ADHD and Tics Flashcards
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
