1- Pediatric Psych: ADHD Flashcards
Females with ADHD present more often with what type of sxs?
Inattentive sxs
What is the etiology of ADHD?
Multifactorial (may include genetic factors and environmental factors)
(genetic: ↑ rate in first-degree relatives of affected individuals
environmental: low birth weight, smoking)
How is attention deficit hyperactivity disorder (ADHD) defined?
Persistent inattention, hyperactivity, and impulsivity
inconsistent with the patient’s developmental stage
The diagnostic criteria of ADHD are a persistent pattern of inattention and/ or hyperactivity-impulsivity that interferes with functioning/ development as characterised by what?
6+ sxs for 6+ mos and inconsistent with developmental level and negatively impacts social/ academic/ occupational activities
What are sxs of inattention that contribute to a dx of ADHD? (must have 6+ for 6+ mos) (9)
- careless mistakes
- forgetful in daily activities
- difficulty sustaining attn
- easily distracted by extraneous stimuli
- avoid tasks that require sustained mental effort
- does not follow through/ finish work
- does not listen when spoken to directly
- difficulty w/ organization
- loses necessary items
What are sxs of hyperactivity-impulsivity that contribute to a dx of ADHD? (must have 6+ for 6+ mos) (9)
- fidgets
- leaves sit when inappropriate
- runs/ climbs excessively when inappropriate
- difficulty playing/ engaging in leisurely activities quietly
- “on the go”
- talks excessively
- blurts out answers prematurely
- difficulty awating turn
- interrupts/ intrudes others
In addition to characteristic sxs of inattention/ hyperactivity-impulsivity, what are the other diagnostic criteria for ADHD?
Sxs present prior to age 12, sxs present in 2+ settings, clear evidence sxs interfere w/ reduce quality of social/ academic/ occupational functioning
How are the types of ADHD specified?
Predominantly inattentive, predominantly hyperactive-impulsive, combined
How do you specify whether a pt is in partial remission with ADHD?
< 6 sxs for 6+ mos, after previous full dx
How do you specify ADHD severity?
Mild, moderate, severe
In what populations is ADHD difficult to dx and why?
Younger children (<5) due to age-appropriate behaviors in active children
In what age group is ADHD most common?
Elementary school-aged children (obtain info from teachers)
In adults, if ADHD is comorbid with SUD, mood disorder, or anti-social personality, the individual is at increased risk for what?
Suicide
Why must one use caution in new diagnoses of ADHD in adults?
Pt childhood recall of ADHD unreliable (obtain school records)
What are some conditions that can co-occur (or be ddx) with ADHD?
Learning disorders, oppositional defiance disorder, conduct disorder, substance abuse
ADHD manifesting as a result of something such as a stressful home, inappropriate schools, or under-stimulation are what?
Environmental factors
What must you be aware of when evaluating DDX of ADHD (in addition to co-occuring conditions and environmental factors)?
Medical conditions (that may manifest with sxs of ADHD)
ex. hearing/ visual impairments, sleep disorders, seizures
What is the purpose of a comprehensive medical, developmental education, and psychosocial eval for ADHD?
Confirm sxs, demonstrate functional complications, exclude ddxs, identify co-morbid conditions
Although there are several rating scales that may contribute to a dx of ADHD, they all still require what?
Validation with DSM5
What is the preferred rating scale for peds with ADHD?
Vanderbilt assessment scales
What is the preferred rating scale for adults with ADHD?
ASRS (ADHD self report scale)
What should you ask a parent when evaluating for ADHD?
- Performance in school
- Teacher acknowledgement of learning problems
- Happiness in school
- Behavioral problems
- Issues with completing assignments
What should you ask a teacher when evaluating for ADHD?
- Behavior
- Interventions required
- Learning patterns
- Functional impairment
- Child interactions with other students
- Work/ grades acceptable
What is the pathophysiology of ADHD?
Environmental factors, NT alterations, neuroanatomical changes in circuits
What does the RAS produce (ascending NT system)?
NE, serotonin, DA, ACh
What are the targets for the NTs produced by RAS?
Discrete nuclei within basal forebrain, limbic system, cerebral cortex
With respect to NTs, what contributes to the overall psych/ behavior function of an individual?
Brain region + concentration of NT inputs + concentration of relative density of receptors = overall psych/ behavioral function
What type of modulation can occur pre- or post-synaptically at the target nuclei or production sites (therefore having different effects)?
Pharmacologic
Increased NE leads to what?
Increased alertness/ arousal
Where is NE produced?
Locus Coeruleus (LC)
Where does NE target?
Throughout forebrain
What disorders are a/w NE imbalance?
Attention deficit disorders, mood disorders, anxiety disorders, drugs of abuse (psychostimulants)
How many receptor classes does NE have?
Two (and multiple subclasses)
NE acting on the cortex/ hypothalamus/ brainstem influences what?
Arousal and sleep/wake cycles, consciousness
NE acting on the cortex only influences what?
Attention
NE acting on the cortex/ limbic system influences what?
Mood, learning/ memory
Where is serotonin produced?
Brainstem (raphe nuclei- dorsal)
Where does serotonin target?
Throughout forebrain
How many receptor classes does serotonin have?
Numerous (and multiple subclasses)
Serotonin acting on the limbic system influences what?
