing, treat a primary diagnosis first or the one that is causing the most functional impairment.
- Symptoms need to be evaluated at baseline and during treatment via a rating scale.
- Scale should be indicated for the problem
- Pick medications that are approved for the child’s age and problem if possible—Go slow and start low
- Use the medication for an adequate trial before changing or adding any medication.
- For PNP’s in primary care if you start to need to add another medication, the child needs to be seen by child mental health specialist.
a. Get a psych eval before prescribing another medication - Multiple medications mean multiple side effects and can be problematic.
- Use environmental or behavioral strategies rather than adding the medication
- Develop an alliance with the family and child. Encourage their participation in drug choice. How do they respond to the word “Medication”.
- Make sure they understand the side effects of the drugs. These need to be reinforced with handout if possible.
22
Q
Three C’s of good pharmacotherapy
A
1, Communication (return phone calls and emails promptly)
- Conscientiousness (of standard of practice and sociocultural needs)
- Collaboration (therapists, other care providers, and families
23
Q
Principles of Pharmacological Treatment of Psychiatric Illness (6)
A
- Identify target symptoms
- Maximize dosages of medication before discontinuing or adding another
- Change and adjust one drug at time
- Monitor side effect
- Discontinue the drug that is of the least benefit
- Give reliable information
24
Q
Informed Consent Prior to Starting Treatment (7)
A
- Document discussion about medication & need for follow up
- Document clear parameters for seeking ED treatment (rash on lithium; suicidal plan on SSRI)
- Educate regarding mild, moderate, or severe side effects
- Document that you informed patient of potential long term adverse effects
- Cost needs to be discussed. Make sure insurance will cover medication
- If you will need to monitor labs, explain this in the chart
- If there is a risk of drug to drug interaction (especially in CYP 450 isoenzymes), make sure family knows not to add a medication without checking with you
25
Tracking adherence (2)
1. Just keep me informed about how often ‘Billy’ takes the medication” so that you be open about medication adherence or lack there of
2. Need to adjust down medication if using another modality and child is improving
26
FDA Boxed Warning: Stimulants and Cardiac Concerns (3)
1. Boxed Warning: Misuse of amphetamines can cause sudden death and serious CV adverse effects
2. Warning but not boxed for Methylphenidate
3. Bottom line: Take a personal and family cardiac history with an emphasis on sudden death, structural defects, syncope, arrhythmias, sudden unexplained death and long QT before writing for stimulants
* MUST TAKE A VERY DETAILED FAMILY HX
27
ADHD Meds: Methylphenidate based
1. Ritalin, concerta, Metadate, Ritalin LA, Focalin, Focalin XR, Daytrana
2. First line agents
28
ADHD Meds: Amphetamine based
1. Dexedrine Spansules, Adderall XR, Vyvanse
| 2. First line agents
29
ADHD Meds: Norepinepherine based (3)
a. Strattera (atomoxetine)
b. Second line
c. Has more side effects
30
ADHD Meds: second line agents (4)
1. Second line agent used unless there is an underlying medical problems, substance abuse problems or an anxiety disorder
2. Adrenergic agonist
3. Guanfacine, and clonidine
4. Guanfacine ER (Intuniv)-6-17 years
31
Stimulants (5)
Two types
1. Methylphenidate
2. Amphetamine
3. Different racemic preparations are considered interchangeable except for dose
4. Treatment effects lasts for 3 to 12 hours
5. Well-researched, effective, commonly used medication treatment for ADHD.
a. Methylphenidate (Ritalin, Concerta, and Metadate)
b. Dextroamphetamine (Adderall)
32
Stimulants mechanism of action (8)
These medications reduce ADHD symptoms by:
1. Blocking the reuptake of norepinephrine (NOR) and dopamine (DOP) and facilitating their release
2. → Enhances NOR and DOP availability in certain brain regions: Prefrontal Cortex and basal ganglia
3. Reuptake inhibition of NE and DA
4. Cause increased release of presynaptic NE/DA
5. Amphetamine promotes passive diffusion of NE and
6. DA into synaptic cleft
7. Amphetamine promotes release of NE and DA from cytoplasmic pools
8. Amphetamine and Methylphenidate are mild inhibitors of MAO
33
Contraindications for Methylphenidate (5)
1. Known hypersensitivity to Methylphenidate
2. Marked anxiety, tension, or agitation
3. Glaucoma
4. Currently using or within 2 weeks of using Monoamine oxidase inhibitor
5. Controversial: Tics or family history of or diagnosis of Tourette syndrome
34
ADHD Stimulants Adverse Effects (4 common, 3 less common, 3 rare)
Common Adverse Events
a. Insomnia
b. Appetite suppression
c. Headache
d. Stomachache
Less Common Adverse Events
a. Cognitive dulling
b. Irritability
c. Exacerbation of tics (controversial)
Rare events
a. Growth; 2cm decline in height associated with stimulant use
b. Hallucinations (visual or tactile, auditory less common)
c. Arrhythmia in those with preexisting cardiac disease
35
Stimulants: Sudden Cardiac Death (4)
