MCQ Quiz: Management of ADHD

The management of Attention-Deficit/Hyperactivity Disorder (ADHD) is a comprehensive, multi-faceted process that extends beyond simple prescription writing. For PharmD students, understanding the nuances of ADHD treatment is essential for providing optimal patient care. A successful management plan often integrates pharmacotherapy, behavioral interventions, patient and family education, and accommodations in academic or occupational settings. This approach requires careful patient assessment, thoughtful medication selection based on individual needs and comorbidities, and diligent monitoring for both efficacy and adverse effects. This quiz will explore key topics covered in the Patient Care VII: Brain and Behavior curriculum, including first-line medications, management of side effects, treatment strategies for different patient populations, and the vital role of the pharmacist in counseling and collaborative care.

1. What is considered the first-line pharmacotherapy for school-aged children and adolescents for the management of ADHD?

• a) Alpha-2 adrenergic agonists
• b) Atomoxetine
• c) Stimulant medications (methylphenidate or amphetamine)
• d) Tricyclic antidepressants Answer: c) Stimulant medications (methylphenidate or amphetamine)

2. A 7-year-old child is diagnosed with ADHD and has significant appetite suppression with an immediate-release stimulant. What is a reasonable management strategy?

• a) Discontinue the medication immediately.
• b) Administer the dose after meals instead of before.
• c) Double the dose to overcome the side effect.
• d) Switch to a potent antipsychotic. Answer: b) Administer the dose after meals instead of before.

3. When initiating treatment with atomoxetine (Strattera), how long should a patient be advised it may take to see the full therapeutic effect?

• a) 1-2 days
• b) 1 week
• c) 4-6 weeks
• d) 3 months Answer: c) 4-6 weeks

4. A patient with ADHD and a co-occurring tic disorder might benefit from which class of medication, as stimulants can sometimes worsen tics?

• a) A higher dose of methylphenidate
• b) An alpha-2 adrenergic agonist like guanfacine or clonidine
• c) An immediate-release amphetamine
• d) Lisdexamfetamine Answer: b) An alpha-2 adrenergic agonist like guanfacine or clonidine

5. Which of the following is a critical monitoring parameter for a patient on long-term stimulant therapy?

• a) Liver function tests
• b) Blood glucose levels
• c) Height and weight
• d) Serum creatinine Answer: c) Height and weight

6. For a patient with a history of substance use disorder, which ADHD medication is often preferred due to its lower abuse potential?

• a) Immediate-release methylphenidate
• b) Mixed amphetamine salts
• c) Atomoxetine
• d) Dexmethylphenidate Answer: c) Atomoxetine

7. A patient taking an extended-release alpha-2 agonist like guanfacine ER (Intuniv) should be counseled to avoid taking it with what type of meal to prevent increased drug absorption?

• a) A high-carbohydrate meal
• b) A high-protein meal
• c) A high-fat meal
• d) A low-sodium meal Answer: c) A high-fat meal

8. What is the primary purpose of using a long-acting stimulant formulation over a short-acting one for a school-aged child?

• a) It is less expensive.
• b) It provides symptom coverage throughout the school day without the need for a midday dose.
• c) It has a faster onset of action.
• d) It has fewer cardiovascular side effects. Answer: b) It provides symptom coverage throughout the school day without the need for a midday dose.

9. A “drug holiday” from stimulant medication is sometimes considered for what purpose?

• a) To increase the medication’s efficacy.
• b) To assess if the medication is still needed and to mitigate growth suppression.
• c) To allow the patient to experience ADHD symptoms.
• d) To reduce the cost of treatment. Answer: b) To assess if the medication is still needed and to mitigate growth suppression.

10. Before initiating stimulant therapy, it is important to screen for a personal and family history of which condition?

• a) Asthma
• b) Diabetes
• c) Seizures
• d) Cardiac disease, including sudden death or arrhythmias. Answer: d) Cardiac disease, including sudden death or arrhythmias.

11. What common side effect should be discussed with a patient starting clonidine for ADHD?

• a) Insomnia
• b) Increased appetite
• c) Sedation and dizziness
• d) Hypertension Answer: c) Sedation and dizziness

12. Lisdexamfetamine (Vyvanse) is a prodrug stimulant designed to have a lower abuse potential. How is it activated in the body?

• a) It is hydrolyzed by enzymes in the red blood cells to dextroamphetamine.
• b) It is metabolized by CYP2D6 in the liver.
• c) It requires an acidic stomach environment for activation.
• d) It is activated by intestinal flora. Answer: a) It is hydrolyzed by enzymes in the red blood cells to dextroamphetamine.

