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ADHD Flashcards

1
Q

3 Types of ADHD

A

Hyperactive
Impulsive
Inattention

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2
Q

What do ADHD symptoms affect?

A 
Cognitive functioning
Academic functioning
Behavioral functioning
Emotional functioning
Social functioning
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3
Q

What other psychiatric disorders is ADHD frequently associated with?

A 
Oppositional defiant disorder (ODD)
Conduct disorder (CD)
Depression
Anxiety disorder
Learning disabilities
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4
Q

Major Transmitters in ADHD

A

Dopamine

Norepinephrine

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5
Q

Where are dopamine sensitive neurons?

A

Frontal lobe

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6
Q

What is the dopamine system associated with?

A 
Reward
Attention
Short term memory
Planning 
Motivation
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7
Q

Functions of the Frontal Lobe

A

Ability to project future consequences
Choice between good & bad actions
Override & suppression of socially unacceptable responses
Determination of similarities & differences

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8
Q

Differences in the Brain of a Person with ADHD

A

Decreased activation in the basal ganglion & anterior frontal lobe
Increase in dopamine transporter activity
Dopamine imbalance allows inappropriate increase in norepinephrine activity

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9
Q

Methylphenidate

A

Increases extracellular dopamine in the brain

Changes areas of function in the frontal lobe

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10
Q

DSM V Symptoms of Inattention or Hyperactivity/Impulsivity

A

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

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11
Q

ADHD Inattentive Symptoms

A

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

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12
Q

ADHD Impulsive-Hyperactivity Symptoms

A

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

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13
Q

Medical Evaluation of ADHD

A 
Vanderbilt forms
Refer for vision & hearing tests
Complete H&P
Blood lead level (maybe)
TSH (maybe)
Sleep study (maybe)
Neurology consult (seizure/neuro disorder)
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14
Q

Treatment of ADHD

A

Ritalin
Adderall
Concerta
Behavioral therapy

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15
Q

Criteria for Initiation of Pharmacotherapy for ADHD

A

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

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16
Q

Things to Note Prior to Therapy for ADHD

A

Comprehensive medical eval + EKG
Pretreatment height, weight, BP, HR
Pretreatment appetite, sleep patterns, headaches, & abdominal pain
Assess for substance use/abuse

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17
Q

Education for ADHD Pharmacology

A

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

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18
Q

Potential Goals for ADHD Treatment

A

Less interruption in class
Turning in homework on time
Keeping their butt in their seat

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19
Q

Medications for ADHD

A

1st: methylphenidate (Ritalin) or dextroamphetamine (Adderall)
2nd: atomoxetine (Straterra)

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20
Q

Considerations for Medication Choice in ADHD

A 
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
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21
Q

Pros of Pharmacotherapy for ADHD

A

Long record of safety & efficacy
Improves: core symptoms, parent-child interactions, aggressive behavior, academic productivity & accuracy, improved self-esteem

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22
Q

Cons of Pharmacotherapy for ADHD

A

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

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23
Q

How to choose which stimulant for ADHD?

