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ADHD Flashcards

clinical tips on ADHD (83 cards)

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1
Q

What is the most common pediatric neuropsychiatric disorder?

A

Attention-deficit hyperactivity disorder (ADHD)

Affects 4–12% of North American school-aged children and 2–8% of preschool-aged children.

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2
Q

ADHD is characterized by three hallmark symptoms: inattention, hyperactivity, and impulsivity. True or False?

A

TRUE

Symptoms are present at a magnitude and frequency beyond what is expected for a given age or developmental stage.

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3
Q

Individuals with ADHD may be diagnosed with which subtypes?

A
  • Primarily inattentive subtype
  • Primarily hyperactive/impulsive subtype
  • Combined subtype

The combined subtype is the most common.

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4
Q

Symptoms of ADHD typically present before the age of _______.

A

12

Symptoms may persist into adulthood, with a prevalence of approximately 3–4% in adults.

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5
Q

People with ADHD are at higher risk for comorbid psychiatric disorders, including _______.

A
  • Oppositional defiant disorder (ODD)
  • Learning disorders
  • Mood disorders
  • Anxiety disorders
  • Substance use disorders

These comorbidities can complicate the diagnosis and treatment of ADHD.

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6
Q

According to DSM-5-TR, how many symptoms are required for diagnosing ADHD in children?

A

Six (or more) symptoms

For older adolescents and adults (age 17 and older), at least five symptoms are required.

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7
Q

What are the four criteria for diagnosing ADHD according to DSM-5-TR?

A
  • Symptoms present prior to age 12
  • Symptoms present in two or more settings
  • Symptoms interfere with social, academic, or occupational functioning
  • Symptoms not better explained by another mental disorder

These criteria help ensure accurate diagnosis.

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8
Q

What are the goals of therapy for ADHD?

A
  • Eliminate or significantly decrease ADHD symptoms
  • Improve behavioral, academic, and/or occupational performance
  • Improve self-esteem and social functioning
  • Prevent or minimize complications
  • Minimize adverse effects of medications
  • Improve quality of life

These goals guide treatment strategies.

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9
Q

Currently, there are no objective tests that diagnose _______.

A

ADHD

Diagnosis is based on behavioral symptoms and their impact on functioning.

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10
Q

What is the first-line treatment for preschool-aged children with ADHD?

A

Behavior management programs

Medication is considered only if behavioral therapy is ineffective.

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11
Q

What are the first-line agents for treating ADHD in children and adults?

A
  • Long-acting stimulant medications (e.g., lisdexamfetamine, methylphenidate)
  • Mixed salts amphetamine

Stimulants are considered the most effective treatment for core symptoms.

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12
Q

True or False: Stimulants are controlled substances and their dispensing is subject to specific regulations.

A

TRUE

Their efficacy at reducing core ADHD symptoms has been demonstrated in a wide range of patients.

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13
Q

What are some nonpharmacologic choices for ADHD treatment?

A
  • Behavior management
  • Cognitive-behavioral therapy
  • Parent training
  • Organizational skills training

These approaches are recommended alongside pharmacologic therapies.

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14
Q

What is the recommended duration for a trial with stimulants in ADHD treatment?

A

3 to 4 weeks

Improvement of core ADHD symptoms is often observed in the first week.

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15
Q

What are the contraindications to stimulant use in ADHD?

A
  • History of hypersensitivity to sympathomimetic amines
  • Symptomatic cardiovascular disease
  • Uncontrolled hyperthyroidism
  • History of drug abuse
  • Concurrent use with an MAOI

These factors must be considered before prescribing stimulants.

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16
Q

What is the prevalence of ADHD in adulthood?

A

Approximately 3–4%

ADHD symptoms may persist into adulthood even without a childhood diagnosis.

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17
Q

What is the recommended first-line therapy for ADHD according to the CADDRA 2020 guidelines?

A

Long-acting stimulants

Examples include mixed salts amphetamine (Adderall XR), methylphenidate (Biphentin and Concerta), and lisdexamfetamine (Vyvanse).

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18
Q

List the advantages of long-acting stimulant formulations.

A
  • Single daily dosing
  • Improved adherence
  • Avoidance of medication administration at school
  • Decreased risk of rebound hyperactivity

Long-acting formulations have a duration of action of 8–14 hours.

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19
Q

What are the common adverse effects of stimulants?