13. A patient reports that their child’s ADHD symptoms seem to worsen in the late afternoon as their morning dose of an immediate-release stimulant wears off. This phenomenon is known as:

• a) Tachyphylaxis
• b) Rebound effect
• c) Paradoxical reaction
• d) Serotonin syndrome Answer: b) Rebound effect

14. What is the black box warning associated with atomoxetine?

• a) Risk of severe liver damage
• b) Increased risk of suicidal ideation in children and adolescents
• c) High potential for abuse
• d) Risk of severe rash (Stevens-Johnson Syndrome) Answer: b) Increased risk of suicidal ideation in children and adolescents

15. What is a key component of non-pharmacological management for a child with ADHD?

• a) Unstructured playtime
• b) Dietary restrictions of all sugars
• c) Behavioral therapy and parent training in behavior management
• d) Increased screen time to improve focus Answer: c) Behavioral therapy and parent training in behavior management

16. Which of the following is an appropriate starting point when counseling a patient or parent on a new prescription for a stimulant?

• a) Explaining the risk of addiction in detail.
• b) Discussing the expected benefits, common side effects, and dosing schedule.
• c) Focusing only on the most severe, rare side effects.
• d) Advising them to read the package insert and ask questions later. Answer: b) Discussing the expected benefits, common side effects, and dosing schedule.

17. Why must alpha-2 agonists like clonidine and guanfacine be tapered off slowly rather than stopped abruptly?

• a) To prevent severe withdrawal psychosis.
• b) To avoid the risk of rebound hypertension.
• c) To prevent an acute drop in blood glucose.
• d) To avoid causing a seizure. Answer: b) To avoid the risk of rebound hypertension.

18. The Concerta OROS delivery system is designed to mimic what dosing schedule?

• a) One large dose in the morning.
• b) A steady, continuous release throughout the day.
• c) Three-times-daily dosing of an immediate-release product.
• d) A small immediate dose followed by a gradually increasing dose. Answer: c) Three-times-daily dosing of an immediate-release product.

19. A patient is experiencing insomnia from their afternoon dose of a stimulant. Which is the LEAST appropriate initial management step?

• a) Move the afternoon dose earlier in the day.
• b) Switch to a long-acting formulation taken only in the morning.
• c) Add a prescription sedative like a benzodiazepine.
• d) Discuss good sleep hygiene practices with the patient. Answer: c) Add a prescription sedative like a benzodiazepine.

20. What is the pharmacist’s role regarding the FDA’s Medication Guide for stimulants?

• a) To dispense it only upon patient request.
• b) To read the entire guide to the patient at every refill.
• c) To ensure the patient receives it with every new prescription and refill.
• d) To file it away and not provide it to the patient. Answer: c) To ensure the patient receives it with every new prescription and refill.

21. When managing ADHD in adults, it is particularly important to screen for and consider co-occurring:

• a) Childhood asthma
• b) Mood and anxiety disorders
• c) Hearing impairments
• d) Food allergies Answer: b) Mood and anxiety disorders

22. A transdermal patch of methylphenidate (Daytrana) offers an alternative for patients who:

• a) Have a fear of needles.
• b) Cannot swallow pills.
• c) Need a faster onset of action than oral tablets.
• d) Have a history of skin allergies. Answer: b) Cannot swallow pills.

23. If a patient does not respond to an adequate trial of a methylphenidate-based stimulant, what is a common next step?

• a) Discontinue all ADHD medications.
• b) Switch to a trial of an amphetamine-based stimulant.
• c) Add an antipsychotic medication.
• d) Immediately start an alpha-2 agonist. Answer: b) Switch to a trial of an amphetamine-based stimulant.

24. Which of the following is a key counseling point for viloxazine (Qelbree), a non-stimulant medication?

• a) The capsules must be swallowed whole and cannot be opened.
• b) It can be taken with or without food, but the capsules can be opened and sprinkled on applesauce.
• c) It has a high potential for abuse.
• d) It works immediately within one hour of the first dose. Answer: b) It can be taken with or without food, but the capsules can be opened and sprinkled on applesauce.

25. A patient’s insurance requires a prior authorization for a long-acting stimulant. What is the pharmacist’s role?

• a) Tell the patient to pay cash for the medication.
• b) Refuse to fill the prescription.
• c) Notify the prescriber that a prior authorization is needed and assist if necessary.
• d) Switch the medication to a different one without telling the prescriber. Answer: c) Notify the prescriber that a prior authorization is needed and assist if necessary.

