6/8- Attention Disorders and Treatment Flashcards
T/F: Attention disorders are behavioral disorders caused by excessive restlessness and distractability, a problem that usually remits during childhood but occasionally persists into adulthood
False. This is the hold conceptualization
What are attention problems/disorders?
Complex disorder in unfolding development of the unconscious self-management system of the brain
- A problem of chemical dynamics in the brain
Impairments with attention disorders include what?
Chronic difficulties in self regulation by emotion
When do symptoms become apparent with attention disorders?
Symptoms may be noticeable in childhood, but may not be apparent until the individual encounters challenges of adolescence or adulthood
T/F: Attention disorders are genetic
True: appear to be primarily genetic, though environmental stressors and support may modify expression of symptoms (environment may make it better or worse!)
T/F: attention disorders increase risk of other comorbidities across the lifespan?
True
ADHD Criteria?
- Symptoms present before the age of 7
- Symptoms are present in more than 1 setting
- Symptoms may be primarily inattentive, hyperactive/impulsive or a combination of both
Inattentive symptoms?
- Makes careless mistakes; poor attention to detail
- Has difficulty sustaining attention
- Does not seem to listen
- Does not follow through or finish tasks
- Avoids activities that require sustained mental effort
- Loses things easily
- Is easily distracted
- Is forgetful
Hyperactivity/impulsivity symptoms?
Hyperactivity:
- Fidgets, squirms
- Has difficulty remaining seated
- Runs or climbs excessively (children), experiences subjective restlessness (adults)
- Has difficulty with quiet activities
- Is “on the go” or “driven by a motor”
- Talks excessively
Impulsivity:
- Blurts out answers before questions are completed
- Are impatient
- Often interrupts others
T/F: If someone has inattention/trouble focusing, the diagnosis to consider is ADHD
False; inattention is a symptom of many disorders
Inattention may be a symptom of what disorders?
- ADHD
- Mood disorders
- Anxiety disorders
- Thought disorders
- Pervasive developmental disorders
- Learning disorders
- Personality disorders
T/F: You can have ADHD (attention deficit hyperactivity disorder) that presents as inattentive
True
__% of children aged 3-5 meet the criteria for ADHD
2-6% of children aged 3-5 meet the criteria for ADHD
(increasingly diagnosed in ages 2-3) … some concerns arisen about using diagnostic criteria in such a young age group (need to wait until ~5 yo)
Early symptoms of ADHD are considered predictive of what?
Later behavioral problems
__% of children in elementary school meet criteria for ADHD? What is the distribution in gender?
3-7% of children in elementary school meet criteria for ADHD
Gender distribution varies:
- Boys more hyperactive
- Girls more inattentive
Elementary school aged kids with ADHD are at higher risk for what?
- Grade retention
- Special education
__% of pts diagnosed with ADHD as children continue to have the full clincial syndrome in adolescence?
78% of pts diagnosed with ADHD as children continue to have the full clincial syndrome in adolescence
Characteristics of ADHD in adolescents?
- Physical hyperactivity diminishes but inattention and impulsivity persists
- Have worse driving habits, more accidents, and more speeding tickets
- More consequences of sexuality
- More challenges in gaining teen’s cooperation with diagnosis and treatment
__% of children with ADHD continue to have symptoms in adolescence and adulthood?
30-70% of children with ADHD continue to have symptoms in adolescence and adulthood (4.4% prevalence)
Characteristics/impact of ADHD in adults?
- May influence job selection
- May tend to overwork due to inefficiency
- May have low frustration tolerance or relationship problems
- Impulsivity may be seen in driving, managing finances
- May have low self-esteem due to chronic feelings of underachievement
T/F: ADHD is something children commonly outgrow
False
- 78% continue into adolescence
- 30-70% continue into adulthood
Questions you can ask when taking a history of attention problems?
- Sitting through a movie
- Reading for pleasure
- Video games (may reveal inability to disengage*)
- Taking notes in class
- Organization skills, misplacing things
- Keeping their room in order
- Daydreaming
- Quickly lose interest
- Participation in conversations, interrupting, perception of peers
- Moodiness, frustration tolerance
*Thus, ADHD may not only involve inattention but also inability to remove attention from something that is especially stimulating
Neuropsychological testing focuses on what in assessing ADHD?
- Processing speed (WAIS III)
- Attention tests (Continuous Performance Test)
- Working memory tests (remember fewer details of story, but doesn’t decrease over time like dementia)
- Executive functioning (Wisconsin Card Sorting)– areas of difficulty suggest involvement of frontal cortex or regions projecting to the frontal cortex
What are some neuroimaging results seen in ADHD?