A
  • Increased heart rate
  • Increased blood pressure
  • GI upset
  • Appetite suppression
  • Anxiety
  • Irritability
  • Insomnia

Monitoring for these effects is crucial in patients taking stimulants.

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20
Q

True or false: Modafinil is often used as a first-line treatment for ADHD.

A

FALSE

Modafinil is less effective than other stimulants and is not often used for ADHD.

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21
Q

What should be monitored in children taking stimulants for potential growth suppression?

A
  • Weight
  • Height

Measurements should be recorded at baseline and then every 3–6 months.

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22
Q

What is the risk associated with ADHD medications regarding suicidal thoughts?

A

Increased risk of suicidal thoughts and behaviours

Monitoring is essential, especially at the start or end of treatment, or when dosages are adjusted.

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23
Q

What is atomoxetine classified as?

A

A norepinephrine reuptake inhibitor

It is recommended as a second-line agent for ADHD treatment.

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24
Q

What are the contraindications for atomoxetine?

A
  • Hypersensitivity to atomoxetine
  • Narrow angle glaucoma
  • History of severe cardiac or vascular disorders
  • Pheochromocytoma
  • Concurrent use with an MAOI

These conditions may increase the risk of adverse effects.

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25
What is the **duration of action** for intermediate-release stimulants?
Up to 8 hours ## Footnote They often require more than once-daily dosing.
26
What is the **role** of alpha2-adrenergic agonists in ADHD treatment?
Reduce symptoms of aggression, impulsivity, and hyperactivity ## Footnote They have less pronounced benefits on inattention.
27
What are the **common adverse effects** of guanfacine?
* Sedation * Headache ## Footnote Guanfacine is used as a second-line agent for ADHD.
28
What is the **effectiveness** of bupropion in treating ADHD?
Moderately effective ## Footnote It is a norepinephrine and dopamine reuptake inhibitor.
29
What should be monitored for **appetite suppression** in children taking ADHD medications?
* Consistent appetite suppression * Changes in weight ## Footnote Monitoring should occur every 2 weeks for the first 2 months, then every 6 months.
30
What is the **recommended management** for insomnia caused by ADHD medications?
* Lower the stimulant dose * Change to an earlier administration time * Add sedating medication at bedtime * Discontinue the offending stimulant ## Footnote Limit stimulating activities in the evenings.
31
What is the **risk** of substance abuse in patients with ADHD treated with stimulants?
Diagnosis of ADHD is a risk factor for substance-use disorder ## Footnote However, treated children may have a lower risk of substance-use disorders later in life.
32
What is the **impact of pregnancy** on ADHD symptoms?
Not well defined ## Footnote Hormonal variations and psychological issues may worsen symptoms.
33
What is the **duration of action** for long-acting stimulants?
8–14 hours ## Footnote They are as effective as appropriately dosed shorter-acting stimulants.
34
What is the **recommended approach** for drug holidays in ADHD treatment?
Wean medication for 2-3 weeks once a year ## Footnote This helps reassess ADHD-related behaviours and confirm the need for continued medication.
35
What is the **preferred treatment** for patients with mild-moderate ADHD symptoms during pregnancy?
Nonpharmacologic treatment ## Footnote This is recommended for patients without functional impairments.
36
True or false: **Methylphenidate exposure** during pregnancy is associated with an overall increased risk of major congenital malformations.
FALSE ## Footnote Methylphenidate exposure does not show an overall increased risk, but may be associated with an elevated risk of cardiac malformations.
37
Which medication should be **avoided during pregnancy**, especially in the first trimester?
Atomoxetine ## Footnote Due to lack of safety data during pregnancy.
38
What are the **risks associated** with using amphetamines during pregnancy?
* Not associated with increased risk of cardiac or major congenital malformations * Caution advised with methylphenidate ## Footnote An observational cohort study of 1.8 million pregnancies found these results.
39
What should be monitored in nursing infants when mothers are treated with **methylphenidate**?
