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Flashcards in ADHD and Tics Deck (57):

Pathophysiology of ADHD

reduced activity of dopamine and norepinephrine in the prefrontal cortex, alterations in the default mode attention network, less cortical mass has been detected in patients


Symptoms of inattention

inattentive to details or activities, difficulty sustaining attention, does not appear to listen when spoken to, lack follow through, difficulty w/ organization, avoidance of task requiring mental effort, frequently losing things, forgetfulness


Symptoms of hyperactivity

frequent fidgeting and squirming, inappropriately leaves seat in class, inappropriately runs or climbs, difficulty playing or performing activities quietly, often on the go, talks excessively


Symptoms of impulsivity

blurts out, difficulty waiting turn, often interrupts or intrudes on others


ADHD diagnosis

dec attention and inc levels of impulsivity, DSM-V diagnostic criteria, at least 5-6 symptoms of inattention or hyperactivity, impulsiveity present for >6 months, some 2 settings, observed by parents and clinician


Differential diagnoses of ADHD

Biomedical problems (metabolic, neurologic, chronic illness), speech/lang probs, academic/learning probs, emotional/psychiatric probs (anxiety, bipolar), family probs (abuse)


Consequences of ADHD

social difficulties, behavioral issues, impaired academic performances, strained familial relationships, inc risk for development of conduct disorders, abuse, psych disorders


Treatment goals of ADHD

alleviate target sx, imp relationships, imp academia, imp rule following, imp QOL, minimize ADRs


Non pharm interventions of ADHD

maintain daily schedule, minimize distractions, set reachable goals, limit choices, encourage hobbies, use calm disciplines, use check lists


Stimulants MOA

all serve to inc [NT], block reuptake, act as agonists


Stimulants PEARLS

first line, onset several weeks, imp behavior in all children, 70-80% response rate, trial w/ alternative stimulant warranted if lack of effectiveness, intolerable ADRs


Stimulants imporve

over activity, attention span, impulsivity and self-control, physical/verbal aggression, social interactions, academic productivity


Stimulants may not improve

academic performance, learning problems, social skills, oppositional behavior, emotional probs, long-term cog, academic, behavioral, emotional and social functions


Stimulant ADRs

loss of appetitie, insomnia, wt loss, possible tachy, HTN, anxiety, irritability, HA, tics, stunted growth, generally mild or short duration, often reversible


Stimulant abuse potential

risk of misuse/diversion by pts, family, prevent by open discussion w/ pts and family, utilize long-acting preparations, monitor refill dates


Stimulant IR

immediate release, duration 4 hrs, up to 3x/day, adderal may be BID, beneficial when first titrating dose, can see wearing off during the day


Methylphenidate IR

Ritalin, methylin; duration 3-4 hrs, adjust every 1-2 weeks as needed, schedule II, contraindications tics, marked agitation


Methylphenidate IR dosage

children 5-15 mg PO BID before breakfast and lunch, adults 10-20 mg PO BID-TID 30-45 mins before meals


Dexmethylphenidate (Focalin)

Duration 4-5 hrs, conversion from methylphenidate: initiate at 1/2 the total daily does of methylphenidate, BID>4-5 hrs apart w/out regard to meals, children >6 y/o and adults


Dextroamhetamine (Dexedrine, Dextrostat)

typically half the methylphenidate dose, rarely used


Stimulants er

extended, controlled, sustained release, long acting formulation, once daily dosing, 8-12 hr duration, preferred dosage form due to diminished rebound ADR and wearing off, convert when stable on IR dose, adolescents and adults may require dose of IR for evening coverage


Methylphenidate ER (Ritalin LA, SR)

schedule II, dosed 1-2x daily w/ breakfast, lunch, 1/2 IR, 1/2 ER, duration 6-10 hrs, switching from IR: usually same daily dose


Daytrana patch

10-30 mg/ 9hrs, apply patch 2 hrs before desired effect, leave on for 9 hrs, dose may be increased weekly, duration 12 hrs, must ensure the pt will leave patch alone, apply to hip, do not cut


Metadate CD

10-60 mg, dose 1 x daily, formulations=30% IR coating, 70% ER center, duration 8-9, may sprinkle over apple sauce



18, 27, 54, 72(adolescents) mg dosed daily, duration 12 hrs,


Dexmethylphenidate ER (Focalin XR)

duration 12 hrs, may take whole or sprinkle over applesauce, schedule II


Dextroamphetamine SR

Dexedrine Apansule (5,10,15 mg) dosse 1-2x daily, formulation IR and ER beads, duration 6-10 hrs schedule II



Dose 10-20 mg PO BID, as dose inc doa inc, duration 6-8 hrs, schedule 2


Adderall XR

dose 10-60 mg PO Daily, duration 10-12 hrs, may sprinkle over applesauce, schedule 2


