ADHD Background

ADHD is characterized by symptoms of inattention, hyperactivity, and impulsivity

The role of dopamine in ADHD

Stimulant medications

Risky behavior

Parent training in behavior management

Dopamine and norepinephrine

ADHD is more common in boys

Inattention, hyperactivity, and impulsivity

A combination of medication and behavioral therapy

Methylphenidate

Children 6 years old and above

Less than 6 symptoms

6 months

Talks excessively

Inattention, hyperactivity, and impulsivity

Fish oils

Stimulants

Atomoxetine

Children 6 years old and above

Guanfacine ER

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The primary presenting symptoms of ADHD are inattention, hyperactivity, and impulsivity.

The primary focus of ADHD research is on the catecholamine system, specifically the dopamine pathways.

The first-line treatment for preschool-aged children with ADHD is parent training in behavior management and/or behavioral classroom intervention.

The diagnostic criteria for ADHD according to the DSM-5 include symptoms of inattention and/or hyperactivity and impulsivity. For children up to age 16, there must be at least 6 symptoms of inattention or hyperactivity and impulsivity. For ages 17 and older, there must be at least 5 symptoms. These symptoms must have been present for at least 6 months and are inappropriate for the individual's developmental level.

The primary symptoms of inattention in ADHD include failing to pay attention, having trouble holding attention, not paying attention when someone is talking, not following through on instructions, failing to finish schoolwork, having difficulty organizing tasks, avoiding or disliking tasks that require mental effort, losing things, being easily distracted, and being forgetful.

Stimulants are the first-line medications for ADHD. These medications are considered the initial treatment option for patients with ADHD, especially those who are 6 years old and above. Long-acting formulations of stimulants are preferred for children to maintain more steady symptom control.

Fish oils have been shown to modestly improve cognitive function and behavior in children with ADHD. They are increasingly used for various psychiatric conditions. Another natural product, melatonin, is used to help with sleep onset in individuals taking stimulants.

ADHD = Most common neurodevelopmental disorder in children Symptoms = Inattention, hyperactivity, impulsivity Primary treatment = Stimulant medications and behavioral therapy First-line treatment for pre-school aged children = Parent training in behavior management and/or behavioral classroom intervention

Dopamine pathways = Defects in these can play a role in ADHD Catecholamine system = Primary focus of ADHD research Methylphenidate = Can be considered if moderate-severe symptoms persist despite behavioral interventions Untreated ADHD = Can lead to impaired academic standing, poor social skills and risky behavior

Stimulant medications = They raise dopamine and norepinephrine levels Behavioral therapy = Used in combination with medication for ADHD treatment Parent training in behavior management = First-line treatment for pre-school aged children Methylphenidate = Can be considered if moderate-severe symptoms persist despite behavioral interventions

Fails to finish schoolwork = Inattention Often fidgets or squirms = Hyperactivity & Impulsivity Does not follow through on instructions = Inattention Talks excessively = Hyperactivity & Impulsivity

Atomoxetine (Strattera) = Non-stimulant Guanfacine ER (Intuniv) = Non-stimulant Melatonin = Natural product Stimulants = First-line medications

Greater than or equal to 6 symptoms for children up to age 16 = Inattention Greater than or equal to 5 symptoms for ages 17 and older = Hyperactivity & Impulsivity Symptoms must have been present for at least 6 months = Both Inattention and Hyperactivity & Impulsivity Symptoms interfere with functioning and are not caused by another disorder = General criteria

Behavioral interventions = Should be used with first-line medications when available Stimulants = First-line medications for ADHD Fish oils = Shown to modestly improve cognitive function and behavior in children with ADHD Atomoxetine (Strattera) = Can be used first line when prescribers are concerned about the possibility of abuse

Capsule

Warming the food

Suspension

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False

True

The long-acting formulations that can be used for young children (and others) who cannot swallow capsules or tablets are: capsule (some can be sprinkled on applesauce), chewable tablet, orally-disintegrating tablet, patch, and suspension.

