ADHD Flashcards
What are some sources of school failure?
- Health issues
- Emotional issues
- Learning issues
- Attention issues
*try to distinguish where coming from – cognitive ability specific to subject? auditory or visual? Emotional changes? Etc.
What are the risks to untreated adhd?
cascade of negative consequences: poor self esteem –> poor academic performance –> risk taking, substance abuse, etc. –> poor employment options, poor health outcomes, poor relationships
3 characteristics of adhd
- inattentiveness
- hyperactivity
- impulsivity
Definition / diagnostic criteria ADHD
- Interferes w/functioning across settings: home, school, work
- Behaviors > signifcant than peers
- Triad of behaviors beyond range of accepted for “normal”
- At least 6 months
- Symptoms before 12 years of age
3 subtypes of adhd
Neurobiology: structural differences associated w/adhd
Chronic neurobehavioral disorder
smaller frontal lobes
Neurobiology: functional differences associated w/adhd
- Lower blood flow
- Response to meds
- Alteration of neurochemical transmission
Chronic neurobehavioral disorder
ADHD: genetics vs environment
- Very high incidence in twin studies
- 75% variance in phenotype is genetic, not environmental
Specific genes associated with adhd
•Dopamine receptor gene
–Cognition, memory, exploratory behaviors
•Dopamine transport gene
–Site of action of stimulants
•Similar genes linked to other mental health issues
prenatal/parinatal factors associated with adhd
- Pregnancy complications
- Prematurity/SGA
- Hypoxemia
- Hypoperfusion: – low cerebral blood flow associated with increased dopamine receptor availability in adols with ADHD
- Maternal smoking
psychosocial factors associated with adhd
- Maternal depression
- parenting skills/stress
biologic factors associated with adhd
- Lead exposure: even low lead levels showed hyperactivity in preschoolers
- Iron deficiency
- Obstructive sleep apnea
diet factors associated with adhd
- food additives
- sugar
*may be triggers in genetically susceptible child - make better or worse
prevalence of adhd in u.s.
~11%
Preschool age: prevalence, type, male vs female
adhd
- Prevalence: 2-5%
- Type: 48% hyperactive/impulsive
- 1:1 female to male
School age: prevalence, type, male vs female
adhd
- Prevalence: 3-11%
- Type: many combined, many inattentive/impulsive
- 1:4 female to male
High School age: type, diagnosis
adhd
- Type: more inattentive, esp girls
- Diagnosis: ?? other DOs- ODD, CD, “adolescence”, also difficulty w/APA criteria (before 12y)
Characteristics of inattentiveness in ADHD
- Easily distracted
- Poor listening skills
- Poor attention to details
- Forgetful
- Disorganized
- Poor sustained attention to play or tasks
- Fewer activities requiring sustained attention
- Loses items
- Needs redirection
Characteristics of hyperactivity in ADHD
- Most troublesome for preschoolers/early school age
- “On the go”, “Driven by a motor”
- Driven to interact with the environment (restlessness in adolescents)
- Unable to remain seated, even briefly
- Difficulty settling to play
- Fidgety
- Excessive talking
Characteristics of impulsivity in ADHD
- Takes risks
- Disregards physical boundaries
- Unable to cooperate with peers or adults
- Interrupts
- Difficulty waiting turns
- Unable to delay gratification, even briefly
Characteristics of preschoolers w/ADHD
- Lack of rhythmicity
- Poor adaptability
- Sleep disturbances
- Moodiness/irritability
- Demanding of attention
- Slower language development
Preschoolers: behavioral risks associated w/adhd
- Poor impulse control
- Expelled from preschool settings
- More disruptive
- Less cooperative
- Less opportunity to develop social skills
- Increased risk of injury
Preschoolers: Social risks associated w/adhd
- Problematic parent/child relationship
- Family stress
- Limited activities /experiences
- Focus on discipline
- Poor social skill development
- 89% - significant impairment in at least one relationship
