ADHD Flashcards
define ADHD
A persistent pattern of INATTENTION and/or HYPERACTIVITY/IMPULSIVITY that interferes with functioning or development as characterized by specific symptoms of each
how many symptoms of inattention and/or hyperactivity do you need to meet criteria for ADHD
6+ (need at least 6 in one of the two categories, not 6 between the two)
(5+ if older than 17)
what is criterion A for ADHD
a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes wtih functioning or development, as characterized by 1) inattention and/or 2) hyperactivity and impulsivity
6+ symptoms required of inattention and/or hyperactivity which have persisted for at least SIX MONTHS to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities
symptoms are NOT solely a manifestation of oppositional behaviour, defiance, hostility or failure to understand tasks or instructions
how many symptoms are listed under criterion A for inattention? impulsivity?
9 for both
list the symptoms of inattention listed in criterion A of the dsm 5
- often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (i.e overlooks or misses details, work is inaccurate)
- often has difficulty sustaining attention in tasks or play activities
- often does not seem to listen when spoken to directly (i.e mind seems elsewhere, even in absence of any obvious distraction)
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (i.e starts tasks but quickly loses focus and is easily sidetracked)
- often has difficulty organizing tasks and activities (i.e difficulty managing sequential tasks, keeping materials and belongings in order, messy, poor time management)
- often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
- often loses things necessary for tasks or activities (i.e school materials, pencils)
- is often easily distracted by extraneous stimuli (for older kids, may include unrelated thoughts)
- is often forgetful in daily activities
list the symptoms of hyperactivity/impulsivity listed in criterion A of the dsm 5
- 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 inappropriate (in older kids, may be limited to feeling restless)
- often unable to play or engage in leisure activities quietly
- often “on the go” acting as if “driven by a motor” (i.e unable to be or is uncomfortable being still for extended periods as in restaurants, meetings)
- often talks excessively
- often blurts out an answer before a question has been completed (i.e completes peoples sentences, cannot wait for turn in coversation)
- often has difficulty waiting their turn
- often interrupts or intrudes on others (i.e butts into conversations or games, may start using other peoples things without permission)
what is criterion B for ADHD
several inattentive or hyperactive/impulsive symptoms were present prior to age 12 years
what is criterion C for ADHD
several inattentive or hyperactive/impulsive symptoms are present in two or more settings (i.e at home, school, work, with friends, other activities)
what is criterion D for ADHD
there is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning
what is criterion E for ADHD
the symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder
what are the 3 diagnostic DSM specifiers for ADHD
- combined presentation–>
if both criterion A1 (inattention) and criterion A2 (hyperactivity) are met for the last 6 months - predominantly inattentive presentation–> if criterion A1 is met but not A2 for the last 6 months
- predominantly hyperactive/impulsive presentation –> if criterion A2 is met but not A1 for the last 6 months
*when full criteria were previously met, but fewer than the full criteria have been met for the last 6 months and the symptoms still results in impairment, can specify IN PARTIAL REMISSION
how do you grade severity for ADHD
mild–> moderate–> severe
define mild ADHD
few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning
define moderate ADHD
symptoms or functional impairment between mild and severe are present
define severe ADHD
many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe are present, or the symptoms result in marked impairment in functioning
what is the essential feature of ADHD
persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
how does inattention manifest behaviourally in ADHD
wandering off task, lacking persistence, having difficulty sustaining focus, being disorganized
not due to defiance or lack of comprehension
what does hyperactivity refer to in ADHD
excessive motor activity (such as a child running about) when it is not appropriate, or excessive fidgeting, tapping or talkativeness
how might hyperactivity manifest in adults with ADHD
extreme restlessness or wearing others our with their activity
what does impulsivity refer to in ADHD
hasty actions that occur in the moment without forethought and that have high potential for harm to the individual (ie darting into the street without looking)
impulsivity may reflect a desire for IMMEDIATE REWARDS or an inability to DELAY GRATIFICATION
how might impulsive behaviours manifest in ADHD
social intrusiveness and/or making important decisions without consideration of long term consequences
how do you make sure symptoms of ADHD occur across settings
consult informants who have seen the individual in those settings
how do symptoms vary within a setting
vary depending on context within a given setting–> ie signs of the disorder may be minimal or absent when the individual is receiving frequent rewards for appropriate behaviour, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation or is interacting in one on one situations
list some associated features that may support diagnosis of ADHD
- though not specific to ADHD, mild delays in language, motor or social development often co occur with adhd
- low frustration tolerance
- irritability
- mood lability
- academic or work performance often impaired even in absence of specific learning disorder
how does ADHD impact risk of suicide
by early adulthood, ADHD is associated with an INCREASED RISK of suicide attempt
*primarily when comorbid with mood, conduct or substance use disorders
is there any biological marker that is diagnostic for adhd?