When putting capsule contents in food, use a small amount of food, do not chew the beads, do not warm the food, and take it right away.

The capsule contents of Vyvanse can be mixed in water, orange juice or yogurt for administration.

Adderall XR, Ritalin lA = Sprinkled on a small amount of applesauce Vyvanse = Mixed in water, orange juice, or yogurt Suspension = Taken as is Patch = Applied directly on skin

Do not chew the beads = When putting capsule contents in food Use a small amount of food = When putting capsule contents in food Take it right away = After mixing capsule contents in food Do not warm the food = Before mixing capsule contents in food

Capsule = Contents can be mixed with food or drink Chewable tablet = Can be chewed and swallowed Orally-disintegrating tablet = Disintegrates in the mouth without the need for water Patch = Applied directly to the skin

Atomoxetine

Clonidine ER

Guanfacine ER

True

False

True

Methylphenidate, Lisdexamfetamine, Dextroamphetamine/Amphetamine

Atomoxetine, Guanfacine ER

Clonidine IR, Diphenhydramine

Methylphenidate = First-line stimulants Atomoxetine (Strattera) = Second-line non-stimulants Guanfacine ER (Intuniv) = Add-on medications Melatonin = Help sleep at night

Stimulants = Take in AM Non-stimulants = Take if risk of abuse Guanfacine ER (Intuniv) = Can be used alone or as add-on Diphenhydramine = Help sleep at night (OTC, 25-50 mg)

Concerta, Daytrana, Ritalin = Methylphenidate Vyvanse = Lisdexamfetamine Strattera = Atomoxetine Adderall and Adderall XR = Dextroamphetamine/Amphetamine

New-onset psychosis or mania

Loss of appetite

Serotonin syndrome

Stimulants have a high potential for abuse and dependence.

Tourette's syndrome

Increased risk of sudden death

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Stimulant medications have a high potential for abuse and dependence.

Do not use within 14 days of an MAO inhibitor.

Increased levels of dopamine and norepinephrine can increase heart rate and blood pressure.

Priapism and Raynaud's disease

The risk of serotonin syndrome is increased

Loss of appetite

Dilated pupils, increased heart rate and blood pressure, sweating, tremor, anxiety = Abuse of stimulant medications Severe depression = Withdrawal from stimulant medications Abnormal behavior, psychotic episodes = Long-term abuse of stimulant medications Hypertensive crisis = Use of stimulants within 14 days of an MAO inhibitor

Marked anxiety, tension, agitation = Most stimulants Comorbid heart failure, recent myocardial infarction, arrhythmias or moderate-severe hypertension = Some stimulants Use within 14 days of an MAO inhibitor = Risk of hypertensive crisis History of Tourette's syndrome or other tic disorders = Most stimulants

Increased levels of dopamine and norepinephrine = Increase in heart rate and blood pressure Cardiac disease at baseline = Increased risk of sudden death with stimulant use Presence of cardiac abnormalities = Avoidance of stimulant use Risk of serious cardiovascular events = Children and adults with or without preexisting cardiac disease

Vascular problems = May require dose reduction or discontinuation Psychosis or mania = Can be new-onset or an exacerbation of preexisting conditions Lowered seizure threshold = Increases risk for seizures Serotonin syndrome = Risk increased with use in combination with other serotonergic drugs

Loss of appetite = Can contribute to a decrease in a child's growth trajectory Visual disturbances = Includes difficulty with accommodation and blurry vision Serotonin syndrome = Risk increased when used with other serotonergic drugs Vascular problems = May require dose reduction or discontinuation

Preexisting psychiatric condition = Caution should be used when prescribing stimulants Seizure threshold = Some stimulants can lower this, increasing the risk for seizures Child's growth trajectory = A loss of appetite, a common side effect, can contribute to a decrease in this Serotonergic drugs = Risk of serotonin syndrome is increased when stimulants are used in combination with these