ADHD

Attention Deficit Hyperactivity Disorder

Neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity with onset in childhood.

1. Hyperactive

2. Impulsive

3. Inattentive

What are the 3 presentations of ADHD?

true, especially for hyperactive/impulsive type; inattentive type has equal gender distribution

T/F: ADHD is more common in males

inattentive type

- hyperactive/impulse is more common in males

Which type of ADHD has equal gender distribution?

Multifactorial:

- Genetic

- Neurobiological

- Environmental

ADHD is best described as having what type of etiology?

Catecholamine

An imbalance of which neurotransmitter system is central to ADHD pathophysiology?

Dopamine

What neurotransmitter activity is decreased in ADHD, contributing to inattentiveness and impulsivity?

- Very low birth weight

- Prenatal alcohol, tobacco, illicit drug exposure

- Head trauma

- Sleep apnea

- Iron deficiency

- Lead exposure

- Adverse childhood experiences

Risk factors for ADHD

-Talks excessively; blurts out answers

- Difficulty waiting turn

- Interrupts or intrudes on others

- Difficulty playing quietly

- Restlessness across situations

Which behaviors are characteristic of impulsivity in ADHD?

- Leaves set unexpectedly

- Runs/climbs inappropriately ("on the go" as if driven by a motor)

- Often fidgets, squirms, restlessness

Which behaviors are characteristic of hyperactivity in ADHD?

- Fails to give close attention; makes careless mistakes

- Difficulty sustaining attention; seems not to listen

- Does not follow through on instructions; disorganized

- Avoids tasks requiring sustained mental effort

- Loses necessary items; easily distracted; forgetful

Which behaviors are characteristic of inattention in ADHD?

High activity level, impulsivity, difficulty following directions; symptoms may overlap with normal behavior → requires careful assessment.

How does ADHD typically present in preschool-aged children?

Academic underperformance, disruptive behavior, incomplete work, organizational problems, and poor peer relationships.

What ADHD-related challenges are commonly seen in school-age children?

Less overt hyperactivity but persistent inattention, executive dysfunction, increased risk-taking, driving accidents, and substance use.

How does ADHD presentation typically change during adolescence?

Learning disorders, anxiety, depression, oppositional defiant disorder, conduct disorder, and tic disorders

Which comorbidities are commonly associated with ADHD across development?

Poor grades, grade retention, need for IEP/504 accommodations, and higher dropout risk.

What academic impairments are commonly seen in children with ADHD?

Peer rejection, bullying (as either victim or aggressor), and increased family conflict.

What social difficulties commonly occur in ADHD?

Unintentional injuries, motor vehicle crashes, and increased risk of substance use.

What safety-related consequences are associated with ADHD?

Reduced educational attainment, higher unemployment, and increased legal problems.

What long-term outcomes are associated with untreated ADHD?

1. ≥6 symptoms of inattention and/or ≥6 symptoms of hyperactivity/impulsivity up to age 16 [For age ≥17, threshold is ≥5 symptoms]

2. Symptoms must be present for ≥6 months

- Symptoms must be inconsistent with developmental level

- Symptoms must be maladaptive

3. Several symptoms must be present before age 12 years

4. Symptoms must be present in ≥2 settings (e.g., home, school, work, social environments)

5. Clear evidence of clinically significant impairment in social, academic, or occupational functioning

6. Symptoms are not better explained by another mental disorder

DSM-5 Diagnostic Criteria for ADHD

Anxiety, depression, oppositional defiant disorder, conduct disorder, and substance use.

Which emotional/behavioral comorbidities should clinicians screen for when evaluating a child for ADHD?

Learning disorders, language disorders, intellectual disability, and autism spectrum disorder.

What developmental comorbidities are important to assess in children with ADHD?

Tic disorders, sleep-disordered breathing, seizures, and chronic medical conditions

Which physical comorbidities should be screened for in ADHD according to AAP guidelines?

ADHD should be managed as a chronic condition within a medical home framework.

How should ADHD be managed within the healthcare system according to AAP guidelines?

Psychoeducation, behavioral interventions, school-based supports, and pharmacotherapy.

What are the core components of a multimodal treatment approach for ADHD?

Behavioral parent training and classroom interventions.

What is the first-line treatment for preschool children (ages 4-5 years) with ADHD?

When impairment is severe despite behavioral interventions.