Lisdexamfetamine (Vyvanse)

Schedule II, dose 1x daily, duration 13-14 hrs, potentially less abuse potential



alternative therapy to stimulants and can be used when comorbid conditions/diseases (anxiety, drug abuse issue, HTN, CVD), intolerable ADRs, therapeutic failure of first line agents, current substance abuse issue


Atomoxetine (Strattera) MOA

NE reuptake inhibitor, selectively inhibits presynaptic NE transporter, not a stimulant, not a controlled medication


Atomoxetine (Strattera) uses and ADRs

approved for pediatric and adults, decreased abuse potential, good option if ADRs w/ stimulants, ADRs- N/V/C, dizziness, irritability, sleep disturbances, dec appetitie, upset stomach, abdominal pain


Atomoxetine (Strattera) dosage

given 20-40 mg PO BID, may take 2-4 weeks to see full benefit


Atomoxetine (Strattera) advantages

shown to improve inattention and hyperactivity impulsive sx, not controlled substances, no abuse potential


Atomoxetine (Strattera) disadvantages

black box warning- inc suicidal thinking in children adolescents and young adults, poor metabolizers of Cyp2D6 which inc cardiac ADR and must dec in liver function impairment, prolonged doa



Buproprion (Wellbutrin), TCAs, 2nd line agents to stimulant and atomoxetine, option if substance abuse a problem


Buproprion (Wellbutrin)

ne/DA reuptake inhibitor, dec hyperactivity and aggressive behavior, reserved for adults if stimulant or atomoxetine fails, ADRs- insomnia, HA, restlessness, tics, seizures


Buproprion (Wellbutrin) advantages

safer CV profile compared to stimulants, atoxetine and TCAs, less toxicity in overdose compared to TCAs, less appetitie suppression, useful if comorbid depression, IR- 150 mg PO BID, XL- 300 mg PO daily


Buproprion (Wellbutrin) disadvantages

less effective for distractibility compared to stimulants, inc time to show therapetic benefit, can worsen tics, dose dependent risk seizures



NE/serotonin reuptake inhibitor, reserved for older children who do not respond to stimulants, use limited, baseline EcG required, may be used to manage stimulant induced insomnia


TCA options

Impiramine (Tofranil), Desipramine (Norpramine)


TCA advantages

usefel in coexisting depression/anxiety, no anorexia, no rebound symptoms, studies indicate a dec in impulsivity&hyperactivity


TCA disadvantages

inc sedation which may impair function at school, CV side effects, anticholinergic side effects, toxic if overdose, inc time to show therapeutic benefit (4 weeks)


TCA toxicity

risk adverse CV events, screen for fam hx of heart disease, baseline ECG and monitoring, do not use or d/c if resting HR> 130 BPM, ECG abnormalities, ADRs- anticholinergic


Alpha-2 agonists

mediate effects of NE in frontal cortex, used for mono-therapy or add-on, dec efficacy compared to stimulants, beneficial in over-aroused, easily-frustrated, highly-active or aggressive individuals, don't stop abruptly 6-8 weeks for max benefit, not controlled substance


Guanfacine (Intuniv, Tenex)

longer t1/2 and fewer ADRs compared to clonidine, use peds 6-17 y/o, may be beneficial in those w/ tics, intolerance to stimulants, or as add-on therapy, absorption inc w/ high fat meal


Clonidine (Catapres, Kapvay)

.2 mg PO BID, catapres available as patch


Types of tics simple

motor: eye blinking, neck jerking, shoulder shrugging, facial grimacing, vocal: coughing, throat clearing, grunting, sniffling, snorting, barking


Types of tics complex

grooming behaviors, smelling, jumping, touching vocal: repeating words


Types of tic disorders

tourette's disorder, chronic motor or vocal tic disorder last>year, transient tic disorder (goes away by themselves), tic disorder not otherwise specified


Tourette's disorder

multiple motor tics and > 1 vocal tic, tics occur many times per day, occur nearly every day or intermittently for >1year, onset before age 18, not due to substance abuse or stimulant use, prevalence


Treatment of tics

Evaluate overall ability of function, mild tics may not require treatment, mod to severe tics often interfere w/ social and academic functioning, behavioral interventions, pharm interventions, comb treatment


Pharm treatment of tics

dopamine antagonist (typical and atypical), alpha-2 agonist


Typical antipsychotics for tics

haloperidol, fluphenazine, risk of extrapyramidal effects, risk of inc QT interval, monitor


Atypical antipsychotics for tics

Risperidone (Risperdal), Olanzapine (Zyprexa), may be preferred due to dec risk of EPS, ADR- wt gain, metabolic abnormalities, sedation, FPS


Alpha-2 agonist for tics

clinidine, guanfacine, in pt w/ concurrent ADHD reevaluation use of stimulants