ADHD Flashcards
3 Types of ADHD
Hyperactive
Impulsive
Inattention
What do ADHD symptoms affect?
Cognitive functioning Academic functioning Behavioral functioning Emotional functioning Social functioning
What other psychiatric disorders is ADHD frequently associated with?
Oppositional defiant disorder (ODD) Conduct disorder (CD) Depression Anxiety disorder Learning disabilities
Major Transmitters in ADHD
Dopamine
Norepinephrine
Where are dopamine sensitive neurons?
Frontal lobe
What is the dopamine system associated with?
Reward Attention Short term memory Planning Motivation
Functions of the Frontal Lobe
Ability to project future consequences
Choice between good & bad actions
Override & suppression of socially unacceptable responses
Determination of similarities & differences
Differences in the Brain of a Person with ADHD
Decreased activation in the basal ganglion & anterior frontal lobe
Increase in dopamine transporter activity
Dopamine imbalance allows inappropriate increase in norepinephrine activity
Methylphenidate
Increases extracellular dopamine in the brain
Changes areas of function in the frontal lobe
DSM V Symptoms of Inattention or Hyperactivity/Impulsivity
Symptoms inappropriate for given age
Negatively impacts social & academic or occupational activities
Symptoms prior to age 12
Symptoms present in 2+ settings
Symptoms present for at least 6 months
Symptoms not better explained by other psychiatric
ADHD Inattentive Symptoms
Failure to give close attention to detail
Difficulty sustaining
attention in task
Failure to listen when spoken to directly
Failure to follow instructions
Difficulty organizing tasks & activities
Reluctance to engage in tasks that require sustained mental effort
Loses things necessary for tasks or activities
Easy distractibility
Forgetfulness in daily activities
ADHD Impulsive-Hyperactivity Symptoms
Fidgetiness with hands & feet or squirms in seat
Difficulty remaining seated in class
Excessive running or climbing in inappropriate situations
Difficulty in engaging in quiet activities
Is often “on-the-go” or acts as if “driven by a motor”
Often talks excessively
Excessive talking & blurting out answers before questions have been completed
Difficulty awaiting turns
Interrupting & intruding on others
Medical Evaluation of ADHD
Vanderbilt forms Refer for vision & hearing tests Complete H&P Blood lead level (maybe) TSH (maybe) Sleep study (maybe) Neurology consult (seizure/neuro disorder)
Treatment of ADHD
Ritalin
Adderall
Concerta
Behavioral therapy
Criteria for Initiation of Pharmacotherapy for ADHD
Complete diagnostic assessment that confirms ADHD
>6 years old
Parental consent
School is cooperative
No previous sensitivity to the medication
Normal HR & BP
No Hx of seizure disorder
Doesn’t have Tourettes, autism spectrum disorder, anxiety disorder, substance abuse among household members
Things to Note Prior to Therapy for ADHD
Comprehensive medical eval + EKG
Pretreatment height, weight, BP, HR
Pretreatment appetite, sleep patterns, headaches, & abdominal pain
Assess for substance use/abuse
Education for ADHD Pharmacology
Meds prescribed to help with self control & ability to focus
Benefits vs. risks
Risks: CV issues, anorexia, insomnia, tics, priapism
Follow up protocol expectations
Patient specific goals
Potential Goals for ADHD Treatment
Less interruption in class
Turning in homework on time
Keeping their butt in their seat
Medications for ADHD
1st: methylphenidate (Ritalin) or dextroamphetamine (Adderall)
2nd: atomoxetine (Straterra)
Considerations for Medication Choice in ADHD
Duration of coverage Ability to swallow pills Time of day when symptoms occur Desire to avoid administration at school Coexisting tic disorder Coexisting emotional or behavioral condition Potential SE Hx of substance abuse Expense
Pros of Pharmacotherapy for ADHD
Long record of safety & efficacy
Improves: core symptoms, parent-child interactions, aggressive behavior, academic productivity & accuracy, improved self-esteem
Cons of Pharmacotherapy for ADHD
Insufficient data to judge long term academic performance
Symptoms tend to improve over time
Does not significantly affect learning problems, reduced social skills, oppositional behavior, emotional problems
How to choose which stimulant for ADHD?
