Attention-Deficit Hyperactivity Disorder (ADHD)

• 3 Hallmark symptoms:

  • inattention

  • hyperactivity

  • impulsivity

• Age of onset is usually before 12

• Risk of comorbid psychiatric disorders with ADHD

• Symptoms of ADHD must persist for at least 6 months to be considered diagnostic

• Screen via the following for cardiovascular risk factors before initiating stimulants:

  • blood pressure, heart rate, height/weight, re-assess at f/u

  • only ECG in patients with concurrent cardiac abnormalities or those with a family hx of cardiac disease or sudden death

Therapy

Nonpharmacological

• parent/teacher training first-line in pre-school aged children

• Options include:

  • behaviour management, CBT, parent training, organizational skill training, etc.

• less effective than stimulants, but combined nonpharm/pharm therapy observed to be more effective than either alone

• Exercise also found to improve core ADHD symptoms, reduce anxiety, and improve cognitive function

• insufficient data exists to say whether specific diets affed ADHD signs/symptoms

Pharmacological

• methylphenidate only considered in preschoolers if they have moderate to severe ADHD and do not respond to behavioural therapy. This is along as the benefit outweighs the harm

Stimulants

• long-acting stimulants considered first-line

• Efficacy and safety differences between stimulants are minimal

• Limited evidence shows preference for amphetamines as first line for adults, and methylphenidate for children

• Immediate- and intermediate-acting stimulants are recommended for use when the patient requires more flexible dosing and minimal hours/day of medication or as add-on therapy to an extended-release formulation.

• Benefit is typically seen in the first week of therapy-

• A full trial is 3-4 weeks for stimulants, with a continuation for 6-12 months if response is adequate with little to no adverse effects

• Stimulant contraindications:

  • history of hypersensitivity to sympathomimetic amines

  • symptomatic CVD

  • uncontrolled hyperthyroidism

  • Hx of drug abuse

  • concurrent use with an MAOI

• What CNS stimulant is not typically used in ADHD due to reduced efficacy?

  • Modafinil

Long-Acting Stimulants

Intermediate-Acting Stimulants

Immediate-Acting Stimulants

Stimulant OD symptoms: glassy eyes, insomnia, hyperactivity