* Agitation * Poor weight gain ## Footnote Transfer of methylphenidate into breast milk appears to be low.
40
Which medications are recommended to be used with caution during **breastfeeding**?
* TCAs * Bupropion * Venlafaxine ## Footnote These can be considered for patients with a good response while monitoring the nursing infant.
41
What is a significant concern when using **CNS stimulants** for ADHD treatment?
Potential for abuse and dependence ## Footnote Assess for this risk prior to prescribing and monitor for signs of abuse.
42
What should be done when switching from stimulant therapy to **atomoxetine**?
Continue a lower dose of the stimulant and taper over approximately 3 weeks ## Footnote This allows the new drug to take effect.
43
What is the **duration of action** for lisdexamfetamine?
13–14 hours ## Footnote This medication is effective for a prolonged period.
44
What are the **common adverse effects** of dextroamphetamine?
* Anorexia * Insomnia * Weight loss * Irritability * Dizziness * Weepiness * Headache * Abdominal pain ## Footnote These effects are usually transient.
45
What should be monitored in pediatric patients on ADHD medications?
* Growth (height and weight) every 3–6 months * Blood pressure and heart rate at baseline and follow-up ## Footnote Monitoring is crucial for safety and efficacy.
46
What is the **maximum dosage** for dextroamphetamine in children aged 6-17?
20–30 mg/day ## Footnote This is the recommended limit for safety.
47
What should be avoided when prescribing **stimulants**?
* MAOIs (e.g., phenelzine, tranylcypromine) * Theophylline ## Footnote These can increase hypertensive effects or other adverse reactions.
48
What is the **onset of effect** for stimulant medications typically seen?
Usually within the first week ## Footnote This is important for patient expectations regarding treatment.
49
What is the **maximum dosage** for mixed salts amphetamine extended-release capsules in adolescents aged 13 and older?
20–30 mg/day ## Footnote This ensures safe administration in older patients.
50
What are the **overdose symptoms** of stimulants?
* Glassy eyes * Insomnia * Hyperactivity ## Footnote If overdose symptoms occur, stop and retitrate the dose.
51
True or false: **Sudden cardiac death** has been reported as a significant risk associated with stimulant use.
TRUE ## Footnote Other significant risks include neurologic symptoms and exacerbation of tics.
52
In patients with a history of **cardiovascular conduction disturbances**, what should be avoided?
Stimulants ## Footnote This includes patients with hypertension, acute psychotic episodes, and hyperthyroidism.
53
If seizures occur in a patient with controlled epilepsy, what should be done?
Stop and re-evaluate ## Footnote Increased frequency of seizures also necessitates stopping and re-evaluating.
54
Which medications should be avoided due to their interaction with stimulants?
* MAOIs (e.g., phenelzine, tranylcypromine, moclobemide) * SSRIs * SNRIs * TCAs * Antipsychotics ## Footnote These can increase the hypertensive effect of stimulants or risk serotonin syndrome.
55
What is the **maximum dose** of methylphenidate for children aged 6 years and older?
60 mg/day ## Footnote Doses greater than 60 mg/day usually do not result in additional efficacy in children.
56
What should be monitored in pediatric patients taking stimulants?
* Growth (height and weight every 3–6 months) * BP and heart rate at baseline and within 1–3 months at follow-up ## Footnote Monitoring for growth is crucial to ensure proper development.
57
When should the last daily dose of stimulants be administered?
Before 4 p.m. ## Footnote This timing helps avoid insomnia.
58
What is the **onset of effect** for stimulants typically seen?
In the first week ## Footnote Individual responses may vary widely.
59
What are common **adverse effects** of methylphenidate?
* Anorexia * Insomnia * Weight loss * Irritability * Dizziness * Weepiness * Headache * Abdominal pain ## Footnote These effects are usually transient and may require continued therapeutic trials.
60
What should be done if a patient exhibits **zombie-like effects** or psychotic reactions?
Stop and re-evaluate ## Footnote Other serious reactions include agitation, tachycardia, and hypertension.
61
What is the **maximum dose** of guanfacine for children aged 6-12 years?
4 mg/day ## Footnote For adolescents aged 13-17 years, the maximum is 7 mg/day for monotherapy.
62
What are the **common adverse effects** of guanfacine?
