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1. Child and Adolescent Psychiatry > Neurodev. D/Os-General + CADDRA ADHD Guidelines > Flashcards

Neurodev. D/Os-General + CADDRA ADHD Guidelines Flashcards

1
Q

What are the neurodevelopmental disorders

A

a group of conditions with onset in the developmental period

characterized by developmental deficits that produce impairments of personal, social, academic or occupational functioning

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2
Q

When do most neurodevelopmental disorders manifest

A

typically in early development, often before a child enters grade school

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3
Q

when do you use “other specified neurodevelopmental disorder”

A

i.e “neurodevelopmental disorder associated with prenatal alcohol exposure”

*when doesnt meet criteria for the other DSM neurodevel disorders but you want to specify the specific reason

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4
Q

when do you use “unspecified neurodevelopmental disorder”

A

when you choose not to specify reason criteria are not met for another neurodevelop disorder

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5
Q

what is “global developmental delay”

A

a diagnosis for individuals UNDER AGE OF 5

used when clinical severity level cannot be reliably assessed during early childhood

given when child fails to meet expected developmental milestones in SEVERAL areas of intellectual functioning

applies to individuals who are unale to undergo systematic assessments of intellectual functioning (including children who are too young to participate in standardized testing)

requires reassessment after a period of time

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6
Q

what % of people with dx of ADHD at kids continue to have impairing symptoms as adults

A

over 50%

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7
Q

what is the prevalence of ADHD in kids and teens

A

5-9%

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8
Q

have prevalence rates of ADHD gone up

A

stable x 30 years per guidelines

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9
Q

what is a mnemonic for ADHD inattention symptoms

A

OLD SaD FAIL

difficulty Organizing tasks
doesnt seem to Listen
Distracted easily

difficulty Sustaining-attention
not attentive to Details

Forgetful in daily activities
Avoids/dislikes tasks requiring sustained mental effort
does not follow through on Instructions, does not finish work
Loses necessary things

(also CALL FOR FRED from other notes)

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10
Q

list 3 neuropsychological/psychoeducational evaluation tools that may be helpful in assessing ADHD

A

Wide Range Assessment of Learning and Memory

California Verbal Learning Test

Wisconsin Card Sort Test

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11
Q

list 3 computerized cognitive assessments that were specifically designed to assess attention and response inhibition, and can be useful in assessing ADHD

A

Conners Continuous Performance Test

Test of Variables of Attention

Gordon Diagnostic System

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12
Q

is EEG a validated diagnostic tool for ADHD

A

no

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13
Q

what differences might be seen on EEG in kids with ADHD vs teens/adults

A

increased theta waves

decreased alpha/beta waves

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14
Q

what model of care should be followed with ADHD

A

chronic disease management model

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15
Q

what questionnaire should be given to parents/teachers for ADHD assessment of a child

A

SNAP-IV

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16
Q

what is a tool to assess functional impact of a mentalhealth concern

A

Weiss Functional Impairment Rating Scale

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17
Q

What are the 3 most common comorbidities with ADHD in CHILDHOOD

A

ODD, learning disabilties (often language), anxiety–> early childhood

anxiety and tic disorders more prominent in middle childhood

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18
Q

What are the 3 most common comorbidities with ADHD in TEENS

A

learning disabilities

mood disorders

SUDs

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19
Q

if someone has a developmental or intellectual disability, or borderline IQ, how much more likely are they do have ADHD than the general pop

A

about 2-3x more likely

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20
Q

What are the most common comorbidities with ADHD in ADULTHOOD

A

anxiety, depression, SUD, borderline PD

(+ learning disability still)

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21
Q

list common medical conditions wiht overlap with ADHD

A

hearing/vision impairment

thyroid function

hypoglycemia

severe anemia

lead poisoning

sleep disorders

FASD

neurofibromatosis

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22
Q

list 2 medications with psychomotor side effects that may resemble or worsen ADHD

A

mood stabilizers (cognitive dulling)

decongestants, beta agonists (psychomotor agitation)

