ADHD

Question 1

what is the definition of ADHD?

Answer 1

neurodevelopmental disorder defined by impairing levels of inattention, disorganisation, and/or hyperactivity-impulsivity

Question 2

what does inattention and disorganisation of ADHD entail?

Answer 2

inability to stay on task, seeming not to listen, and losing materials, at a level that are inconsistent with age or developmental level

Question 3

what does hyperactivity-impulsivity of ADHD entail?

Answer 3

overactivity, fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait - symptoms that are excessive for age or developmental level

Question 4

what is the DSM 5 diagnosis criteria for ADHD?

Answer 4

A. a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
B. several inattentive of hyperactive-impulsive symptoms were present prior to age 12
C. several inattentive-impulsive symptoms are present in two or more settings
D. there is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning
E. the symptoms do not occur exclusively during the course of schizophrenia, or another psychotic disorder and are not better explained by another mental disorder

Question 5

what are the 3 subtypes of ADHD?

Answer 5

1. inattentive
2. hyperactive-impulsive
3. combined

Question 6

at what age do ADHD symptoms have to be present before in order to qualify for a diagnosis?

Answer 6

12

Question 7

what are some risk factors for ADHD?

Answer 7

low birth weight/prematurity
exposure to smoking during pregnancy
family history of ADHD
perinatal stress
fetal alcohol syndrome
lead poisoning
traumatic brain injury
severe early oxygenation deprivation
adverse parent-child relationships

Question 8

T or F
people with ADHD exhibit EEG abnormalities

Answer 8

true
90% do but not diagnostic

Question 9

what is the pathophysiology of ADHD?

Answer 9

anatomical structures
- delay and rate of cortical thickening contributes to difficulty prioritizing tasks
- lack of connectivity between PFC is associated with lapses in attention and poor impulse control

DA and NE abnormalities
- deficit in DA reward pathway impairs brains ability to maintain attention to dull or repetitive tasks, postpone indulgence, regulate mood and arousal, resist distractions
- NE dysfunction leads to inability to modulate attention, arousal, and mood

Question 10

dysfunction of which neurotransmitters are associated with ADHD?

Answer 10

dopamine and norepinephrine

Question 11

what is the effect of too little DA and NE?

Answer 11

fatigue

Question 12

what is the effect of too much DA and NE?

Answer 12

stressed

Question 13

what are signs and symptoms of ADHD seen in infancy?

Answer 13

• difficulty being soothed because irritability, fidgeting, crying and/or colic
• feeding problems including poor sucking, crying during feedings
• short periods of sleep or very little sleep
• when crawling in constant motion

Question 14

what are some s/sx of ADHD seen in school age children?

Answer 14

• constantly “on the go”, unable to stay seated or play quietly
• easily distracted, trouble completing tasks
• impulsive, unable to wait turn, may blurt out answers, needs instant gratification
• may appear accident prone due to hyperactivity and impulsivity
• disorganised, forgetting or losing homework

Question 15

what are s/sx of ADHD seen in adolescence?

Answer 15

• dominant features include disorganisation, forgetfulness, inattention, overreaction
• reckless driving and risky behaviour may occur

Question 16

what are s/sx of ADHD seen in adulthood?

Answer 16

• hyperactive symptoms include inability to sit through class/work meetings, excessive talking, needs to get to places quickly
• impulsive symptoms include frequent job changes, low frustration tolerance, unstable interpersonal relationships
• inattentive symptoms include poor time management, poor motivation and concentration, forgetfulness, excessive mistakes

Question 17

which assessment tools are recommended by CADDRA for initial information gathering for suspected ADHD?

Answer 17

SNAP-IV 26 questionnaire and CADDRA teacher assessment form

Question 18

what % of people diagnosed with ADHD in childhood have symptoms persisting into adulthood?

Answer 18

60%

Question 19

what are the differences seen between boys and girls with ADHD?

Answer 19

boys present with hyperactivity/impulsive symptoms that are more noticeable
girls present with more inattentive symptoms

Question 20

how do symptoms of ADHD change with age?

Answer 20

hyperactive symptoms begin to decline in adolescents but impulsive and inattention symptoms persist
inattentive symptoms become more prominent in adolescence and are the most common symptoms seen in adults

Question 21

which symptoms of ADHD are associated with higher rates of bipolar/psychosis in adults?

Answer 21

hyperactive/impulsive

Question 22

what are common co-morbidities seen with ADHD?

Answer 22

conduct or behavioural problems
anxiety
MDD
OCD
depression
oppositional defiant disorder
Tourette’s disorder
autism
epilepsy
substance use disorder
learning disorder

Question 23

what is ODD?

Answer 23

oppositional defiant disorder
behavioural problem that is characterised by active confrontation of authority

Question 24

what is CD?

Answer 24

conduct disorder
show a pattern of repeated aggression, lying, stealing, vandalizing, and skipping school

Question 25

what are the consequences of untreated ADHD?

Answer 25

decrease social, educational, vocational, and self-care functioning increased rates of accidental injury increase time and energy to cope with ADHD related challenges

Question 26

what is the most effective treatment of ADHD?

Answer 26

behavioural therapies + medications

Question 27

what are non-pharm treatments of ADHD?

Answer 27

- behavioural parent training - behavioural classroom management - behavioural peer interventions - CBT

Question 28

what did the study of concerta vs atomoxetine conclude?

Answer 28

in treatment of ADHD without comorbidities (besides ODD) concerta is 1st line option ATX is second line option for concerta non-respondings

Question 29

what is the MOA of methylphenidate?

Answer 29

inhibits the presynaptic reuptake of DA and NE by specifically blocking transport proteins - DA appears to have larger role than NE - leads to increased sympathomimetic activity in CNS - limited peripheral activity

Question 30

what is the MOA of amphetamine?

