ADHD Flashcards
Associated adverse outcomes of ADHD :
- 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%
Predictors of persistence of ADHD:
- 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.
Etiology of ADHD?
- 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
What investigations to order for ADHD?
- 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
Differential diagnosis of ADHD
- 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
Comorbid disorders for ADHD?
- 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
Nonpharmacological interventions for ADHD
- 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
Treatment for children with ADHD <6 years ?
- first-line intervention is parent behaviour training
* medications should be considered for >=6 yrs
Benefits of Stimulant medications in ADHD
- improved academic achievement
- lower rates of comorbid anxiety and depression
- better employment outcomes
- reduced morbidity and mortality
- improves parent-reported quality of life
What is first line stimulant therapy for ADHD?
- 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
What is tachyphylaxis (for stimulant meds)?
- tachyphylaxis - dosing requirements may be increased initially because of up-regulation of liver enzymes
What are adverse effects of stimulants?
- 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
Indications for non-stimulants in aDHD
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
What to treat ADHD with if hx of substance abuse disorder?
nonstimulant or ER stimulant medication with lower risk for abuse and diversion
Adverse effects of atomoxetine
- 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
Adverse effects of guanfacine
- wean to prevent rebound hypertension, tachycardia, hypertensive encephalopathy
- sedation
- somnolence
- fatigue
- orthostatic hypotension, bradycardia, syncopal episodes
- Raynaud’s phenomenon
- prolongation of QTc
Recommendation 11: monitor blood pressure in patients on alpha-adrenergic drugs (guanfacine and clonidine) before initiating treatment, following dose increases and periodically
Adverse effects of clonidine
- wean to prevent rebound hypertension, tachycardia, hypertensive encephalopathy
- sedation, dizziness, hypotension
- prolongation of QTc
Recommendation 11: monitor blood pressure in patients on alpha-adrenergic drugs (guanfacine and clonidine) before initiating treatment, following dose increases and periodically
What conditions have both ADHD and ASD?
Management?
Fragile X syndrome, tuberous sclerosis, Williams syndrome, 22q11 deletion
Management
- first-line: psychostimulants - same treatment algorithm as for ADHD alone
- more likely to be nonresponders and to have side effects
- SE: irritability with emotional outbursts, increased stereotypic behaviours
- limited studies suggest atomoxetine improves ADHD symptoms in ASD+ADHD patients
- children with ASD benefit from early intense behavioural interventions
What % of kids with ASD have ADHD?
What % of kids with ADHD have ASD?
- more than 50% of individuals with ASD meet criteria for ADHD
- up to 50% of children with ADHD have ASD traits
What are other conditions associated with intellectual disability?
at least 50% of ID cases are associated with:
- chromosomal (Fragile X, Klinefelter, Turner syndrome)
- metabolic (aminoacidemias, PKU, galactosemia) or
- neurological conditions (neurofibromatosis, tuberous sclerosis, myotonic dystrophy)
What is the most common comorbid condition with ADHD?
Specific learning disorder
- 1/3 of children with ADHD also have LD
What conditions show a higher prevalence of ADHD?
fragile X syndrome turner syndrome tuberous sclerosis neurofibromatosis 22q11 deletion syndrome
What do you do before establishing a diagnosis of ADHD & initiating treatment for preschoolers?
AAP recommends parents enrol in a parent training program before being referred for ADHD assessment
What are diet modifications that can be suggested in kids with ADHD?
supplementation with free fatty acids, eliminate artificial food dyes - evaluate for suspected deficiencies
What are lower medication adherence associations for kids being treated with ADHD?
- older age
- learning, mood or behavioural comorbidity
- dosing that is too low for too long
- high doses and AE
What is the most common neurodevelopmental disorder comorbid with ID?
ADHD
What adverse effects are kids with ID & ADHD at risk for when they take stimulants?
higher risk for tics and social withdrawal
IQ > 50 predicts better response to stimulants
What is the management for kids with ID & ADHD?
- Psychopharmacology
- Stimulants: short-acting methylphenidate (studied in RCTs) - below response rate of ADHD alone
- IQ above 50 predicts better response to stimulants; low IQ predicts poor response
- higher risk for tics and social withdrawal
- Nonstimulants: when psychostimulants and psychotherapy suboptimal
- Risperidone
- Stimulants: short-acting methylphenidate (studied in RCTs) - below response rate of ADHD alone
What is the criteria for ADHD?
- Persistent pattern of inattention and/or hyperactivity-impulsivity.
INATTENTION (6 or more of):
- fails to give close attention to details
- difficulty sustaining attention in tasks or play activities
- avoids or dislikes tasks requiring sustained mental effort
- doesn’t seem to listen
- distracted easily
- doesn’t follow through on instructions
- forgetful in daily activities
- difficulty organizing tasks and activities
- loses things
HYPERACTIVITY (6 ore more of):
- fidgets
- leaves seat
- runs about or climbs
- unable to play or engage in leisure activities quietly
- blurts out an answer before question completed
- can’t wait turn
- often interrupt or intrudes on others
- talks excessively
- “on the go” as if “driven by a motor”
- Symptoms present prior to 12 yrs
- 2 or more settings
- Interfere with functioning
