ADHD

Question 1

What are some adverse outcomes in childhood/adolescence that is associated with ADHD?

Answer 1

1. EDUCATIONAL problems - lower rates of high school grade & post secondary education completion
2. difficult PEER relationships
3. Increased rates of MVAs, accidental injuries, substance misuse (this is further increased if ADHD is co-morbid with conduct disorder)

Question 2

Choose factors that are thought to play a role in ADHD:

1. Genetics
2. In utero exposure to ETOH
3. Epilepsy
4. TBI
5. prematurity

Answer 2

All of the following are contributory factors though prematurity was not listed in CPS statement

• Genetics factors –> highly hereditary
• Prenatal/postnatal –> in utero exposure to ETOH, tobacco, LBW
• neuro factors –> hypoxic/anoxic brain injury, epilepsy d/o, TBI
• Environmental factors –> e.g. toxins

Question 3

Name non-pharm tx of ADHD

Answer 3

1. Parent training program –> help parents dev age appropriate developmental expectations, specific management skills for behaviour issues. FIRST LINE intervention for children < 6 yoa
2. Organizational skills training
3. Physical exercise
4. Psychoeducation
5. Shared decision making
6. Classroom management -> e.g. setting up rules & expectations
7. Daily report card
8. Behavioural peer interventions

*Note: no clear evidence for social skills training in improving classroom behaviour or peer interaction skills

Question 4

What is true regarding the diagnosis of ADHD:

1. Symptoms must be present before the age of 12
2. They must be present for at least 3 months
3. Symptoms are severe, persistent and inappropriate for patient’s age & developmental level
4. There is an impairment in academic achievement, peer & family relations, adaptive skills
5. Symptoms must be present in 3 different settings
6. Must require at least 5 of 9 symptoms in inattentive or hyperactive symptoms in order to meet criteria

Answer 4

1,3,4 are true

• 2 is false b/c sx must continue for > 6 months
• 5 is false b/c sx must be present in 2 or more different settings (e.g. school, home)
• 6 is false b/c need 6 out of 9 symptoms to make diagnosis

Question 5

DDx for ADHD

Answer 5

• mood & anxiety disorders
• Bipolar*, psychosis
• personality disorders
• ODD, conduct disorder, tic disorder, substance use disorder
• Developmental coordination d/o
• reactive attachment disorder
• adjustment disorders, PTSD
• learning disorder, language disorder
• intellectual disability
• ASD
• sleep disorders
• Fragile X, TS, NF, DiGeorge
• sensory impairment (e.g. vision, hearing)
• chronic health conditions (e.g. epilepsy, post-concussion status)

Question 6

Name some cormorbidities with ADHD

Answer 6

1. ODD, CD
2. Anxiety d/o, OCD
3. Mood d/o (including Bipolar)
4. SUD
5. Tic D/o
6. Developmental coordination d/o
7. ASD
8. Eating disorder
9. Specific learning disorder –> this is the most COMMON comorbid condition

Question 7

Choose all that are true. Benefits of stimulant use include:

1. improved parent reported QOL
2. improvement in academic performance
3. lower rates of comorbid anxiety & depression
4. evening driving performance
5. fewer injuries leading to ED visits
6. reduced morbidity/mortality with MVAs
7. core sx diminishing over time

Answer 7

All are true except 7

Question 8

in combination with non-pharm therapies, which medications are first line for tx of ADHD?

Answer 8

• Extended release stimulant medications are the preferred medication
• Non-stimulants such as Guanfacine & Strattera have lower response rates & effect size vs stimulants; typically used when stimulants are ineffective, not tolerated, or contraindicated

Question 9

Which of the following are SE of stimulants?

1. Reduced appetite
2. irritability, moodiness
3. Raynaud’s
4. Priapism
5. Psychosis
6. increased HR & BP

Answer 9

All of the above!

- Priapism and psychosis are rare

Question 10

Which patients should undergo ECG testing +/- peds cardio consult?

Answer 10

Those at risk of stimulant induced CV adverse events (based on fam & persona hx, cardiac exam)

Question 11

Side effects of Strattera (Atomoxetine) include all of the following EXCEPT:

1. Headaches
2. moodiness, irritability
3. GI sx
4. increased BP & HR
5. suicide-related events
6. seizures
7. hepatic disorders

Answer 11

Answer - 6

Question 12

Select all side effects of Guanfacine:

1. Orthostatic hypotension
2. Bradyacrdia
3. Sedation
4. Raynauds
5. QTc prolongation

Answer 12

All are side effects!

Question 13

What are children at risk for if guanfacine is stopped abruptly?

Answer 13

Rebound HTN, tachycardia or hypertensive encephalopathy (rare)