ADHD Flashcards Preview

Psych > ADHD > Flashcards

Flashcards in ADHD Deck (59):
1

What is ADHD?

- manifests in childhood w/ sxs of hyperactivity, impulsivity, and/or inattention
- sxs affect cognitive, academic, behavioral, emotional and social fxning

2

Prevalence of ADHD?

- in school aged kids: 8-10%
one of the most common disorders of childhood
- male to female ratio:
4:1 for predom. hyperactive
2:1 for predom inattentive

3

What other psych disorders is ADHD frequently assoc with?

- oppositional defiant disorder
- conduct disorder
- depression
- anxiety disorder
- learning disabilities

4

Neuropathogenesis of ADHD?

- fxnl brain imaging reveals decreased activation in areas of basal ganglion and anterior frontal lobe
- major neurotransmitters involved in ADHD are dopamine and NE

5

Fxn of dopamine?

- most of dopamine sensitive neurons are located in the frontal lobe
- dopamine system is assoc with:
reward, attention, short term memory tasks, planning and motivation
- dopamine limits and selects sensory information arriving from the thalamus to the forebrain

6

Fxn of the frontal lobe?

- ability to project future consequences resulting from current actions
- choice b/t good and bad actions (or better and best)
- override and suppression of socially unacceptable responses
- the determination of similarities and differences b/t things or events

7

How does ADHD affect the fxn of the brain?

- decreased activation in the areas of the basal ganglion and anterior frontal lobe
- increase in dopamine transporter activity thus clearing dopamine from the synapse too quickly
- the dopamine imbalance allows an inappropriate increase in NE activity

8

The mechanism of ADHD tx wtih methylphenidate?

- increases extracellular dopamine in the brain
- changes the areas of fxn in the frontal lobe
- in pts w/o ADHD mehylphenidate doesn't have same effect on frontal lobe fxn

9

What is the DSM V criteria for ADHD?

- need 6 or more sxs of inattention or hyperactivity/impulsivity, 5 or more for age 17 and older
- sxs inappropriate for any given age
- negatively impacts social and academic or occupational activities
- sxs developed prior to age 12
- sxs present in 2 or more settings
- sxs present for at least 6 months
- sxs are not better explained by other psychiatric disorders

10

What are the inattentive sxs for ADHD?

- failure to give close attention to detail
- difficulty sustaining attention in task
- failure to listen when spoken to directly
- failure to follow directions
- difficulty organizing tasks and activities
- reluctance to engaage in tasks that reqr sustained mental effort
- loses things necessary for tasks or activities
- easy distractibility
- forgetfulness in daily activities

11

What are the impulsive-hyperactive sxs of ADHD?

- fidgetiness w/ hands and feet or squirms in seat
- difficulty remaining seated in class
- excessive running or climbing in inappropriate situations
- diff. in engaging in quiet activities
- is often on the go or acts as if driven by a motor
- often talks excessively
- excessive talking and blurting out answers b/f questions have been completed
- difficulty awaiting turns (while waiting in line)
- interrupting and intruding on others

12

Medical eval of pt with suspected ADHD?

- parents and teacher need to fill out a form such as the Vanderbilt form
- refer for vision and hearing tests
- complete Hx, ROS, and PE to rule out other causes and psychiatric illnesses
- if hx suggests may consider the following testing:
blood lead level
TSH
sleep study
neuro consult if concern for seizures or other neuro disorder

13

dx and tx of ADHD in adults?

- dx should be made by mental health professional
- sxs often continue into adulthood and can have significant effects on social and occupational fxning
- same meds used for adults as for kids

14

What methods of tx are used in ADHD?

- stimulants (ritalin, adderall, and concerta) are the TOC
- behavioral therapy tx: hasn't been show to reduce sxs in absence of concurrent stimulant rx (in conjuction with rx - shown to be helpful)
- other alt. such as cognitive tx, dietary modification, and mutlivitamins haven't been shown to be effective in controlled studies

15

What is the criteria for initiation of pharm therapy for ADHD?

