1: ADHD Flashcards
prevalence and impact of ADHD
- prevalence rate: 6-10%
- male more than females
diagnostic criteria for inattention symptoms of ADHD
need at least 6 of the following:
- fails to give close attention to details/ makes careless mistakes
- difficulty sustaining attention
- doesn’t seem to listen when spoken to directly
- doesn’t follow through on instructions/fails to finish work
- difficulty organizing tasks and activities
- avoids tasks requiring sustained mental effort
- loses things necessary for tasks/activities
- easily distracted by extraneous stimuli
- forgetful in daily activities
diagnostic criteria for hyperactivity-impulsivity symptoms of ADHD
need at least 6 of the following:
- difficulty playing/engaging in activities quietly
- always on the go or acts as if driven by a motor
- talks excessively
- blurts out answers
- difficulty waiting in lines or awaiting turn
- interrupts or intrudes on others
- runs about or climbs inappropriately
- fidgets with hands or feet or squirms in seat
- leaves seat in class/situations when expected to sit
general diagnostic criteria for ADHD
- symptoms present before age 12
- clinically significant impairment in social or academic/occupational functioning
- symptoms that cause impairment in 2 or more settings
- not due to another disorder
three subtypes of ADHD
- combined type
- predominantly inattentive subtype
- predominantly hyperactive/impulsive subtype
describe the combined type of ADHD
- clinical levels of both inattention and hyperactivity/impulsivity
- most common subtype
describe the predominantly inattentive type of ADHD
- clinical levels of inattention only
- often not identified until middle school
- sluggish cognitive tempo
describe the predominantly hyperactive/impulsive type of ADHD
- clinical levels of hyperactivity/impulsivity only
- more common among very young children prior to school entry
associated peer problems
- inattentive sx -> ignored
- hyperactive/impulsive sx -> actively rejected
- not deficient in social reasoning/understanding, but rather the execution of appropriate social behavior
associated family dysfunction/parental issues
- no clear causal relationship b/w family problems and ADHD
- family probs can impact the severity and developmental course/outcomes of ADHD
associated problems with self-esteem
- inflated: positive illusory bias (Hoza)
- low self esteem associated with co-morbid depression
developmental course of ADHD
- persistent across lifespan in most cases
- inattention remains stable
- hyperactivity declines with age
- adult outcomes including psychiatric comorbidity (conduct disorder or depression or anxiety)
etiological factors of ADHD: heritability
.80-.85 (extremely high)
-environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions
etiological factors of ADHD: prefrontal lobe dysfunction
- involved in inhibition, executive functions
- abnormal brain activation during attention and inhibition tasks
etiological factors of ADHD: genes involved in dopamine regulation
- dopamine transporter DAT1 gene implicated
- 7 repeat of dopamine receptor gene DRD4 implicated
- gene x environment interactions
etiological factors of ADHD: possible differences in size of brain structures
- prefrontal cortex
- corpus callosum
- caudate nucleus
ADHD differences in brain structure and function
- diffs in brain maturation, structure, fxn - particularly in frontostriatal circuitry (prefrontal cortex, basal ganglia, cerebellum)
- these areas are associated with executive fxn abilities:
- attention, spatial working memory, short term memory
- response inhibition and set shifting
what neurotransmitters are different in ADHD?
- *dopamine
- norepi (mostly a dopamine prob, but dopa makes norepi)
- epi
- serotonin
dopamine associated with approach and pleasure-seeking
norepi role in emotional/behavioral regulation
executive functioning deficits
deficits in cognitive processes which activate, integrate, and manage other brain functions (sx overlap with ADHD, but not all kids with ADHD have EF deficits)
- cognitive: working memory, planning, organizing strategies
- language: verbal fluency, communication
- motor: response inhibition, motor coordination
- emotional: self-regulation of emotion, frustration tolerance
what is the basis of executive functioning deficits in ADHD?
behavioral disinhibition - a performance, rather than knowledge, deficit
evidence-based assessment of ADHD
- teacher and parent-completed questionnaires (Connor scales)
- structured clinical interview with parent(s)
- IQ/achievement testing to screen for learning disabilities (50% comorbidity)
- behavioral observations at home and school
- no medical screen, cognitive test, or brain imaging technique can detect ADHD
- kids with ADHD can focus long enough to watch TV, play video games or sit still at doc’s office
well-established ADHD treatments
- stimulant meds
- behavioral interventions
- behavioral parent training
- behavioral classroom management
- intensive summer treatment programs
what are the best known stimulant meds for ADHD?
methylphenidate
- Ritalin
- Concerta
- metadate
dextroamphetamine
-Adderall
how do these stimulant meds reduce ADHD symptoms (mechanism of action)?
- block reuptake of norepi, dopamine and facilitate their release
- enhances norepi, dopamine availability in certain brain regions: prefrontal cortex, basal ganglia
how do these stimulant meds reduce ADHD symptoms (visible behavior changes)?
- extremely effective short term
- decrease disruption in class
- increase academic productivity and on-task behavior
- improve teacher ratings of behavior
common side effects of ADHD stimulant meds
- insomnia
- decreased appetite
what is an alternative non-stimulant medication for ADHD?
strattera/atomoxetine
- non-stimulant alternative
- could need 4-6 weeks to work
- hasn’t been studied as long as the stimulants
- smaller effect size relative to stimulants
limitations of stimulant treatment
- individual differences in response (80% respond)
- limited impact on domains of fxnal impairment
- does not normalize behavior (managed, but not cured)
- family problems beyond scope of medication
- no long-term effects established
- long-term use rare
- limited parent/teacher satisfaction
- some families not willing to try meds
ADHD behavioral treatment components
- psychoeducation about ADHD
- structure/routines
- clear rules/expectations
- attending/rewards
- planned ignoring
- effective commands
- time out/loss of privileges
- point/token systems
- daily school-home report card
- intensive summer treatment programs
multi-modal treatment study for ADHD (MTA) - describe the set up/parameters
- 6 sites
- 579 kids, 7-9 y/o
- ADHD, combined type
- assigned to 14 months of:
- med management
- intensive behavior therapy
- combined treatment
- treatment as usual in the community (TAU)
MTA results
- all groups showed reduced ADHD over time
- meds alone + combined therapy did better than behavior therapy alone and TAU
- combined tx was often not better than meds alone
- higher med doses were needed in meds alone group relative to combined tx group
