4-26 ADHD - Brandt Flashcards
What are the risk factors for ADHD?
¨M:F of 3:1
¨Risk factors
¤Perinatal: maternal smoking, substance abuse, obstetrical complications, malnutrition, toxic or viral exposure
What are the main symptoms of ADHD? How often should they occur?
¨KEY: pattern of extreme inattentiveness and/or restlessness
¨Occurs in at least two settings for at least 6 months with onset before the age of 12 with at least 6 symptoms
¨3 types: inattentive type; hyperactive-impulsive type; combined
When do symptoms initially present?
¨Symptoms of hyperactivity are usually are very obvious by first grade when children are asked to sit still and focus in class.
¨Symptoms need to be present before age 7.
¨Treatment of choice is stimulants such as methylphenidate.
What are the symptoms of ADHD into adulthood?
¨Adults can have difficulties at work and thus may need meds.
¤Estimates are that 60% of the cases persist until adulthood.
¨3-10% of young & school age children
¨Male-female ratio is 4:1
¨Without treatment there are more arrests, suicide attempts, substance abuse, car accidents and poor school/work performance.
What is the DSM-V criteria for inattentive ADHD?
¨Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
¨Inattention – 1A
¨Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
¨Often has trouble keeping attention on tasks or play activities.
¨Often does not seem to listen when spoken to directly.
¨Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
¨Often has trouble organizing activities.
¨Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
¨Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
¨Is often easily distracted.
¨Is often forgetful in daily activities.
¨
What is the DSM-V criteria for inattentive ADHD?
¨Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
¨Inattention – 1A
¨Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
¨Often has trouble keeping attention on tasks or play activities.
¨Often does not seem to listen when spoken to directly.
¨Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
¨Often has trouble organizing activities.
¨Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
¨Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
¨Is often easily distracted.
¨Is often forgetful in daily activities.
What is the DSM-IV criteria for hyperactive ADHD?
¨Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
¨Hyperactivity – Impulsivity 1B
¨Often fidgets with hands or feet or squirms in seat.
¨Often gets up from seat when remaining in seat is expected.
¨Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
¨Often has trouble playing or enjoying leisure activities quietly.
¨Is often “on the go” or often acts as if “driven by a motor”.
¨Often talks excessively.
¨Often blurts out answers before questions have been finished.
¨Often has trouble waiting one’s turn.
¨Often interrupts or intrudes on others (e.g., butts into conversations or games).
What are some criteria for overall Dx of ADHD?
¨Symptoms that cause impairment were present before age 12 years.
¨Impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
¨There must be clear evidence of significant impairment in social, school, or work functioning.
¨The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
¨Based on these criteria, two types of ADHD are identified:
¨ADHD, Inattentive Type: if both criteria 1A for the past 6 months
¨ADHD, Predominantly Hyperactive-Impulsive : if criterion 1B is met but criterion 1B is not met for the past six months
ADHD, Combined Type: if Criterion
What are some ways that ADHD drugs can last for longer?
¨Change the rate it dissolves
¨
¨Osmotically released Oral Stimulates
¨
¨Transdermal
¨
¨Or just give multiple dosing
What are the pharmacological actions of drugs used to treat ADHD?
¨Methylphenidate
¤Increased postsynaptic dopamine by blocking it’s reuptake
¨
¨Amphetamine
¤Inhibits multiple monoamine transport systems
¤Increases release from synaptic vesicles
Lesdexamfetamine
What are some tips that can help reduce dependence on ADHD meds?
¨Starter doses
¨Managing the afternoon crash
¨Drug Holidays
¨Short half life drug of short term focus
¨Managing sleep
What are the principle side effects of ADHD meds?
¨Appetite suppression
¨
¨Irritability
¨
¨Exacerbation of Tic symptoms
¨
¨?Psychosis
How is clinical management of ADHD done?
¨Stimulants are effective for 80% of patients and are first line treatment.
¤Methylphenidate or mixed amphetamine salts
nWeight-based dosing. Typical 0.5 – 1 mg/kg/day
nSide Effects: Decreased appetite, irritability, insomnia, weight loss, abdominal pain & misuse, abuse/diversion are concerns – Monitor growth & weight & get feedback from teachers.
¨Nonstimulants – atomoxetine
¨Alpha 2 agonists – clonidine, guanfacine
¨Rarely tricyclics or bupropion
¨Start at lowest recommended dose and increase slowly, as tolerated and indicated
¨Treatment with stimulants has decreased risk for substance abuse.
What are some environmental changes that are helpful with ADHD?
¨Parents
¤need to learn behavioral management
¤limit-setting
¤positive reinforcement techniques
¨School
¤Teachers need to understand the disorder
¤Minimize distractions
¤Divide work into smaller subsets of problems
¤Make sure the student masters one topic before moving to the next
¨Psychotherapy
¤Group therapy for social skills and impulse control