Intrusive, in your face, no boundaries, first in line, taking turns, sharing
Preschoolers: academic risks associated w/adhd
- Poor pre-academic skill development
- Delayed emergent literacy
- Parents don’t extend and expand language
- Disrupted phonological awareness
- Lower scores
- Working memory
- Planning
- Cognitive flexibility
Preschoolers: comorbidities associated w/adhd
- 35-50% Oppositional Defiant Disorder
- 15% Anxiety
- 13% Depression
- 19% >1 comorbidity
Challenges to diagnosing adhd in preschoolers
- high energy level: may be nl
- non-compliant behavior
- day-to-day variability in behavior
- situational response to environment
- Neurologic immaturity
- Child-environment mismatch
- Adult expectations of behavior: may be unrealistic for age
- Co-morbidity: e.g., dvptl problems
General Characteristics of adhd in school-age children
- Issues with peers
- Emotionally immature
- Prefer younger children or adults
- Emotional lability
- Procrastination
- Disorganization
- Distractibility
Characteristics of adhd in EARLY school-age children
boys vs girls
Boys: high activity level
Girls: “good”, no trouble
Characteristics of adhd in LATER school-age children
boys vs girls
Boys: increasing oppositional behavior
Girls: more social, talkative
risks for school-age child with adhd
- Family stress
- Family relationships
- Social issues
- Academics
challenges in diagnosis of adhd in school age children
- Normal development
- Learning disabilities
- Medical issues
- Comorbidities
Course of adhd in adolescents
- Previously
- Maturational lag
- Outgrown in adolescence
- Currently
- 65% persist with symptoms at least into adolescence, often adulthood
- Some not diagnosed until adolescence
Characteristics of adhd in adolescents
- Hyperactivity declines
- Inattentiveness more obvious
- School struggles
- Multiple teachers
- Multiple expectations
- Cognitive demands increase
- Memory
- Higher level thinking
- Independence expected
Comorbidities associated with adhd in adolescents
ODD, anxiety, depression, substance abuse DO, personality DO, learning disabilities**
Characteristics suggestive of ODD or conduct DO in adolescents
- Argumentative
- Negative
- Easily frustrated
- Conflicts at school
- School refusal
Characteristics suggestive of anxiety in adolescents
- Restlessness
- Difficulty concentrating
- Irritability
Characteristics suggestive of depression in adolescents
- Social isolation
- Irritability
- Boredom
- Reckless behavior
- Academic underachievement
Principles of assessment of adhd
- Multiple sources
- Good tools
- Recurring themes
- Connections to school and life outside of school
- Profile of strengths and weaknesses
Components of ADHD assessment: History
- History
- Past medical
- Birth
- Chronic illness
- Acute illness
- Trauma
- Development
- Past medical
- Social history
- Family stressors
- Out-of-home care
- Family structure
- Family Medical
- Genetics
- Sibs, cousins
Components of ADHD assessment: PE
- Affect/emotional response
- Dysmorphic features
- Behavior
- Communication skill
Components of ADHD assessment: Medical Screenings (as indicated)
- Sensory
- Lead
- Iron
- Thyroid
Components of ADHD assessment: Developmental / neurodevelopmental screening
- Language/linguistics
- Memory
- Personal-social
- Motor
Why are parent interviews important in adhd?
- Home less structured
- Different expectations
- Appropriate
- Inappropriate
- Unaware of full range of behaviors
- School behavior
- Social interactions
What to look for in interview w/preschool teacher: adhd
- Normative perspective
- Structured and unstructured samples of behavior
Important concepts w/elementary/HS teacher interview: adhd
- May have no knowledge of outside classroom behavior
- poor interrater reliability among teachers
- Parent-teacher agreement =74%
Characteristics of students perspectives on adhd symptoms
- Under report symptoms
- Under rate level of impairment
Who should be involved in adolescent interviews for adhd and why?
