Neurodev. D/Os-General + CADDRA ADHD Guidelines Flashcards
What are the neurodevelopmental disorders
a group of conditions with onset in the developmental period
characterized by developmental deficits that produce impairments of personal, social, academic or occupational functioning
When do most neurodevelopmental disorders manifest
typically in early development, often before a child enters grade school
when do you use “other specified neurodevelopmental disorder”
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
when do you use “unspecified neurodevelopmental disorder”
when you choose not to specify reason criteria are not met for another neurodevelop disorder
what is “global developmental delay”
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
what % of people with dx of ADHD at kids continue to have impairing symptoms as adults
over 50%
what is the prevalence of ADHD in kids and teens
5-9%
have prevalence rates of ADHD gone up
stable x 30 years per guidelines
what is a mnemonic for ADHD inattention symptoms
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)
list 3 neuropsychological/psychoeducational evaluation tools that may be helpful in assessing ADHD
Wide Range Assessment of Learning and Memory
California Verbal Learning Test
Wisconsin Card Sort Test
list 3 computerized cognitive assessments that were specifically designed to assess attention and response inhibition, and can be useful in assessing ADHD
Conners Continuous Performance Test
Test of Variables of Attention
Gordon Diagnostic System
is EEG a validated diagnostic tool for ADHD
no
what differences might be seen on EEG in kids with ADHD vs teens/adults
increased theta waves
decreased alpha/beta waves
what model of care should be followed with ADHD
chronic disease management model
what questionnaire should be given to parents/teachers for ADHD assessment of a child
SNAP-IV
what is a tool to assess functional impact of a mentalhealth concern
Weiss Functional Impairment Rating Scale
What are the 3 most common comorbidities with ADHD in CHILDHOOD
ODD, learning disabilties (often language), anxiety–> early childhood
anxiety and tic disorders more prominent in middle childhood
What are the 3 most common comorbidities with ADHD in TEENS
learning disabilities
mood disorders
SUDs
if someone has a developmental or intellectual disability, or borderline IQ, how much more likely are they do have ADHD than the general pop
about 2-3x more likely
What are the most common comorbidities with ADHD in ADULTHOOD
anxiety, depression, SUD, borderline PD
(+ learning disability still)
list common medical conditions wiht overlap with ADHD
hearing/vision impairment
thyroid function
hypoglycemia
severe anemia
lead poisoning
sleep disorders
FASD
neurofibromatosis
list 2 medications with psychomotor side effects that may resemble or worsen ADHD
mood stabilizers (cognitive dulling)
decongestants, beta agonists (psychomotor agitation)
do most people with ADHD need labs
no
what factor confers worse prognosis for comorbid CD and ADHD
if onset of CD is before age 10
CD + ADHD has poorer outcome than ADHD or CD alone
what is a treatable risk factor for ASPD
ADHD
what is the prevalence of borderline personality disorder in ADHD
34%
what is the most common shared trait between ADHD and borderline PD
impulsivity
is there any evidence that improvement of ADHD leads to improvement of borderline PD
no
what are the main goals of treatment in comorbid ADHD and borderline PD
stabilizing impulsive behaviours
optimizing emotional regulation
what are the principles of management of ADHD + addictions
specific intervention for addictive behaviour + specific intervention for ADHD
ideally CONCURRENTLY
do people with ADHD have higher risk for substance abuse/misuse
yes–> about 2x risk
?underlying poor self esteem + impulsivity
what % of teens with SUD have ADHD
50%
what % of adults with SUD have ADHD
about 25%
what is the most commonly abused agent in ADHD
cannabis
why do we care about substance use problems in ADHD
can increase severity of ADHD sx
can also mimic ADHD
why might early stimulant treatment for ADHD be important
reduces or delays SUD–> protective effect may be lost in adulthood
is cannabis effective for ADHD
no evidence for this
which class of stimulant has lower abuse potential
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
what % if kids have ADHD + anxiety? adults?
