ADHD - Dr. G Study Guide

What is the most common childhood neurodevelopmental disorders in the U.S.?

ADHD

Do all three core symptoms (inattention, hyperactivity, impulsivity) have to be present for the diagnosis of ADHD?

No. Diagnostic criteria evaluate symptoms in two domains, inattention and hyperactivity/impulsivity.

What neurotransmitters are involved in the dysregulation of DA and NE in ADHD?

Decrease in NE and DA

ADHD diagnosis includes symptoms of _____ and/or ______ in __ settings.

inattention, hyperactivity-impulsivity, 2+

How many symptoms need to be present for children 16 years or younger?

6 or more

How many symptoms must be present in adolescents/adults 17 or older?

5 or more

An 11 y/o patient arrives at a psychiatry clinic with his parents. Upon evaluation, the psychiatrist notes that the patient has difficulty paying attention in school, talks excessively when answering a question, is easily distracted, forgets things, climbs curtains, and has trouble waiting in line. What symptoms of ADHD are present in this patient?

Difficulty paying attention

Talks excessively

Easily distracted

Forgetful

Climbs when not appropriate

Trouble waiting in line

If a person meets the diagnostic criteria in only one setting (e.g., only at home but not in school or work), is the diagnosis of ADHD accurate?

NO, ADHD is characterized by symptoms of inattention and/or hyperactivity/impulsivity and functional impairment in multiple settings.^1-6 Symptoms of ADHD can be severe and can change over time.^1-6

True or False: There is a higher prevalence of ADHD in males vs females.

True

What are the symptoms of Inattention?

Fails to give close attention to details, Trouble holding attention, Doesn't listen, Does not follow through on instructions, trouble organizing, often loses things, forgetful, easily distracted, avoids/dislikes task that require mental effort

What are the symptoms of hyperactivity/impulsivity?

Fidget/tap, leaves seat, runs or climbs when not appropriate, unable to play or take part of leisure activity quietly, "on the go", talks excessively, blurts out answers, trouble waiting, interrupts or intrudes on others

What is the most effective treatment, and what are the two types?

Stimulants - methylphenidate and amphetamine

Do stimulants need to be tapered off?

No

True or False: Majority of individuals with ADHD are treated with pharmacotherapy.

False

What are the common co-occurring conditions seen in children with ADHD?

co-occurring condition (e.g., behavioral or conduct problems, anxiety, depression, learning disorders).

The etiology of ADHD is unknown but has many risk factors including genetic susceptibility. True or False: 

Genetic susceptibility with ADHD is considered low.

False

What are the two symptoms ADHD and bipolar have?

hyperactivity & impulsivity

True or False: Children 16 yo or younger need more symptoms (> 6) for the dx of ADHD than for those 17 yo or older ((> 5).

True

An individual’s ADHD categorization can change with age. Adult ADHD has less ______ symptoms.

hyperactivity

True or False: There must be at least 6 ADHD symptoms for 6 months for the dx of ADHD in a 12 yo boy.

True

Rating scales are used to assist with diagnosis, including identification of subtype, and for follow-up assessments. They can also be helpful to identify symptom variation based on setting if scales are completed by the parent and the _____.

Teacher

True or False: In preschool-aged children (age 4 years to the 6th birthday) with ADHD, first-line intervention is evidence-based parent training in behavior management (PTBM).

True

If parent training in behavior management fails (< 6yo), what ADHD meds can be considered?

Diagnosis should be made according to DSM-5 criteria, and intervention recommendations vary based on age. In preschool-aged children (age 4-5) with ADHD, first-line intervention is evidence-based parent training in behavior management (PTBM), with or without behavioral classroom interventions. If these interventions are inadequate, methylphenidate may be considered.

What is the first-line intervention for children and adolescents (6-18 yo)?

first-line intervention is treatment with an FDA-approved medication for ADHD, in conjunction with PTBM, with or without behavioral classroom interventions, adolescents with ADHD aged 12-17 → first-line intervention is treatment with FDA-approved medication for ADHD. If available, evidence-based training interventions and/or behavioral interventions as additional treatment are also encouraged.⁶

Name some commonly prescribed methylphenidate medications for the treatment of ADHD.