- Adolescent alone
- Confidentiality
- Concerns
- Perception of school and family issues
- Sensitive topics
- Use of ETOH, drugs
- Driving habits
- Parents alone
- Perceptions of issues
- Contact with school
- Approaches tried
- Expectations from evaluation
- Adolescent and parents together
* Shared concerns?
Rating scales in adhd: why, disadvantes, types
- Attempt to objectify behavior
- Some normed to age and gender
- Impressionistic, subjective
- Some specific to ADHD, others to range of emotional/behavioral problems
Specific provider rating tools for adhd, recommended
- Vanderbilt (AAP)
- ADHD
- Comorbidities
- Connors
- McCarney (ADDES) short / long forms
- Brown ADD Diagnostic Form for Adolescents – Revised
Self-assessment tools for adhd
- Pediatric Symptom Checklist
- ANSER Self-Report ( >9 years)
- Brown ADD Scales for Adolescents
- Conners-Wells Adolescent Self Report Scale
other adhd assessment tools
- Early Childhood Inventory IV
- SNAP-IV
- Child Behavior Checklist
- Preschool Age Psychiatric Assessment
- Behavior Assessment System for Children
- ANSER system
academic information used to assess adhd mgmt
- Report cards
- School progress- teachers’ comments
- Standardized testing
- Psychoeducational testing
- Neuropsychological testing
Differentials to adhd for preschoolers: medical
- Normal exuberance
- Medical disorders
- Seizures
- Significant lead poisoning
- Sensory deficit
- OSA
- Iron deficiency
- Chronic OM
Differentials to adhd for preschoolers: developmental DOs
- Language delay
- Fragile X syndrome
- Intellectual disability
- Autism spectrum
- FAS
Differentials to adhd for preschoolers: psychiatric DOs
- Depression
- Anxiety
- ODD
Differentials to ADHD for school age and adolescents
- Learning disability
- Mental health issues
- Chronic conditions
- Sensory deficit
- Parental expectations
What are the components of learning, according to PRK’s slides?
-
Attention
- mental energy controls
- processing controls
- production controls
- Temporal - sequential ordering
- Spatial ordering
-
Memory
- short term
- active working
- long term
Language
- receptive
- expressive
- written
Neuromotor functions
- gross motor
- fine motor
Social Cognition
Higher order cognition
Levine, M_, A Mind at a Time_
Components of a student profile of a child w/adhd
- Strengths
- What works best?
- Affective resources
- Coping styles
- Needs
- Where does the breakdown happen?
- What makes it better?
- Environmental influences
- How can school facilitate success?
- Affinities
- Motivators
Inattentive
Hyperactive/impulsive
combined
What are the goals of adhd mgmt?
Develop self-regulatory behaviors:
- maintain self esteem
- develop social skills
- foster learning behaviors
- improve family functioning
General mgmt guidelines
- Chronic condition
- Long term management
- Ongoing evaluation of treatment options
- Careful planning
- Support for child, caregivers, teachers
- Identification of target outcomes
mgmt of adhd: education of parents, dhild, adolescent
- Demystify
- Chronic condition
- Symptoms manageable
- Outcomes good
- Destigmatize
- Not associated with intelligence
- Not associated with being “bad kid”
Environmental mgmt of adhd
- Safe, appropriate boundaries
- Sense of order and control
- Consistent expectations/routines
- Active involvement
- Collaboration and cooperation
- Reduced stimuli – TV, music, and computer, phones
behavioral mgmt training for adhd: goals
- Goals
- Decrease core symptoms
- Improve parent-child interaction
- Improve peer interaction
- Decrease oppositional behaviors
- Generalize to other settings
- Much research about use with preschoolers
- difficult for disorganized families to implement*
- Focus on immediate issues*
Components of behavior mgmt for adhd
- Positive reinforcement
- Token system
- Time out
- Response contingency: withdrawal of attn
- Limit setting
- Appropriate commands and reprimands
- Group social skills
- Cognitive/ behavioral self control training
- Anger management
- “report card”
- Overcorrection
- Minimize negative feedback
Considerations when initiating pharm mgmt
- Seldom should be only treatment but often is only treatment
- Consider co-morbid conditions
- Informed consent/assent of adolescents
- Risk/benefits
Monitoring pharm mgmt of adhd
- Side effects: occurrence, monitoring
- Toxicity: abuse, cardiac, liver
- Periodic assessment
What is the most commonly used category of medications for adhd?