* Somnolence * Headache * Fatigue * Upper abdominal pain * Irritability * Emotional lability * Nightmares * Bradycardia * Hypotension ## Footnote These effects are typically mild and may improve with continued use.
63
What should be monitored when prescribing **CNS stimulants**?
* Signs of abuse and dependence * Suicidal thoughts/ideation ## Footnote Assess for the risk of abuse prior to prescribing.
64
What is the **initial dose** of clonidine for ADHD management?
0.05–0.1 mg/day PO ## Footnote The dose can be adjusted based on patient response.
65
What is the **onset of effect** for clonidine?
Usually 2–3 weeks ## Footnote Clonidine typically improves hyperactivity and impulsiveness more than inattention.
66
What is the effect of agents like **carbamazepine**, **systemic dexamethasone**, **phenobarbital**, **phenytoin**, and **rifampin** on guanfacine serum concentrations?
They significantly reduce guanfacine serum concentrations ## Footnote Caution is advised with agents that decrease heart rate and/or BP.
67
What is the **onset of effect** for guanfacine?
Usually after 2 weeks ## Footnote Guanfacine is a selective alpha2a-adrenergic agonist with less sedation and hypotension than clonidine.
68
In Canada, guanfacine is indicated only for children aged _______.
6–17 years ## Footnote Monitoring of BP and heart rate is required during and after discontinuation.
69
What is the **initial dosage** of **bupropion** for ADHD treatment?
2–3 mg/kg/day PO ## Footnote Usual dosage is 200–300 mg/day in 2 divided doses.
70
List some **side effects** of bupropion.
* Agitation * Dry mouth * Insomnia * Headache * Constipation * Nausea * Vomiting * Nervousness * Dizziness * Sweating * Hypertension * Tachycardia * Suicidal ideation * Seizures ## Footnote Avoid in patients with a history of seizure disorders or eating disorders.
71
True or false: **Bupropion** can be used safely with MAOIs.
FALSE ## Footnote Use with MAOIs may cause mania, excitation, and hyperpyrexia.
72
What is the **initial dosage** of **venlafaxine** for adults?
37.5–75 mg daily PO for 1 week ## Footnote Titrate gradually to 150–300 mg daily.
73
What are some **side effects** of venlafaxine?
* Nausea * Drowsiness * Nervousness * Dizziness * Dry mouth * Increased BP if dose >300 mg/day ## Footnote May take up to 4 weeks for optimal drug effect.
74
What is the **usual maximum dosage** of **desipramine** for adolescents?
50 mg/day PO in 3–4 divided doses ## Footnote Maximum dosage is 150 mg/day.
75
List some **side effects** of desipramine.
* Postural hypotension * Anticholinergic effects * Dizziness * Nausea * Drowsiness * Weakness * Tremor * Weight gain * Tachycardia * Arrhythmias ## Footnote Avoid in patients with a history of cardiovascular conduction disturbances.
76
What is the **usual maximum dosage** of **imipramine** for children aged 6–12 years?
20 mg/day PO in 3–4 divided doses ## Footnote Maximum dosage is 150 mg/day.
77
What are some **side effects** of imipramine?
* Postural hypotension * Anticholinergic effects * Dizziness * Nausea * Drowsiness * Weakness * Tremor * Weight gain * Tachycardia * Arrhythmias ## Footnote Avoid with MAOIs due to potential for mania and excitation.
78
What is the **usual maximum dosage** of **nortriptyline** for adolescents?
50 mg/day PO in 3–4 divided doses ## Footnote Maximum dosage is 150 mg/day.
79
List some **side effects** of nortriptyline.
* Postural hypotension * Anticholinergic effects * Dizziness * Nausea * Drowsiness * Weakness * Tremor * Weight gain * Tachycardia * Arrhythmias ## Footnote Avoid with MAOIs; may cause mania and excitation.
80
What is the **initial dosage** of **risperidone** for behavioral symptoms?
0.25–0.5 mg HS PO ## Footnote Increase at weekly intervals by 0.5 mg/day in 2 divided doses as needed.
81
What are some **side effects** of risperidone?
* Weight gain * Drowsiness * Headache * Orthostatic hypotension * Dyspepsia * Extrapyramidal effects * Hyperprolactinemia ## Footnote Advise patients about body temperature dysregulation.
82
What is the **initial dosage** of **atomoxetine** for children aged 6–17 years and <70 kg?
0.5 mg/kg/day PO × 10 days ## Footnote Then titrate to 0.8 mg/kg/day for 10 days.
83
List some **side effects** of atomoxetine.
* Headache * Rhinorrhea * Upper abdominal pain * Nausea * Sedation * Vomiting * Decreased appetite * Dizziness * Fatigue * Emotional lability ## Footnote Significant risks include suicidal ideation and liver toxicity.
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