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23
Q

do most people with ADHD need labs

A

no

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24
Q

what factor confers worse prognosis for comorbid CD and ADHD

A

if onset of CD is before age 10

CD + ADHD has poorer outcome than ADHD or CD alone

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25
Q

what is a treatable risk factor for ASPD

A

ADHD

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26
Q

what is the prevalence of borderline personality disorder in ADHD

A

34%

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27
Q

what is the most common shared trait between ADHD and borderline PD

A

impulsivity

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28
Q

is there any evidence that improvement of ADHD leads to improvement of borderline PD

A

no

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29
Q

what are the main goals of treatment in comorbid ADHD and borderline PD

A

stabilizing impulsive behaviours

optimizing emotional regulation

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30
Q

what are the principles of management of ADHD + addictions

A

specific intervention for addictive behaviour + specific intervention for ADHD

ideally CONCURRENTLY

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31
Q

do people with ADHD have higher risk for substance abuse/misuse

A

yes–> about 2x risk

?underlying poor self esteem + impulsivity

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32
Q

what % of teens with SUD have ADHD

A

50%

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33
Q

what % of adults with SUD have ADHD

A

about 25%

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34
Q

what is the most commonly abused agent in ADHD

A

cannabis

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35
Q

why do we care about substance use problems in ADHD

A

can increase severity of ADHD sx

can also mimic ADHD

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36
Q

why might early stimulant treatment for ADHD be important

A

reduces or delays SUD–> protective effect may be lost in adulthood

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37
Q

is cannabis effective for ADHD

A

no evidence for this

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38
Q

which class of stimulant has lower abuse potential

A

methylphenidate

–> slower dissociation from site of action

–> slower uptake into the striatum

–> slower binding/dissociation with DAT (vs cocaine)

–> oral admin, decreases likability of a substance

–> not associated with euphoria if used parenterally

*also long acting meds have less abuse liability

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39
Q

what % if kids have ADHD + anxiety? adults?

A

children–> 33%
adults–> 50%

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40
Q

how do you approach treating anxiety + ADHD

A

treat most impairing condition first

psychostimulant may increase anxiety–> slower titration

if anxiety too intense, reduce or withdraw psychostimulant and treat anxiety until stable then retrial stimulant

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41
Q

what ADHD stimulants can be used in the case of comorbid anxiety

A

any of them

atomoxetine is also beneficial and guanfacine is well tolerate

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42
Q

what antidepressants may be preferentially considered if treating comorbid depression and ADHD

A

those with catecholamine activity–> i.e BUPROPRION

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43
Q

is the combo of SSRI + stimulants safe

A

yes

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44
Q

what ADHD meds have most risk of drug interactions with which SSRIs

A

atomoxetine + amphetamines

interact with

fluoxetine, paroxetine

due to 2D6

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45
Q

how should you approach treatment of comorbid ADHD + bipolar disorder

A

treat BIPOLAR FIRST
–reduce or stop stimulants in order to most effectively treat bipolar

then once mood stabilized, can cautiously restart stimulants

small risk of switch with psychostimulants

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46
Q

are stimulants safe in bipolar + ADHD

A

yes, once bipolar stabilized

safe + effective

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47
Q

is there worsening of OCD with stimulants

A

no

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48
Q

does the presence of OCD + ADHD change treatment approach either condition

A

no

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49
Q

are stimulants safe in comorbid ADHD + tics

A

yes generally–monitor for worsening tics

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50
Q

what treatment “shows promise” in treating comorbid tics + ADHD

A

alpha 2 adrenergic agonists (clonidine, guanfacine)

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51
Q

what medication to use if stimulants exacerbate tics

A

atomoxetine

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52
Q

name 2 non pharmacological treatments for tics

A

habit reversal therapy

CBIT (comprehension behavioural intervention for tics)

