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Flashcards in 6 - ADHD Deck (23)
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1
Q

Describe ADHD

A
  • Most common neurodevelopmental disorder in children
  • Unknown cause – genetics, low birth weight, male:female = ~2:1
    • 25% of children w/ ADHD have a parent who meet ADHD dx
    • Females less likely to have disruptive sx
2
Q

Developmental impact of ADHD across lifespan

A
  • 2-5x greater risk of trauma, burns, poisoning
  • Substance use disorder 2x greater
  • Affects academic problems, social interactions, self-esteem issues throughout life
3
Q

Diagnosis of ADHD

A
  • No objective tests/ biological markers for diagnosis
  • General mental health screening (to identify comorbidities & differential diagnoses)
  • ADHD assessment tool
  • Info gathering from parents/ caregivers & teachers and self-assessment
  • Exclude medical causes that mimic/ aggravate ADHD sx
  • Review lifestyle habits (ex: exercise, high-risk activities, substance use)
4
Q

Describe the core sx of ADHD. How many are needed for a diagnosis?

A
  • Need 6/9 sx from either group for diagnosis
  • Majority of px are combined subtype instead of primarily inattentive or primarily hyperactive/impulsive
  • Inattentive sx – sustained attention problem solving
    • Difficulty following through or finishing tasks; disorganization; trouble sustaining mental effort
  • Inattentive sx – selective attention
    • Pays little attention to detail; makes careless mistakes; doesn’t listen; loses things; forgets things; easily distracted
  • Impulsive sx
    • Talks excessively; blurts out; interrupts; doesn’t wait one’s turn
  • Hyperactive sx
    • Fidgets; leaves one’s seat; running/ climbing; constantly “on-the-go”, has trouble playing quietly
5
Q

Goals of therapy for ADHD

A
  • Eliminate or significantly decrease ADHD sx
  • Improve behavioural, academic, and/or occupational performance
  • Improve self-esteem & social functioning
  • Minimize adverse effects of medications
  • Improve QOL
6
Q

Best tx approach

A
  • Non-drug (psychosocial) + medications (ex: stimulants, atomoxetine) to improve QOL & core ADHD sx
  • Stimulants & atomoxetine have greatest effect on core sx of ADHD
  • Behavioural therapies important for improving social interactions, self-esteem, & common behaviours seen in ADHD; inferior to drug alone at reducing core ADHD sx
  • Combination more effective at reducing oppositional behaviour & anxiety and improving social interactions & self-esteem compared to either tx alone
7
Q

Psychosocial interventions for ADHD

A
  • Psychoeducation –> educate & empower px/families providing info on ADHD
  • Parent management training models –> reinforce positive behaviour, ignore low-level provocative behaviour, provide clear, consistent, & safe responses to unacceptable behaviour
  • Social skills training –> perceive & interpret subtle cues & problem-solve in social interactions
  • Cognitive behavioural therapy –> focuses on interaction between cognition, emotion, behaviour
  • Mindfulness training –> increase mindful attention to own thoughts & actions
8
Q

Medication options for ADHD

A
  • Psychostimulant (amphetamine-based or methylphenidate-based)
  • Selective norepi reuptake inhibitor (atomoxetine)
  • Alpha 2-agonist (clonidine, guanfacine)
  • Antidepressant (bupropion, venlafaxine, TCAs)
  • Dopaminergic agent (modafinil)
9
Q

Medication guidelines for ADHD

A
  • First line = long-acting psychostimulants (Adderall, biphentin, concerta, Vyvanse)
    • Dosed once daily; less abuse potential/ diversion; harder to titrate; more expensive
  • Second line = long-acting non-psychostimulants (atomoxetine, guanfacine)
  • Second line/ adjunctive = short & intermediate-acting psychostimulants (Dexedrine to augment Adderall/ vyvanse, Ritalin to augment biphentin/ concerta)
    • Role = PRN for certain activities, augment long-acting preps early or later in day; if long-acting cost prohibitive
10
Q

Describe pt factors that should be considered when selecting a medication for ADHD

