ASD and ADHD

what is applied behavioral analysis (ABA)?

therapist teaches ASD youth appropriate emotions

what is conduct disorder (CD)?

pattern of behavior violating rights of others

what is oppositional defiant disorder (ODD)?

pattern of oppositional behavior

what are the 2 core symptom domains in ASD?

-persistent social communication and social interaction deficits

-restricted or repetitive patterns of behavior

what are 4 neurobiological differences that contribute to ASD?

-amygdala dysfunction

-increased 5HT synthesis

-increased D2 receptor binding

-excessive glutamate

what are 4 examples of first line nonpharmacologic therapy for ASD?

-parent and family education

-structured activities/routine

-speech therapy

-ABA

what are 5 recommendations for creating healthy eating habits for those with ASD?

-establish mealtime routine

-minimize distractions

-reward positive behavior, ignore negative behavior

-"rule of 3": 2 foods they like + 1 new food

-present food in small bites

what are 2 FDA approved therapies for ASD along with their target symptoms and unique ADRs?

-risperidone: aggression, irritability, repetitive behaviors; drooling and prolactin elevation

-aripiprazole: aggression, irritability, repetitive behaviors; nausea

what are 2 medications used to treat inattention or hyperactivity in ASD?

-methylphenidate/amphetamine

-atomoxetine

what is buspirone used to treat in ASD?

restricted and repetitive behaviors in 2-6 year olds

what medication is a well tolerated and effective complementary treatment for ASD?

melatonin, take 1-3 mg an hour before bed (max 10 mg qd)

what 5 medications may be effective as complementary treatments for ASD?

-omega 3: 750-1500 EPA/DHA for hyperactivity

-N-acetylcysteine: 600-900 bid-tid for irritability

-levocarnitine: 50 mg/kg/day for emotional relatedness

-vitamin C: 500-2000 mg/day

-multivitamin: B supplements common

what are 4 outcomes of untreated ADHD?

-impair learning

-impair social development

-low self esteem

-contribute to family discord

what are the diagnostic criteria for ADHD?

-6/9 symptoms of inattention, hyperactivity, impulsivity

-duration of 6 months

what are 5 common comorbid conditions with ADHD?

-learning disability

-oppositional defiant disorder

-anxiety

-depression

-ASD

how does ADHD differ through 3 life stages?

-childhood: most symptoms, unable to focus, hyperactive, excessive talking

-adolescence: disorganization, late, overreacting to frustration

-adults: fewer symptoms, unstable relationships, inflexible

what are 6 symptom rating scales for ADHD?

-connors

-vanderbilt

-child behavior checklist

-ADHD rating

-scale IV

-SKAMP

what are 2 aspects of ADHD as a functionally impairing brain disorder?

-deficits in D2/D3 receptors and DAT

-failure of default mode network to suppress stimuli leading to lapses in attention and poor impulse control

how does the brain differ in ADHD at ages 8-11 vs adult hood?

-average ADHD brain shows less development, less thickening

-adults have less cortical thickness and gray matter

what is first line treatment of ADHD for 3-5 year olds?

behavioral interventions

what is first line treatment for ADHD?

methylphenidate/dexmethylphenidate (MPH) or amphetamine salts (MXA)

what are 6 adverse reactions to MPH or MXA?

-nausea

-anorexia

-insomnia

-tics

-increased HR/BP

-growth effects in youth

what is first line for ADHD if substance use disorder is present?

atomoxetine, a selective norepinephrine reuptake inhibitor

what are 4 adverse reactions to atomoxetine?

-nausea

-sedation

-tachycardia

-rarely hepatotoxicity

what is the MOA of stimulants?

-inhibit presynaptic reuptake of NE and DA

-MAO inhibition

-amphetamines increase catecholamine release

-modulates "default mode network"

what are the 2 categories of stimulant?

