ADHD Flashcards
What problems are present with diagnosing ADHD?
- Pressure from parents
- Pressure from school
- Time needed for thorough evaluation
- Need to coordinate multiple resources to provide treatment
- Time needed for follow-up and evaluation of effectiveness of treatment
- Differential diagnosis
What evidence supports the validity of ADHD?
- Predictive validity
- Cross-cultural Validity
- Genetic studies
- Imaging studies
- Consistent impairments
What is the current concept about ADHD?
- Brain disorder of response inhibition in executive functioning (prefrontal)
- Attention is different for different tasks (exciting stimuli may draw attention)
What causes ADHD?
- The causes of ADHD are multifactorial…with influences of environment, genetics and CNS influences
A. Environment includes home, school and community
B. CNS Injury/Insults—head trauma, hypoxia as neonate, etc
How do symptoms of ADHD change as a pt gets older?
- Inattention remains constant
- Hyperactivity decreases
- Impulsivity
- 40% outgrow symptoms of ADHD, 60% continue to have some impairing symptoms into adulthood
decrease
What are potential areas of impairment for children with ADHD?
- Academic limitations
- Poor peer relationships
- Increased injuries
What are potential areas of impairment for adolescents with ADHD?
- Low self-esteem
2. Risk-taking activities: smoking, substance abuse, sexual activity
What are potential areas of impairment for adult with ADHD?
- MVA
- Legal difficulties
- Occupational/vocational
What are the types of ADHD?
- Combined Type
- Predominantly Inattentive Type
- Predominately Hyperactive-Impulsive Type
What are sxs of inattention?
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
- Often has trouble holding attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
- Often has trouble organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted
- Is often forgetful in daily activities
What are the inattentiiveness criteria?
Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults
What are the hyperactivity and impulsivity criteria?
Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults
What are the sxs of hyperactivity and impulsivity?
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
- Often unable to play or take part in leisure activities quietly.
- Is often “on the go” acting as if “driven by a motor”.
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting his/her turn.
- Often interrupts or intrudes on others (e.g., butts into conversations or games)
What is combined presentation?
if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
What is predominately inattentive presentation?
if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
What is predominately hyperactive-impulsive presentation?
if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
What are the genetic factors for ADHD?
40% parents affected
35% siblings affected
Hypofunctional dopamine system in frontal lobes
What external factors can contribute to ADHD?
Perinatal injury Maternal drug/alcohol use Toxins/Lead Social-cultural factors Family factors (disruptive family, absent parent, impaired parent, abuse)
What dx studies can be used for ADHD?
- Abnormal PET scans
- Neurotransmitter imbalance
A. Dopamine
B. Serotonin - Not related to allergies, sugar, food additives
What factors may be asst. with ADHD?
- Mental Retardation
- Learning Disabilities
- 25-50% of L.D. have ADD
- 10-30% of ADD have L.D.
- Neurological Disorders
- Enuresis/Encopresis
What are the ddx for ADHD?
- Mood Disorders
- Anxiety Disorders
- Psychosis
- Pervasive Developmental Disorder
- Learning Disabilities
- Poor environmental controls
- Family Dysfunction
- PTSD
- Oppositional Defiant Disorder
- Conduct Disorder
- Tourette’s Syndrome
- Age – appropriate over-activity
What factors can be used to help diagnose ADHD?
- Family – parents (individually), siblings, extended family
- School
A. Teachers
B. Report Cards - Past Medical Records
- Rating Scales – Vanderbilt, BASC
- Psychological Evaluations
- Family History
- Home Environment
- Social Events
- Babysitters
- School Functioning
- Peer Relationships
- Police Records, problems with authority
- Associated Complaints
What domains does the Vanderbilt Rating Scale cover?
- Inattention
- Hyperactivity
- Oppositional Defiant
- Conduct
- Anxiety/Depression
- Performance
Who can you refer ADHD pts to?
1. Psychological Testing A. I.Q. B. Learning Disabilities 2. Psychiatric Consult 3. Neurology Consult
What is the pre-school ADHD presentation?
- Very hyperactive: always, always on the go
- Dangerously daring
- Multiple accidental injuries
- Very destructive play
- Difficulty with the initiation of sleep is common
- Low levels of compliance
- Difficulty sustaining baby sitters or day care
What are the assessment challenges for preschool children?
- ADHD-like behaviors may be developmentally normal in this group when they are mild to moderate and without impairment
- ADHD versus environmental versus developmental disorder versus ODD/BPD
- Early intervention change trajectory?
What are the treatment goals?
Improved Cognition
Decreased motor activity
Improved social skills
Improved efficiency
What factors can delay the diagnosis of ADHD?
- Primary Inattentive Subtype
- Female Sex
- Highly Supportive Family
- High IQ
- Well Developed Social Skills
What are the assessment challenges for adolescent children?
- Multiple teachers for shorter periods of observation
- Less observation time with the parents
- Different clinical presentation of ADHD in adolescents
- How do we assess clinical information and rating scales from the teen, parents and teachers?
