ADHD

Question 1

Associated adverse outcomes of ADHD :

Answer 1

• educational problems (low rates of high school graduation and completion of postsecondary education)
• difficult peer relationships
• increased MVAs
• accidental injuries
• substances misuse
• third most common mental health disorder (after depression & anxiety) - affects 3.4%

Question 2

Predictors of persistence of ADHD:

Answer 2

• combined inattention/hyperactivity
  * increased symptom severity
  * comorbid depression or mood disorder
  * high comorbidity (>3 additional DSM disorders)
  * parental anxiety
  * parental antisocial personality disorders
• 50% continue to have symptoms in adolescence and adulthood.

Question 3

Etiology of ADHD?

Answer 3

• highly heritable
  
  • rare copy number variants or accumulation of larger deletions & duplications influencing gene transcription are more commonly found in individuals with ADHD
• risk with:
  
  • in utero exposure to alcohol or tobacco
  • low birth weight (<2500g)
  • hypoxic-anoxic brain injury
  • epilepsy disorders (2-3 times higher than in general population)
  • TBI
  • genetic conditions (fragile X syndrome, turner syndrome, tuberous sclerosis, neurofibromatosis, 22q11 deletion syndrome)
• linked to environmental toxins (lead, organophosphate pesticides, polychlorinated biphenyls)
• delayed cortical maturation

Question 4

What investigations to order for ADHD?

Answer 4

• unless indicated by history and physical exam, do NOT:
  * order lab tests, genetic testing, EEG, neuroimaging
  * order psychological, neuropschological or speech-language assessments
  * use psychological tests as means to monitor symptom or functional improvement in dailty activities

Question 5

Differential diagnosis of ADHD

Answer 5

• learning disorder
• sleep disorder
• oppositional defiant disorder
• anxiety disorder
• intellectual disability
• language disorder, mood disorder, tic disorder, conduct disorder
• autism spectrum disorder
• developmental coordination disorder

Question 6

Comorbid disorders for ADHD?

Answer 6

• specific learning disorder *** most common comorbid condition
• Disruptive behaviour disorder - ODD & CD. Prevalence as high as 90%
• Anxiety disorder/obsessive compulsive disorder
  
  • anxiety disorders occur in 30% of patients with ADHD
• Mood disorder (including bipolar disorder)
• substance use disorders
• tic disorders
• developmental coordination disorder
• autism spectrum disorder
• eating disorders

Question 7

Nonpharmacological interventions for ADHD

Answer 7

• psychoeducation
• shared decision-making
  
  • parents focused on academic achievement more likely to start medication
  • parents focused on behaviour more likely to start behavioural therapy
• Parent behaviour training - first choice intervention in preschool age children
• classroom management
• daily report card
• behavioural peer interventions
• social skills training
• organizational skills training
• cognitive training
• EEG neurofeedback
• Diet - supplementation with free fatty acids, eliminate artificial food dyes - evaluate for suspected deficiencies
• exercise

Question 8

Treatment for children with ADHD <6 years ?

Answer 8

• first-line intervention is parent behaviour training

* medications should be considered for >=6 yrs

Question 9

Benefits of Stimulant medications in ADHD

Answer 9

• improved academic achievement
• lower rates of comorbid anxiety and depression
• better employment outcomes
• reduced morbidity and mortality
• improves parent-reported quality of life

Question 10

What is first line stimulant therapy for ADHD?

Answer 10

• recommendation 2: Medication use should be reserved for children diagnosed with ADHD whose academic performance or social interactions are impaired
• In combination with nonpharmacological interventions, ER stimulants are recommended as first-line therapy
  
  • ER medications less likely to be diverted for recreational use (difficult to crush)
  • give at breakfast time. Aim to “wear off” to avoid dinnertime suppression and sleep problems
  • titrate to lowest effective dose
• No drug holidays for kids who are at risk of poor outcomes and risky behaviours

Question 11

What is tachyphylaxis (for stimulant meds)?

Answer 11

• tachyphylaxis - dosing requirements may be increased initially because of up-regulation of liver enzymes

Question 12

What are adverse effects of stimulants?

Answer 12

• Preschool children have higher rates of AE , especially irritability and moodiness
• Raynaud’s - stimulants and nonstimulants
• Psychosis
• Priapism
• Increase in HR & BP (slight)
• growth (decrease by 2.5 cm) - final height associated with cumulative dose of stimulants
• Appetite - slight overall reduction in BMI, may delay pubertal growth-spurt timing

NOTE: tic disorder - overall risk for tic disorder not increased. comorbid tic disorder is not a contraindication for ADHD treatment

Question 13

Indications for non-stimulants in aDHD

Answer 13

Use when stimulants are:

* contraindicated
* ineffective
* or not tolerated 

low potential for diversion (lack a mechanism linked to abuse potential and immediacy of effect)

Atomoxetine (approved for 6-17 years)

* lower risk for weight loss and exacerbating tics
* reported to improve anxiety 
* little evidence for using stimulant and atomoxetine adjunctively 

Guanfacine chlorohydrate (approved for 6-17 years) 
    * utility as monotherapy or adjunctively for both ADHD and comorbid oppositional symptoms 

Clonidine (nonselective alpha adrenergic agonist) - not approved for use

Question 14

What to treat ADHD with if hx of substance abuse disorder?