no
what findings might there be on EEG that would be consistent with ADHD
increased slow wave EEGs
what findings might there be on MRI that would be consistent with ADHD
reduced total brain volume
+
delay in posterior to anterior cortical maturation
what is the prevalence of ADHD
5% of children and 2.5% of adults across most cultures
after what age do symptoms of hyperactivity become more clearly distinguishable from normative behaviours
after age 4
when is ADHD most often identified
elementary school years
what is the natural course of ADHD
most often IDed in elementary school–> most people have relatively STABLE course through early adolescence, though some have worsening course with development of ANTISOCIAL behaviours –> in most people, symptoms of hyperactivity become less obvious in adolescence and adulthood but difficulties with RESTLESSNESS, INATTENTION, poor PLANNING and IMPULSIVITY persist
a substantial proportion of kids with ADHD remain relatively impaired into adulthood
what is the main manifestation of ADHD in preschool
hyperactivity
when does inattention become more prominent in ADHD
elementary school
ADHD is associated with which temperamental factors
ADHD is associated with: 1. reduced behavioural inhibition, effortful control, or constraint
2. negative emotionality
3. elevated novelty seeking
*may predispose to ADHD but not specific to the disorder
list environmental risks for ADHD
- very LOW BIRTH WEIGHT (less than 1500 grams)–> 2-3x risk for ADHD
(but most kids with low birth weight do not develop adhd) - correlated with SMOKING during pregnancy
- minority of cases may be related to reactions to aspect of diet
- may be history of childhood abuse, neglect, multiple foster placements
- neurotoxin exposure (i.e lead)
- infections (i.e encephalitis)
- alcohol exposure in utero
what is the genetic risk associated wtih ADHD
risk of ADHD elevated in first degree relatives–> heritability is substantial
specific genes HAVE been correlated to adhd, but they are neither necessary nor causal
what are some physiologic conditions that may be considered to have influence on adhd symptosm
visual and hearing deficits
metabolic abnormalities
sleep disorders
nutritional deficiencies
epilepsy
is adhd associated with any particular physical features
no–> however, rates of minor physical anomalies (hypertelorism, highly arched palate, low set ears) may be relatively elevated
subtle motor delays and other soft neuro signs may occur
do family interaction patterns in early childhood cause adhd
no, but may influence the course if the condition
how does diagnosis of adhd differ between males and females
adhd more frequently diagnosed in males than females in the general population –>
RATIO 2:1
*females more likely to present with primarily inattentive
describe the functional impact of ADHD
adhd is associated with:
- reduced school performance and academic achievement
- social rejection
- poorer occupational performance, attainment, attendance and higher probability of unemployment in adults
- elevated interpersonal conflict
- kids wtih ADHD are significantly more likely to develop CONDUCT DISORDER in adolescence and ANTISOCIAL personality disorder in adulthood (thus increased likelihood of substance use and incarceration)
- more likely to be injured
- traffic accidents and violations are more common in drivers with ADHD
- may be elevated likelihood of obesity
how does ADHD impact risk of substance use disorders
elevated risk of SUDs, especially when conduct disorder or antisocial personality traits develop
how might ADHD affect interpersonal functioning
symptoms may be misinterpreted by others as laziness, irresponsibility or failure to cooperate
family relationships may have discord and negative interactions
peer relationships may have peer rejection, neglect, teasing
which negative functional outcomes of adhd tend to be more associated with inattention symptoms? hyperactive symptoms?