Answer 30

increase the release of DA and NE into the presynaptic nerve terminal enhance release of NE in peripheral from adrenergic nerve terminals may stimulate the release of serotonin and act as a serotonin agonist (at higher doses) inhibit the reuptake of monoamines in extraneuronal space

Question 31

what is the MOA of atomoxetine?

Answer 31

inhibits the presynaptic reuptake of NE in CNS

Question 32

which antidepressant is atomoxetine similar in structure to?

Answer 32

fluoxetine

Question 33

what are the 2 alpha-2 adrenergic receptor agonists used in treatment of ADHD?

Answer 33

guanfacine and clonidine

Question 34

T or F clonidine is more selective for the alpha2a receptor than guanfacine?

Answer 34

false guanfacine is more selective

Question 35

what does agonism of alpha 2a receptor result in?

Answer 35

leads to improvement in underlying working memory and behavioural functions

Question 36

according to CADDRA guidelines, what is 1st, 2nd, and 3rd line treatment of ADHD?

Answer 36

1st line: long acting stimulants 2nd line: non-stimulants (atomoxetine, guanfacine XR), short/intermediate acting psychostimulants 3rd line: bupropion, clonidine, imipramine, modafinil; exceeding recommended max doses

Question 37

what are examples of long acting stimulants?

Answer 37

Adderall XR Vyvanse Biphentin Concerta Foquest Quillivant

Question 38

what is the efficacy of long-acting stimulants?

Answer 38

core ADHD symptoms reduced by 30-40% in 70%+ of treated patients

Question 39

when is a response seen in treatment with long acting stimulants?

Answer 39

some response seen in 1st week for some, adequate trial 3-4 weeks

Question 40

what is the next move is patient fails on a long acting stimulant?

Answer 40

try the other class before moving towards non-stimulant

Question 41

what are the advantages of long acting stimulants over intermediate/short acting?

Answer 41

maintain privacy for patients and family in context of school, work, social situations may diminish diversion and rebound associated with better tolerability

Question 42

what is the efficacy of atomoxetine?

Answer 42

core ADHD symptoms reduced by 25-30% in 60-70% treated

Question 43

when is a response seen with non-stimulants?

Answer 43

onset 2 weeks max effect seen at 6-8 weeks

Question 44

T or F non-stimulants take longer to show max effect than stimulants?

Answer 44

true

Question 45

when are atomoxetine/guafacine treatments considered first line in ADHD?

Answer 45

if stimulants are CI intolerable a/e develop comorbid active SUD severe anxiety or tic disorders present parents hesitant to use a stimulant

Question 46

when are short/intermediate acting psychostimulants used in ADHD?

Answer 46

to augment long-acting formulations early or late in day or early evening

Question 47

when are 3rd line treatments used in ADHD?

Answer 47

treatment resistant cases and may require specialized care

Question 48

what are the amphetamine based psychostimulants?

Answer 48

Adderall XR vyvanse dexedrine

Question 49

what are the methylphenidate based psychostimulants?

Answer 49

biphentin concerta foquest quillivant ER Ritalin SR

Question 50

which stimulants are in the formulary?

Answer 50

Dexedrine Concerta Ritalin SR require EDS: - Vyvanse - biphentin not covered: - Adderall XR - Foquest - Quillivant ER

Question 51

what are the CIs and precautions with all ADHD medications?

Answer 51

CI: known hypersensitivity precaution: cardiac disease, bipolar, psychosis, pregnancy and lactation

Question 52

what are CI and precautions with stimulants?

Answer 52

CI: treatment with MAOI (14 days), narrow angle glaucoma, untreated hyperthyroidism, moderate to severe HTN, pheochromocytoma, symptomatic CVD, history of mania or psychosis precaution: history of substance abuse, anxiety, renal impairment, tic disorders, epilepsy, peripheral vasculopathy

Question 53

what are CI and precautions with atomoxetine?

Answer 53

CI: treatment with MAOI (14 days), narrow angle glaucoma, uncontrolled hyperthyroidism, pheochromocytoma, moderate to severe HTN, symptomatic CVD, severe CV disorders, advanced atherosclerosis precaution: asthma, CYP2D6 poor metabolisers, peripheral vasculopathy

Question 54

what are CI and precautions with alpha2 agonists?

Answer 54

CI: inability for parents or pts to ensure regular daily dosage precaution: hepatic or renal impairment

Question 55

why is adherence to alpha2 agonists to important?

Answer 55

risk of rebound hypertension when stopped abruptly

Question 56

what are DIs with amphetamine based products?

Answer 56

acidifying agents (fruit juices) alkalizing agents opioids linezolid antidepressants: MAOIs (CI), SSRIs, SNRIs, TCAs alpha2 agonsits beta blockers antipsychotics decongestants

Question 57

what are DI with methylphenidate based products?

Answer 57

linezolid warfarin phenobarb, phenytoin, primidone antidepressants: MAOI (CI), SSRI, SNRI, TCAs alpha2 agonists decongestants

Question 58

what are AEs seen with stimulants?

Answer 58

increase BP and HR appetite suppression constipation/diarrhea dry mouth GI upset nausea/vomiting anxiety dizziness dysphoria/irritability headache initial insomnia somnolence tics decrease in weight skin reactions

Question 59

what are some AEs seen with atomoxetine?

Answer 59

BP and HR increase appetite suppression constipation/diarrhea dry mouth GI upset nausea/vomiting anxiety dysphoria/irritability headache initial insomnia somnolence decrease is weight sexual dysfunction skin reactions

Question 60

what are some AEs seen with alpha-2 agonists?

Answer 60

BP and HR decrease constipation/diarrhea dry mouth nausea/vomiting headache somnolence