- Increased rate of co-morbid conditions in adolescents compared to elementary school-age children
What is the treatment plan for ADHD?
1. Multimodal Treatment Plan A. Behavioral Counseling B. Parenting Classes C. Medication D. School Involvement E. Activities F. Other Problems 2. Regular Follow-up and Re-evaluation
What pyschoeducation may be helpful in treating ADHD?
Parenting Classes
Reading Materials
What behavioral counseling may be helpful for pts with ADHD?
CONSISTENCY
Positive Reinforcement
Time Management
Parents / Child / School
What are the general principles for medical treatment?
- Perform a thorough diagnostic and bio-psycho-social evaluation
- Children & adolescents are embedded in family and neighborhood networks involving parents/caretakers, siblings, friends, schools, etc.
- Psychiatric medications are generally just one part of a multimodal multidisciplinary treatment plan
- Medications cannot replace need for therapeutic support, behavioral strategies, problem-solving, etc.
- Children and adolescents developmentally different than adults: learn the differences by medication class for efficacy and side effects
- Children may require proportionately higher doses: faster metabolism, greater kidney clearance, and greater liver-to-total-body-size ratio
- Fully involve the family and child in the decision-making process about use of medications (shared decision making)
A. Inquire about concerns, continue to address their concerns - Treat primary diagnosis (or the most urgent or impairing problem) with indicated medication first
- Use systematic rating scale to measure symptoms at baseline and throughout treatment
- Whenever possible, use medications supported by double-blind RCTs for this age group and diagnosis
11.Start low, go slow, taper slow (exception: stimulants can be discontinued more quickly) - Use medications at appropriate dose for adequate duration before changing or augmenting
- Minimize use of multiple medications
- When changing meds: Make only one med change at a time; monitor results
A. Always consider environmental strategies as alternative or complement - Use systematic rating method to measure side effects
- Evaluate iatrogenic effects of multiple medications
A. When unclear, consider tapering or discontinuing most worrisome medication or the one with the least amount of RCT evidence
What meds are stimulants?
- Methylphenidate (eg: Ritalin, Concerta, Focalin)
2. Amphetamine (eg: Dexedrine, Adderall, Vyvanse)
What meds are non-stimulants?
- Atomoxetine (Strattera)
- Guanfacine XR (Intuniv)
- Clonidine XR (Kapvay)
What is the moa of MPH?
- exerts much of its effect through dopamine uptake blockade by inhibition of dopamine transporter (DAT) of central adrenergic neurons
- increase spontaneously released dopamine that enhances response to environmental stimuli
What is the moa of amphetamines?
- amphetamines not only block DAT, but also increase catecholamine release as a primary mechanism.
- Increase spontaneously released dopamine that enhances response to environmental stimuli
What is the moa of Atomoxetine (Strattera)?
Atomoxetine (Strattera) blocks reuptake at the noradrenergic neurons
What is the moa of Guanfacine XR and Clonidine XR?
alpha-2A adrenergic receptor agonist
What is the initial medical workup for stimulants?
- Physical Exam
2/ Height and Weight - Blood Pressure and Pulse
- Lab tests as baseline data (cbc and dif, LFT) 5. Screening for tics, involuntary movements
- Pregnancy Tests
- ECG if family hx of cardiac arrythmias
What are the SE of stimulants?
Decreased appetite Insomnia Gastrointestinal pain Rebound phenomena Mood swings and irritability Increased heart rate (clinically insignificant) Growth retardation Tic disorders Psychosis Mood swings / depression Increased heart rate and BP (significant)
What are the general considerations for prescribing and titrating?
- Children < 5 yrs should not be given stimulants as a treatment of first choice
- Probability of positive response less
- Higher incidence of side effects
- Few controlled research studies
- Risk of drug abuse is greater in adolescents. Obtain detailed history.
- Patients failure to respond to one stimulant does not preclude a positive response to another stimulant
- Although body weight has not shown to be related to drug response, it may be used as a rough guideline for determining starting dose.
- Giving the dose after meals decreases side effects on anorexia and stomachaches
What are the outcomes for ADHD?
- 25% - symptoms abate
- 75% - symptoms persist, usually less hyperactivity
- Increased risk for Conduct Disorder and Antisocial Personality Disorder
- Increased risk for psychiatric problems
- Adult ADHD
- Ritalin abuse
What are the dopamine pathway functions?
- Reward/motivation
- Motor function fine tuning
- pleasure
- compulsion
- perseveration
What are the serotonin pathway functions?
- Mood
- Sleep
- cognition
- Memory processing
How is the brain affected in ADHD?
- ADHD is a developmental delay
- Smaller, less active, less developed brain regions
- Differences found more on the right side of the brain
- Size of networks in brain correlated to the severity of ADHD presentation
- Same ares of brain impacted by ADHD are those that are asst. with emotions, self awareness, and self regulation
