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Psychiatry > ADHD > Flashcards

ADHD Flashcards

1
Q

What does ADHD stand for

A

Attention Deficit Hyperactivity Disorder

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2
Q

What is ADHD

A

A persistent pattern (≥6 months) of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development and which interferes with functioning and/or development

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3
Q

How common is ADHD in children

A

Present in around 4-5% of children

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4
Q

What are some factors that contribute to ADHD

A

Genetic predisposition
Perinatal precipitants
Psychosocial adversity

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5
Q

What genes are mainly involved in ADHD

A

Those for dopamine and serotonin transporters

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6
Q

What are some perinatal factors that can contribute to ADHD

A
  • Alcohol and tobacco use during pregnancy
  • Significant prematurity and perinatal hypoxia
  • Other complications include unusually short or long labour, foetal distress, low forceps delivery and eclampsia
  • Some evidence suggests an association with exposure to viral infection in first trimester
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7
Q

What are some forms of psychosocial adversity that can predispose to ADHD

A

Severe marital discord, lower social class, large family size, paternal criminality, maternal mental disoder, maltreatment and emotional trauma

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8
Q

Describe the neurobiology of ADHD

A

Under-active function of the frontal lobe, which is mainly responsible for reasoning, planning and impulse control

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9
Q

Describe the neurochemistry of ADHD

A

Excessively efficient dopamine-removal system, so lower levels of dopamine in synapses

Reduction of NA and serotonin

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10
Q

Which brain systems are involved in reward, attention and arousal?

A

Locus coeruleus-noradrenergic system
Mesocorticolimbic system

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11
Q

Describe the location of the mesocorticolimbic system

A

This projects from the ventral tegmental area (VTA) to the limbic system and the pre-frontal cortex

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12
Q

Describe the functions of the mesocorticolimbic system

A

It transmits dopamine and so is involved in reward-related cognition:

  • Incentive salience
  • Pleasure
  • Positive reinforcement

It also takes part in executive functions

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13
Q

Where does the locus coeruleus get its name?

A

This is latin for blue spot as it appears azure on unstained brain tissue due to melanin

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14
Q

What is the function of the locus coeruleus?

A

This is the most important source of noradrenaline in the brain
It is broadly associated with vigilance and reaction speed

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15
Q

What are the functions of NA in the brain

A
  • Enhances processing of sensory inputs
  • Enhances attention
  • Enhances formation and retrieval of both long and short term and working memory
  • Enhances the ability of the brain to respond to inputs by changing the activity pattern in the pre-frontal cortex and other areas
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16
Q

Describe the location of the locus coeruleus

A
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17
Q

What are some of the impacts of childhood ADHD

A
  • Significant difficulties parenting children with ADHD
  • Increased level of home stress and high expressed emotions
  • Emotional dysregulation leads to difficulties in peer relationships and reckless and dangerous behavior
  • Poor problem solving ability leading to developmentally inappropriate decision making
  • Significant barrier to learning and potentially exlusion from education
  • Higher likelihood of antisocial behaviours
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18
Q

What are some of the impacts of adult ADHD

A
  • There is an increase in the frequency of psychiatric comorbidity as compared to children
  • Higher levels of criminality, antisocial behaviour
  • Higher level of substance misuse - link to self-medication?
  • Significant impairments in occupational function that could easily be accommodated for if diagnosis known
  • Most adults will still present with residual symptoms but will no longer meet diagnostic criteria
    • Possibly because there is an improvement in cortical thickness (maturation) that allows for the brain to compensate for cognitive deficits
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19
Q

What is the triad of ADHD symptoms?

A

Inattention
Hyperactivity
Impulsivity

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20
Q

What are some non-triad symptoms of ADHD

A

Impairment of self-regulation of executive functioning and emotional regulation

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21
Q

What are the 3 clusters of inattention symptoms in ADHD?

A

Cluster 1 - Focus
Cluster 2 - Distractibility
Cluster 3 - Forgetfulness/Dysexecutive

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22
Q

What are some cluster 1 (Focus) symptoms of ADHD?

A
  • Difficulty sustaining attention in tasks that don’t provide high levels of stimulation or reward
  • Lacking attention to detail
  • Making careless mistakes in school or work assignments
  • Not completing tasks
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23
Q

What are some cluster 2 (Distractibility) symptoms of ADHD

A
  • Easily distracted by extraneous stimuli or unrelated thoughts
  • Often appears not to listen
  • Frequently daydreams or has their mind elsewhere
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24
Q

What are some cluster 3 (Forgetfulness/Dysexecutive) symptoms of ADHD

A
  • Loses things
  • Forgetful in daily activities
  • Difficulty remembering to complete daily tasks
  • Difficulty planning, managing and organising schoolwork, tasks and other activities
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25
Q

What are the 4 groups of hyperactivity-impulsivity symptoms in ADHD?

A

Physical or hyperkinetic
Loud
Social
Lack of deliberation of risks of consequences

26
Q

What are some hyperkinetic or physical symptoms of ADHD

A
  • Excessive motor activity
  • Can’t sit still
  • Often runs about
  • Fidgeting
27
Q

What are some loud symptoms of ADHD?