inattentive–> academic deficits, school related problems, peer neglect
hyperactive–> peer rejection, accidental injury
ddx for ADHD
- ODD
- intermittent explosive disorder
- other neurodevelopmental disorders
- specific learning disorder
- intellectual disability
- ASD
- reactive attachment disorder
- anxiety disorders
- depressive disorders
- bipolar disorder
- disruptive mood dysregulation disorder
- substance use disorders
- personality disorders
- psychotic disorders
- medication induced symptoms
- neurocognitive disorders
what distinguishes ODD from ADHD
ODD–> resist work or school tasks because they resist CONFORMING to others demands
ADHD–> aversion to school or mentally demanding tasks due to difficulty in sustaining mental effort, forgetting instructions, impulsivity
*complicated by fact that some kids with ADHD may develop secondary oppositional attitudes towards such tasks
what traits do ADHD and intermittent explosive disorder share
high levels of impulsive behaviour
what distinguishes intermittent explosive disorder from ADHD
those with intermittent explosive disorder show serious aggression towards others, which is not characteristic of ADHD (and in intermittent explosive disorder they do not have difficulty sustaining attention)
intermittent explosive disorder is also RARE in childhood
how to distinguish between stereotypic movement disorder and ADHD
in stereotypic movement disorder, the motoric behaviour is generally FIXED and REPETITIVE whereas fidgetiness and restlessness in ADHD are typically generalized and not characterized by repetitive stereotypic movements
why might children with specific learning disorder appear inattentive (in the absence of ADHD)
due to frustration, lack of interest or limited ability (but this inattention is not impairing outside of academic work, as it is in ADHD)
which is more likely in a preadolescent who displays severe irritability and anger, bipolar disorder or ADHD?
ADHD–> bipolar disorder is rare among preadolescents, even when severe irritability and anger are prominent, whereas ADHD is common among children and teens who display excessive anger and irritability
what features do personality disorders like borderline PD share with ADHD
disorganization, social intrusiveness, emotional dysregulation and cognitive dysregulation
what are some medications that can result in symptoms mimicking ADHD
bronchodilators
isoniazid
neuroleptics–> akathisia
thyroid meds
(can lead to symptoms of inattention, hyperactivity or impulsivity)
what % of kids with combined type ADHD also meet criteria for ODD? what about those with inattentive type ADHD?
50% of kids with combined type also have ODD
25% of kids with inattentive type also have ODD
what % of kids with combined type ADHD also meet criteria for conduct disorder?
25% (depends on age and setting)
what is the relationship between occurrence of disruptive mood dysregulation disorder and ADHD?
MOST kids with disruptive mood dysregulation disorder have symptoms that also meet criteria for ADHD
a lesser percent of kids with ADHD have symptoms that meet criteria for disruptive mood dysregulation disorder
what are some common comorbidities that occur with ADHD
ODD
conduct disorder
disruptive mood dysregulation disorder
specific learning disorder
anxiety and depression (minority of people with ADHD, but rate is still higher than in the general population)
intermittent explosive disorder (occurs in minority of adults with ADHD, but higher rate than population levels)
substance use disorders (“)
antisocial and other PDs (in adults)
OCD, tic disorders, autism
how do you distinguish between ODD and ADHD
those with ODD may resist work or school tasks that require self application because they RESIST CONFORMING to others demands –> behaviour characterized by NEGATIVITY, HOSTILITY, DEFIANCE
this must be distinguished from aversion to school or mentally demanding tasks due to difficulty sustaining mental effort, forgetting instructions, and impulsivity in those with ADHD
*those with ADHD may develop secondary oppositional attitudes toward such tasks and devalue their importance
what do ADHD and intermittent explosive disorder have in common
high levels of impulsive behaviour
how do you distinguish between intermittent explosive disorder and ADHD
those with IED show serious aggression towards others, which is not characteristic of ADHD
those with IED do not have problems sustaining attention
IED is rare in childhood
what do those with ADHD and ASD have in common
both exhibit inattention, social dysfunction, and difficult to manage behaviour
how do you distinguish between ADHD and ASD
ADHD–> social dysfunction and peer rejection
ASD–> social disengagement, isolation, indifference to facial and tonal communication cues
what medication may mimic symptoms of ADHD
(i.e symptoms of inattention, hyperactivity, impulsivity)
–bronchodilators
–isoniazid
–neuroleptics (resulting in akathesia)
–thyroid replacement meds
how often do ADHD and ODD co-occur
in approx 50% of children with the combined ADHD type, and in about 25% with the predominantly inattentive type
how often do conduct disorders co occur with ADHD