A
  • Age & individual variation
  • Duration of effect required by timing of sx
  • Concurrent psychiatric/ medical issues
  • Physician/ family/ pt attitudes
11
Q

Describe medication factors that should be considered when selecting a medication for ADHD

A
  • MOA, DIs
  • Delivery system, duration of action
  • Available doses
  • Canadian clinical indications
  • Affordability, accessibility
12
Q

Describe other considerations that should be made when selecting a medication for ADHD

A
  • Combining meds for adjunct effects
  • Potential for abuse, misuse, diversion
  • Generic formulations
13
Q

Common side effects of ADHD medications

A
  • Headache, decreased appetite, increased appetite in evening, insomnia, tics, irritability, rebound hyperactivity
  • Most improve w/in 2-3 weeks of continuous use
14
Q

Stimulants & CV risk

A
  • Increase BP 3-4 mmHg & HR 1-2 bpm in children/ adolescence
  • Monitor BP, HR at baseline & follow-up
  • Routine EKG screening not recommended
  • Avoid stimulant/ atomoxetine use in those w/ serious heart problems or where BP/HR increase would be problematic
15
Q

ADHD & substance use disorder

A
  • Comorbidity of SUG & ADHD is high (25% adults, 50% adolescence)
  • LA stimulants may have lower abuse potential than IR products
  • Atomoxetine, bupropion, guanfacine options if active SUD
  • Oral psychostimulants don’t have the same abuse liability as illicit stimulants (ex: cocaine)
  • Alcohol increases SE from stimulants
16
Q

Stimulants & growth

A
  • May be associated w/ decreased height at least in first 1-3 years of tx
  • Most achieve satisfactory adult height
  • Monitor height, weight, BMI at baseline & annually
    • If crosses 2 percentile lines –> drug holiday or switch to non-stimulant
17
Q

Advantages of drug “holidays”

A
  • May minimize loss of height & weight
  • Allow pt & physician to continue to reassess benefits & risks of medication
  • Weekend “drug holiday” might work for insomnia or appetite suppression
18
Q

Disadvantages of drug “holidays”

A
  • Risks of medication discontinuation may exceed any potential benefit
  • Consensus recommendation is that risks, benefits, & alternative coping strategies be discussed & individualized approach taken
19
Q

Stimulants – monitoring

A
  • Efficacy (core sx) – response = 1 week; trial = 3-4 weeks
  • Safety, common SE (headache, insomnia, anxiety, increased BP/ HR, appetite suppression) – most resolve in 2-3 weeks
  • Safety; growth – baseline & annually
20
Q

Non-psychostimulant options

A
  • Selective norepi reuptake inhibitor (Atomoxetine)

- Selective alpha 2-adrenergic receptor agonist (Guanfacine)

21
Q

Describe atomoxetine. Indication and monitoring

A
  • 25-30% reduction in core sx in 60-70% of people after 6-12-week tx
  • Indication = 6 y & older, adolescents, adults w/ ADHD
    • Role = no response to stimulant, comorbid anxiety, active SUD
  • Suicidal ideation in children/adolescents increases 4/1000; monitor in the first few months
  • Monitor efficacy (core sx) – response in 3-4 weeks, trial = 6-12 weeks (slower onset)
  • If suicidal thoughts/ behaviours, stop tx
22
Q

Describe alpha 2-adrenergic agonists

A
  • Clonidine, guanfacine
  • Moderate benefit in children/ adolescence
  • Primarily reduce aggression, impulsivity, hyperactivity; less pronounced benefits on inattention
  • Combined w/ stimulants – target sleep disruption, aggression, impulsivity, tics
  • Monitor efficacy (core sx) – response in 3-4 weeks, trail = 6-12 weeks
  • Withdrawal reactions occur if stopped suddenly after long-term use (1-2 months)
    • Taper 25% q3-7days to prevent rebound HTN, sedation
23
Q

What other drugs can be used for ADHD?

A
  • Antidepressants (bupropion, venlafaxine) – 2nd/3rd line or adjunctive, less effective than stimulants
    • Role = comorbid depression, anxiety, enuresis, tic disorders
  • Antipsychotics – may negatively affect cognition in ADHD px