children–> 33%
adults–> 50%
how do you approach treating anxiety + ADHD
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
what ADHD stimulants can be used in the case of comorbid anxiety
any of them
atomoxetine is also beneficial and guanfacine is well tolerate
what antidepressants may be preferentially considered if treating comorbid depression and ADHD
those with catecholamine activity–> i.e BUPROPRION
is the combo of SSRI + stimulants safe
yes
what ADHD meds have most risk of drug interactions with which SSRIs
atomoxetine + amphetamines
interact with
fluoxetine, paroxetine
due to 2D6
how should you approach treatment of comorbid ADHD + bipolar disorder
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
are stimulants safe in bipolar + ADHD
yes, once bipolar stabilized
safe + effective
is there worsening of OCD with stimulants
no
does the presence of OCD + ADHD change treatment approach either condition
no
are stimulants safe in comorbid ADHD + tics
yes generally–monitor for worsening tics
what treatment “shows promise” in treating comorbid tics + ADHD
alpha 2 adrenergic agonists (clonidine, guanfacine)
what medication to use if stimulants exacerbate tics
atomoxetine
name 2 non pharmacological treatments for tics
habit reversal therapy
CBIT (comprehension behavioural intervention for tics)
*considered first line when available
ADHD increases the risk of what eating disorder
bulimia nervosa–> especially in girls
what % of kids with autism are suggested to have ADHD
about 30-70% are suggested to meet ADHD criteria
what are some medication considerations in treating ADHD in those with ASD
- may be MORE sensitive to side effects
–irritability, hyper focus, stereotypies - 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
is epilepsy more common amongst those with ADHD vs general population
yes
is there evidence that psychostimulants worsen seizures if stable
no
lesions in what brain areas may lead to secondary ADHD
right putamen
thalamus
orbitofrontal gyrus
what differences in sleep are seen in those with ADHD
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
how do you treat sleep problems in ADHD
behavioural sleep interventions = first line
little evidence for pharma tx of sleep problems in ADHD–> maybe melatonin
is enuresis more common in kids with ADHD
yes–> 2-3x more likely to have eneuresis
kids with nocturnal eneuresis more likely to have ADHD
what is the first line treatment for PRESCHOOL ADHD (age 3-5)
NON pharmacological treatment
when are most children diagnosed with ADHD
school age
what type of accident is more likely to happen if someone has ADHD
MVAs–> 2-4x increase risk
what psychosocial treatments are available for ADHD
CBT for ADHD
behavioural interventions
parent training
cognitive training
social skills training
what is the overall goal of psychosocial treatments for ADHD
educate and empower patients
per cochrane review, were there significant tx effects of social skills training on behaviour or symptoms of ADHD
no
what are the two focuses of CBT for ADHD
time management
organizational skills
who is CBT for ADHD effective for
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
which areas of the brain show functional improvements after CBT for ADHD in adults
fronto-parietal network
cerebellum
what changes are seen in the brain of adults with ADHD after undergoing cognitive based therapy that includes mindful meditation
structural changes in amygdala
increased grey matter volume in hippocampus
what are the impacts of cognitive based therapy with mindfulness meditation in those with ADHD
reduces hyperactivity, impulsivity, inattention
increases self regulation and self directedness
** improvements are maintained over time
what is FIRST LINE pharmacotherapy for ADHD
LONG ACTING stimulants
why are long acting stimulants first line for ADHD
–> augments compliance, symptom coverage and tx response
–> less risk for diversion and rebound sx vs immediate release
–> often better tolerated
when should you consider trialling a second line med in ADHD
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
list the second line med agents for ADHD
- atomoxetine
- guanfacine XR
- shorter acting psychostimulants
what is one option for treatment if there is suboptimal response to first line long acting stimulants
can augment with non-stimulant second line meds
list the third line medication treatments for ADHD
buproprion
clonidine
imipramine
modafinil
AAPs
–> can also consider exceeding recommended maximum doses for other meds
when might you use a third line med for ADHD
treatment resistant cases
they are all off label use–> may have higher risk, more SEs, lower efficacy
list the specific medications (not just class) that are first line for ADHD
vyvanse/lisdexamfetamine (amphetamine)
adderall XR/mixed amphetamine
biphentin/multilayer methylphenidate beads
concerta/methylphenidate OROS
foquest/methylphenidate
list the specific second line meds (not just class) for ADHD
atomoxetine –NRI
guanfacine –alpha 2 agonist (selective)
dexedrine (dextroamphetamine) –short acting
ritalin (methylphenidate) –short acting
what ADHD meds cannot be stopped suddenly
the alpha 2 agonists due to risks of rebound HTN–> i.e clonidine, guanfacine
ADHD meds can affect what cardiovascular factors
BP, HR
when should you do a cardia workup before initiating ADHD pharmacological therapy
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)
is routine ECG monitoring recommended in ADHD med management
NO
only do if there are identifiable risk factors for cardiac disease i.e abnormal exam, personal hx, family hx
