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PH3113 > ADHD (DONE) > Flashcards

ADHD (DONE) Flashcards

1
Q

ADHD overview

A

Prevalent debilitating disorder
Persistent developmentally, inappropriate levels of overactivity, inattention or impulsivity
No biomedical test
Diagnosis based on observation on behavioural symptoms
9 symptoms across 2 domains
Can be combined type or dominant in one or other form

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2
Q

ADHD- predominantly inattentive type

A 
Fails to give close attention
Does not appear to listen
Struggles to follow instruction
Difficulty with organization
Loses things
Easily distracted
Forgetful in daily activities
Avoids tasks requiring sustained mental effort
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3
Q

ADHD- predominantly hyperactive/impulsive type

A 
Fidgets or squirms in chair
Difficulty remaining seated
Runs about or climbs excessively
Difficulty engaging in activities quietly
Talks excessively
Blurts out answers
Difficulty waiting
Interrupts or intrudes
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4
Q

ADHD- combined type

A

Individual meets both sets of inattention and hyperactive/impulsive criteria

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5
Q

ADHD differential diagnosis

A 
Sensory impairment
Epilepsy and related states
Effects of head injury
Acute or chronic medical illness
Poor nutrition
Sleep disorders
Side effects of medication
School or classroom difficulties
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6
Q

ADHD potential causes

A 
Genetics- inherited polymorphisms
Bad parenting
Broken homes- cause or effect
Alcohol and tobacco exposure
Low birthweight
Poor diet
Childhood illness
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7
Q

ADHD genetics

A

5 times increased risk to members of the family
More likely in identical twins
Greater risk of inheritance through males
Multiple genes involves
Gene for dopamine D4 implicated

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8
Q

Neuropathology

A

Reduced brain size
Reduced size of particular nuceli- striatum, prefrontal cortex white matter, corpus callosum
DrD4 associated with reduced cortical thickening, resolved in adolescence

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9
Q

Neurophysiology

A

EEG studies show reduced response to stimuli and immature patterns of activity
Blood flow studies how reduced flow in areas of caudate nucleus, striatum and frontal areas

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10
Q

Neurochemistry

A

Dopamine- affected by psychostimulants

Noradrenaline- affected by psychostimulants; reduced metabolites in the urine of children with ADHD

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11
Q

ADHD educational difficulties

A 
90% under-productive with school work
90% underachieve
20% reading difficulties
60% serious handwriting difficulties
30% drop out of school
Only 5% complete further education
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12
Q

ADGD Psychosocial factors

A

Parenting more of a challenge
Importance of good parenting crucial
Effects on attachment relationship

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13
Q

ADHD interventions

A

Psychological treatments
Medical treatments- reserved for severely affected
Educational interventions
Social interventions

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14
Q

Treating ADHD- NICE guidance

A

In all preschool and school-age children and young people with mild to moderate ADHD, drug treatment should not be first line
Parent training/education programmes first line- group based/individual
Drug treatment reserved for severe ADHD in school age children and young people- part of comprehensive treatment plan with psychological, behavioural and educational interventions

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15
Q

Pharmacotherapy for ADHD

A

Amphetamine and methylphenidate proven as best therapy
If refractory to one, the other generally works
Most effective drugs: enhance DA and NA function, rapid onset of action with no ceiling effect, increase in DA efflux not limited to cortex

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16
Q

Choice of drug treatment

A

Methylphenidate- generally first choice
Atomoxetine- if other tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
Dexamphetamine- only if other drugs ineffective at raised doses

17
Q

Decide which drug treatment to use based on:

A 
Comorbidities
Different adverse effects
Potential problems with compliance
Potential for drug diversion and misuse
Preferences of the child or young person and their parent or carer
18
Q

Methylphenidate

A 
Stimulant- CD 2
Dopamine reuptake inhibitor
VMAT2 inhibitor
Ritalin- immediate release
Concerta XL- once daily
Daytrana- transdermal patch
19
Q

Atomoxetine

A

Non-stimulant- POM
Noradrenaline reuptake inhibitor
Increases NA, DA and 5-HT levels in PFC
e.g. Strattera

20
Q

Dexamphetamine

A

Dopamine reuptake inhibitor, catecholamine releasing agent
Actively transported into cells, competitively inhibits DAT
Inhibitors of VMAT2
Vesicular pools displaced and NA/DA released
Inhibitors of MAO
CD2

21
Q

A2 agonists

A

Clonidine and guanfacine- POM
Used off label for many years, esp. if tics present
Guanfacine clear effects in clinical trials
Thought to modulate noradrenergic tone in the PFC

22
Q

Other non-licensed medications

A

Bupropion- weak dopamine reuptake inhibitor, used off label, moderate efficacy
Modafinil- licensed for treatment of narcolepsy, weak DA reuptake inhibitor, no SERT or NET activity, withdrawn for use in children despite significant activity die to side effects

23
Q

Atomoxetine monitoring

A

Closely observe children or young people for agitation, irritability, suicidal thinking and self harming behaviour, particularly during the initial months of treatment or after a dose change
Liver damage in rare cases

24
Q

Treatment of adults

A

Methylphenidate normally first line treatment
Consider atomoxetine or dexamphetamine if symptoms do not respond to methylphenidate or the person is intolerant after 6 weeks

25
Q

Selection of appropriate medications

A

Immediate release preparations if more flexible dosing is required or during initial titration
If there is a choice of more than one drug, use the drug of lowest overall cost

26
Q

Advantages of modified release preparations for ADHD

A

PK profile
Improved adherence
Reduced stigma (drug does not need to be taken at school)
Reduced problems of storing and administering CDs in school
Abuse liability

27
Q

ADHD and addiction

A

Consider atomoxetine as first line treatment if there are concerns about drug misuse and diversion
Caution if prescribing dexamphetamine to people at risk of stimulant misuse or diversion

28
Q

NICE guidance on drug choice

A

Methylphenidate for ADHD without significant comorbidity
Methylphenidate for ADHD with comorbid conduct disorder
Methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion present
Atomoxetine if methylphenidate has been tried and has been ineffective at the max dose, or the child intolerant to low or moderate doses of methylphenidate

29
Q

ADHD major areas affected

A

Vigilance- attention
Cognitive control- executive function, working memory, response inhibition
Motivation- processing reward, timing of reward

PH3113 (30 decks)

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