Daytrana → methylphenidate patch, Concerta → oros, Jornay PM → at night

Name some commonly prescribed amphetamine-based medications for the treatment of ADHD.

Adderall → high abuse potential, Vyvanse (prodrug) → less abuse risk no high peak, Mydayis → IR and ER

Why does vitamin C decrease the absorption of stimulants for ADHD?

Acidifies the urine, so methylphenidate and amphetamines become more ionized (charged). Ionized drugs cannot easily cross the cell membrane → less likely to be reabsorbed back into the bloodstream from the renal tubules → More drug stays in the urine and is eliminated from the body, decreasing the effect

What other types of food should be avoided in patients taking stimulants?

High-fat meals slow stomach emptying, so the drug stays in the stomach longer before moving to small intestines → delayed absorption

VT is an 8 y/o male who takes Adderall 5 mg at 5 pm. Are there any issues with this?

All stimulants cause insomnia, and the latest dose should not be taken past 4 pm

What are the general side effects of stimulants?

Nausea

Upset stomach

Decreased appetite

Weight loss

Insomnia

Headache

Decreased growth and weight

Tachycardia

High BP

Hallucination

What are the cardiac side effects that patients should be aware of when starting stimulants?

increase in HR and increase in SBP or DBP

What are the growth side effects that patients should be aware of when starting stimulants?

decrease in height in the first 2-3 years of usage

What are the psychiatric side effects that patients should be aware of when starting stimulants?

may cause psychosis, mania, anxiety, and/or panic disorder

You have an 8 y/o patient who was started on Adderall, which led to side effects including insomnia, tics, anxiety, and aggression. What do you recommend?

Patient has an intolerance to stimulants, so discontinue stimulants and try Clonidine XR (Kapvay)or Guanfacine (Intuniv)

Which stimulant (generic and brand) can be taken at night?

Methylphenidate (Jornay PM)

Explain why Jornay PM can be taken at night. What is a potential advantage of this formulation?

10 hrs before Jornay PM is released 

ADV → avoid high fat meals and orange juice in morning bc delay release

What is the brand name of dexmethylphenidate?

Focalin

What are the FDA indications for Vyvanse?

Binge Eating Disorder

ADHD

Which drug is less abusable than other stimulants? Why?

Lisdexamfetamine (Vyvanse) — prodrug

requires metabolism into the active dextroamphetamine and cannot be easily snorted or injected. There is also a more prolonged onset than other stimulants

What is the MOA of stimulants for the treatment of ADHD?

The primary mechanism of action of the stimulant medication class involves the inhibition of dopamine and norepinephrine transporters

True or False: Amphetamine-based stimulants is slightly more efficacious than methylphenidate-based agents, yet methylphenidate-based stimulants have shown better overall tolerability.

True

What is the duration of action for Concerta for QD administration? Ritalin LA?

Concerta: 12 hours

Ritalin LA: 8 hours

Which antidepressant can be used off-label for ADHD?

Bupropion (Wellbutrin)

Which two Alpha-2 Agonists are approved for treating ADHD?

Clonidine (Kapvay ER)

Guanfacine (Intuniv ER)

What is the generic of Strattera?

Atomoxetine

When should Strattera be used?

Polysubstance abuse

What is the MOA of Strattera?

SNRI

What are the 4 nonstimulant medications that are FDA-approved for ADHD?

Strattera (atomoxetine), 

Qelbree (viloxazine), 

Kapvay (clonidine) + Onyda (clonidine extended release), 

Intuniv (guanfacine extended release).

True or False: Strattera (atomoxetine) can be recommended for people with ADHD and hx of substance abuse.

True

True or False: Clonidine is an alpha-2 adrenergic agonist for the treatment of ADHD sxs of hyperactivity/impulsivity and agitation/aggression.

True

True or False: Vitamin C can acidify the urine and significantly decrease the concentration/efficacy of stimulants as weak bases.

True