*considered first line when available

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53
Q

ADHD increases the risk of what eating disorder

A

bulimia nervosa–> especially in girls

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54
Q

what % of kids with autism are suggested to have ADHD

A

about 30-70% are suggested to meet ADHD criteria

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55
Q

what are some medication considerations in treating ADHD in those with ASD

A
  1. may be MORE sensitive to side effects
    –irritability, hyper focus, stereotypies
  2. lower response rate to methylphenidate if have ASD (50% vs 70-80%)

however–> treating ADHD in ASD is very effective and helps functioning but may have lower effect sizes

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56
Q

is epilepsy more common amongst those with ADHD vs general population

A

yes

57
Q

is there evidence that psychostimulants worsen seizures if stable

A

no

58
Q

lesions in what brain areas may lead to secondary ADHD

A

right putamen

thalamus

orbitofrontal gyrus

59
Q

what differences in sleep are seen in those with ADHD

A

more restless sleep than peers

may be differences in circadian rhythms

NO consistent differences in sleep variables like duration or architecture

stimulants can give shorter nights sleep

60
Q

how do you treat sleep problems in ADHD

A

behavioural sleep interventions = first line

little evidence for pharma tx of sleep problems in ADHD–> maybe melatonin

61
Q

is enuresis more common in kids with ADHD

A

yes–> 2-3x more likely to have eneuresis

kids with nocturnal eneuresis more likely to have ADHD

62
Q

what is the first line treatment for PRESCHOOL ADHD (age 3-5)

A

NON pharmacological treatment

63
Q

when are most children diagnosed with ADHD

A

school age

64
Q

what type of accident is more likely to happen if someone has ADHD

A

MVAs–> 2-4x increase risk

65
Q

what psychosocial treatments are available for ADHD

A

CBT for ADHD

behavioural interventions

parent training

cognitive training

social skills training

66
Q

what is the overall goal of psychosocial treatments for ADHD

A

educate and empower patients

67
Q

per cochrane review, were there significant tx effects of social skills training on behaviour or symptoms of ADHD

A

no

68
Q

what are the two focuses of CBT for ADHD

A

time management

organizational skills

69
Q

who is CBT for ADHD effective for

A

effective for adults with ADHD–> functional effect on brain similar to stimulant meds

mixed results in kids and teens –> works better in those with ADHD + anx/dep vs those with ADHD + ODD

70
Q

which areas of the brain show functional improvements after CBT for ADHD in adults

A

fronto-parietal network

cerebellum

71
Q

what changes are seen in the brain of adults with ADHD after undergoing cognitive based therapy that includes mindful meditation

A

structural changes in amygdala

increased grey matter volume in hippocampus

72
Q

what are the impacts of cognitive based therapy with mindfulness meditation in those with ADHD

A

reduces hyperactivity, impulsivity, inattention

increases self regulation and self directedness

** improvements are maintained over time

73
Q

what is FIRST LINE pharmacotherapy for ADHD

A

LONG ACTING stimulants

74
Q

why are long acting stimulants first line for ADHD

A

–> augments compliance, symptom coverage and tx response
–> less risk for diversion and rebound sx vs immediate release
–> often better tolerated

75
Q

when should you consider trialling a second line med in ADHD

A

recommend trying long acting methylphenidate AND amphetamine formulations before moving to a second line agent

move to second line if suboptimal response, side effects or no access to first line

76
Q

list the second line med agents for ADHD

A
  1. atomoxetine
  2. guanfacine XR
  3. shorter acting psychostimulants
77
Q

what is one option for treatment if there is suboptimal response to first line long acting stimulants

A

can augment with non-stimulant second line meds

78
Q

list the third line medication treatments for ADHD

A

buproprion

clonidine

imipramine

modafinil

AAPs

–> can also consider exceeding recommended maximum doses for other meds

79
Q

when might you use a third line med for ADHD

A

treatment resistant cases

they are all off label use–> may have higher risk, more SEs, lower efficacy

80
Q

list the specific medications (not just class) that are first line for ADHD

A

vyvanse/lisdexamfetamine (amphetamine)

adderall XR/mixed amphetamine

biphentin/multilayer methylphenidate beads

concerta/methylphenidate OROS

foquest/methylphenidate

81
Q

list the specific second line meds (not just class) for ADHD

A

atomoxetine –NRI

guanfacine –alpha 2 agonist (selective)

dexedrine (dextroamphetamine) –short acting

ritalin (methylphenidate) –short acting

82
Q

what ADHD meds cannot be stopped suddenly

A

the alpha 2 agonists due to risks of rebound HTN–> i.e clonidine, guanfacine

83
Q

ADHD meds can affect what cardiovascular factors

A

BP, HR

84
Q

when should you do a cardia workup before initiating ADHD pharmacological therapy

