Flashcards in ADHD Deck (59)
What is ADHD?
- manifests in childhood w/ sxs of hyperactivity, impulsivity, and/or inattention
- sxs affect cognitive, academic, behavioral, emotional and social fxning
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
What other psych disorders is ADHD frequently assoc with?
- oppositional defiant disorder
- conduct disorder
- anxiety disorder
- learning disabilities
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
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
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
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
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
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
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
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
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
neuro consult if concern for seizures or other neuro disorder
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
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
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
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
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
TOC in ADHD?
- depends on what pt and parents agree on
- stimulants are first line agent:
- atomoxetine (strattera) is an alt. (non-stimulant) - use if hx of substance abuse in family
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)
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
core sxs of ADHD
parent child interactions
academic productivity and accuracy
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:
reduced social skills
How do you choose b/t stimulants?
- providers preference and comfort level
- pt and parent preference: after discussion of meds
Tx preschool kids?
- this age group needs referral to behavioral health specialist
What are the drug classes used in tx of ADHD?
1. stimulants (schedule II controlled substance):
first line therapy
amphetamines: detroamphetamine and detroamphetamine-amphetamine
3. alpha-2-adrenergic agonists (refer for these)
4. Antidepressants: TCAs, bupropion
What are the short acting stimulants - 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
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
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
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
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