26. Why might bupropion be considered for off-label use in a patient with ADHD?

• a) It has a very calming and sedative effect.
• b) It inhibits norepinephrine and dopamine reuptake and may be useful in patients with comorbid depression.
• c) It is a potent serotonin agonist.
• d) It is a controlled substance with a rapid onset. Answer: b) It inhibits the norepinephrine and dopamine reuptake and may be useful in patients with comorbid depression.

27. In the management of ADHD, what does a “multimodal” treatment approach refer to?

• a) Using multiple stimulant medications at the same time.
• b) Combining pharmacotherapy with behavioral and educational interventions.
• c) Using both oral and transdermal medication formulations.
• d) Prescribing medication from different doctors. Answer: b) Combining pharmacotherapy with behavioral and educational interventions.

28. What is a common challenge in the transition of care for adolescents with ADHD to adult healthcare?

• a) Medications suddenly become ineffective.
• b) A lack of adult healthcare providers comfortable with managing ADHD.
• c) Insurance no longer covers ADHD treatment after age 18.
• d) The symptoms of ADHD always disappear in adulthood. Answer: b) A lack of adult healthcare providers comfortable with managing ADHD.

29. The primary goal of ADHD pharmacotherapy is to:

• a) Cure the disorder.
• b) Eliminate all symptoms completely.
• c) Reduce core symptoms to improve daily functioning.
• d) Sedate the patient to reduce hyperactivity. Answer: c) Reduce core symptoms to improve daily functioning.

30. Which vital signs should be routinely monitored in patients receiving stimulant medications?

• a) Temperature and respiratory rate
• b) Blood pressure and heart rate
• c) Oxygen saturation
• d) Blood glucose Answer: b) Blood pressure and heart rate

31. A patient is prescribed Adderall XR. What is a correct counseling point regarding its administration?

• a) It can be crushed or chewed for faster effect.
• b) The capsule can be opened and the beads sprinkled on applesauce.
• c) It must be taken on an empty stomach.
• d) It should only be taken at night to help with sleep. Answer: b) The capsule can be opened and the beads sprinkled on applesauce.

32. The management of ADHD in preschool-aged children (4-5 years old) typically begins with:

• a) High-dose stimulant medication.
• b) Evidence-based parent and/or teacher-administered behavior therapy.
• c) Atomoxetine as a first-line agent.
• d) No intervention until they are older. Answer: b) Evidence-based parent and/or teacher-administered behavior therapy.

33. What is a key reason for using a rating scale (e.g., Vanderbilt, Conner’s) in the management of ADHD?

• a) To diagnose the condition without a clinical interview.
• b) To provide an objective measure of symptom severity and treatment response over time.
• c) To satisfy legal requirements for prescribing stimulants.
• d) To determine the patient’s IQ. Answer: b) To provide an objective measure of symptom severity and treatment response over time.

34. For a patient with ADHD and comorbid anxiety, which medication class might be a cautious choice due to the potential to worsen anxiety symptoms?

• a) Alpha-2 adrenergic agonists
• b) Atomoxetine
• c) Stimulants
• d) Tricyclic antidepressants Answer: c) Stimulants

35. A patient taking methylphenidate should be advised to avoid concurrent use of which over-the-counter product without consulting a pharmacist or doctor?

• a) Acetaminophen
• b) Decongestants like pseudoephedrine
• c) Calcium supplements
• d) Fiber laxatives Answer: b) Decongestants like pseudoephedrine

36. The management of side effects like irritability or moodiness on stimulants may involve:

• a) Increasing the dose rapidly.
• b) Reducing the dose or trying a different formulation or medication class.
• c) Adding a mood stabilizer without changing the stimulant.
• d) Ignoring the side effect as it is temporary. Answer: b) Reducing the dose or trying a different formulation or medication class.

37. How should a pharmacist respond if a patient asks to fill a stimulant prescription early because they “lost” their medication?

• a) Fill it immediately without asking any questions.
• b) Refuse the fill and tell the patient they are not allowed to get any more.
• c) Verify the fill date, explain the regulations and controlled substance policies, and contact the prescriber if necessary.
• d) Tell them to go to a different pharmacy. Answer: c) Verify the fill date, explain the regulations and controlled substance policies, and contact the prescriber if necessary.