Answer 14

nonstimulant or ER stimulant medication with lower risk for abuse and diversion

Question 15

Adverse effects of atomoxetine

Answer 15

• GI symptoms (appetite loss, upper abdo pain)
• somnolence, headaches, moodiness, irritability
• hepatic disorders (rare)
• suicide related events (rare)
• metabolized by CYP2D6 - long half life
  Raynaud’s phenomenon

Question 16

Adverse effects of guanfacine

Answer 16

• wean to prevent rebound hypertension, tachycardia, hypertensive encephalopathy
• sedation
• somnolence
• fatigue
• orthostatic hypotension, bradycardia, syncopal episodes
• Raynaud’s phenomenon
• prolongation of QTc

Recommendation 11: monitor blood pressure in patients on alpha-adrenergic drugs (guanfacine and clonidine) before initiating treatment, following dose increases and periodically

Question 17

Adverse effects of clonidine

Answer 17

• wean to prevent rebound hypertension, tachycardia, hypertensive encephalopathy
• sedation, dizziness, hypotension
• prolongation of QTc

Recommendation 11: monitor blood pressure in patients on alpha-adrenergic drugs (guanfacine and clonidine) before initiating treatment, following dose increases and periodically

Question 18

What conditions have both ADHD and ASD?

Management?

Answer 18

Fragile X syndrome, tuberous sclerosis, Williams syndrome, 22q11 deletion

Management

• first-line: psychostimulants - same treatment algorithm as for ADHD alone
  
  • more likely to be nonresponders and to have side effects
• SE: irritability with emotional outbursts, increased stereotypic behaviours
  
  • limited studies suggest atomoxetine improves ADHD symptoms in ASD+ADHD patients
• children with ASD benefit from early intense behavioural interventions

Question 19

What % of kids with ASD have ADHD?

What % of kids with ADHD have ASD?

Answer 19

• more than 50% of individuals with ASD meet criteria for ADHD
• up to 50% of children with ADHD have ASD traits

Question 20

What are other conditions associated with intellectual disability?

Answer 20

at least 50% of ID cases are associated with:

• chromosomal (Fragile X, Klinefelter, Turner syndrome)
• metabolic (aminoacidemias, PKU, galactosemia) or
• neurological conditions (neurofibromatosis, tuberous sclerosis, myotonic dystrophy)

Question 21

What is the most common comorbid condition with ADHD?

Answer 21

Specific learning disorder

- 1/3 of children with ADHD also have LD

Question 22

What conditions show a higher prevalence of ADHD?

Answer 22

fragile X syndrome
turner syndrome
tuberous sclerosis
neurofibromatosis
22q11 deletion syndrome

Question 23

What do you do before establishing a diagnosis of ADHD & initiating treatment for preschoolers?

Answer 23

AAP recommends parents enrol in a parent training program before being referred for ADHD assessment

Question 24

What are diet modifications that can be suggested in kids with ADHD?

Answer 24

supplementation with free fatty acids, eliminate artificial food dyes - evaluate for suspected deficiencies

Question 25

What are lower medication adherence associations for kids being treated with ADHD?

Answer 25

* older age * learning, mood or behavioural comorbidity * dosing that is too low for too long * high doses and AE

Question 26

What is the most common neurodevelopmental disorder comorbid with ID?

Answer 26

ADHD

Question 27

What adverse effects are kids with ID & ADHD at risk for when they take stimulants?

Answer 27

higher risk for tics and social withdrawal IQ > 50 predicts better response to stimulants

Question 28

What is the management for kids with ID & ADHD?

Answer 28

* Psychopharmacology * Stimulants: short-acting methylphenidate (studied in RCTs) - below response rate of ADHD alone * IQ above 50 predicts better response to stimulants; low IQ predicts poor response * higher risk for tics and social withdrawal * Nonstimulants: when psychostimulants and psychotherapy suboptimal * Risperidone

Question 29

What is the criteria for ADHD?

Answer 29

1. Persistent pattern of inattention and/or hyperactivity-impulsivity. INATTENTION (6 or more of): - fails to give close attention to details - difficulty sustaining attention in tasks or play activities - avoids or dislikes tasks requiring sustained mental effort - doesn't seem to listen - distracted easily - doesn't follow through on instructions - forgetful in daily activities - difficulty organizing tasks and activities - loses things HYPERACTIVITY (6 ore more of): - fidgets - leaves seat - runs about or climbs - unable to play or engage in leisure activities quietly - blurts out an answer before question completed - can't wait turn - often interrupt or intrudes on others - talks excessively - "on the go" as if "driven by a motor" 2. Symptoms present prior to 12 yrs 3. 2 or more settings 4. Interfere with functioning