A

history of suspected sudden cardiac death in family

if patient has hx of unexplained lightheadedness, SOB, cardiac sx

should NOT be used if there are structural cardiac abnormalities (i.e LV dysfunction, scarring, hypertrophy, valvular disease)

85
Q

is routine ECG monitoring recommended in ADHD med management

A

NO

only do if there are identifiable risk factors for cardiac disease i.e abnormal exam, personal hx, family hx

86
Q

can you use psychostimulants if patients has long QT syndrome

A

one study showed no adverse outcomes with stimulants or beta blockers

suggest cardiology constult

87
Q

can you use psychostimulants if patients has HTN or CAD

A

caution is advised –> monitor BP and HR

88
Q

what should you monitor for when prescribing psychostimulants

A

BP

HR

priapism

growth retardation

peripheral vasculopathy

89
Q

what are CONTRAindications to using stimulant medications

A
  1. treatment with MAOI and up to 14 days after d/c
  2. hx mania/psychosis
  3. mod-severe HTN
  4. symptomatic CVD
  5. pheochromocytoma
  6. untreated hyperthyroidism
  7. narrow angle glaucoma
90
Q

in which patients should you be cautious and take precautions when prescribing psychostimulants

A

anxiety

hx substance abuse

tic disorders

epilepsy

renal impairment

peripheral vasculopathy including raynauds

91
Q

what are contraindications for atomoxetine

A
  1. treatment with MAOI and up to 14 days after d/c
  2. hx mania/psychosis
  3. mod-severe HTN
  4. symptomatic CVD, severe CVD
  5. pheochromocytoma
  6. untreated hyperthyroidism
  7. narrow angle glaucoma
  8. advanced arteriosclerosis
92
Q

in which patients should you take precautions when prescribing atomoxetine

A

poor CYP2D6 metabolizers

asthma

peripheral vasculopathy

93
Q

what should you monitor when prescribing atomoxetine

A

liver injury symptoms

urinary retention

growth retardation

peripheral vasculopathy

priapism

94
Q

what is a contraindication to using alpha 2 agonists

A

inability to ensure regular daily dosing

95
Q

in which patients should you use precaution when prescribing alpha 2 agonists

A

hepatic impairment

renal impairment

96
Q

what should you monitor when prescribing alpha 2 agonists

A

sedation, somnolence

BP (risk of hypotension)

bradycardia

syncope

rebound increased BP/HR

Qtc interval if other contributing risks

97
Q

what antibiotic should be avoided when prescribing amphetamines and methylphenidate

A

linezolid

*may increase HTN

98
Q

how might amphetamines/methylphenidate interact with SSRIs, SNRIs

A

may increase risk of SEs of SSRI

increased risk of serotonin syndrome

99
Q

what foods may decrease amphetamine levels

A

fruit juices, ascorbic acid `

100
Q

how does methylphenidate affect warfarin

A

may increase warfarin levels–> monitor INR

101
Q

how does methyphenidate interact with clonidine

A

may increase SEs of clonidine

102
Q

is it recommended to combine clonidine and guanfacine

A

no–> due to similar mechanism and risk of side effects

103
Q

why is combining guanfacine and AAPs (i.e chlorpromazine, haldol) not recommended