Providers preference & comfort level
Patient & parent preference
Drugs Classes of ADHD Medications
Stimulants
Atomoxetine
Alpha-2-adrenergic agonists
Antidepressants
Stimulant Medications for ADHD
Methylphenidate
Detroamphetamine
Detroamphetamine-amphetamine
Antidepressant Medications for ADHD
TCAs
Bupropion
Short Acting Methylphenidate’s for ADHD
Ritalin
Methylin
Time Frames for Ritalin & Methylin
Onset: 20-60 minutes
Duration: 3-5 hours
Half-life: 2-3 hours
Extended Release Long Acting Methylphenidate’s for ADHD
Metadate ER
Methylin ER
Ritalin SR
Time Frames for Extended Release Long Acting Methylphenidate’s for ADHD
Onset: 20-60 minutes
Duration: 8 hours
Sustained Release Long Acting Methylphenidate’s for ADHD
dexmethyllphenidate (Focalin XR)
Metadate CD
Ritalin LA
Time Frames for Sustained Release Long Acting Methylphenidate’s for ADHD
Onset: 20-60 minutes
Duration: 9 hours; 12 hours (Focalin XR)
BID dosing
Long Acting Osmotic Release Methylphenidate for ADHD
Concerta
Times Frame for Concerta
Onset: 20-60 minutes
Duration: 12 hours
Long Acting Oral Suspension Methylphenidate for ADHD
Quillivan XR
Time Frames for Quillivan XR
Onset: 60 minutes
Duration: 12 hours
Long Acting Transdermal Methylphenidate for ADHD
Daytrana
Time Frames for Daytrana
Onset: 60 minutes
Duration: 12 hours
Last 3 hours after removal of patch
Short Acting Amphetamines for ADHD
Dextroamphetamine’s
Amphetamine-destroamphetamine (Adderall)
Time Frames for Dextroamphetamines
Onset: 20 minutes
Duration: 4-6 hours
Time Frames for Adderall
Onset: 20 minutes
Duration 4-6 hours
Examples of Dextroamphetamine’s
Dexedrine
Dextrostate
Procenta (Oral solution)
Examples of Long Acting Amphetamines
Lisdexamfetamine (Vyvanase)
Dextroamphetamine SR (Dexedrine spansule)
Amphetamine-dextroamphetamine (Adderall XR)
Time Frame for Lisdexamfetamine (Vyvanase)
Onset: 1 hour
Duration: 10-12 hours
Time Frame for Dextroamphetamine SR (Dexedrine spansule)
Onset: 20 minutes
Duration: 6-8 hours
Time Frame for amphetamine-dextroamphetamine (Adderall XR)
Onset: 20 minutes
Duration: 8-10 hours
Reasons for a Short Acting Stimulant
Initial prescription in children
Reasons for a Long Acting Preperation
Initially age 6+
Start at lowest dose & titrate up
Methylphenidate SR (Ritalin) Dose Titration
Increase 20 mg/day q 3-7 days
Weight based
Methylphenidate LA (Ritalin LA) Dose Titration
Increase 10 mg/dose q 3-7 days
Weight based
Methylphenidate ER (Concerta) Dose Titration
Increase 9-18 mg/dose q 3-7 days
Age based
Dextroamphetamine SR (Dexedrine Spansule) Dose Titration
Increase 5 mg every 3-7 days
Weight based
Amphetamine-Dextroamphetamine SR (Adderall XR) Dose Titration
Increase 5 mg every 3-7 days
Max dose 40 mg
Lisdexamphetamine (Vyvanase) Dose TItration
Increase 10-20 mg q 3-7 days
Max dose 70 mg
Non-stimulant Medications
Atomoxetine (Strattera)
Alpha-2-adrenergic agonsists
Antidepressants
Alpha-2-adrenergic Agonists for ADHD
Clonidine (Catapres)
Guanfacine (Tenex)
Antidepressants for ADHD
TCAs: imipramine (Tofranil), desipramine (Norpramin)
Bupropion (Wellbutrin)
Atomoxetine (Strattera) Dose Titration for
Increase 1.2 mg/kg/day after 3 days
Max dose lesser of 1.4 mg/kg or 100 mg/day
Atomoxetine (Strattera) Dose Titration for >70 kg
Increase to 80 mg after 3 days
After 2-4 weeks may increase to 100 mg
Monitoring for SE
Assess weekly during titration
Parent/teacher feedback
Monthly after titration for weight, HR & BP until stable with no SE
Optimal dose = favorable outcomes with minimal SE
SE of ADHD Pharmacotherapy
Decreased appetite Poor growth Dizziness Insomnia/nightmares Mood lability Rebound Tics Psychosis Diversion & misuse
Managing Decreased Appetite
Give at/after a meal