A
  • Difficulty engaging in activities quietly
  • Talks too much
28
Q

What are some social symptoms of ADHD?

A
  • Blurts out answers in school or work
  • Difficulty in waiting their turn in conversation, games or activities
  • Interrupts or intrudes on others’ conversations or games
29
Q

What are some symptoms of lack of deliberation of risks or consequences in ADHD?

A
  • Engaging in behaviours with potential for physical injury
  • Impulsive decisions
  • Reckless driving
30
Q

How is ADHD assessed in childhood?

A

Ideal assessment is school observation with screening and diagnostic questionnaires and background information including exploration of early history and attachment styles

31
Q

What are the diagnostic criteria for ADHD in children?

A
  • 6 or more symptoms of inattentiveness; and/or
  • 6 or more symptoms of hyperactivity and impulsiveness
  • Present before 5 years
  • Reported by parents, school, and seen in clinic
  • Symptoms get in the way of daily life
32
Q

How is ADHD assessed in adulthood

A

Specific adult screening tools, with clinical picture and historical picture fitting with the diagnosis

33
Q

What are the diagnostic criteria for ADHD in adulthood

A
  • In general, 5 or more of the symptoms of inattentiveness; and/or
  • 5 or more of hyperactivity and impulsiveness
  • Historical concerns since early age

Also effects of:
- Underachieving at work or in education
- Driving dangerously
- Difficulty making or keeping friends
- Difficulty in relationships with partners

34
Q

What are some psychosocial interventions used in mild, moderate or severe ADHD in children?

A
  • Parent training
  • Social skills training
  • Sleep and diet (controversial)
  • Behavioural classroom management strategies
  • Specific educational interventions
35
Q

What is the 1st line pharmacological treatment of moderate-severe ADHD

A

Stimulants

36
Q

What is the 2nd line pharmacological treatment of moderate-severe ADHD

A

SNRIs

37
Q

What is the 3rd line pharmacological treatment of moderate-severe ADHD

A

Alpha-agonists

38
Q

What are some examples of stimulants

A
  • Methylphenidate
  • Dexafetamine
  • Lisdexafetamine
39
Q

MOA of methylphenidate

A

This works by increasing dopamine by blocking the dopamine transporter

40
Q

How long do methylphenidate effects last

A

It lasts around 4 hours, however, longer lasting preparations are available which can last 8-12 hours such as Concerta or Xaggitin

41
Q

MOA of dexafetamine

A

This works by increasing dopamine by blocking the dopamine transporter, as well as increasing extracellular noradrenaline and possibly serotonin

42
Q

How long does dexaphetamine last?

A

4 hours

43
Q

MOA of lisdexafetamine (Elvanse)

A

This is a prodrug of dexafetamine which is gradually metabolised in the liver into dexafetamine, therefore giving it a 13-hour duration

44
Q

What are some monitoring requirements for stimulants?

A

Before stimulants are started, baseline checks are require, which include:

  • Height and weight
  • Pulse and BP
  • Cardiovascular assessment
45
Q

What are some factors that require cardiological opinion before starting stimulants?

A

A cardiological opinion may be required in cases of congenital heart disease, FH of sudden death in under 40s, SOB, signs of heart failure, murmur or hypertension

46
Q

Very common side effects of stimulants

A
  • Appetite suppression
  • Insomnia
  • Headache
47
Q

Common side effects of stimulants

A
  • Nausea and vomiting
  • Nervousness
  • Nasopharyngitis
  • Dizziness
  • Tachycardia
48
Q

Rare side effects of stimulants

A
  • Aggression
  • Mood changes
49
Q

Example of an SNRI used in ADHD

A

Atomoxetine

50
Q

MOA of atomoxetine

A

This works by increasing noradrenaline by blocking its transporters

51
Q

How long does the effect of atomoxetine last?

A

This has a 24 hour effect, but takes 2 months to start working

52
Q

Very common side effects of atomoxetine

A
  • Loss of appetite
  • Nausea and vomiting
  • Increased alertness
53
Q

Common side effects of atomoxetine

A

Constipation
Fatigue

54
Q

Rare side effects of atomoxetine

A
  • Skin rashes
  • Jaundice and hepatic damage
  • Aggression
55
Q

Examples of alpha-agonists used in ADHD

A

Clonidine
Guanfacine

56
Q

MOA of alpha-agonists

A

Agonise a2 adrenoceptors and so increase NA by reducing sympathetic stimulation
This strengthens regulation of attention and behaviour by the pre-frontal cortex via stimulation of post-synaptic a2A adrenoceptors on dendritic spines, inhibiting cAMP-mediated opening of HCN and KCNQ channels, enhancing neuronal firing

57
Q

How long does guanfacine last?

A

Guanfacine has a 24-hour effect and takes 2 weeks to work

58
Q

Very common side effects of guanfacine

A
  • Sleepiness/fatigue
  • Headache
  • Stomach pain
59
Q

Common side effects of guanfacine

A
  • Loss of appetite
  • Weight gain
  • Poor sleep
  • Bradycardia
  • Postural drop
  • GI upset
60
Q

Rare side effects of guanfacine

A
  • Hypotension
  • Syncope
  • Depression
61
Q
A

Psychiatry (20 decks)

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