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Flashcards in ADHD Deck (59)
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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)