ADHD review with medications | Lecture notes Biology

ADHD

1) Diagnosis

I. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder

defined as an impairment in the levels of inattention, disorganization and/or

hyperactivity-impulsivity (Cabral et al., 2020).

II. Inattention and disorganization included a difficulty staying on task, not being able to

listen, loosing things at a level that differ from what a normal developmental age would

include (APA, 2013).

III. Hyperactivity-impulsivity includes a person displaying overactivity such as fidgeting, not

being able to stay still, not being able to wait, interrupting people (APA, 2013).

IV. It is important to note that in childhood, ADHD symptoms can overlap with other

disorders such as oppositional defiant disorder or conduct disorder (APA. 2013).

V. ADHD also will persist into adulthood and patients will often have impairments in their

social, academic and occupational functioning (APA, 2013).

VI. This diagnosis can occur across all cultures and is present in about 5% of children and

about 2.5% of adults (APA, 2013).

2) Testing

I. In order to diagnose a patient with ADHD a clinician needs to conduct a full psychiatric

evaluation that includes evaluating a clients medical, behavioral, family, and social

history (Cabral et al., 2020). Since there is a strong genetic factor, a provider needs to

make sure to determine which family members have ADHD or other neurobehavioral

disorders (Cabral et al., 2020). It is important for a provider to document academic

difficulties, problems at work and school (Cabral et al., 2020). A provider should also

interview and get evaluations from teachers, school staff, coaches, and employers (Cabral

et al., 2020).

II. In 2019, the APP guidelines recommend that a provider use a scale to validate their

diagnosis which could include Conners Rating Scales (CSR) or the Child Behavior

Checklist (CBCL) (Cabral et al., 2020). A clinician can also use the Test of Variable of

attention (TOVA) which is a computerized test that records a patient's response to visual

and auditory stimuli (Cabral et al., 2020).

3) Symptoms

I. Inattention requires at least six symptoms for at least 6 months and for 17 years and older

at least five symptoms for 6-month (APA, 2013). Symptoms: careless, lack of close

attention to detail, difficulty sustaining attention, absent-mindedness, not being able to

complete task, difficulty remaining organized, avoid works, loses things, easily distracted

and forgetful (APA, 2013).

II. Hyperactivity and impulsivity requires at least six symptoms for at least 6 months and for

17 years and older at least five symptoms for 6 months (APA, 2013). Symptoms: fidgets

or squirms in seat, cannot remain still, restlessness, unable to engage in leisure activity,

talks excessively, on the go, blurting out words, issues waiting his or her turn and often

interrupts and intrudes on others (APA, 2013).

4) DSM-5 criteria

I. The DSM-5 categories ADHD as a persistent pattern of inattention and/or hyperactivity

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ADHD

1) Diagnosis I. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder defined as an impairment in the levels of inattention, disorganization and/or hyperactivity-impulsivity (Cabral et al., 2020). II. Inattention and disorganization included a difficulty staying on task, not being able to listen, loosing things at a level that differ from what a normal developmental age would include (APA, 2013). III. Hyperactivity-impulsivity includes a person displaying overactivity such as fidgeting, not being able to stay still, not being able to wait, interrupting people (APA, 2013). IV. It is important to note that in childhood, ADHD symptoms can overlap with other disorders such as oppositional defiant disorder or conduct disorder (APA. 2013). V. ADHD also will persist into adulthood and patients will often have impairments in their social, academic and occupational functioning (APA, 2013). VI. This diagnosis can occur across all cultures and is present in about 5% of children and about 2.5% of adults (APA, 2013). 2) Testing I. In order to diagnose a patient with ADHD a clinician needs to conduct a full psychiatric evaluation that includes evaluating a clients medical, behavioral, family, and social history (Cabral et al., 2020). Since there is a strong genetic factor, a provider needs to make sure to determine which family members have ADHD or other neurobehavioral disorders (Cabral et al., 2020). It is important for a provider to document academic difficulties, problems at work and school (Cabral et al., 2020). A provider should also interview and get evaluations from teachers, school staff, coaches, and employers (Cabral et al., 2020). II. In 2019, the APP guidelines recommend that a provider use a scale to validate their diagnosis which could include Conners Rating Scales (CSR) or the Child Behavior Checklist (CBCL) (Cabral et al., 2020). A clinician can also use the Test of Variable of attention (TOVA) which is a computerized test that records a patient's response to visual and auditory stimuli (Cabral et al., 2020). 3) Symptoms I. Inattention requires at least six symptoms for at least 6 months and for 17 years and older at least five symptoms for 6-month (APA, 2013). Symptoms: careless, lack of close attention to detail, difficulty sustaining attention, absent-mindedness, not being able to complete task, difficulty remaining organized, avoid works, loses things, easily distracted and forgetful (APA, 2013). II. Hyperactivity and impulsivity requires at least six symptoms for at least 6 months and for 17 years and older at least five symptoms for 6 months (APA, 2013). Symptoms: fidgets or squirms in seat, cannot remain still, restlessness, unable to engage in leisure activity, talks excessively, on the go, blurting out words, issues waiting his or her turn and often interrupts and intrudes on others (APA, 2013). 4) DSM-5 criteria I. The DSM-5 categories ADHD as a persistent pattern of inattention and/or hyperactivity