- Large MRI study demonstrated smaller brain volumes that did not normalize with maturity
- PET studies identified abnormalities of cerebral metabolism in the prefrontal and premotor areas of the frontal lobe in ADHD adults who had children with ADHD
Treatment for attention disorders?
- Stimulants
- Atomoxetine
- Clonidine
- Guanfacine
Non-Stimulant Medications:
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
- Buproprion
- SSRIs, SNRIs
Behavioral treatments
Academic and workplace modifications
Stimulants used for treating attention disorders have what characteristics?
- Structurally similar to endogenous catecholamines
- Have dopaminergic and noradrenergic neurotransmission but differ between compounds (part basis for pt selection)
- Improve cognitive performance but do not necessarily normalize performance
What are some commonly used stimulants for attention disorders?
- Methylphenidate (Ritain, Concerta)
- D-methylphenidate (Focalin)
- D-amphetamine (Dexedrine)
- Mixed amphetamine salts (Adderall)
- Lisdexamfetamine (Vyvanse)
Stimulant Dosing Comparison (table)
What is the longest-acting stimulant? How long?
Shorter-acting?
Shortest-acting?
10-12 hours (take 1x/day)
- Long acting methylphenidate (Concerta)
- Mixed amphetamine salts- extended release (Adderall XR)
4-6 hours (take 2x/day)
- Mixed amphetamine salts (Adderall)
- D-methylphenidate (Focalin)
3-4 hours (take 3x/day):
- Immediate release Methylphenidate (Ritalin)
Side effects of stimulant medications?
- Appetite suppression (unclear impact on growth)
- Sleep disturbances, mood disturbances
- “Dull” feeling - Irritability, anxiety
- Psychosis, mania (in overdose)
- Restlessness
- Awareness of peaks
- Headaches
- Tic disorders
- GI problems
- Increased pulse and BP
- Lethargy, fatigue
- Potential for abuse (no clear evidence)
- SUDDEN CARDIAC DEATH- particularly if there is an underlying hear defect or disease
What is Atomexetine?
Class:
Approved for:
Results in:
Side effects:
Requires:
Abusable (yes/no):
Dose frequency:
Atomexetine:
Non-stimulatory
Class: specific NE re-uptake inhibitor
Approved for: children and adults
Results in: improved performance on neuropsychological measures
Side effects:
- Appetite decrease* (more in kids; may cause poor nutrition)
- GI symptoms
- Mild increase in BP and pulse
- Rare and serious hepatotoxicity (TEST QUESTION)
Requires: titration to target dose
Abusable (yes/no): No
Dose frequency: Daily
What is the “good grade” pill refer to?
- Non-specific performance enhancement and increased alertness
- Though not necessarily casual, increased use of alcohol and cannibis are predictors of non-medical use of stimulants
T/F: The most common demographic to mis-use Adderall are competitive students using it to improve grades/school performance
False
What is Clonidine?
Class:
Uses:
Side effects:
Clonidine
Class: alpha adrenergic agonist
Uses: primarily for HTN, but also for hyperactivity and impulsivity symptoms
Side effects:
- Sedation
- Hypotension
- Dry mouth
- Depression
- Rebound hypertension
The “epidemic of ADHD”: why was there such a difference in diagnosis/prevalence of ADHD geographically (e.g. NC > CA)?
Predictors of diagnosis was educational policy!
- No Child Left Behind (linking school financing with standardized test performance) resulted in increased ADHD diagnosis rates
- Nationwide ADHD diagnosis increased by 22% in the 1st 4 years after NCLB
What is Guanfacine?
Class:
Uses:
Side effects:
Guanfacine:
Class: more selective alpha antagonist than clonidine
Uses: treatment for impulsive/hyperactive symptoms
Side effects:
- Less sedating than clonidine
- Less hypotensions than clonidine
- Dry mouth
- Depression
- Rebound hypertension
What are some additional non-stimulant medications for ADHD?
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
- Buproprion
- SSRIs, SNRIs
What do behavioral treatments for ADHD include?
These are the mainstay! “Medications are like a bandaid”
- Prioritizing demanding activities to most productive times
- Tutoring
- Compensatory behaviors (list making, reminders)
- Career advice
- Supportive psychotherapy
- Group psychotherapy
- Family psychotherapy
- Coaching
How are stimulants capable of treating something that seems to be a result of over-stimulation (ADHD)?
Stimulating part of the brain that is inactive, which in turn, calms down the frontal lobes
What academic and workplace modifications can be used to help with ADHD?
- Limited interruptions in the workplace
- Modified exams
- Access to class notes
- Taping lectures
- Extended testing time
- Testing in isolated environment
- Reasonable modifications of degree plans
T/F: ADA is a protected diagnosis
True
T/F: Workplace modifications are not practical to help with ADHD because they inconvenience the workplace
False (ideally).
Patients are entitled to reasonable request for modifications