38. What is an advantage of extended-release guanfacine or clonidine over their immediate-release counterparts in ADHD management?

• a) They have a much faster onset of action.
• b) They provide smoother, once-daily dosing with potentially less sedation.
• c) They have a higher potential for abuse.
• d) They are indicated for treating comorbid depression. Answer: b) They provide smoother, once-daily dosing with potentially less sedation.

39. When assessing the effectiveness of an ADHD medication, it is most important to gather information from:

• a) Only the patient.
• b) Only the parent or spouse.
• c) Multiple sources, such as the patient, parents, and teachers.
• d) The patient’s friends. Answer: c) Multiple sources, such as the patient, parents, and teachers.

40. A patient reports a “zombie-like” effect or being overly quiet on a stimulant. This most likely indicates that:

• a) The medication is not working.
• b) The dose is too high.
• c) The patient is having an allergic reaction.
• d) The patient does not have ADHD. Answer: b) The dose is too high.

41. Which of the following is a key goal of managing ADHD in an adult in the workplace?

• a) To allow them to work longer hours than their peers.
• b) To improve organizational skills, time management, and task completion.
• c) To eliminate all need for collaboration with coworkers.
• d) To ensure they get a promotion. Answer: b) To improve organizational skills, time management, and task completion.

42. A pharmacist’s role in managing ADHD includes counseling on the proper storage of stimulant medications, which is:

• a) In the refrigerator.
• b) On the kitchen counter for easy access.
• c) In a secure location away from others who might misuse them.
• d) In the car’s glove compartment. Answer: c) In a secure location away from others who might misuse them.

43. The process of dose optimization for a stimulant medication involves:

• a) Starting at the highest possible dose.
• b) Gradually increasing the dose until target symptoms improve without causing intolerable side effects.
• c) Keeping the patient on the lowest dose regardless of symptom control.
• d) Doubling the dose every other day. Answer: b) Gradually increasing the dose until target symptoms improve without causing intolerable side effects.

44. If a patient is taking atomoxetine and is also prescribed a strong CYP2D6 inhibitor like paroxetine, what adjustment may be needed?

• a) The atomoxetine dose may need to be increased.
• b) No adjustment is necessary.
• c) The atomoxetine dose may need to be reduced.
• d) The paroxetine dose should be doubled. Answer: c) The atomoxetine dose may need to be reduced.

45. Which of the following is NOT a primary target symptom for ADHD treatment?

• a) Inattention
• b) Hyperactivity
• c) Impulsivity
• d) Auditory hallucinations Answer: d) Auditory hallucinations

46. When counseling on the Daytrana (methylphenidate) patch, what is an important point to include?

• a) The patch should be cut in half to start a lower dose.
• b) The patch should be applied to the same spot every day.
• c) The patch should be removed after 9 hours to avoid over-medication and skin irritation.
• d) The patch is waterproof and can be worn while swimming for extended periods. Answer: c) The patch should be removed after 9 hours to avoid over-medication and skin irritation.

47. A patient with ADHD and comorbid insomnia might be a poor candidate for which medication schedule?

• a) A long-acting stimulant taken first thing in the morning.
• b) A non-stimulant like atomoxetine taken in the morning.
• c) An immediate-release stimulant taken in the late afternoon or evening.
• d) Guanfacine ER taken at bedtime. Answer: c) An immediate-release stimulant taken in the late afternoon or evening.

48. Why is it important to ask about other prescription and over-the-counter medications when dispensing an ADHD medication?

• a) To check for potential drug-drug interactions.
• b) To judge the patient’s lifestyle choices.
• c) It is not important to ask about other medications.
• d) To recommend they stop all other medications. Answer: a) To check for potential drug-drug interactions.

49. The overall management strategy for ADHD should be:

• a) Decided solely by the physician.
• b) A collaborative process involving the patient, family, physician, and pharmacist.
• c) Determined by the patient’s insurance company.
• d) Based on what medication is newest to the market. Answer: b) A collaborative process involving the patient, family, physician, and pharmacist.

50. A patient stabilized on a stimulant for several years reports a sudden decrease in efficacy. What is an unlikely pharmacological reason?

• a) Development of drug tolerance.
• b) A change in formulation from brand to generic with different pharmacokinetic properties.
• c) The patient has suddenly “outgrown” the need for the medication.
• d) A new concomitant medication is affecting the stimulant’s metabolism. Answer: c) The patient has suddenly “outgrown” the need for the medication.