Attention Deficit Hyperactivity Disorder (ADHD) Flashcards
1
Q
What is ADHD?
A
- A neurodevelopmental disorder in which symptoms of inattention and/or hyperactivity/impulsivity significantly interfere with daily functioning.
- Causes include genetic and environmental
- 57% chance child of adult with ADHD will have it
- Generally improves with age (especially overactivity) but 2/3 still have symptoms in adulthood and 1/6 retain diagnosis
2
Q
Developmental impact of ADHD
A
- Key features:
- Behavioural disturbance
- Academic impairment
- Occupational difficulties
- Smoking/alcohol/drug abuse
3
Q
Presentation of ADHD in adults
A
- Chaotic
- Disorganised
- Always late
- Losing things
- Starts a lot, finishes little
- Multiple jobs & relationships
- Careless mistakes
- Avoid books/films/queues
- Others organise life
- Restless
- Fidgeting
- Can’t relax or switch off
- Rude
- Can’t wait
- Impatient
- Conflicts at work
- Lose train of thought
- Forget question
- Unthinking breaching of ‘rules’
4
Q
Diagnostic assessment of ADHD
A
- 2-3 sessions
- Detailed psychiatric and developmental assessment
- Collateral Hx to triangulate - school, parents etc
- Diagnostic criteria
- Neuropsychiatric assessment optional
- National Audit Reading Test - premorbid IQ
- Rey AVLT, Trail Making, Stroop
5
Q
Inattentive symptoms in ADHD (remember DADMOMLFC)
A
- Difficulty sustaining attention
- Avoids sustaining attention
- Distracted easily
- Misplaces things
- Organisation problems
- Mistakes made
- Listening difficult
- Forgetful in daily activities
- Completing tasks or jobs
6
Q
Hyperactivity/Impulsive sympsoms (remember LFROST/WIB)
A
- Loud in quiet situations
- Fidgetiness
- Restless or overactive
- On the go all the time
- Seating difficult
- Talks excessively
- Waiting difficult
- Interrupts or intrudes
- Blurts out prematurely
7
Q
DSM-V Criteria for ADHD
A
- •ADHD – inattentive, hyperactive or combined sub-types
- ≥5 Sx of inattention, and/or ≥5 Sx hyperactivity/impulsivity
- Started before age 12
- Present ≥ 6/12
- Affecting ≥ 2 settings
- Significant impairment in functioning
- Symptoms not due to another cause
8
Q
ICD-10 Criteria of ADHD
A
- Hyperkinetic Disorder
- ≥6 Sx of inattention
- ≥3 Sx of hyperactivity
- ≥1 Sx of impulsivity
- Started before age 7
- Present ≥ 6/12
- Affecting ≥ 2 settings
- Significant impairment in functioning
- Symptoms not due to another cause
9
Q
Differentials in ADHD
A
- Normal behaviour
- Malingering (seeking stimulant medication - mainly students)
- Hyperthyroidism
- Substance abuse
- Mania
- Agitated depression
- Anxiety disorders
- EUPD
- ASPD
- LD
- ASD
- Tourette’s syndrome
10
Q
Post diagnosis management
A
- Responsibility
- Delineate ADHD symptoms from comorbidities and normal behaviour
- Inform employers/university/school/DVLA/car insurers
- Support groups
- NHS - psychiatry, OT
11
Q
Medical management of ADHD
A
- ADHD treatments increase neurotransmission of dopamine and/or noradrenaline
- 1st line - stimulants (immediat action, positive affect on attention in those without ADHD, more potential for diversion, controlled drugs)
- 2nd line - non-stimulants (delayed onset, no positive affect on attention in those without ADHD, preferable if concern about diversion, not-controlled drugs)
12
Q
Methylphenidate (stimulant)
A
- DA and NA reuptake inhibitor
- Immediate release preparations (Ritalin/Medikinet, cheaper and allows more fine tuning of dosing)
- Slow release preparations (Concerta, Medikinet XL, Equasym XL, allow once daily AM dosing)
- Both can be combined to fine tune symptom control at certain times of day e.g. immediate release prep added in evening when studying
- Dose titration (use either slow release or immediate release)
- Increment - smallest available
- Interval - at least 2 weekly
- Until - adequate response or intolerable side effects or ↑BP ↑HR
- Side effects include reduced appetite, insomnia, headache, irritability, ↑HR, tics, seizures
13
Q
Dexamfetamine (stimulant)
A
- Similar efficacy to Methylphenidate
- DA and NA releaser and reuptake inhibitor
- Considered to have more abuse/diversion potential than Methylphenidate
- Immediate release (Dexamfetamine)
- Slow release (Lisdexamfetramine [Elvanse])
14
Q
Atomoxetine (non-stimulant)
A
- NARI (analogous to Reboxetine)
- Preparations include Strattera
- Useful when stimulant not tolerated or risk of diversion
- Delayed onset of action - several weeks
- Some individuals are poor metabolisers of Atomoxetine (sensitive to side effects at low doses)
- Acute liver failure and suicidality are rare but significant potential side effects
- Does not require the same individualised fine tuning of dose that stimulants require
- Side effects are usually avoided by a gradual dose titration (reduced appetite, nausea, insomnia, dizziness, constipation, sweating, sexual dysfunction, seizures)
- Contraindicated in phaeochromocytoma
- Doses beyond 80mg have not shown any additional benefit
15
Q
Other therapeutic options
A
- Guanfacine/Clonidine (alpha agonists)
- Bupropion (Zyban) - DA and NA reuptake inhibitor
- Modafinil (Provigil) - NA reuptake inhibitor
- Nortriptyline or Desipramine - potent inhibitors of NA reuptake
16
Q
Assessing response
A
- Core symptoms
- Associated symptoms (mood instability, ceasless mental activity)
- Functioning
- Patient report/collateral
- Scales - WFIRS
- 6-monthly BP/HR
- Drug holidays
- Consider annually
- Assess whether ‘grown out’ of ADHD
- Gradual withdrawal with nonstimulants, rapid with stimulants
17
Q
Prescribing when co-morbidity present
A
- Psychosis - non-stimulant preferable, antipsychotic cover
- Depression – careful with side effects if already on antidepressant with NA effect
- Mania - mood stabiliser/antipsychotic cover
- Anxiety - stimulants may exacerbate, atomoxetine preferable
- Addiction – depends on substance, 6/12 abstinence
- Tourette’s syndrome – stimulants make tics worse
18
Q
Non-pharmacological management
A
- Behavioural parent training
- Individualised school intervention programmes including behavioural and educational interventions
- Good nutrition (balanced diet)
- Exercise
