ADHD/Learning Disorder Flashcards
subtypes of ADHD
hyperactive-impulsive
inattentive
combined
criteria for diagnosis
symptoms present in more than one setting (i.e school and home)
persist for at least 6 months
present before age of seven years
impair function in academic, social or occupational activities
excessive for the developmental level of the child
must exclude other mental/medical disorders that could account for the symptoms
how do you ask about the hyperactive-impulsive subtype
does the child seem excessively restless or has difficulty sitting still? difficulty waiting turns or interrupting?
how do you ask about the inattentive subtype
are they easily distractable, forgetful or disorganized? do they often daydream? do they have difficulty completing tasks?
what other conditions should you screen for
conduct disorder
anxiety/depression
oppositional defiant disorder
sexual abuse/physical abuse
tourettes or other tic disorder
learning disorder
vision or hearing impairment
how do you screen for conduct disorder
has there been legal trouble? are they cruel towards people or animals?
how do you screen for ODD
do they often argue with adults or lose their temper easily
how do you screen for childhood anxiety/depression
do they excessively worry? ever expressed thoughts of self harm?
what other questions to ask on history for ADHD
at what age behaviours first noticed? who has observed them? have they progressed?
are they the same behaviours noted outside of school? i.e at home or with peers
are these behaviours funtionally impairing the child?
any inappropriate sexual behaviour?
any repetitive vocal or motor tics?
any concerns with vision or hearing
any problems with bowel/bladder control, or bedwetting?
can we have school assessments that have been done?
what should you ask about the childs PMHx when assessing ADHD
complications with pregnancy, early infancy, hospitalizations
exposures to toxins such as lead or EtOH
learning disability or psychiatric illness history
seizure or other brain disorder
have they met all developmental milestones
previous immunizaitons? nutrition?
what medications might cause behaviour that mimics ADHD
bronchodilators steroids antihistamines antipsychotics anticonvulsants
what physical exam should you do for ADHD
ruling out underlying medical disorders and look for signs of neglect and abuse
including screening for hearing and vision, neuro, MSE
cardiac exam before starting stimulants
is diagnostic testing required for ADHD
not normally indicated unless you suspect other causes
*it is a clinical dx
before diagnosing, need to gather all info and consult DSM criteria
medical ddx for ADHD
medication related thyroid disease infection brain injury lead toxicity malnutrition sensory impairment seizure disorder sleep disorder
developmental ddx for ADHD
mental retardation
developmental delay
language disorder
learning disability
psychiatric ddx for ADHD
anxiety depression conduct disorder ODD substance use pervasive developmental disorder
environmental ddx for ADHD
neglect or abuse
dysfunctional parenting or home life
history of bullying
how do you manage ADHD
team approach
there are behavioural and pharmacological approaces
behavioural approach to ADHD management
rewards for good behaviour and consequences to unwanted behaviour
maintain schedules and set routines, set small and reachable goals, charts and checklists to keep kids on task
support groups and parental skills training
teacher education with academic support
sleep and nutrition support
CBT and psychotherapy
involve school in care
pharmacological approach to ADHD management
stimulants are first line
i.e methylphenidate (ritalin) and dextromethamphetamine
start at low dose and slowly titrate up over 2-4 weeks
indications to start meds in ADHD
diagnostic assessment complete and it confirms aDHD
older than 6 years
parents accept meds as treatment
school on board with administering meds
no known sensitivities to the meds
normal vitals with no evidence of CV disease
no seizure d/o
no tourettes or autism d/o
no known substance abusers in the home
side effects of stimulants
sleeping difficulties appetite suppression anxiety or irritability tics CV effects
*chronic use may DELAY growth
what is a second line med for ADHD
strattera (atomoxetine)
use if stimulants fail, parents dont want stimulanta or concern over stimulant abuse
watch for SI
other second line are bupropion, TCAs, alpha agonists like clonidine
when are TCAs especially useful with ADHD
when it is comorbid wtih depression and enuresis