stimulants (1.5 million)
What is the most successful category of medication used for adhd?
stimulants: 80% will improve
What areas do stimulants improve in adhd?
- concentration (mental energy, focus and processing controls)
- behavior (decreased impulsiveness)
- socialization (reduced activity and intrusiveness)
MOA of stimulants for adhd
- Enhance neurotransmitter in brain pathways involved in inhibition
- Activate brain stem arousal
How to dose stimulants
until effectiveness w/o side effects
What are the categories of stimulants?
methylphenidates, amphetamines
Methylphenidates used for adhd
- Ritalin ( S & L): capsule you can empty
- Focalin ( S & L): isomer of ritalin (5mg=10mg of ritalin)
- Methylin ( S & L )
- Metadate ( S & L): capsule you can empty
- Concerta ( L): must be swallowed whole
- Daytrana – patch (L)
- Quillivant XR 25mg/5ml (L): liquid
Stimulant that has less abuse potential
Vyvanse - needs to get into stomach to work, less abuse potential
Which stimulant is good for afternoon overactivity?
Methadate
amphetamines used for adhd
- Dexedrine (S & L)
- Adderall ( S & L)
- Vyvanse ( L)
Characteristics of short-acting stimulants
Characteristics of long-acting stimulants
E.g., concerta is good for older students - steady period of action, ~12h duration
What is unique about Daytrana?
- Apply 2 hours before needed on alternating hips (can be annoying)
- Remove in 9 hrs.
- Prior use of stimulants recommended
- Same safety/ risk profile as oral
What is the newest stimulant and how is it dosed?
- Quillivant 25/5ml
- Liquid
- Long acting
- Start at 20mg ?!
- Same safety and SE profile as others
Potential side effects of stimulants
- Appetite suppression
- Weight loss
- Headaches
- Increased heart rate
- Increased blood pressure
- Tics
- Delayed sleep onset
- Rebound phenomenon
- Growth suppression ? unclear data
- Moodiness
- Sadness
- Lowering of seizure threshold
How to manage appetite suppression/wt loss on stimulants
eat breakfast before medication
If on ER, will happen around lunch. They can have snacks before school.
amphetamines seem to have more appetite suppression
What are some cautions with stimulants
- Significant anxiety, tension, agitation
- Allergies to components
- Glaucoma
- Current or recent use of MAOI
- Motion or verbal tics or family history
- Structural cardiac defects
- Abuse potential
Is routine cardiovascular monitoring needed before starting stimulants?
Previously it was
in 2008, AAP recommended no ECG: no increased risk of SCD and questionable S/S of ECG in predicting SCD
When should CV monitoring be done before starting on stimulants?
+ FMH or + personal history of cardiomyopathy, WPW, arrhythmia, long QT, other functional, structural heart issues
**Also screen adopted kids who don’t know family Hx
What CV history do you need before starting stimulants?
- Careful evaluation before starting stimulants
- Child’s history
- Family medical history
- Early events
- Cardiomyopathy
- Long QT syndrome
What CV f/u is needed on stimulants?
- Vital signs
- Symptoms referable to CV system- syncope, palpitations ( butterfly in my chest), SOB, “heart pain”
State of the evidence on medicating preschoolers for ADHD
- Previous studies in preschoolers
- Few
- Short duration
- Increase in off-label use of stimulants (3-fold increase during 90s)
- Many medications not approved for <6 year olds
- Few long term outcomes or safety data
- Newer study: Pre-school adhd treatment study (pats)
What is PATS?