II. In order to be diagnosed with ADHD a patient needs to display at least six symptoms of inattention for at least six months. For a patient 17 years or older they need to have at least five symptoms (APA, 2013) III. For hyperactivity and impulsivity, a patient needs to have at least 6 or more for the past six months. A patient 17 years or older they only need to have five symptoms for at least six months (APA, 2013). IV. These symptoms of inattention and or hyperactivity-impulsivity need to be present prior to the age of 12 and these symptoms need to in at least two or more settings. These settings can include work, home and school (APA, 2013). V. One thing to note is that these symptoms should not be better explain by other mood disorders, substance abuse disorders or psychotic symptoms (APA, 2013).

Medication s- first line, second line along with side effects. I. The treatment of ADHD includes medication management, education, skill training and psychological counseling (Cabral et al., 2020). II. Stimulants are the first-line ADHD treatment for school age children which can include two medications methylphenidate and amphetamines (Cabral et al., 2020). Both methylphenidate and amphetamines are available in both short and long forms(Cabral et al., 2020). Methylphenidate which include brands such Concerta, Focalin, Metadate, Methylin and Ritalin (Cabral et al., 2020). Amphetamines brand names can include Adderall, Dexedrine, Dextrostat and Vyanse (Cabral et al., 2020). (1) Short-acting stimulants take about 30 to 40 minutes and short-acting are typically dose once per day and then increase by two or three times daily (Cabral et al., 2020). (2) Long acting are typically taken once per day in the morning (Cabral et al., 2020). (3) Side effects can include weight loss, decrease appetite, trouble falling asleep, nervousness, increase heart rate and blood pressure, headache, social withdrawal, irritability and moodiness (Cabral et al., 2020). III. Second line treatments include nonstimulants such as Atomoxetine which can be used for when patients need an alternative treatment such as a history of drug abuse or an intolerance to stimulants (Cabral et al., 2020). Side effects can include weight loss, decreased appetite, vomiting, nausea and upset stomach (Cabral et al., 2020). Guanfacine XR and clonidine XR are also considered second line treatments (Healthy Children, 2021). Guanfacine is an alpha agonist that is FDA approved in the treatment of ADHD in children with possible side effects of sleepiness, headaches and irritability (Healthy Children, 2021). Long-acting clonidine (Kapvay) is also another FDA approved medication for the treatment of ADHD, with side effects including lethargy, fatigue, and sleepiness (Healthy Children, 2021). IV. Behavioral treatments can be used in order to change a child's environment, regulate self- control and improve behaviors at school (Cabral et al., 2020). Anxiety

1. Diagnosis

jitteriness and restlessness (Farach et al., 2012). These medications can take 2 to 6 weeks for a patient to feel improvement of symptoms (Farach et al., 2012). II. It also important to note the benzodiazepines are not recommend for the routine treatment of anxiety disorders due to their high potential for dependency. III. Buspirone can also be used to treat generalized anxiety disorder as it is FDA approved (Willson & Tripp, 2022). Buspirone is often used as a second-line therapy for treating anxiety and often used to augment an SSRI (Willson & Tripp, 2022). Side effects include diarrhea, nausea, sore throat, dizziness and drowsiness (Willson & Tripp, 2022). IV. Cognitive behavior therapy (CBT) is also recommended as a first-line treatment of generalized anxiety disorder (Hirsch et al., 2019). CBT helps a patient modify and reprocess maladaptive processes which cause psychological distress (Hirsch et al., 2019)

References: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders DSM-5 (5th ed.). American Psychiatric Association. Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience , 19 (2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational pediatrics , 9 (Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09. Farach, F. J., Pruitt, L. D., Jun, J. J., Jerud, A. B., Zoellner, L. A., & Roy-Byrne, P. P. (2012). Pharmacological treatment of anxiety disorders: current treatments and future directions. Journal of anxiety disorders , 26 (8), 833–843. https://doi.org/10.1016/j.janxdis.2012.07. Healthy Children. (2021). Non-stimulant Medications Available for ADHD treatment. American Academy of Pediatrics. https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Non-Stimulant- Medications-Available-for-ADHD-Treatment.aspx Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching Cognitive Behavior Therapy For Generalized Anxiety Disorder From A Cognitive Process Perspective. Frontiers in psychiatry , 10 , 796. https://doi.org/10.3389/fpsyt.2019. Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a Primary Care Setting. Cureus , 12 (5), e8224. https://doi.org/10.7759/cureus. Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international , 155 (37), 611–620. https://doi.org/10.3238/arztebl.2018. Wilson, T.K. & Tripp, J. (2022). Buspirone. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK531477/

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