can you use psychostimulants if patients has long QT syndrome
one study showed no adverse outcomes with stimulants or beta blockers
suggest cardiology constult
can you use psychostimulants if patients has HTN or CAD
caution is advised –> monitor BP and HR
what should you monitor for when prescribing psychostimulants
BP
HR
priapism
growth retardation
peripheral vasculopathy
what are CONTRAindications to using stimulant medications
- treatment with MAOI and up to 14 days after d/c
- hx mania/psychosis
- mod-severe HTN
- symptomatic CVD
- pheochromocytoma
- untreated hyperthyroidism
- narrow angle glaucoma
in which patients should you be cautious and take precautions when prescribing psychostimulants
anxiety
hx substance abuse
tic disorders
epilepsy
renal impairment
peripheral vasculopathy including raynauds
what are contraindications for atomoxetine
- treatment with MAOI and up to 14 days after d/c
- hx mania/psychosis
- mod-severe HTN
- symptomatic CVD, severe CVD
- pheochromocytoma
- untreated hyperthyroidism
- narrow angle glaucoma
- advanced arteriosclerosis
in which patients should you take precautions when prescribing atomoxetine
poor CYP2D6 metabolizers
asthma
peripheral vasculopathy
what should you monitor when prescribing atomoxetine
liver injury symptoms
urinary retention
growth retardation
peripheral vasculopathy
priapism
what is a contraindication to using alpha 2 agonists
inability to ensure regular daily dosing
in which patients should you use precaution when prescribing alpha 2 agonists
hepatic impairment
renal impairment
what should you monitor when prescribing alpha 2 agonists
sedation, somnolence
BP (risk of hypotension)
bradycardia
syncope
rebound increased BP/HR
Qtc interval if other contributing risks
what antibiotic should be avoided when prescribing amphetamines and methylphenidate
linezolid
*may increase HTN
how might amphetamines/methylphenidate interact with SSRIs, SNRIs
may increase risk of SEs of SSRI
increased risk of serotonin syndrome
what foods may decrease amphetamine levels
fruit juices, ascorbic acid `
how does methylphenidate affect warfarin
may increase warfarin levels–> monitor INR
how does methyphenidate interact with clonidine
may increase SEs of clonidine
is it recommended to combine clonidine and guanfacine
no–> due to similar mechanism and risk of side effects
why is combining guanfacine and AAPs (i.e chlorpromazine, haldol) not recommended
may increase QTc interval
how does guanfacine interact with valproic acid
may increase VPA levels
how might anticonvulsants impact guanfacine
may decrease guanfacine levels through CYP3A4 induction
what CYP enzyme metabolizes guanfacine
CYP 3A4
why is linezolid contraindicated with atomoxetine
may increase neurotoxic effect of atomoxetine
should you combine TCAs with atomoxetine
not recommended–> may increase atomoxetine levels
does atomoxetine prolong Qt
yes it can, esp. in combo with other agents
name the ONLY medication that is approved as an adjunctive treatment with psychostimulants by health canada
guanfacine XR
what is the issue with concerta generic vs concerta OROS
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
how quickly might you see effect stabilization on a given dose of psychostimulants
1-3 weeks
how quickly might you see effect stabilization on a given dose of atomoxetine
4-6 weeks
how long does it take to see full response for psychostimulants and atomoxetine
up to 3 months
list common GI/nutrition side effects from psychostimulants
appetite suppression
decreased weight
constipation, diarrhea
dry mouth
GI upset
list common neuro side effects of psychostimulants
dizziness
headache
rebound effect
tics
list common psychiatric side effects of psychostimulants
anxiety
dysphoria/irritability
initial insomnia
are sexual dysfunctions common with psychostimulants
no, uncommon
can you get skin reactions to psychostimulants
yes
list common GI/nutrition side effects of atomoxetine
appetite suppression
decreased weight
constipation, diarrhea
dry mouth
GI upset
what are common neuro side effects of atomoxetine
headache
somnolence
(same as guanfacine)
is guanfacine known to have sexual dusfunction
no
which side effects of ADHD are less likely to resolve over time
adverse mood/personality changes
(sleep, appetite issues are more likely to resolve)
is it recommended to interrupt psychostimulants every weekend
no, may increase SEs
how long does adderall XR last
about 12 hours
what is the mechanism of action of amphetamine based products
- block reuptake of NE/DA into presynaptic neuron
- increase release of NA/DA into extraneuronal space
how long does dexedrine last
tablets–> 4 hours
spansules–> 6-8 hours
how long does vyvanse last
13 hours in kids and 14 hours in adults
how do methylphenidate based products work (MOA)
block reuptake of NE/DA into presynaptic neuron
preferential effect on dopamine
which of the psychostimulants has a preferential effect on dopamine
methylphenidate
how long does ritalin last
ritalin–> 3-4 hours
ritalin SR–> 5-6 hours
how long does biphentin last
10-12 hours
how long does concerta last
12 hours
how quickly should you titrate nonstimulant ADHD meds
q14 days
what is the MOA of atomoxetine
NE reuptake inhibitor
how long does atomoxetine last
up to 24 hours, may provide continuous coverage
in which situations might you use atomoxetine vs psychostimulants (even tho it generally doenst work as well)
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
what is a rarely reports adverse event in atomoxetine
SI (monitor)
in which situations might you choose to use guanfacine XR
• 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