- Pre-school adhd treatment study (pats):
- a multi-site randoized control trial (3-5.5yrs)
- Components: parent training, medication trial
- Results: parent training alone not helpful, 85% with good response to methylphenidate
When are adhd medications recommended for preschoolers, and which ones, according to aap?
- IF careful assessment and severe symptoms
- Use methylphenidate
- start low, titrate up to effectiveness w/o SEs (tmg)
- Use short acting throughout day (TID)
Impact of stimulants on developing brain, preschoolers
no long term safety / efficacy impact
SEs of stimulants on preschoolers?
- Question of growth suppression
- Crabbiness, irritability, fatigue – diminished over time
- Worry and anxiety -persisted over time
- Sleep and appetite issues- persisted over time
Are dependence and abuse issues when prescribing stimulants?
•Dependence
–Abused at high doses
–Possibly psychological
- Abuse
- Marketable
- SAD: Conflicting reports
–Well managed students, less SAD
–Potential in non-prescribed students for SAD
Concerns with energy drinks and stimulants?
Synergy!
When might you Rx strattera?
Not responding to stimulants or high abuse potential
–Mood stabilizing effect if comorbidity
What is Strattera?
–First non-stimulant for ADHD
–Norepinephrine reuptake inhibitor
When should effects of Strattera be seen?
–2-6 weeks before effects seen
–24 hour period of action
SEs of Strattera
–GI upset –
- High protein foods
- Start low dose (.5mg/kg)titrate upwards (1.2mg/kg)
–Liver toxicity
- Dark urine
- Itchy skin
- Jaundice
- RUQ pain
When is Intuniv recommended?
Non-stimulant! Good for high activity levels, issues w/stimulants
Recommended:
- Core ADHD symptoms plus irritability, temper regulation
- Intolerant of stim, tics or sleep issues
- 6-17 year olds
Is Intuniv approved for use w/stimulants?
yes!
How should Intuniv be taken?
- 1,2,3 and 4 mg tablet qd
- Swallow only
- No fatty foods
- Effectiveness ~2-3 weeks
- Taper by 1 mg q 3-7 days
Intuniv MOA
Interacts with receptors in prefrontal cortex
guanfacine - a BP med
Central alpha-2 adrenergic agonist
Side effects of Intuniv
- Fatigue, drowsiness
- Lowers blood pressure:
- Lightheadedness, syncope
- GI: Nausea, stomach pain, constipation, appetite, dry mouth
- Neuro: Irritability, headaches
Monitoring of Intuniv
BP and HR @beginning and with every ↑ and then q med check
What is the newest non stimulant for adhd?
Kapvay / Clonadine
MOA of Clonadine
MOA unknown in ADHD
May involve prefrontal cortex activity like Intuniv
Indications and dosing for Kapvay?
- Age indication: 6-17 years old
- 0.1- 0.4 mg/day (bid)
- Swallow whole
- Taper over 3-7 days
- Mono or adjunct tx with stimulants!
SEs of kapvay
- Similar to Intuniv
- Bradycardia
- Somnolence, etc.
Intuniv vs kapvay
BID as opposed to Intuniv which is QD. Also good for hyperactivity.
Like Intuniv, Combine w/stimulant for attention
What needs to be discussed when initiating medication for adhd?
- Clear discussion parent and patient
- Needs
- Expectations
- Targeted outcomes
- Side effects
- FMH
- Personal history
- Plan for follow up
- Contract
Considerations when choosing a medication for adhd?
- Subtype
- Issues with “quality of life”
- Short acting vs long acting
- Delivery method
- Start low, titrate up
cautions when Rxing stimulants
- Controlled substances
- DEA number, 1mo supply, not called in
- High risk behaviors
- Other meds/drugs
- Caffeine and energy drinks
- Selling, sharing, abusing
- Parental monitoring of meds
When / how to follow up after initiating adhd meds
- Phone check: 2 weeks
- Office visit: 1 month
- Effectiveness
- Side effects
- Need for dose change or type or class change
- HR, BP, weight, neuro
How should regular f/u be conducted w/adhd on medication?
