ADHD Flashcards
Classic Triad of ADHD
Inattention, Impulsivity, Hyperactivity
Diagnostic criteria for ADHD
Same 18 symptoms in IV and 5. Divided into two symptom domains (inattention and hyperactivity/impulsivity). Need at least 6 symptoms for diagnoses
Changes in DSM-5 regarding ADHD
Examples added to criterion to be applicable across life span.
Cross-situational requirement is now “several symptoms”
Symptoms must have been present before age 12
Comorbid diagnosis with autism spectrum disorder is allowed
5 symptoms for Adults must be present
DSM Diagnostic Criteria for Inattention
Makes careless mistakes Difficulty sustaining attention in tasks Does not seem to listen when spoken to directly Difficulty following instructions Difficulty organizing tasks Avoids tasks that require sustained mental effort Easily distracted by extraneous stimuli Often forgetful in daily activity
DSM Diagnostic Criteria for Hyperactivity/Impulsivity
Fidgets Leades seat Runs or climbs excessively Talks excessively Difficulty waiting turn Interrupts or intrudes on others
DSM Functional Criteria
6 of 9 symptoms in either or both categories
Inattentive; Hyperactive-Impulsive, or combined type
Persistent for at least 6 months
Some symptoms prior to age 12
Impairment in 2 or more settings
Social/academic/occupational impairment
Overlap of symptoms and diagnoses
ADHD is exhibits same symptoms as anxiety and some symtoms as LD and ODD
Differential Diagnosis (Psychiatric)
Mood and/or Psychotic Disorder Anxiety Disorder Learning disorder Mental Retardation/Borderline IQ ODD Pervasive Developmental Disorder Substance Abuse Axis II Disorders Psychosocial Cx
Differential Diagnosis (Medical)
Seizure Disorder Chronic Otitis Media Hyperthyroidism Sleep Apnea Drug-Induced Inattentional Syndrome Head Injury Hepatic Illness Toxic Exposure Narcolepsy
Epidemiology
- Most common diagnosed behavioral disorder of childhood (1/20)
- 3-7% of school kids
- 2-9:1
- Girls show less hyperactivity, conduct problems, and less externalizing behavior
Epidemiology
- 30-50% of cases persist past 15 years
- strong predictor of poor prognosis is pre-pubertal aggression
- over 80% of psychotropics are Rx by primary care providers
- outpatient inc from 1.6-4.2 million from ‘90-‘93
World Wide prevalence of ADHD
is 3-7%
ADHD is familial
sibling inc 2-5x
parents 3-5x inc
Co-morbidity of ADHD
2/3 of children present 1 or more cormbid axis I disorders (anxiety, odd, ld etc)
Adolescents w/ ADHD Rx have (higher or lower) rates of substance abuse than untreated
Lower
ADHD Outcomes
- lower grades
- higher expel rates
- worse on exec function tests
- fewer friends
- lower self-esteem
- higher arrest rates
- lower occupational rank
- higher termination rates
Natural History
1/3 -> complete resolution
1/3 -> continue inattention, some impulsivity
1/3 -> early ODD, poor academic achievement, substance abuse, antisocial disorder
Age Related changes
preschool- hyperactive impuslive
school - combination symptoms
adolescence - more inattention w/ restlessness
adult - largely inattention w/ periodic impulsivity
ADHD (Striatum, posterior brain regions) Larger or Smaller?
Smaller (Correlates with severity of ADHD)
Specific Genes
-Thyroid receptor
-Dopamine Transport gene
Dopamine Receptor D4 gene
DAT Dysfunction
Increased reuptake of dopamine via DAT results in hypodopaminergic state (not enough)
Potential Non-genetic causes
Perinatal stress Low birth weight traumatic brain injury smoking during pregnancy severe deprivation
Executive Functioning
- response inhibition
- vigilance
- working memory
- difficulty with planning
Establishing a Convincing Diagnosis
No single test to identify ADHD
- Continous Performance Tests (TOVA, CPT, Gordon Computerized Diagnosis System)
- Must be multi-factorial
Clinical Interview (ADHD)
- Diagnostic assessment of primary complaints
- review of psychiatric systems
- medical, psychiatric, and developmental history
- detailed educational and social history
Collateral Interviews (ADHD)
- Patient
- Primary caregivers
- Teachers
- School counselors
- Sunday school teachers
“Some” symptoms
- by age 7 years
- Symptoms must be in multiple settings
Rating Scales
- Snap IV
- Conners
- ACTeRS
- Child Behavior Checklist
- ADHD Rating Scale -IV
Treatment Trial
- Risk of adverse effects is signficant
- Not necessarily “diagnostic” even if effective
- 2-3 treatments should be used before deemed non-responder
Latino and black children are (more/less) likely to be diagnosed with ADHD by parent report than white children
less
Black children are (more/less) less likely to receive stimulants than white children
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