6 - ADHD

Question 1

Describe ADHD

Answer 1

• Most common neurodevelopmental disorder in children
• Unknown cause – genetics, low birth weight, male:female = ~2:1
• • 25% of children w/ ADHD have a parent who meet ADHD dx
• • Females less likely to have disruptive sx

Question 2

Developmental impact of ADHD across lifespan

Answer 2

• 2-5x greater risk of trauma, burns, poisoning
• Substance use disorder 2x greater
• Affects academic problems, social interactions, self-esteem issues throughout life

Question 3

Diagnosis of ADHD

Answer 3

• No objective tests/ biological markers for diagnosis
• General mental health screening (to identify comorbidities & differential diagnoses)
• ADHD assessment tool
• Info gathering from parents/ caregivers & teachers and self-assessment
• Exclude medical causes that mimic/ aggravate ADHD sx
• Review lifestyle habits (ex: exercise, high-risk activities, substance use)

Question 4

Describe the core sx of ADHD. How many are needed for a diagnosis?

Answer 4

• Need 6/9 sx from either group for diagnosis
• Majority of px are combined subtype instead of primarily inattentive or primarily hyperactive/impulsive
• Inattentive sx – sustained attention problem solving
• • Difficulty following through or finishing tasks; disorganization; trouble sustaining mental effort
• Inattentive sx – selective attention
• • Pays little attention to detail; makes careless mistakes; doesn’t listen; loses things; forgets things; easily distracted
• Impulsive sx
• • Talks excessively; blurts out; interrupts; doesn’t wait one’s turn
• Hyperactive sx
• • Fidgets; leaves one’s seat; running/ climbing; constantly “on-the-go”, has trouble playing quietly

Question 5

Goals of therapy for ADHD

Answer 5

• Eliminate or significantly decrease ADHD sx
• Improve behavioural, academic, and/or occupational performance
• Improve self-esteem & social functioning
• Minimize adverse effects of medications
• Improve QOL

Question 6

Best tx approach

Answer 6

• Non-drug (psychosocial) + medications (ex: stimulants, atomoxetine) to improve QOL & core ADHD sx
• Stimulants & atomoxetine have greatest effect on core sx of ADHD
• Behavioural therapies important for improving social interactions, self-esteem, & common behaviours seen in ADHD; inferior to drug alone at reducing core ADHD sx
• Combination more effective at reducing oppositional behaviour & anxiety and improving social interactions & self-esteem compared to either tx alone

Question 7

Psychosocial interventions for ADHD

Answer 7

• Psychoeducation –> educate & empower px/families providing info on ADHD
• Parent management training models –> reinforce positive behaviour, ignore low-level provocative behaviour, provide clear, consistent, & safe responses to unacceptable behaviour
• Social skills training –> perceive & interpret subtle cues & problem-solve in social interactions
• Cognitive behavioural therapy –> focuses on interaction between cognition, emotion, behaviour
• Mindfulness training –> increase mindful attention to own thoughts & actions

Question 8

Medication options for ADHD

Answer 8

• Psychostimulant (amphetamine-based or methylphenidate-based)
• Selective norepi reuptake inhibitor (atomoxetine)
• Alpha 2-agonist (clonidine, guanfacine)
• Antidepressant (bupropion, venlafaxine, TCAs)
• Dopaminergic agent (modafinil)

Question 9

Medication guidelines for ADHD

Answer 9

• First line = long-acting psychostimulants (Adderall, biphentin, concerta, Vyvanse)
• • Dosed once daily; less abuse potential/ diversion; harder to titrate; more expensive
• Second line = long-acting non-psychostimulants (atomoxetine, guanfacine)
• Second line/ adjunctive = short & intermediate-acting psychostimulants (Dexedrine to augment Adderall/ vyvanse, Ritalin to augment biphentin/ concerta)
• • Role = PRN for certain activities, augment long-acting preps early or later in day; if long-acting cost prohibitive

Question 10

Describe pt factors that should be considered when selecting a medication for ADHD

Answer 10

• Age & individual variation
• Duration of effect required by timing of sx
• Concurrent psychiatric/ medical issues
• Physician/ family/ pt attitudes

