ADHD

Question 1

sx of ADHD in toddler, preschool, elementary school, and adolescent stages

Answer 1

tod: before age 4, excessive motor activity (but highly variable anyway)
pre: hyperactivity
elem: inattention becomes more prominent and impairing
early adolescence: fidgety, restless, impatient, inattentive, poor planning, impulsive; hyperactivity is less common

Question 2

ADHD comorbidities

Answer 2

many: disruptive mood dysregulation d/o
common: specific learning d/o
minor: anxiety/MDD d/o, substance use, OCD, tic d/o, ASD, intellectual disabilities

Question 3

non-pharm tx of ADHD

Answer 3

psychodynamic interventions: good for emotionally-based sx
family system: focus on connection b/t parent-child intxn and sx
behavioral-cognitive interventions including parent training to learn appropriate punishment and reinforcement
school behavioral intervention: target positive behaviors with stickers and rewards

Question 4

actions of meds for ADHD

Answer 4

modify signal to noise ratio: increase signal by increasing NE, decrease noise by increasing DA

Question 5

method of stimulants

Answer 5

increased signal attention in PFC (NE) and decrease noise from extraneous stimuli (DA)
*may cause over-focus

Question 6

method of adrenergic agents

Answer 6

specifically increase signal (attention) by increased NE

*no effect on restlessness (inc noise) directly

Question 7

stimulants for ADHD

Answer 7

first line; indirect sympathomimetics

methylphenidate, dexmethylphenidate, dextroamphetamine, lisdexamfetamine, mixed amphetamine salts, pemoline (off market)

Question 8

non-stimulant meds for ADHD

Answer 8

2nd line: atomoxetine

3: TCAs, bupropion
4: a2 agonists (clonidine, guanfacine)

Question 9

characteristics of stimulants

Answer 9

equal efficacy in reducing sx, but effective dose unpredictable
different DEA classes (amphetamines and methylphenidate are schedule 2), durations of action, adverse effects, and drug interactions

Question 10

methylphenidate MOA and metabolism

Answer 10

inhibits reuptake of DA and NE by presynaptic terminals by blocking DAT and NET
metabolized by CYP 2D6
*schedule 2 d/t high abuse potential

Question 11

ADRs of methylphenidate

Answer 11

anorexia, insomnia, tic d/o (transient or chronic), growth (take break when not in school), DA elevation may worsen psychosis, abuse potential (inc DA), drug interactions w CYP inhibitors or inducers

Question 12

drug interactions with methylphenidate

Answer 12

CYP 2D6 inhibitors- fluoxetine, paroxetine
MAOIs- increase effect = medical emergency
TCAs- increase TCA effect
phenytoin- increase its effect
clonidine- cardiac arrhythmia, unknown MOA

Question 13

amphetamine MOA

Answer 13

indirect sympathomimetic, inhibits reuptake of DA and NE by presynaptic neuron and enhances release of DA
*schedule 2

Question 14

ADHD stimulants and cardiovascular risk

Answer 14

stimulants raise BP and HR; can cause MI, stroke, sudden death

Question 15

antidepressants used in ADHD

Answer 15

bupropion
imipramine
desipramine

Question 16

when a2-agonists are used in ADHD

Answer 16

children who are unusually insomniac, irritable, explosive, or labile

Question 17

atomoxetine MOA, metabolism, effectiveness

Answer 17

selective NE reuptake inhibitor (but more effective for ADHD than depression)
metabolized by CYP 2D6
more effective than placebo but less than stimulants
non-stimulant = less abuse potential, not a controlled substance

Question 18

atomoxetine ADR

Answer 18

GI upset, fatigue, decreased appetite, HTN, tachycardia, possible growth retardation
BBW: potential for severe liver dz, potential for suicidal ideation in children and adolescents

Question 19

long-term effects of pharmacologic treatment of ADHD

Answer 19

improvement in core symptoms but not academic achievement or social skills, but no conclusive evidence that long-term treatment is harmful (except dose-related ADRs, possible abuse potential)