ADHD - Mitchell

Learning Objectives

• Describe diagnostic criteria, rating scales, and clinical course of ADHD

• Identify pharmacological and no-pharmacological treatment options for ADHD

• Compare MOA (or generally understand across all lectures) of drugs and schedules of stimulant and non-stimulant meds for ADHD

• Compare adverse effects pf ADHD medications

• Discuss symptoms and treatment of adult ADHD

What does the DSM-5 define as ADHD?

A PERSISTENT pattern of inattention and or hyperactivity/impuslvity that interferes with development and functioning characterized by the following:

• 6 OR MORE symptoms of inattention that have persisted for at least 6 months (inattentive ADHD)

• 6 OR MORE symptoms of hyperactivity/impulsivity that have persisted for at least 6 months (hyperactive ADHD)

• For individuals > 17 years old, only 5 symptoms are required

What are the inattention symptoms for DSM-5 criteria for ADHD?

• Easily distracted

• Loses necessary items

• Avoids tasks requiring sustained attention

• Difficulty organizing tasks

• Fails to follow instructions

• Does not seem to listen

• Difficulty sustaining attention

• Careless mistakes

• Forgets daily activities

What are the Hyperactive symptoms for DSM-5 criteria for ADHD?

• Leaves seat frequently

• Talks excessively

• Difficulty with leisure activities

• Acts as if “driven by a motor”

• Fidgets frequently

• Excessively runs or climbs

What are the Impusivity symptoms for DSM-5 criteria for ADHD?

• Difficulty waiting for turn

• Interrupts others

• Blurts out answers

What are the Clinician Administered ADHD rating scales?

1. ADHD rating Scale-5

2. Continuous Performance Test (CPT)

   1. Conners

   2. Vigil

3. Psychological/Neuropsychological testing

“A-C-P/N”

What are the Parent-rated ADHD rating scales?

1. Conner’s scale for ADHD assessment

2. Swanson, Nolan, and Pelham-IV (SNAP-IV)

3. Vanderbilt Assessment Scales

“C-SNAP-V”

What are the Teacher-rated ADHD rating scales?

1. Conner’s scale for ADHD assessment

2. Swanson, Kotkin, Agler, M-Flynn and Pelham-IV (SKAMP)

3. Vanderbilt Assessment Scales

“C-SKAMP-V”

First line treatment for ADHD?

Stimulants!

• Mixed Amphetamine salts (Adderall, Adderall XR)

• Amphetamine Sulfate (Evekeo)

• Mixed salt single entity (MyDayis)

• Dextroampehatmine (d-AMP) —→ (Dexedrine, Dextrostat, ProCentra, Zenzedi, Xelstrym, Dexedrine Spansule)

• Lisdexamphetamine (Vyvanse)

• Methylphenidate (Methylin, Ritalin, Methylin ER (intermediate), MANY long acting agents)

• Dexmethylphenidate (Focalin, Focalin XR)

• Seerdexmethylphenidate/Dexmethylphenidate (SDX) —→ (Aztarys [prodrug])

What are important points about using STIMULANTS as first line for ADHD?

• Continue to try ALL OPTIONS until exhausted before moving to 2nd line (unless contraindications)

• Short acting stimulants last about 3-6 hours (BID-TID dosing — approved in 3+ children)

• Intermediate acting stimulants last about 3-8 hours (QD-BID dosing)

  • Methylin ER

• Long-acting stimulants last about 8-12 hours

  • EXCEPT Jornay PM and MyDayis (both 16 hours!!!)

When should you use second line options for ADHD treatment?

When:

• stimulants are contraindicated

• intolerable ADRs from stimulants

• Active substance misuse or abuse

• Family or patient preference

• Current anxiety disorder or TIC disorder

What are the SECOND-LINE treatment options for ADHD?

SNRIs

• Atomoxetine

• Viloxazine (can use capsule for food)

Alpha-2-adrenergic agonists

• Clonidine-XR

• Guanfacine-ER

Non-pharmacological treatment for ADHD

• Alter behavior by modifying stress and social environment

  • family focused, child focused, etc, CBT

• Endeavor Rx (game for ADHD kids)

• Non-Pharm preferred in PRESCHOOL KIDS

• eTMS (nerve stimulation)

Common side effects of ADHD medications

Insomnia:

• manage by:

  • establish bed time

  • use sleep hygiene

  • meds to treat insomnia

Decline in Appetite:

• manage by:

  • eating nutritious breakfast

  • Allow eating in evenings when hungry

  • Supplement meals with meal replacement shakes/protein

Others:

• GI upset

• Headache

• weight loss

• irritability

• HR and BP increase

LESS common side effects of ADHD medications

• Hallucinations

• Growth delay

• Dysphoria

• Zombie-like symptoms

• Skin discolorations (transdermal)

• Priapism (w/ methylphenidate)

• Psychiatric autoimmune encephalitis

EMERGENCY side effects of ADHD medications

• Cardiovascular effects

• Aggression

• Mood instability

• Tics or abnormal movement

• Peripheral vasculopathy

Inattention symptoms for DSM-5 diagnosis of ADHD in ADULTS

• Poor concentration

• Poor time management skills

• Neglect

• Poormotivation

• Forgetfulness

• Excessive mistakes

Hyperactivity symptoms for DSM-5 diagnosis of ADHD in ADULTS

• Uncomfortable sitting through meeting/class

• Self-proclaimed workaholic

• Unwilling to wait

• Excessive speeding while driving

• Complaint of taking too much or out of turn

Impulsivity symptoms for DSM-5 diagnosis of ADHD in ADULTS

• Low frustration tolerance

• Frequent job changes

• Unstable interpersonal relationships

Treatment algorithm for ADHD treatment in ADULTS

Psychoeducation —→ Stiimulants (Amphetamine, Methylphenidate) —→ Atomoxetine or Viloxazine