A

may increase QTc interval

104
Q

how does guanfacine interact with valproic acid

A

may increase VPA levels

105
Q

how might anticonvulsants impact guanfacine

A

may decrease guanfacine levels through CYP3A4 induction

106
Q

what CYP enzyme metabolizes guanfacine

A

CYP 3A4

107
Q

why is linezolid contraindicated with atomoxetine

A

may increase neurotoxic effect of atomoxetine

108
Q

should you combine TCAs with atomoxetine

A

not recommended–> may increase atomoxetine levels

109
Q

does atomoxetine prolong Qt

A

yes it can, esp. in combo with other agents

110
Q

name the ONLY medication that is approved as an adjunctive treatment with psychostimulants by health canada

A

guanfacine XR

111
Q

what is the issue with concerta generic vs concerta OROS

A

CADDRA considers generic concerta to be a DIFFERENT DRUG

different distribution curve

difference delivery system

easily crushed

concerta OROS is the one recommended by CADDRA

112
Q

how quickly might you see effect stabilization on a given dose of psychostimulants

A

1-3 weeks

113
Q

how quickly might you see effect stabilization on a given dose of atomoxetine

A

4-6 weeks

114
Q

how long does it take to see full response for psychostimulants and atomoxetine

A

up to 3 months

115
Q

list common GI/nutrition side effects from psychostimulants

A

appetite suppression

decreased weight

constipation, diarrhea

dry mouth

GI upset

116
Q

list common neuro side effects of psychostimulants

A

dizziness

headache

rebound effect

tics

117
Q

list common psychiatric side effects of psychostimulants

A

anxiety

dysphoria/irritability

initial insomnia

118
Q

are sexual dysfunctions common with psychostimulants

A

no, uncommon

119
Q

can you get skin reactions to psychostimulants

A

yes

120
Q

list common GI/nutrition side effects of atomoxetine

A

appetite suppression

decreased weight

constipation, diarrhea

dry mouth

GI upset

121
Q

what are common neuro side effects of atomoxetine

A

headache

somnolence

(same as guanfacine)

122
Q

is guanfacine known to have sexual dusfunction

A

no

123
Q

which side effects of ADHD are less likely to resolve over time

A

adverse mood/personality changes

(sleep, appetite issues are more likely to resolve)

124
Q

is it recommended to interrupt psychostimulants every weekend

A

no, may increase SEs

125
Q

how long does adderall XR last

A

about 12 hours

126
Q

what is the mechanism of action of amphetamine based products

A
  1. block reuptake of NE/DA into presynaptic neuron
  2. increase release of NA/DA into extraneuronal space
127
Q

how long does dexedrine last

A

tablets–> 4 hours

spansules–> 6-8 hours

128
Q

how long does vyvanse last

A

13 hours in kids and 14 hours in adults

129
Q

how do methylphenidate based products work (MOA)

A

block reuptake of NE/DA into presynaptic neuron

preferential effect on dopamine

130
Q

which of the psychostimulants has a preferential effect on dopamine

A

methylphenidate

131
Q

how long does ritalin last

A

ritalin–> 3-4 hours

ritalin SR–> 5-6 hours

132
Q

how long does biphentin last

A

10-12 hours

133
Q

how long does concerta last

A

12 hours

134
Q

how quickly should you titrate nonstimulant ADHD meds

A

q14 days

135
Q

what is the MOA of atomoxetine

A

NE reuptake inhibitor

136
Q

how long does atomoxetine last

A

up to 24 hours, may provide continuous coverage

137
Q

in which situations might you use atomoxetine vs psychostimulants (even tho it generally doenst work as well)

A

Need 24 hour coverage
• Comorbid tics, anxiety that worsen with stimulants • Resistance or SE to stimulants (incl sleep)
• Concurrent SUD (no known abuse potential)
• Concurrent enuresis

138
Q

what is a rarely reports adverse event in atomoxetine

A

SI (monitor)

139
Q

in which situations might you choose to use guanfacine XR

A

• Requires close follow-up due to SE profile
• Can be first choice if stimulants not recommended • Non-response or intolerance to stimulants
• Indication for combo with stimulants (age 6-17)
• Comorbid tic disorder or sig anxiety
• Comorbid oppositional behavior aggression

1. Child and Adolescent Psychiatry (32 decks)

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