- complete dx assessment that confirms ADHD
- 6 or older
- parental consent
- school is cooperative (if dosing during school hours)
- no previous sensitivity to the chosen med
- normal HR and BP
- no hx of seizure disorder (if so refer to neuro to tx ADHD too)
- doesn't have tourette syndrome, autism spectrum disorder, or substance abuse among household members

16

Before starting stimulant therapy what should be done?

- comprehensive medical eval - no hx of seizure disorder, tourettes, autism spectrum
- EKG (rule out arrhythmia)
- document pretx ht, wt, BP, HR
- document presence of any of the following sxs prior to tx: general appetite, sleep pattern, HAs, and abdominal pain
- assess for substance use or abuse: need tx b/f starting ADHD meds

17

What should be included in the pt's pretx education?

- tell pt that meds are beign prescribed to help with self control and ability to focus
- benefits and potential risks:
emphasize uncertainty about causal assoc b/t serious CV risks to include sudden unexpected death and stimulants for kids with cardiac sxs or positive family hx of heart disease
- other potential risks: anorexia, insomnia, tics, priapism with methylphenidate or atomoxetine
- the f/u protocol that is expected
-pt specific tx goals

18

TOC in ADHD?

- depends on what pt and parents agree on
- stimulants are first line agent:
methylphenidate (ritalin)
dextroamphetamine (adderall)
- atomoxetine (strattera) is an alt. (non-stimulant) - use if hx of substance abuse in family

19

What are general considerations that may affect med choice in ADHD?

- daily duration of coverage needed - completion of homework or driving after school?
- ability of child to swallow pills or capsules
- time of day when target sxs occur
- desire to avoid admin at school
- coexisting tic disorder (avoid stimulants)
- coexisting emotional or behavioral condition
- potential adverse effects
- hx of substance abuse in pt or household member (avoid stimulants)
- expense (short acting are least expensive)

20

What are the pros of pharm therapy for ADHD?

- stimulants have long record of safety and efficacy
- at least 80% of school age kids and adolescents will respond to stimulant med
- improves:
core sxs of ADHD
parent child interactions
aggressive behavior
academic productivity and accuracy
improved self-esteem

21

What are the cons of pharm therapy for ADHD?

- insufficient data to judge affect on long term academic performance
- ADHD sxs tend to improve over time regardless of tx modality
- doesn't significantly affect:
learning problems
reduced social skills
oppositional behavior
emotional problems

22

How do you choose b/t stimulants?

- providers preference and comfort level
- pt and parent preference: after discussion of meds

23

Tx preschool kids?

- this age group needs referral to behavioral health specialist

24

What are the drug classes used in tx of ADHD?

1. stimulants (schedule II controlled substance):
first line therapy
methylphenidate
amphetamines: detroamphetamine and detroamphetamine-amphetamine
2. atomoxetine
3. alpha-2-adrenergic agonists (refer for these)
4. Antidepressants: TCAs, bupropion

25

What are the short acting stimulants - methylphenidate?

methylphenidate:
ritalin and methylin are short acting formulations
- tablet, chewable tab or liquid
- time to onset of action ranges from 20-60 min
- duration of action: 3-5 hrs
- half life is 2-3 hrs

26

What are the long acting stimulants -methylphenidate?


single pulse: metadate ER, methylin ER and ritalin SR
onset of action 20-60 min, duration: 8 hrs

- sustained release capsules: focalin XR
(dexmethylphenidate), metadate CD, ritalin LA:
- onset of action 20-60 min, duration: 9 hrs except for focalin XR duration is 12 hrs
- contain a mix of immediate release and enteric coated delayed release beads
- approximates BID dosing of short acting

- osmotic release: concerta - immediate release on outside then uses osmotic pump to slowly release med
- approximates TID dosing of short acting formula, onset of action 20-60 min, duration of action 12 hrs
- oral suspension: quillivan XR: onset of action: 60 min, duration: 12 hrs
- transdermal: daytrana - onset of action 60 min, duration 12 hrs, effects last 3 hrs post removal of the patch

27

Short acting stimulants - amphetamines?

- detroamphetamine: dexedrine, dextrostat, procenta (oral) - onset: 20 min, duration 4-6 hrs
- amphetamine - dextroamphetamine: adderall, Onset: 20 min, duration: 4-6 hrs

28

What are long acting stimulants - amphetamines?