Nutrient dense foods
Off food child likes for noon meal
Managing Poor Growth
Drug holidays
Managing Dizziness
Monitor BP & HR
Adequate fluid intake
Managing Insomnia or Nightmares
Bedtime routine
Good sleepy hygiene habits
Omit/reduce last dose of day
Consider short acting vs. long acting
Managing Mood Lability
Convert to long acting formulation or BID to TID
Mood changes at peak concentration
Symptoms of Mood Lability
Sadness
Irritability
Increased activity
Controlling Mood Changes at Peak Concentration
Reduce dose
Switch to long acting
Managing Rebound
Stepping down dose at end of day
Managing Tics
Drug trial at different doses to see if related to med
Managing Psychosis
Verify dose is appropriate
Verify medication administered as prescribed
Refer to mental health specialist
Symptoms of Psychosis with ADHD Medications
Suicidality
Hallucinations
Increased aggression
Management of Diversion & Misuse
Monitor symptoms & prescription refills
Long acting less potential for abuse
Keep track of prescription dates
Open discussion
Reasons for ADHD Treatment Failure
Lack of adherence Medication diversion Goals & expectations realistic Co-morbid psychiatric diagnosis Fail multiple stimulants or intolerable SE, trial atomoxetine or alpha-2-adrenergic or buproprion
When are drug holidays permissible?
Weekends
Summers
ONLY FOR STIMULANTS
Maintenance of ADHD Therapy
Follow up every 3-6 months
Monitor height, weight, BP, HR
Termination of ADHD Therapy
Stimulants or atomoxetine can be abruptly
Alpha-2-adrenergics & TCAs should be tapered
Ritalin (Methylphenidate)
Short & Long acting agents
Blocks dopamine & norepinephrine re-uptake
Short Acting Ritalin (Methylphenidate)
Ritalin
Methylin
Long Acting Ritalin (Methylphenidate)
Metadate ER
Methylin ER
Ritalin SR
Longer Acting Ritalin (Methylphenidate)
Focalin XR
Metadate CD
Ritalin LA
Longest Acting Ritalin (Methylphenidate)
Concerta
Quillivan XR
Daytrana
SE of Ritalin (Methylphenidate)
Anxiety Weight loss Psychosis Aggression Hallucinations Sudden cardiac death in at risk people Easy bruising Schedule II
Amphetamine-dextromphetamine (Adderall)
Schedule II
Popular
Slightly more effective than Ritalin
SE of amphetamine-dextroamphetmine (Adderall)
Anxiety Weight loss Psychosis Hallucinations Aggression Sudden cardiac death in at risk people
Dextroamphetamine (Dexedrine)
Among most effective treatment for ADHD
Schedule II
Sudden cardiac death in at risk people
Heart Related Problems with Dextroamphetamine (Dexedrine)
Sudden death in people with heart problems or defects
Sudden death, stroke & MI in adults
Increased BP & HR
Psychiatric Problems in Dextroamphetamine (Dexedrine)
New/worse behavior & thought problems
New/worse bipolar
Children/Teenager Problems in Dextroamphetamine (Dexedrine)
Seeing things
Hearing voices
Believing things that aren’t true
New manic symptoms
Lixdexamphetmaine (Vyvanase)
Less addictive but still Schedule II
Atomoxetine (Strattera)
Works on norepinephrine
Black box warning: increased risk of suicidal behavior
Less effective than stimulants
Expensive
SE of Atomoxetine (Straterra)
Dry mouth Insomnia Nausea Decreased appetite Constipation Decreased libido Erectile dysfunction Urinary hesitancy Dizziness Sweating Chest pain SOB Irregular heart beat Unusual thoughts or behavior Aggression Hallucinations Jaundice Abdominal pain
Alpha-2-adrenergic Agonist
ER Guanfacine (Intuniv)
SE for ER Guanfacine (Intuniv)
Fast/slow HR Pounding heartbeat, chest tightness Numbness/tingling High rate of fainting Depression Hypotension
When should you caution use of guanfacine (Intuniv)
Kidney or liver disease
Alternative Treatment for ADHD
Buproprion (Wellbutrin)
SE of Bupropion (Wellbutrin)
Anxiety
Insomnia