-methylphenidate/dexmethylphenidate

-dextroamphetamine/mixed amphetamine salts

which drug is the safest and most effective for preschoolers with ADHD?

methylphenidate

what are 3 durations of methylphenidate formulations?

-IR: 3-4 hr

-ER: 8-12 hr

-extra long acting: 16 hr

what are 5 ER formulations of methylphenidate?

-Ritalin LA capsule

-Metadate CD capsule

-Focalin XR capsule

-Concerta 3 pulse delivery system

-Jornay PM delayed release beads

what are 2 factors that can lower risk of adolescent SUD and risk of injury?

-early stimulant treatment before age 9

-longer duration of stimulant use, 6 years or more

what are 4 benefits of stimulant use in ADHD?

-improved academic performance and classroom behavior

-better social interactions

-development of self esteem

-prevents self medication with drugs and alcohol

what are 5 risks of stimulant use in ADHD?

-upset stomach, decreased appetite

-insomnia, irritability

-cardiac and potential growth effects

-earlier onset psychosis

-drug diversion

what are 3 durations of amphetamine formulations?

-IR: 4-6 hr

-ER: 10-13 hr

-extra long acting: 16 hr

what is the dosing for concerta and its considerations?

-18-54 mg/day for adolescents

-3 pulse drug delivery

-may appear in stool

-cannot crush/snort

-less abuse risk

what is the dosing for metadate CD?

start 10 mg, max is 60 mg/day

what is the dosing for ritalin LA?

start 10 mg, max is 60 mg/day

what is the dosing for focalin XR and its main component?

-30 mg for child, 40 mg in adult

-dexmethylphenidate

what is the dosing for adderall XR?

start 10 mg/day; max for children is 30 mg, max in adults is 40 mg

what is the dosing for vyvanse and its main component?

-20-70 mg/day

-lisdexamfetamine

what are 3 common stimulant SEs and management?

-upset stomach: give on a full stomach

-insomnia: dose in am, melatonin

-headache: tolerance over time, APAP

what are 6 uncommon to rate stimulant SEs and management?

-tics: lower dose

-dysphoria: reassess diagnosis, lower dose

-hallucinations: DC

-over-focused: lower dose

-priapism

-peripheral vasculopathies

how does stimulant use for ADHD in youth relate to CV health?

-2x the risk of a CV event

-higher doses, higher risk

-regular monitoring essential

-behavioral therapy can allow for lower doses

how does stimulant treatment in youth relate to growth?

-some decreased growth, but long term effects minimal in most

-possible alterations in growth hormone or growth factor secretion; appetite loss leads to reduced calorie intake

what are 4 nonstimulant drugs for ADHD and their notable adverse effects?

-atomoxetine (strattera): severe liver injury

-bupropion (wellbutrin): dose related risk of seizures

-clonidine (catapres): heart block

-guanfacine (tenex or intuniv): potentially lower risk of sedation

what are 5 coexisting conditions with ADHD and their special treatment considerations?

-OD or CD: short term adjunctive risperidone or alpha 2 agonist

-SUD: supervised stimulant, atomoxetine or bupropion

-ASD: caution, seizure risk

-tourettes: methylphenidate is effective

-bipolar disorder: stabilize mood before stimulant

what are 4 considerations for those with ADHD and substance use?

-alcohol abuse significantly higher if ADHD

-treatment may include substance abuse recovery

-atomoxetine is a good option for those with SUD

-bupropion is another option, but be mindful of seizure risk

what are 4 ADHD medication counseling points?

-stimulants are most effective

-improve symptoms in 1-2 hr, takes 2-4 wk for trial

-once daily stimulants preferred to improve adherence

-never abruptly stop treatment, especially with alpha 2 agonists due to rebound effects and relapse

what are 4 complementary and alternative therapies for ADHD?

-iron supplement in youth with deficiencies

-omega 3 supplementation

-avoid sugar and aspartame

-avoid food coloring and preservatives