Question 11

Describe medication factors that should be considered when selecting a medication for ADHD

Answer 11

• MOA, DIs
• Delivery system, duration of action
• Available doses
• Canadian clinical indications
• Affordability, accessibility

Question 12

Describe other considerations that should be made when selecting a medication for ADHD

Answer 12

• Combining meds for adjunct effects
• Potential for abuse, misuse, diversion
• Generic formulations

Question 13

Common side effects of ADHD medications

Answer 13

• Headache, decreased appetite, increased appetite in evening, insomnia, tics, irritability, rebound hyperactivity
• Most improve w/in 2-3 weeks of continuous use

Question 14

Stimulants & CV risk

Answer 14

• Increase BP 3-4 mmHg & HR 1-2 bpm in children/ adolescence
• Monitor BP, HR at baseline & follow-up
• Routine EKG screening not recommended
• Avoid stimulant/ atomoxetine use in those w/ serious heart problems or where BP/HR increase would be problematic

Question 15

ADHD & substance use disorder

Answer 15

• Comorbidity of SUG & ADHD is high (25% adults, 50% adolescence)
• LA stimulants may have lower abuse potential than IR products
• Atomoxetine, bupropion, guanfacine options if active SUD
• Oral psychostimulants don’t have the same abuse liability as illicit stimulants (ex: cocaine)
• Alcohol increases SE from stimulants

Question 16

Stimulants & growth

Answer 16

• May be associated w/ decreased height at least in first 1-3 years of tx
• Most achieve satisfactory adult height
• Monitor height, weight, BMI at baseline & annually
• • If crosses 2 percentile lines –> drug holiday or switch to non-stimulant

Question 17

Advantages of drug “holidays”

Answer 17

• May minimize loss of height & weight
• Allow pt & physician to continue to reassess benefits & risks of medication
• Weekend “drug holiday” might work for insomnia or appetite suppression

Question 18

Disadvantages of drug “holidays”

Answer 18

• Risks of medication discontinuation may exceed any potential benefit
• Consensus recommendation is that risks, benefits, & alternative coping strategies be discussed & individualized approach taken

Question 19

Stimulants – monitoring

Answer 19

• Efficacy (core sx) – response = 1 week; trial = 3-4 weeks
• Safety, common SE (headache, insomnia, anxiety, increased BP/ HR, appetite suppression) – most resolve in 2-3 weeks
• Safety; growth – baseline & annually

Question 20

Non-psychostimulant options

Answer 20

• Selective norepi reuptake inhibitor (Atomoxetine)

- Selective alpha 2-adrenergic receptor agonist (Guanfacine)

Question 21

Describe atomoxetine. Indication and monitoring

Answer 21

• 25-30% reduction in core sx in 60-70% of people after 6-12-week tx
• Indication = 6 y & older, adolescents, adults w/ ADHD
• • Role = no response to stimulant, comorbid anxiety, active SUD
• Suicidal ideation in children/adolescents increases 4/1000; monitor in the first few months
• Monitor efficacy (core sx) – response in 3-4 weeks, trial = 6-12 weeks (slower onset)
• If suicidal thoughts/ behaviours, stop tx

Question 22

Describe alpha 2-adrenergic agonists

Answer 22

• Clonidine, guanfacine
• Moderate benefit in children/ adolescence
• Primarily reduce aggression, impulsivity, hyperactivity; less pronounced benefits on inattention
• Combined w/ stimulants – target sleep disruption, aggression, impulsivity, tics
• Monitor efficacy (core sx) – response in 3-4 weeks, trail = 6-12 weeks
• Withdrawal reactions occur if stopped suddenly after long-term use (1-2 months)
• • Taper 25% q3-7days to prevent rebound HTN, sedation

Question 23

What other drugs can be used for ADHD?

Answer 23

• Antidepressants (bupropion, venlafaxine) – 2nd/3rd line or adjunctive, less effective than stimulants
• • Role = comorbid depression, anxiety, enuresis, tic disorders
• Antipsychotics – may negatively affect cognition in ADHD px