Mood
Serotonin acting on the cortex and thalamus influences what?
Sensation/ perception
Serotonin acting on the hypothalamus influences what?
Circadian rhythms, appetite
What disorders are a/w a 5-HT imbalance?
Mood disorders, impulse control disorders, OCD, anxiety disorders, eating disorders, drugs of abuse
Where is dopamine produced?
In the midbrain (SN- substantia nigra, VTA- ventral tegmental area)
Where does dopamine target?
Throughout forebrain
Dopamine acting on the substantia nigra (SN) to basal nuclei influences what?
Motor control
Dopamine acting on the ventral tegmental area (VTA) to limbic system and cortex influences what?
Reward, reinforcement, cognition
How many receptor classes does dopamine have?
Multiple
What disorders are a/w dopamine?
Psychotic disorders, substance use disorders, movement disorders, cognitive disorders, mood disorders
What leads to positive sxs of psychosis?
Hallucinations and delusions
Where is acetylcholine produced?
Basal forebrain (medial septum- MS, nucleus basalis of meynert- nBM)
Where does ACh target?
Throughout forebrain
How many receptors does ACh have?
Two receptor classes (and numerous subclasses)
What disorders are a/w ACh imbalance?
Dementia and neurocognitive disorders
ACh acting on the MS (medial septum) to hippocampus influences what?
Learning/ memory
ACh acting on the NBM (nucleus basalis of meynert) to cortex influences what?
Attention
Where is glutamate produced?
Throughout CNS
Targets of glutamate are what?
Local and distributed
(primary excitatory NT of CNS)
How many receptor classes does glutamate have?
3
What disorders are a/w glutamate imbalances?
Psychotic disorders, bipolar disorders, substance abuse disorders, dementia (Alzheimers)
(theory for Alzheimers = glutamate receptor (NMDA) hypersensitive to stimulation in AD)
Where is GABA produced?
Throughout CNS (interneurons, most ubiquitous NT in brain)
Where does GABA target?
Local neurons
(primary inhibiory NT in CNS)
How many receptor classes does GABA have?
2 (and numerous subclasses)
(receptors have binding sites for multiple chemicals)
What disorders are a/w GABA imbalance?
Seizure disorders (anticonvulsants are GABA agonists), mood disorders, drugs of abuse (all depressants = GABA agonists), anxiety disorders
What are the targets of ADHD meds?
- Presynaptic modulation (NT release and reuptake)
- Synaptic modulation (NT breakdown)
- Postsynaptic modulation (receptor binding, signal transduction, genomic alterations)
What treatments are used for ADHD?
Psychotherapy, pharmacotherapy, environmental manipulation, educational intervention, behavioral modification
What is first line for management of ADHD in preschool children (4-5 yo)?
Behavioral therapy (meds only if needed)
(med = methylphenidate)
What is first line for management of ADHD in school-aged children (≥ 6 yo) and adolescents?
Medication (then behavioral interventions added to meds)
What is NOT recommended in the tx of ADHD?
Diets or supplements
What is used in the management of ADHD in adults? (4)
- Medication (amphetamine salts)
- Atomoxetine (buproprion) if substance abuse is concern
- Antidepressants
- CBT as adjunct
When treating ADHD in adults, if substance abuse is a concern, what things can be done to help manage this?
Controlled substance agreement with patient, urine drug screening
Maintain daily schedule, minimize distractions, provide specific/ logical places to keep items, set small/ reachable goals, reward pos behavior, use charts/ checklists, limit choices, find activities in which the child can be successful, and using calm discipline are all examples of what type of management for ADHD?
Behavior modification
Tutoring, individualized education programs (IEPs), write assignments on board, smaller class size, sit near teacher, frequent breaks, extra time to complete tasks/ tests, signal from teach when child is off task, and daily reports to parents are all examples of what kind of management for ADHD?
Educational intervention
What do stimulants do and what are the most commonly used?
Increase release of DA and NE
Methylphenidate and dextroamphetamine most commonly used (controlled substances)
Ritalin, Methylin, Concerta, Focalin, Metadate are all examples of what (generic name)?
Methylphenidate
Dexedrine and Vyvanse are examples of what (generic name)?
Dextroamphetamine
Adderall is an example of what (generic name)?
Mixed amphetamine salts
What type of formulations are available for stimulants?
Short-acting and long-acting
(solution, pill, chewable tablet, patch)
How are ADHD outcomes quantified?
Symptom severity, treatment retention, adverse events (decreased appetite most common)
What are the SEs of stimulants?
Appetite disturbance, weight loss, personality changes, sudden cardiac death if underlying cardiac disease
(other: social withdrawal, irritability, nervousness, sleep disturbance, HA, stomach pain, tics, contact derm, increased HR/ BP)
What is the MOA for atomoxetine?
SNRI
Is atomoxetine a controlled substance?
No = less potential for abuse
What is a disadvantage of atomoxetine?
More expensive than methylphenidate and dextroamphetamine and may not be as effective for some pts
If pt has SEs to initial chosen stimulant, what should you do?
Choose another (be prepared to titrate dosages)
Why should you get assent with adolescents in treating ADHD?
Pt preference is important
What mood disorders are a/w a GABA imbalance?
Bipolar disorders
