Behavioral Health > ADHD: DIAGNOSIS AND PHARMACOTHERAPY > Flashcards

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Attention deficit hyperactivity disorder
1. Manifests in childhood with what kind of symptoms? 3

2. These symptoms have effects on what?5

1. Manifests in childhood with symptoms of
-impulsivity, and/or

2. Symptoms affect
-emotional, and
-social functioning


Male to female ratio
1.___ for the predominantly hyperactive type
2.____ for the predominantly inattentive type

1. 4:1

2. 2:1


ADHD is frequently associated with other psychiatric disorders

1. Oppositional defiant disorder
2. Conduct disorder
3. Depression
4. Anxiety disorder
5. Learning disabilities


Neuropathogenesis of ADHD

1. Functional brain imaging reveals decreased activation in the areas of the basal ganglion and anterior frontal lobe.

2. Major neurotransmitters involved in ADHD are dopamine and norepinephrine


1. Most of the dopamine sensitive neurons are located in the what?

2. Dopamine system is associated with what? 5

3. Dopamine limits and selects sensory information arriving from the where to the where?

1. frontal lobe.

-short term memory tasks

3. the thalamus to the forebrain


What the frontal lobe does

1. Ability to project future consequences resulting from current actions

2. The choice between good and bad actions (or better and best)

3. The override and suppression of socially unacceptable responses

4. The determination of similarities and differences between things or events


What is different about the brain function of those with ADHD?

1. Decreased activation in the areas of the basal ganglion and anterior frontal lobe

2. Increase in dopamine transporter activity thus clearing dopamine from the synapse too quickly

3. The dopamine imbalance allows an inappropriate increase in norepinephrine activity


The basis of treatment of ADHD with what?



The administration of methylphenidate does what? 2

1. Increases extracellular dopamine in the brain
2. Changes the areas of function in the frontal lobe

In patients without ADHD methylphenidate does not have the same effect on frontal lobe function


DSM V criteria for ADHD

1-6- general symptoms

7-15- Inattentive symptoms

16-24 Hyperactivity symptoms

Need 6 or more symptoms of inattention or hyperactivity/impulsivity
5 or more for age 17 and older

1. Symptoms inappropriate for the given age
2. Negatively impacts social and academic or occupational activities
3. Symptoms developed prior to age 12
4. Symptoms present in 2 or more settings
5. Symptoms present for at least 6 months
6. Symptoms are not better explained by other psychiatric disorder(s)

7. Failure to give close attention to detail
8. Difficulty sustaining attention in task
9. Failure to listen when spoken to directly
10. Failure to follow instructions
11. Difficulty organizing tasks and activities
12. Reluctance to engage in tasks that require sustained mental effort
13. Loses things necessary for tasks or activities
14. Easy distractibility
15. Forgetfulness in daily activities

16. Fidgetiness with hands and feet or squirms in seat
17. Difficulty remaining seated in class
18. Excessive running or climbing in inappropriate situations
19. Difficulty in engaging in quiet activities
20. Is often “on-the-go” or acts as if “driven by a motor”
21. Often talks excessively
22. Excessive talking and blurting out answers before questions have been completed
23. Difficulty awaiting turns (while waiting in line)
24. Interrupting and intruding on others


Medical evaluation of ADHD?

1. Parents and teacher need to fill out a form such as the Vanderbilt form
2. Refer for vision and hearing tests
3. Complete history, ROS and physical exam to rule out other causes and psychiatric illnesses


If history suggests may consider the following testing for ADHD:

1. Blood lead level
2. TSH
3. Sleep study
4. Neurology consult if concern for seizures or other neurologic disorder


Treatment of ADHD

1. Stimulants (Ritalin, Adderall and Concerta) are the treatment of choice

2. Behavioral therapy treatment
(has not been shown to reduce symptoms in absence of concurrent stimulant Rx (in a patient that truly has a diagnosis of ADHD!))


Criteria for initiation of pharmacotherapy for ADHD

1. Complete diagnostic assessment that confirms ADHD
2. ≥ 6 years old
3. Parental consent
4. School is cooperative (if dosing during school hours)
5. No previous sensitivity to the chosen medication
6. Normal heart rate and BP
7. No history of seizure disorder (if so refer to neurology to treat ADHD too)
8. Does not have Tourette syndrome, Autism spectrum disorder, anxiety disorder, or substance abuse among household members


Before starting therapy what do ADHD pts need?