A

Providers preference & comfort level

Patient & parent preference

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24
Q

Drugs Classes of ADHD Medications

A

Stimulants
Atomoxetine
Alpha-2-adrenergic agonists
Antidepressants

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25
Stimulant Medications for ADHD
Methylphenidate Detroamphetamine Detroamphetamine-amphetamine
26
Antidepressant Medications for ADHD
TCAs | Bupropion
27
Short Acting Methylphenidate's for ADHD
Ritalin | Methylin
28
Time Frames for Ritalin & Methylin
Onset: 20-60 minutes Duration: 3-5 hours Half-life: 2-3 hours
29
Extended Release Long Acting Methylphenidate's for ADHD
Metadate ER Methylin ER Ritalin SR
30
Time Frames for Extended Release Long Acting Methylphenidate's for ADHD
Onset: 20-60 minutes Duration: 8 hours
31
Sustained Release Long Acting Methylphenidate's for ADHD
dexmethyllphenidate (Focalin XR) Metadate CD Ritalin LA
32
Time Frames for Sustained Release Long Acting Methylphenidate's for ADHD
Onset: 20-60 minutes Duration: 9 hours; 12 hours (Focalin XR) BID dosing
33
Long Acting Osmotic Release Methylphenidate for ADHD
Concerta
34
Times Frame for Concerta
Onset: 20-60 minutes Duration: 12 hours
35
Long Acting Oral Suspension Methylphenidate for ADHD
Quillivan XR
36
Time Frames for Quillivan XR
Onset: 60 minutes Duration: 12 hours
37
Long Acting Transdermal Methylphenidate for ADHD
Daytrana
38
Time Frames for Daytrana
Onset: 60 minutes Duration: 12 hours Last 3 hours after removal of patch
39
Short Acting Amphetamines for ADHD
Dextroamphetamine's | Amphetamine-destroamphetamine (Adderall)
40
Time Frames for Dextroamphetamines
Onset: 20 minutes Duration: 4-6 hours
41
Time Frames for Adderall
Onset: 20 minutes | Duration 4-6 hours
42
Examples of Dextroamphetamine's
Dexedrine Dextrostate Procenta (Oral solution)
43
Examples of Long Acting Amphetamines
Lisdexamfetamine (Vyvanase) Dextroamphetamine SR (Dexedrine spansule) Amphetamine-dextroamphetamine (Adderall XR)
44
Time Frame for Lisdexamfetamine (Vyvanase)
Onset: 1 hour Duration: 10-12 hours
45
Time Frame for Dextroamphetamine SR (Dexedrine spansule)
Onset: 20 minutes Duration: 6-8 hours
46
Time Frame for amphetamine-dextroamphetamine (Adderall XR)
Onset: 20 minutes Duration: 8-10 hours
47
Reasons for a Short Acting Stimulant
Initial prescription in children
48
Reasons for a Long Acting Preperation
Initially age 6+ | Start at lowest dose & titrate up
49
Methylphenidate SR (Ritalin) Dose Titration
Increase 20 mg/day q 3-7 days | Weight based
50
Methylphenidate LA (Ritalin LA) Dose Titration
Increase 10 mg/dose q 3-7 days | Weight based
51
Methylphenidate ER (Concerta) Dose Titration
Increase 9-18 mg/dose q 3-7 days | Age based
52
Dextroamphetamine SR (Dexedrine Spansule) Dose Titration
Increase 5 mg every 3-7 days | Weight based
53
Amphetamine-Dextroamphetamine SR (Adderall XR) Dose Titration
Increase 5 mg every 3-7 days | Max dose 40 mg
54
Lisdexamphetamine (Vyvanase) Dose TItration
Increase 10-20 mg q 3-7 days | Max dose 70 mg
55
Non-stimulant Medications
Atomoxetine (Strattera) Alpha-2-adrenergic agonsists Antidepressants
56
Alpha-2-adrenergic Agonists for ADHD
Clonidine (Catapres) | Guanfacine (Tenex)
57
Antidepressants for ADHD
TCAs: imipramine (Tofranil), desipramine (Norpramin) | Bupropion (Wellbutrin)
58
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
59
Atomoxetine (Strattera) Dose Titration for >70 kg
Increase to 80 mg after 3 days | After 2-4 weeks may increase to 100 mg
60
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
61
SE of ADHD Pharmacotherapy
``` Decreased appetite Poor growth Dizziness Insomnia/nightmares Mood lability Rebound Tics Psychosis Diversion & misuse ```
62
Managing Decreased Appetite
Give at/after a meal Nutrient dense foods Off food child likes for noon meal
63
Managing Poor Growth
Drug holidays
64
Managing Dizziness
Monitor BP & HR | Adequate fluid intake
65
Managing Insomnia or Nightmares
Bedtime routine Good sleepy hygiene habits Omit/reduce last dose of day Consider short acting vs. long acting
66
Managing Mood Lability
Convert to long acting formulation or BID to TID | Mood changes at peak concentration
67
Symptoms of Mood Lability
Sadness Irritability Increased activity
68
Controlling Mood Changes at Peak Concentration
Reduce dose | Switch to long acting
69
Managing Rebound
Stepping down dose at end of day
70
Managing Tics
Drug trial at different doses to see if related to med
71
Managing Psychosis
Verify dose is appropriate Verify medication administered as prescribed Refer to mental health specialist
72
Symptoms of Psychosis with ADHD Medications
Suicidality Hallucinations Increased aggression
73
Management of Diversion & Misuse
Monitor symptoms & prescription refills Long acting less potential for abuse Keep track of prescription dates Open discussion
74
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 ```
75
When are drug holidays permissible?
Weekends Summers ONLY FOR STIMULANTS
76
Maintenance of ADHD Therapy
Follow up every 3-6 months | Monitor height, weight, BP, HR
77
Termination of ADHD Therapy
Stimulants or atomoxetine can be abruptly | Alpha-2-adrenergics & TCAs should be tapered
78
Ritalin (Methylphenidate)
Short & Long acting agents | Blocks dopamine & norepinephrine re-uptake
79
Short Acting Ritalin (Methylphenidate)
Ritalin | Methylin
80
Long Acting Ritalin (Methylphenidate)
Metadate ER Methylin ER Ritalin SR
81
Longer Acting Ritalin (Methylphenidate)
Focalin XR Metadate CD Ritalin LA
82
Longest Acting Ritalin (Methylphenidate)
Concerta Quillivan XR Daytrana
83
SE of Ritalin (Methylphenidate)
``` Anxiety Weight loss Psychosis Aggression Hallucinations Sudden cardiac death in at risk people Easy bruising Schedule II ```
84
Amphetamine-dextromphetamine (Adderall)
Schedule II Popular Slightly more effective than Ritalin
85
SE of amphetamine-dextroamphetmine (Adderall)
``` Anxiety Weight loss Psychosis Hallucinations Aggression Sudden cardiac death in at risk people ```
86
Dextroamphetamine (Dexedrine)
Among most effective treatment for ADHD Schedule II Sudden cardiac death in at risk people
87
Heart Related Problems with Dextroamphetamine (Dexedrine)
Sudden death in people with heart problems or defects Sudden death, stroke & MI in adults Increased BP & HR
88
Psychiatric Problems in Dextroamphetamine (Dexedrine)
New/worse behavior & thought problems | New/worse bipolar
89
Children/Teenager Problems in Dextroamphetamine (Dexedrine)
Seeing things Hearing voices Believing things that aren't true New manic symptoms
90
Lixdexamphetmaine (Vyvanase)
Less addictive but still Schedule II
91
Atomoxetine (Strattera)
Works on norepinephrine Black box warning: increased risk of suicidal behavior Less effective than stimulants Expensive
92
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 ```
93
Alpha-2-adrenergic Agonist
ER Guanfacine (Intuniv)
94
SE for ER Guanfacine (Intuniv)
``` Fast/slow HR Pounding heartbeat, chest tightness Numbness/tingling High rate of fainting Depression Hypotension ```
95
When should you caution use of guanfacine (Intuniv)
Kidney or liver disease
96
Alternative Treatment for ADHD
Buproprion (Wellbutrin)
97
SE of Bupropion (Wellbutrin)
Anxiety | Insomnia

Behavioral Health (25 decks)

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