- lisdexamfetamine (vyvanase): prodrug of dextroamphetamine, pharm. activated after oral ingestion, designed to discourage drug misuse, onset: 1 hr, duration: 10-12 hrs
- dextroamphetamine SR (dexedrine spansule): combo of immediate and continuous release meds, onset: 20 minutes, duration: 6-8 hrs
- amphetamine-dextroamphetamine (adderall XR): combo of immediate and continuous release meds, onset: 20 min, duration: 8-10 hrs
this is most commonly rx, well tolerated

29

What is first line therapy in ADHD tx?

- methylphenidate, dexmethylphenidate, and amphetamines are equally effective
- have similar side effect profiles
- short acting agents: initial rx in kids younger than 6, or can be used to determine optimal dosing b/f switching to longer acting agent
- longer acting prep: may be used initially in ages over 6, starting at lowest dose and titrating up

30

Nonstimulant meds used fo ADHD tx?

- second line: atomoxetine (strattera)
- third line:
alpha-2-adrenergic agonists - clonidine (catapres), guanfacine (tenex)
- antidepressants: imipramine (tofranil), desipramine (norpramin)
- bupropion (wellbutrin)

31

How long may it take b/f effects of strattera are noted?

- 1-2 wks
* pop. in younger kids since it is a non-stimulant
- dosing by wt (older than 6)

32

How do you monitor the response to therapy and assess for SEs?

- assess weekly during titration stage (can last 1-3 months)
- monitored behavior through parent and teacher feedback
- after titration stage pts seen monthly to monitor wt, HR, BP until stable dose w/o new SEs
- optimal dose is where there are favorable outcomes with minimal side effects
- ?s to ask: when does side effect occur in relation to admin? Is effect related to coexisting disorder or enviro stressor?
- mild adverse effects may resolve w/ time or adjusting any of the following:
dose
time of administration
formulation of med

33

What side effects should you eval for at every visit?

- decreased appetite
- poor growth
- dizziness
- insomnia/nightmares
- mood lability
- rebound
- tics
- psychosis
- diversion and misuse

34

How do you manage a pt with the side effect of decreased appetite?

- give med at or after meal
- encourage child to eat nutrient dense foods (no empty calories)
- offer food that child likes for noon meal

35

How do you manage SE: poor growth?

- drug holidays may be beneficial

36

How do you manage SE: dizziness?

- monitor BP and pulse (make sure you took a good hx - any arrhythmias?)
- ensure adequate fluid intake
- if assoc with peak effect, try longer acting prep

37

How do you manage insomnia or nightmares as SE of meds?

- establish a bedtime routine
- good sleep hygiene habits
- omit or reduce the last dose of the day
- if using long acting preparation consider short acting

38

How do you manage mood lability as SE of meds?

- sxs that may occur as med wears off can be averted by using longer acting formulation or increasing from BID to TID if short acting:
sadness
irritability
increased activity
- sometimes mood changes can occur at peak concentration - try reducing dose or switching to longer acting

39

How do you manage rebound sxs from meds?

- this may improve by stepping dose down at end of the day

40

How do you manage tics as SE of meds?

- conduct a drug trial at different doses included no med to be sure that they are related to meds

41

How do you manage psychosis as SE of meds?

- Psychosis: suicidality, hallucinations, increased aggression
- verify dose is approp and med is admin as prescribed: if so d/c stimulant (can be done abruptly)
- refer to mental health specialist

42

Diversion and misuse of stimulants - educating pts?

- have to monitor sxs and prescribe refills - to look for evidence of misuse or diversion
- long acting stimulants have less potential for abuse
- keep track of rx dates
- open discussion with pt

43

What are reasons for tx failure?

- lack of adherence to med regimen
- possibility of med diversion
- are tx goals and expectations realistic?
- is there a comorbid psych dx?
- can try another stimulant med
- if fail mult stimulants or intolerable side effects then trial atomoxetine or an alpha-2 adrenergic

44

What are drug holidays?

- d/c of stimulant med on weekends or during summer
- decide on a case by case basis
- not an option for atomoxetine or alpha-2-adrenergic agonists becuase of extended half life

45

Maintenance of drug therapy?