1. A comprehensive medical evaluation (see previous slide)
+ EKG (rule out arrhythmia)

2. Document pretreatment height, wt, BP, HR

3. Document the presence of any of the following symptoms prior to treatment: general appetite, sleep pattern, headaches and abdominal pain

4. Assess for substance use or abuse
--Need treatment before starting ADHD meds


ADHD Pharmacology
Pretreatment education

1. Meds are being prescribed to help with self control and ability to focus
2. Benefits and potential risks
3. Other potential risks
4. The follow up protocol that is expected
5. Patient specific treatment goals


Benefits vs potential risks of ADHD pharmacotherapy?

Emphasizing uncertainty about a causal association between serious CV risks to include sudden unexpected death and stimulants for children with cardiac symptoms or positive family history of heart disease


Other patient risks for pharmacotherapy for ADHD?

1. Anorexia,
2. insomnia,
3. tics
4. Priapism with Methylphenidate or Atomoxetine


Choice of Agent
If patient and parents agree to medications
First line? 2
Second line? 1

Stimulants are first line agent
1. Methylphenidate (Ritalin)
2. Dextroamphetamine (Adderall)
3. Atomoxetine (Strattera) is an alternative (non stimulant)


General considerations that may affect medication choice in ADHD

1. Daily duration of coverage needed
2. Completion of homework or driving after school?
3. Ability of child to swallow pills or capsules
4. Time of day when target symptoms occur
5. Desire to avoid administration at school
6. Coexisting tic disorder (avoid stimulants)
7. Coexisting emotional or behavioral condition
8. Potential adverse effects
9. History of substance abuse in patient or household member (avoid stimulants)
10. Expense (short acting stimulants are least expensive)


The PROS of pharmacotherapy for ADHD

1. Stimulant medications have a long record of safety and efficacy

2. Core symptoms of ADHD
3. Parent-child interactions
4. Aggressive behavior
5. Academic productivity and accuracy
6. Improved self-esteem


The CONS of pharmacotherapy for ADHD

1. Insufficient data to judge affect on long term academic performance
2. ADHD symptoms tend to improve over time regardless of treatment modality
Does not significantly affect
3. Learning problems
4. Reduced social skills
5. Oppositional behavior
6. Emotional problems


ADHD Pharmacology
Preschool children need what?

This age group needs referral to a Behavioral Health Specialist


Drug classes used in the treatment of ADHD
-Stimulants (schedule II controlled substance)
First line therapy

1. Methylphenidate
2. Amphetamines


Three other classes that may be used for ADHD treatment? 3

1. Atomoxetine
2. Alpha-2-adrenergic agonists
3. Antidepressants


What are the antidepressants that we could use for ADHD? 2

1. Tricyclics
2. Bupropion


Short acting stimulants: Methylphenidate
1. What are the short acting formulations? 2

2. Adminitrations options? 3

3. Time to onset of action ranges from _____minutes

4. Duration of action is ____ hours

5. Half-life is ____ hours

1. Ritalin and Methylin

2. Tablet, chewable tablet or liquid

3. 20 to 60

4. 3-5

5. 2-3


Long acting stimulants: Methylphenidate
Two types of formualtions?

1. Single pulse: Metadate ER, Methylin ER and Ritalin SR
Onset of action 20-60 min, duration of action 8 hrs

2. Sustained release capsules: Focalin XR (dexmethylphenidate), Metadate CD, Ritalin LA
-Onset of action 20-60 min, duration of action 9 hrs except for Focalin XR duration of action is 12 hrs
-Contain a mixture of immediate release & enteric coated delayed release beads
-Approximates BID dosing of the short-acting


Long acting stimulants: Methylphenidate

Osmotic release: Concerta
1. Describe how it is administered?
2. How many times a day?
3. Onset of action? Duration of action?

1. Immediate release on the outside then uses an osmotic pump to slowly release medication
2. Approximates TID dosing of the short acting formula
3. Onset of action 20-60 min, duration of action 12 hrs


Long acting stimulants: Methylphenidate

Oral suspension: Quillivan XR
-Onset and duration of action?

Onset of action 60 min, duration of action 12 hours