ADHD Flashcards
1
Q
Associated adverse outcomes of ADHD :
A
- educational problems (low rates of high school graduation and completion of postsecondary education)
- difficult peer relationships
- increased MVAs
- accidental injuries
- substances misuse
- third most common mental health disorder (after depression & anxiety) - affects 3.4%
2
Q
Predictors of persistence of ADHD:
A
- combined inattention/hyperactivity
* increased symptom severity
* comorbid depression or mood disorder
* high comorbidity (>3 additional DSM disorders)
* parental anxiety
* parental antisocial personality disorders - 50% continue to have symptoms in adolescence and adulthood.
3
Q
Etiology of ADHD?
A
- highly heritable
- rare copy number variants or accumulation of larger deletions & duplications influencing gene transcription are more commonly found in individuals with ADHD
- risk with:
- in utero exposure to alcohol or tobacco
- low birth weight (<2500g)
- hypoxic-anoxic brain injury
- epilepsy disorders (2-3 times higher than in general population)
- TBI
- genetic conditions (fragile X syndrome, turner syndrome, tuberous sclerosis, neurofibromatosis, 22q11 deletion syndrome)
- linked to environmental toxins (lead, organophosphate pesticides, polychlorinated biphenyls)
- delayed cortical maturation
4
Q
What investigations to order for ADHD?
A
- unless indicated by history and physical exam, do NOT:
* order lab tests, genetic testing, EEG, neuroimaging
* order psychological, neuropschological or speech-language assessments
* use psychological tests as means to monitor symptom or functional improvement in dailty activities
5
Q
Differential diagnosis of ADHD
A
- learning disorder
- sleep disorder
- oppositional defiant disorder
- anxiety disorder
- intellectual disability
- language disorder, mood disorder, tic disorder, conduct disorder
- autism spectrum disorder
- developmental coordination disorder
6
Q
Comorbid disorders for ADHD?
A
- specific learning disorder *** most common comorbid condition
- Disruptive behaviour disorder - ODD & CD. Prevalence as high as 90%
- Anxiety disorder/obsessive compulsive disorder
- anxiety disorders occur in 30% of patients with ADHD
- Mood disorder (including bipolar disorder)
- substance use disorders
- tic disorders
- developmental coordination disorder
- autism spectrum disorder
- eating disorders
7
Q
Nonpharmacological interventions for ADHD
A
- psychoeducation
- shared decision-making
- parents focused on academic achievement more likely to start medication
- parents focused on behaviour more likely to start behavioural therapy
- Parent behaviour training - first choice intervention in preschool age children
- classroom management
- daily report card
- behavioural peer interventions
- social skills training
- organizational skills training
- cognitive training
- EEG neurofeedback
- Diet - supplementation with free fatty acids, eliminate artificial food dyes - evaluate for suspected deficiencies
- exercise
8
Q
Treatment for children with ADHD <6 years ?
A
- first-line intervention is parent behaviour training
* medications should be considered for >=6 yrs
9
Q
Benefits of Stimulant medications in ADHD
A
- improved academic achievement
- lower rates of comorbid anxiety and depression
- better employment outcomes
- reduced morbidity and mortality
- improves parent-reported quality of life
10
Q
What is first line stimulant therapy for ADHD?
A
- recommendation 2: Medication use should be reserved for children diagnosed with ADHD whose academic performance or social interactions are impaired
- In combination with nonpharmacological interventions, ER stimulants are recommended as first-line therapy
- ER medications less likely to be diverted for recreational use (difficult to crush)
- give at breakfast time. Aim to “wear off” to avoid dinnertime suppression and sleep problems
- titrate to lowest effective dose
- No drug holidays for kids who are at risk of poor outcomes and risky behaviours
11
Q
What is tachyphylaxis (for stimulant meds)?
A
- tachyphylaxis - dosing requirements may be increased initially because of up-regulation of liver enzymes
12
Q
What are adverse effects of stimulants?
A
- Preschool children have higher rates of AE , especially irritability and moodiness
- Raynaud’s - stimulants and nonstimulants
- Psychosis
- Priapism
- Increase in HR & BP (slight)
- growth (decrease by 2.5 cm) - final height associated with cumulative dose of stimulants
- Appetite - slight overall reduction in BMI, may delay pubertal growth-spurt timing
NOTE: tic disorder - overall risk for tic disorder not increased. comorbid tic disorder is not a contraindication for ADHD treatment
13
Q
Indications for non-stimulants in aDHD
A
Use when stimulants are:
* contraindicated * ineffective * or not tolerated
low potential for diversion (lack a mechanism linked to abuse potential and immediacy of effect)
Atomoxetine (approved for 6-17 years)
* lower risk for weight loss and exacerbating tics * reported to improve anxiety * little evidence for using stimulant and atomoxetine adjunctively
Guanfacine chlorohydrate (approved for 6-17 years)
* utility as monotherapy or adjunctively for both ADHD and comorbid oppositional symptoms
Clonidine (nonselective alpha adrenergic agonist) - not approved for use
14
Q
What to treat ADHD with if hx of substance abuse disorder?
A
nonstimulant or ER stimulant medication with lower risk for abuse and diversion
15
Q
Adverse effects of atomoxetine
A
- GI symptoms (appetite loss, upper abdo pain)
- somnolence, headaches, moodiness, irritability
- hepatic disorders (rare)
- suicide related events (rare)
- metabolized by CYP2D6 - long half life
Raynaud’s phenomenon