- once on a stable dose:
follow up in office should be 3-6 months
- continue to monitor ht, wt, BP, and HR

46

How should you terminate ADHD meds?

- may abruptly d/c stimulants or atomoxetine
- alpha-2-adrenergic agonists and TCAs should taper off over several weeks

47

MOA of ritalin (methylphenidate)?

- short and long acting available
- acts on dopamine and NE to block reuptake
- 70% of pts experience significant benefit
(shortest acting: ritalin and methylin
longest acting: concerta, quillivan XR, daytrana)

48

SEs of ritalin?

- anxiety
- wt loss
- psych sxs: psychosis, aggression, hallucinations
- heart problems in at risk people
- easy bruising
- high potentiatl for addiction and abuse - schedule II drug

49

Use of adderral (amphetamine-dextroamphetamine) -Pros? Downside? SEs?

- high potential for abuse (II)
- may lead to drug dependence
- extremely popular
- may be slightly more effective than ritalin
- SEs:
anxiety, wt loss, psychosis, hallucinations, aggression
- ** heart problems in at risk people (sudden death)

50

Use of dexedrine? super dangerous SE?

- previously used for OTC diet pill
- among most effective tx for ADHD
- schedule II
- sudden death in people that have heart problems or cardiac defects

51

What SEs are concerning with dexedrine?

- heart related problems including:
sudden death in people that have heart problems or defects, sudden death, stroke and heart attack in adults.
increased BP and HR
- psych probs: new or worse behavior and thought problems, new or worse behavior
- kids and teens:
seeing things or hearing things
believing things that aren't true, new manic sxs

52

MOA of Lisdexamphetamine (vyvanase)?

- converted to dextroamphetamine after oral ingestion
- no generic
- less addictive but still schedule II
- amphetmaines cause release of catecholamines (primarily dopamine and NE) from their storage sites in presynaptic nerve terminals
- a less significant mechanism may include their ability to block the reuptake of catecholamines by competitive inhibition

53

Use of atomoxetine (strattera)? MOA? BBW? Most common SEs?

- initially only approved non stimulant tx until Intuniv
- works on NE
- initially tested for depression but didn't do much
- BBW: increased risk of suicidal behavior under 25 YOs
- may not be as effective as stimulant meds
-expensive
- most common SEs: dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido, ED, urinary hesitancy, dizziness, and sweating 1-2 wks to notice effects
- other SEs: chest pain, SOB, irregular heart beat, unusual thoughts or behavior, aggression, hallucinations, nausea, abdominal pain, loss of appetite, jaundice

54

Why should atomoxetine (strattera) be used with some caution?

- risk of suicidal ideation in kids and adolescents
- weigh risks vs benefits
- should be monitored closely for suicidal thinking and behavior
- families and caregivers should be advised of need for close observation and communication with provider

55

Pros and cons of ADHD tx?

- ritalin: temporary effects - sleep not interrupted, inexpensive, effects and safety have been studied for decades, may cause jitters after snorting
- adderall XR: most popular study drug, very similar to vyvanse but comparatively more addictive, inexpensive generics available, increases dopamine levels in the brain, can impact sleep patterns
- vyvanse: expensive, no generics, some insurance plans don't cover vyvanse. Smoother absorption than adderall and less addictive, can suppress appetite drastically
- focalin XR: expensive, no generics available. SEs include loss of appetite, jitters and headache

56

What is extended release guanfacine (intuniv)?

- alpha-2-adrenergic agoinst (antiHTN)
- approved for tx of ADHD
- SEs:
fast or slow HR
pounding heartbeat, chest tightness
numbness or tingling
high rate of fainting
depression
BP problems (low)
- caution with kidney or liver disease

57

Use of bupropion (wellbutrin)?

- alt tx for ADHD, other uses - Major depressive disorder cessation
- MOA: inhibits reuptake of dopamine
- mildly stimulating so good for pts with fatigue, hypersomnia, or poor concentration
- no sexual side effects or wt gain
- SEs: anxiety, insomnia, lowers seizure threshold, avoid in bulemia

58

When should you not use stimulants in ADHD pts?

- hx of substance abuse
- structural heart defects
- arryhthmia or increased CV risk profile

59

ADHD screening for parents and teachers?

Vanderbilt assessment scales