ADHD Flashcards
ADHD Overview
Neurodevelopment disorder of childhood, that causes either symptoms of INATTENTIVENESS or HYPERACTIVITY/IMPULSIVENESS
Two main types, but also see a combined type where the two are equal or one predominates
Present in 3-7% of school aged US children; M:F 2:1 to 9:1 (former probably closer of who SHOULD be diagnosed, and latter is who is ACTUALLY diagnosed)
Girls more likely to have INATTENTIVE type ADHD, so they are less likely to be recognized than a boy jumping off the walls
30-50% of kids diagnosed will have symptoms for OVER 15 YEARS – mildest cases can resolve completely, most severe last into adulthood
More a PRIMARY CARE disorder than a psych disorder (80% of ADHD drugs prescribed by PCP)
Highly heritable!
Comorbidities
2/3 of kids with ADHD have comorbidities such as learning problems, oppositional defiant disorder, mood disorders, anxiety, tics
As an adult, over 80% will have some kind of mental disorder
Long-term consequences –> employment issues, drug use
Treating kids with stimulants for ADHD actually DECREASES risk of drug use later on
Untreated ADHD – significantly higher rates of car accidents, medical costs, substance abuse
Course of ADHD (RULE OF THIRDS)
Over the natural course, HYPERACTIVITY and IMPULSIVITY decline, while INATTENTION PERSISTS INTO ADULTHOOD
Patients with most aggressive symptoms early on will have worse symptoms as adults
1/3 show complete resolution by high school
1/3 will continue to have some symptoms in adulthood
1/3 will develop conduct disorders, substance abuse, antisocial personalities
Inattentive type = most common in OLDER ADULTS, but can occur at all ages
Hyperactive-impulse = LEAST COMMON and occurs in younger patients
Combined = MOST COMMON (hyperactive/impulse decrease with age and inattentiveness persists)
Neurodevelopment of ADHD
Remember that cortical gray matter thickens in childhood with a PEAK THICKNESS AT AGE 7 –> with puberty, there is a thinning, then a second thickening, then a second thinning, from BACK TO FRONT (accelerated in schizophrenia)
ADHD –> FIRST THICKENING IS DELAYED!!!
Instead of peak cortical thickness by age 7, it occurs by age 10 in kids with ADHD (3 year lag in brain development)
PREFRONTAL CORTEX (executive function) is most severely affected
Kids with ADHD have SMALLER BRAINS and the decrease in brain size correlates with the severity of the patients’ symptoms
Defects in DA reuptake transporters (DAT) and DA receptor 4 (DRD4) result in HYPOdopaminergic states, and may be a cause of ADHD
Environmental factors – stress at birth (ANOXIA, PREMIES), TBI of the prefrontal cortex, and maternal alcohol/cigarette use during pregnancy
Diagnosing ADHD
9 Symptoms in each category (inattentiveness and hyperactivity/impulsive) –> need AT LEAST 6 SYMPTOMS in either or both categories
Symptoms MUST BE PRESENT BEFORE AGE 7
MUST LAST 6 MONTHS (minimum)
Child must have impairments in AT LEAST TWO SETTINGS!!!!!
Cannot be explained by another illness!
Diff Dx for ADHD
OCD, Depression
Absence seizure!
Chronic OTITIS MEDIA (may not follow directions because of some hearing loss!)
Sleep disorders
Hyperthyroidism
Asthmatics on beta agonists may be hyperactive
Main difference between Treatments of ADHD and other psych illness?
PSYCHOTHERAPY DOES’T HELP
Behavioral therapy we do use consists of parent management (be patient, be consistent with child, reward them), organization skills training, social skills training
Medications for ADHD
STIMULANTS used
Work quickly, higher the dose, quicker the response
Meds alone are NOT enough for SEVERE ADHD
Stimulants are protective as well - less likely to develop co-morbidities while on them
METHYLPHENIDATE (Ritaline) and AMPHETAMINES (Adderall)
METHYLPHENIDATE - blocks mostly DA reuptake
AMPHETAMINES - block DA reuptake AND increase the amount of DA/NE available for release
70% respond to first one, 90% respond to one of them!!
Side Effects of METHYLPHENIDATE and AMPHETAMINES
Decrease appetite (kids are smaller and weigh less than expected)
May exacerbate psychoses
Potentially arrhythmia risk but not really thought of anymore
STIMULANTS so don’t give to HTN, CV patients, glaucoma, hyperthyroid, tics, drug abuse or psychosis
ATOMOXETINE is a good alternative for contraindications (inhibits NE reuptake)
Strongest predictor of poor-prognosis…
PRE-PUBERTAL AGGRESSION
More Co-morbidities
Anxiety disorder 10-30% Oppositional Defiant Disorders 40-65% Conduct disorder 10-25 Mood disorder 15-75% Tic disorder 10-35% Learning/academic problems 90%!!! 80%+ will go on to have mental disorders as adults Employment problems Greater sexual-reproductive risks Greater motor vehicle risks Legal Problems
55% lifetime risk of substance abuse (normal is 27%)
BUT remember, treating them with stimulants makes substance abuse LESS LIKELY
Inattentive Criteria
Makes careless mistakes/poor attention to detail
Difficulty sustaining attention in tasks/play
Does not seem to listen when spoken to directly
Difficulty following instructions
Difficulty organizing tasks/activities
Avoids tasks requiring sustained mental effort
Loses items necessary for tasks/activities
Easily distracted by extraneous stimuli
Often forgetful in daily activities
Hyperactive/Impulsive Criteria
Fidgets
Leaves seat
Runs or climbs excessively (or restlessness)
Difficulty engaging in leisure activities quietly
“On the go” or “driven by a motor”
Talks excessively
Blurts out answers before question is completed
Difficulty waiting turn
Interrupts or intrudes on others