25% of those with combined type (depending on age and setting)
what is the relationship between disruptive mood regulation disorder and ADHD
MOST kids with DMDD also meet criteria for ADHD
a LESSER % of those with ADHD have symptoms that meet criteria for DMDD
how often do anxiety and depressive disorders co occur with ADHD
more than in the general population but still a minority of those with ADHD
are substance use disorder common among those with ADHD
occurs in minority of those with ADHD but still more than the general population
list common comorbidities with ADHD
ODD*
Conduct disorder*
DMDD*
specific learning disorder*
anxiety and depressive disorders
intermittent explosive disorder (adults)
substance use disorders
antisocial/other PDs
OCD
tic disorder
autism
*=fairly common co occurence
by how much does having ADHD increase risk for accidental injuries
by 2x
how does ADHD affect substance use
higher risk of earlier substance use
greater difficulty with substance use
what is the heritability of ADHD
about 76%
parents with ADHD have a more than 50% chance of having a child with ADHD
close to 25% of kids with ADHD have a parent who meet formal criteria
first degree relatives of diagnosed ADHD people have a 30-40% chance
list genes implicated in ADHD
DAT1
DRD4
DRD5
DBH
5-HTT
HTR1B
SNAP-25
list non-genetic factors that can increase risk of ADHD
perinatal stress
low birth weight
TBI
maternal smoking during pregnancy
severe early deprivation
frequent digital media use
what is a mnemonic to remember the inattentive symptoms of ADHD
CALL FOR FRED
Careless mistakes
Attention Difficulty
Listening problems
Loses things
Fails to finish what they start
Organizational skills lacking
Reluctance to do tasks that require sustained mental effort
Forgetful in Routine activites
Easily Distracted
what is a mnemonic to remember the hyperactivity-impulsivity symptoms of ADHD
RUNS FASTT
Runs or is restless
Unable to wait turn
Not able to play quietly
Slow? Oh no! Hes on the go!
Fidgets with hands or feet
Answers are blurted out
Staying seated is difficult
Talks excessively
Tends to interrupt
in a classroom, which child is most likely to get an ADHD diagnosis
the child with the latest birthdate in the class (i.e august bday in a class with sept 1 cutoff)
likely due to teacher perceiving immature but age appropraite behaviours as reflecting ADHD in this really much younger child
name some rating scales that can help assess ADHD
SNAP-IV 26
Adult ADHD self report scale
Conners rating scale revised
what brain changes might you see in someone with ADHD
smaller bilateral amygdala, accumbens and hippocampus
*under debate
what sleep disorder should you consider on ddx for ADHD
OSA
also insomnia or central sleep apnea
what is a principle upon which to organize approach to treatment of ADHD
- psychoeducation and support for ALL
- behavioural treatments for MOST
- medications for SOME
what are two medications with psychomotor activation that may mimic ADHD
decongestants
beta agonists (puffers)
what are some medical conditions that should be considered when evaluating for ADHD
neurofibromatosis
phenylketonuria
fragile X
lead poisoning
anemia
hypoglycemia
thyroid disease
seizure disorders
TBI
sleep disorders
what should be conveyed in psychoeducation around ADHD
Explaining the rationale for the diagnosis, referencing examples of symptoms and impairment given by the parents and child/adolescent
Explaining that although ADHD has a genetic component, environmental interventions can still be immensely helpful
Reviewing the natural course and prognosis of ADHD and discuss comorbid conditions
Discussing available treatment options (both pharmacological and non-pharmacological)
Conveying a message of hope and optimism, telling the patient and family that ADHD tends to improve over time and is among the most treatable of psychiatric disorders
what is the first line treatment for ADHD in preschoolers
parent management training/psychosocial treatment
list types of behavioural interventions that have been investigated in ADHD
parent management training modules
social skills training
CBT
mindfulness training
what is the average response rate to medications in ADHD
about 70%
about 90% will respond to stimulants in the short term
what % of people will respond equally to methylphenidate and amphetamine stimulants
40%
another 20% each will respond only to one class of medications
(on population level, no difference in efficacy or tolerability between these classes, but individuals may have differing responses)
what are 3 principles of ADHD pharmacotherapy
- long acting stimulants preferred as first line (should do adequate trial of both classes of long acting stimulant before going to second line)
- short and intermediate acting stimulants and non stimulants are second line
- third line agents = buproprion, clonidine, modafinil, AAPs may be adjunct with 1st or 2nd line agents
is there difference between picking clonidine vs guanfacine as adjunct
not in terms of efficacy
how might second line stimulants be used
as primary agent
as PRN
to augment long acting formulations early or late in the day or early in evening
