When my brain finally cooperates, that’s a real atomoxi-win
Concentration? Sorry, I only drink juice
Attention? Never met her.
My prefrontal cortex is doing its best, okay?
Ritalin? More like Rita-win
100
True or False: ADHD can be diagnosed in the absence of formal schooling? (Example child is homeschooled)
Bonus points: If grades are good does ADHD need to be treated?
Yes! ADHD symptoms must be present in at least 2 settings, these settings do not have to include formal schooling.
Not necessarily, if symptoms are NOT interfering with daily life, then ADHD does not have to be treated, it depends of the child and the family.
100
True or false: ADHD is overtreated.
False! Recent National Health and Nutrition Examination Survey suggests that far more children meet diagnostic criteria for ADHD then are being treated. This is especially true for those below the federal poverty level, in non-English speaking households, and children with parents with less than a high school education.
100
True or false: ADHD does not typically have features/diagnoses of other mental health disorders.
False!
Studies indicate that up to 78% of children with diagnosis of ADHD exhibit features of another mental health disorder as well including anxiety, depression, oppositional defiant disorder, conduct disorder.
100
True or false: Excess sugar intake replicates ADHD symptoms.
False!
While controversial, meta-analysis in JAMA, concluded that sugar does not affect the behavior or cognitive performance in children.
Likely due to strong belief that it does and due to expectancy and common association.
100
True or false: ADHD symptoms generally improve in 4-6 weeks with initiation of medication.
False! 80% of children will show improved attention and improvement in symptoms typically in 3-7 days.
200
At what age must symptoms of ADHD be present to meet diagnostic criteria?
Before age 12.
200
What tools can you use to evaluate for ADHD?
The Vanderbelt is frequenlty used as it is free, accessible, and generally can be complieted efficiency. It also has the added benefit of screening for other mental health disorders (anxiety, depression).
Other tools include the Conners Rating Scale-Revised; validated for broad range of ages (including pre-school children). The Child Behavior Checklist-Attention Problem, more comprehensive (used by mental health care professionals). Both have moderate to high sensitivity and specificity. Both cost money and are much longer to complete.
200
How old was Marquis de Lafeyette when he fought at the Battle of Yorktown with George Washington?
24 years old
200
True or false: Long acting stimulant tablets must be swallowed whole without crushing or chewing.
True!
This is a major barrier for young patients that can not swallow pills.
200
How often do you need to follow up on a child that is stable on their ADHD medication regimen?
Bonus points: how often is follow up needed during initiation of medications?
Every 3 months.
Weekly check ins (or calls) for monitoring of side effects, which tend to be more severe initially and then improve with time.
300
How many of the DSM-5 criteria criteria do you have to meet (out of 9) to make ADHD diagnosis if you are under 17?
Bonus points: How many must you meet if you are over 17?
6
5
300
What medical (non-psychological) can be associated with ADHD symptoms?
Obstructive Sleep Apnea; surgical treatment has demonstrated improvement in these symptoms in many children.
300
What are some non-pharmaceutical ways to manage ADHD?
Emphasis to family and patients that this is a chronic medical condition requiring frequent adjustments and frequent reevaluation of goals and expectation as patient grows older.
Behavioral therapy such as parent training in behavior management, IEPs, reinforcement of positive behaviors.
Parents and teachers were more satisfied with the treatment plan with combination therapy, with children using combination therapy requiring lower doses of medications.
300
What are some of the side effects of ADHD medications that parents and/or child should be aware of?
Bonus points: What are side effects are you, as the physician, monitoring for?
Decreased appetite, sleep disturbance, and GI upset.
Weight loss, hypertension
300
What cardiac risk is there to initiation of ADHD?
In 2006 FDA reviewed several case reports of adverse cardiac events associated with the use of stimulants, however sudden death in patients taking stimulant medication is exceedingly rare and recent studies indicate that tis risk is the same for children not on stimulant medications.
A 2024 study in JAMA did show long term use of stimulants was associated with a small increase in the lifetime risk of hypertension and arterial disease, but no significant increase in the risk of arrythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease.
400
Name 4 out of the 9 criteria for the Hyperactivity category of ADHD.
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
- Often unable to play or take part in leisure activities quietly.
- Is often “on the go” acting as if “driven by a motor.”
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting their turn.
- Often interrupts or intrudes on others (e.g., butts into conversations or games).
400
What lifestyle/family factors can be associated with ADHD symptoms?
Poor sleep and chronic fatigue, lack of routine, unrealistic expectations by parents or teachers.
400
What medication do you typically start with for the treatment of ADHD?
Bonus points: what age would you start?
Stimulant medications are first line of therapy and generally highly effective.
Stimulant dosing is not weight based, so start with the lowest dose of either methylphenidate (Ritalin) or Dextroamphetamine (Adderall, Vyvanse), preferably using long acting formula.
6 years of age.
400
What is the black box warning for Atomoxetine?
Possibility of suicidal ideation at the initiation of therapy, avoid in any patients with concern for suicidal ideation.
However a 2016 study in Pediatrics did not show any increased risk of suicidal events with Atomoxetine compared with stimulants.
400
Shannon Hoon, the front man for Blind Melon, was also a backup vocalist for what 1980s and 1990s heavy metal band? Hint: He was featured as back up vocalist in the song "Don't cry".
Guns and Roses
500
Name 6 of the 9 diagnostic criteria for the Inattention category of ADHD.
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
- Often has trouble holding attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
- Often has trouble organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted.
- Is often forgetful in daily activities.
500
What are risk factors for ADHD and ADHD like symptoms?
There is a genetic component to ADHD (linked to abnormalities in dopaminergic, serotonergic, and noradrenergic pathways), family history of ADHD, depression/anxiety, bipolar.
Other risk factors: prematurity, prenatal exposure to drugs/alcohol/tobacco
500
What medications can you prescribe that are not stimulants, either for monotherapy or adjunctive therapy?
Name at least 2.
Atomoxetine (Strattera): a norepinephrine-reuptake inhibitor is second line monotherapy for ADHD.
Guanfacine (Intuniv): alpha 2 agonists
Clonidine(Kapvay): alpha 2 agonists
500
For children 4-5 what is the initial treatment for ADHD?
Bonus points: what is the initial pharmaceutical treatment?
Behavioral therapy.
Dextroamphetamine is the only FDA approved medication for preschoolers. However the Clinical Practice Guideline recommends methylphenidate as initial therapy because several studies have demonstrated safety and efficacy, keep in mind this is considered "off label" treatment.
500
Oh no! The patient's pharmacy is having a medication shortage and currently can not fill your patient's prescription. What are you going to do?
Changing medications should be avoided if at all possible, to avoid new/worsening side effects. Start with obvious and see if another pharmacy can fill the prescription. Does patient need the medication or a new medication urgently-important test coming up? Going into summer break?
Other things to consider, insurance, drug type (long acting vs short acting)
If you MUST change medications start at the lowest dose and titrate up, switch to a new drug within the same stimulant class (rather than switching drug classes), check medication conversion table before switching.