- Appropriate, effective, well tolerated dose
- See q 3 months
- School and home info
- Progress, efficacy, concerns
- VS, HT, WT, neuro
- Review expectations
- School and home info
- Rescreen with Vanderbilt F/ U forms
- Adjust management as needed
Why might med aherence be decreased in teens?
- 48% adolescents stop meds
- Deny problem
- Issues of independence
- Parents less willing to insist or administer
- 4.5 Rx filled/year!!!
What might increase adherence in teens?
- Better self concept
- Stable family
- Internal locus of control
- Increased motivation
- Simplified medication regimes
- Fewer adverse effects
- Use of motivational interviewing
Some CAM / alternative approaches to adhd?
- Dietary changes
- Additives
- Sugars
- Herbs
- Omega 3 Fatty Acids
- Zinc
- Iron/vitamins
- Relaxation training
- Cerebellar training
- Neuromapping
- Optometry
- Exercise
- Outdoor activity
- Chamomile and valerian ok for restlessness, concentration and sleep issues. Kava kava has adverse effects on CNS with chronic use*
- No support of megadose of vits/minerals – should treat iron deficiency*
options for educational intervention in adhd?
- Individuals with Disabilities Education Act (funding)
- Services for disabilities that affect educational performance
- 504 Sec of Rehabilitation Act ( no $)
- Prohibits discrimination against anyone with disability
- Regular class, spec services, (FAPE)
- can be very creative to meet needs, motor breaks, etc
What is a 504 plan?
- Provides accommodations, modifications in regular classroom
- Preferential seating
- Extended time
- Modified assignments
- Alternative test setting
- Overflow activity
- Motor breaks
What is an individualized education plan (IEP)?
- Legal document (IDEA)
- Updated annually at Planning and Placement Team (PPT)
- Resource room
- Resource support
- Remedial help
- Tutorials
- Study skills training
- etc.
Components of F/U for adhd
- Criteria for efficacy
- Educational
- Behavioral
- Social
- Pharmacologic
- Family
- Communication
- Parents
- Teachers
- Students
- Other professionals
- Phone
- Office visits
- Repeat checklists/rating scales
Outcomes of effective assessment and mgmt?
- Improved self esteem
- Improved learning outcomes
- Improved family harmony
- Improved social skills
- Improved educational/
- vocational opportunities
Pediatrics: KAS from subcommittee on adhd
KASs:
1 – The PCC should evaluate for ADHD if 4-18yo w/academic or behavioral sx of inattention, hyperactivity, impulsivity (B)
2 – DSM-IV (now 5) criteria should be met for Dx. Info primarily from parents/guardians, teachers, other school and mental health clinicians involved in child’s care. R/O alternative cause (B)
3 – PCC should assess for coexisting conditions (anxiety, dep, ODD, CD, learning/language DO, neurodvptl do, tics, OSA) (B)
4 – PCC to recognize ADHD as chronic = special health care needs. Follow chronic care model and medical home (B)
5 – Tx varies by age. PCC recs:
- Preschool (4-5yo): EB parent and/or teacher administered behavioral tx as 1st line (A), and Rx methylphenidate if no significant improvement and mod-severe continuing disturbance in child’s function. If EB behavioral tx not available, weigh risks of meds vs delay in tx (B)
- Elementary (6-11yo): FDA approved med (A) and/or EB behavioral tx (B), preferably both. Evidence strong for stiulants, sufficient for atomexetine, ER guanfacine, ER conidine (in that order). The school, program, or placement is part of any tx plan.
- Adolescents (12-18yo): FDA approved meds w/assent of adolescent (A), and maybe behavioral tx (C), preferable both
6 – titrate doses of meds for adhd to achieve maximum benefit w/minimum adverse effect (B)
