ADHD and differential diagnoses Flashcards
internalising presentations
emotional, thinking or somatic difficulties
fearfullness, sadness, withdrawal, abdominal pain, suicidal thought s
externalising presentations
behaviour problems
deliquency, disobedience (oppositional defiance), attentional problems, aggression, tantrums
most presentations are
mixed
ADHD is an
externalising problem
names for ADHD
attention deficit hyperactivity disorder - DSM-5, DSM-4
hyper kinetic disorder - ICD10
attention deficit disorder - DSM-3
why is hyperkinetic disorder different
requires hyperactivity for diagnosis
ADHD as per the DSM-5 is with or without hyperactivity
ADHD phenotype
DSM-5 contains 18 items (core phenotype)
- 9 for inattention and 9 for hyperactivity/impulsivity
there are non-DSM phenotypes as well (peripheral phenotype)
non-DSM phenotypes of ADHD
emotional hyper-reactivity
mood lability
low tolerance of frustration
explosive dyscontrol
ceaseless mental activity (ego-dystonic)
initial insomnia
inertia/procrastination
hyper-focusing
inattention (disorganisation) phenotypes
details/mistakes
sustain attention
not listen
not follow-through
disorganised
avoid tasks
loses things
distracted
forgetful
hyperactive/impulsive phenotypes
fidgets
leaves seat
runs around
noisy
‘on the go’
talks
blurts out
can’t wait
interrupt
DSM-5 diagnostic criteria for ADHD
B. several inattentive or hyperactivity-impulsive symptoms were present before 12 years of age
C. several symptoms present in two or more settings (home, school, work, friends, family, other activities)
D. symptoms interfere with, or reduce the quality of, costal, academic or occupational functioning
E. symptoms don’t occur exclusively during a psychotic disorder, and are not better explained by another mental disorder eg. mood, anxiety, dissociative, personality, substance
what to you need to fill criterion A of the DSM-5 criteria of ADHD
6/9 items or inattention (A1)
additionally, 6/9 items of hyperactivity/impulsivity if A2
what type of rewards work best for children with ADHD
immediate rewards
complicated reward systems/charts that provide only long term rewards don’t work
common medical differential diagnoses
hearing, vision, sleep, pain, iron, foetal alcohol spectrum disorder
what is likely the genetic cause of ADHD
dopamine D4 receptor polymorphisms
structural brain abnormalities in ADHD
studies show reduced volumes in:
dorsolateral prefrontal cortex
caudate, globus pallidum
corpus collosum
cerebellum
but also inconsistent findings
hypothetical circuits from the cortex to the corpus striatum basal ganglia to the thalamus back to the cortex:
cortico-striatal-thalamic-cortical loops
‘sit still and concentrate loop’
parts of the cortex and what they control
dorsal anterior cingulate cortex regulates selective attention
dorsolateral prefrontal cortex regulates sustained attention and problem solving
prefrontal motor cortex regulates motor hyperactivity
orbital frontal cortex regulates impulsivity
common comorbidities in ADHD
specific learning disorder
language disorder
developmental coordination disorder
autism spectrum disorder
Tourette disorder and tic disorder
obsessive compulsive disorder
oppositional defiant disorder
conduct disorder
depression
anxiety disorder
side effects of stimulants
headache
stomach ache
loss of appetite
nervousness
moodiness, tearfulness, depression
short lived and resolve 1-2 weeks
first line treatment
methylphenidate (lower seizure threshold)
dexamphetamine (epileptic subjects, non-responders)
second-line treatment ADHD
atomoxetine 80-100mg
start at 20mg and then increase every 5/7 and wait for response for 4/52
side effects of atomoxetine
nausea, dry mouth, agitation, vivid dreams
useful for anxious, panicky individuals
refractory cases or third-line treatment
modafinil
clonidine
risperidone
imipramine
bupropion, reboxetine, venlafaxine, SSRI