1. Concerns about the cardiac safety of stimulants peaked in 2005 when Health Canada discontinued sales of Adderall XR.
2. FDA discovery of 25 reports of death among users of stimulants between 1999 and 2003 and 54 cases of serious CV problems (e.g., strokes, MI, arrhythmia).
3. Estimated rate of SCD among treated patients was 2 – 5 times below the rate in the general population
4. Risk of dying of a sudden cardiac event
a. Still under 1/1,000,000
b. No more than is expected in an untreated population
36
APA and AHA Cardiac Monitoring with stimulants (8)
1. Cardiovascular evaluation and monitoring of children receiving drugs for the treatment of ADHD
AAP and AHA carefully assess children for heart conditions who need to receive treatment with drugs for ADHD.
2. Obtaining a patient and family health history
3. Do a physical exam focused on cardiovascular disease risk factors (Class I recommendations in the statement).
4. Consider acquiring an ECG is a Class IIa recommendation-Not mandatory
5. Treatment of a patient with ADHD should not be withheld because an ECG is not done.
6. Medications that treat ADHD have not been shown to cause heart conditions nor have they been demonstrated to cause sudden cardiac death.
7. Can increase or decrease heart rate and blood pressure.
8. Monitored in children for side effects
37
Simulants and tic disorders (8)
1. Up to 65% of children initiating Rx with MPH may develop a transient tic
2. Simple Motor, Complex Motor, or Vocal • Stimulants may cause or unmask tics
Treatment:
3. Alteration in stimulant dose
4. Change of stimulant
5. alpha-2 agonists
6. Antipsychotics
7. CBT
8. Strattera
38
Limitations to stimulant tx (8)
1. Individual differences in response
a. Not all children respond (approximately 80%)
2. Limited impact on domains of functional impairment
a. Primary reason for treatment seeking
3. Does not normalize behavior
4. Family problems beyond the scope of medication
5. No long-term effects established
6. Long-term use rare
7. Limited parent/teacher satisfaction
8. Some families are not willing to try medication
39
Using/Dosing Medications (5 steps)
Using Stimulants
1. Step 1 - Baseline ADHD symptom assessment
2. Step 2 - Start with low dose, short acting agent
a. Test dose on weekend (assessing for tolerability not efficacy)
3. Step 3 - If patient tolerates step 2, advance to long acting agent (e.g. concerta 18mg)
4. Step 4 - Titrate by ~10mg/week at weekly intervals until rating scale scores are subclinical or you reach maxImum dose of 2mg/kg/day or 72mg/day for MPH (concerta)
5. Step 5 - If you prefer amphetamines, start with MAS (Adderall) 5mg daily and transition/advance to MAS (Adderall XR) 10mg. Max dose = 1.5mg/kg/day or 30mg/day for AMS (XR)
40
Monitoring medications (4)
1. Height and weight q 3-4 months
2. Most lose ¼-1/2 of inch over lifetime
3. HR and BP periodically
4. Serial EKG if:
a. Known Cardiac disease
b. Strong history of sudden cardiac death
c. Multiple agents with cardiac effects
d. If you are considering doses that exceed FDA-approved doses
41
Stimulants and Concerns about Abuse and Dependence (2)
1. High potential for abuse
| 2. May divert stimulants for money
42
Level One Medications: Safety Profile (3)
Stimulants
1. FDA approval over 6 years with over 50 years on market
2. Low over dose harm
3. Boxed warning for drug abuse potential
4. Rare long term risk to health - ex: growth deceleration
2. alpha-Adrenergic agonist (Guanfacine, clonidine)
i. FDA approval over 6 with over 30 years on the market stimulate the 2 adrenergic receptor (AR) in the brain clonidine stimulates all 3 subtype A, B, & C—leads to more sedation and hypotension/bradycardia side effect
3. Guanfacine only stimulates A receptor
* No long term health risk