When is methylphenidate considered in preschool-aged children (4-5 years)?

ADHD medication plus behavioral and educational interventions.

What is the recommended treatment approach for school-age children and adolescents with ADHD?

IEP/504 plans, structured classroom environments, organizational coaching, and behavioral classroom strategies.

What types of educational supports may be used to help children with ADHD?

Blocks reuptake of dopamine and norepinephrine in presynaptic neurons, increasing synaptic catecholamine levels

What is the mechanism of action of methylphenidate?

Dexmethylphenidate is the active d-enantiomer with ~2× the potency of racemic methylphenidate.

How does Dexmethylphenidate differ from Methylphenidate?

IR: 3-4 hours

ER: 8-12+ hours

*match product to daily schedule and symptom timing

What is the typical onset and duration of action for IR vs. ER methylphenidate formulations?

Decreased appetite/weight loss, insomnia, abdominal pain, headache, and mild increases in heart rate and blood pressure.

Common AEs of Methylphenidate

Ritalin, Methylin 5 mg once to twice daily

- max: 60 mg/day

- short-acting; duration: 3-5 h

IR Methylphenidate formulations

1. Methylphenidate SR 20 mg QAM

- max: 60 mg/day

- duration: 3-8 h

2. Ritalin LA/Metadate CD (ER beads) 20 mg QAM

- max: 60 mg/day

- duration: 8-12 h

- capsules may be opened

3. Concerta (OROS) 18 mg QAM

- max: 72 mg/day

- duration: 10-12 h

- shell in stool

4. Aptensio XR 10 mg QAM

- max: 60 mg/day

- duration: 10-12 h

- 40% IR, 60% ER

ER Methylphenidate formulations

Daytrana 10 mg patch. Apply to the hip in the AM and remove after 9 hours

- max: 30 mg patch

- duration 12 h (9h wear)

Which methylphenidate product is available as a transdermal patch?

Cotempla XR-ODT 17.3 mg QAM

- max: 51.8 mg/day

- duration: 10-12 h

Which methylphenidate product is available as an ODT?

Quillivant XR 10-20 mg QAM

- shake well

- max: 60 mg/day

- duration: 10-12 h

Which methylphenidate product is available as a liquid?

QuilliChew ER 20 mg QAM

- max: 60 mg/day

- duration: 10-12 h

Which methylphenidate product is available as a chewable tablet?

Jornay PM 20 mg PM

- take between 7-9 pm for AM control

- max: 100 mg/day

- duration: 10-12 h

Which methylphenidate formulation is taken at night (PM dosing) to provide symptom control the following morning?

Focalin IR 2.5 mg QAM/BID

- half the MPH dose

- max: 20 mg/day

- duration: 3-5 h

IR dexmethylphenidate formulation

Focalin XR 5 mg QAM

- max: 30 mg/day (kids)

- duration: 10-12 h

ER dexmethylphenidate formulation

Azstarys (serdexmethylphenidate/dexmethylphenidate) 39.2/7.8 mg QAM

- max: 52.3/10.4 mg

- duration: 10-12 h

- prodrug for smoother profile

Prodrug of dexmethylphenidate

increase synaptic dopamine and norepinephrine via reuptake inhibition and enhanced release.

MOA for amphetamine-based stimulants

1. Adderall IR (mixed salts) 2.5-5 mg QAM/BID

- MDD: 40 mg

- duration: 4-6 h

2. Evekeo 2.5-5 mg QAM

- MDD: 40 mg

- duration: 4-6 h

- 1:1 isomer ratio

3. Dextroamphetamine IR 2.5 mg QAM/BID

- MDDL 40 mg

- duration: 3-5 h

- pure d-amphetamine

IR amphetamine formulations

1. Adderall XR 5-10 mg QAM

- MDD: 30 mg

- duration: 10-12 h

- once daily MAS

2. Mydayis 12.5-25 mg QAM

- MDD: 25 mg (peds)

- duration: 12-16 h

- triple bead formulation

3. Dexedrine spansule 5 mg QAM

- MDD: 40 mg/day

- intermediate-acting; duration: 5-8 h

ER amphetamine formulations

Adzenys XR-ODT 3.1 mg QAM

- MDD: 18.8 mg

- duration: 10-12 h

- MAS equivalent

ODT formulation of amphetamine

1. Adzenys ER Suspension 6.3 mg QAM

- MDD: 18.8 mg

- duration: 10-12 h

2. Dyanavel XR 2.5-5 mg QAM

- MDD: 20 mg

- duration: 10-12 h

Liquid formulations of amphetamine

Xelstrym Patch (dextroamphetamine patch) 4.5 mg; Apply in the AM and remove after 9 h

- max: 18 mg patch

- duration: 12 h (9h wear)

Patch formulation of amphetamines

Vyvanse (lisdexamfetamine) 30 mg QAM

- MDD: 70 mg/day

- duration: 10-12 h

- lower misuse potential

Amphetamine prodrug formulation

Vyvanse (lisdexamfetamine)

Which stimulant has a lower misuse potential?

Amphetamines are generally more potent than methylphenidate on a mg-for-mg basis

How does the potency of amphetamines compare to methylphenidate?

No, they use different release mechanisms

Can extended-release (ER) amphetamine formulations be substituted for each other?

Decreased appetite, weight loss, insomnia, abdominal pain, headache, and mild increases in HR/BP

AEs of amphetamines

Selective norepinephrine reuptake inhibitors.

What is the MOA of Atomoxetine (Strattera) and Viloxazine (Qelbree)?

In patients with comorbid anxiety or substance use disorder (SUD)

- onset over several weeks

In what clinical situations are Atomoxetine (Strattera) and Viloxazine (Qelbree) particularly useful?

alpha-2 adrenergic agonists

What is the MOA of Guanfacine XR and Clonidine XR?

Hyperactivity, impulsivity, tics, and sleep-onset problems

Which ADHD symptoms respond well to alpha-2 agonists (guanfacine XR, clonidine XR)?

It is a monocyclic antidepressant that weakly inhibits dopamine and norepinephrine reuptake

What is the mechanism of action of bupropion in ADHD?

Melatonin

What natural product may be used to help with sleep-onset insomnia in children with ADHD?

Fish oil (limited evidence)

Which natural supplement is sometimes preferred when parents want a non-pharmacologic option with minimal risk?

Personal and family cardiac history, blood pressure, heart rate, height, weight, and psychiatric history.

What baseline assessments should be completed before starting stimulant or nonstimulant ADHD medications?

Appetite, weight/BMI, sleep, BP/HR, mood changes, tics, and signs of diversion/misuse

What parameters should be monitored on an ongoing basis once ADHD medication is started?

Decreased appetite/weight, insomnia, mild ↑BP/↑HR, rare psychosis or mania, and growth deceleration (monitor percentiles).

What are the major adverse effects associated with stimulant medications?

Increased risk of suicidal ideation in youth; requires close monitoring of mood and behavior.

What boxed warning is associated with atomoxetine?

Sedation, hypotension, and bradycardia

What are key adverse effects of alpha-2 adrenergic agonists (guanfacine XR, clonidine XR)?

To avoid rebound hypertension

Why must alpha-2 agonists be tapered slowly when discontinuing therapy?

Behavioral therapy

What is the first-line treatment for preschoolers (ages 4-5) with ADHD?

Methylphenidate at low doses with close monitoring

Which medication is preferred for preschoolers if pharmacotherapy is required?

Substance use, depression, and anxiety

What should clinicians screen for in adolescents before starting stimulant therapy?

When there is a high risk of substance use disorder (SUD)

When should nonstimulants be considered in adolescents?

Alpha-2 agonists (guanfacine XR, clonidine XR) or cautious stimulant use

Which medications are preferred for patients with tic disorders?

More slowly, with consideration of nonstimulants or lower stimulant doses.

How should ADHD medications be titrated in patients with comorbid anxiety or ASD?

When there is no response after 1–2 weeks despite continuous titration efforts.

When should ADHD medication therapy be changed due to lack of response?

Change chronotherapy: adjust timing, formulation, or switch to a different release profile

What should be done if the patient experiences bothersome side effects with their ADHD medication?

Add supplemental "booster" doses using a combination of ER and IR formulation

What strategy can be used if symptoms return later in the day despite an ER medication?

Every 2-4 weeks to adjust dose and address adverse effects.

How often should clinicians contact patients during stimulant titration?

Every 3-6 months.

Once a patient is stable on ADHD medication, how often should follow-up visits occur?

At least annually

How often should clinicians reassess the ADHD diagnosis and the need for ongoing medication?