ADHD - MH Flashcards
Diagnostic Criteria #1
A. Either 1 or 2
1. Six (or more) of the following symptoms of inattention have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with developmental level
Inattention
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)
g. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
Diagnostic Criteria #2
- Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 mo to a degree that is maladaptive and inconsistent with developmental level
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations in which remaining seated is expected
c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
d. Often has difficulty playing or engaging in leisure activities quietly
e. Is often “on the go” or often acts as if “driven by a motor”
f. Often talks excessively
Impulsivity
g. Often blurts out answers before questions have been completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present < 7 yr of age
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home)
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
E. The symptoms do not occur exclusively during
the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder)
Subtypes
314.01 Attention-Deficit/ Hyperactivity Disorder, Combined Type: if both criteria A1 and A2 are met for the past 6 mo
314.00 Attention-Deficit/ Hyperactivity Disorder, Predominantly Inattentive Type: if criterion A1 is met but criterion A2 is not met for the past 6 mo
314.01 Attention-Deficit/ Hyperactivity Disorder, Predominantly Hyperactive, Impulsive Type: if criterion A2 is met but criterion A1 is not met for the past 6 mo
314.9 Attention-Deficit/ Hyperactivity Disorder Not Otherwise Specified
Sxs and impairment meet criteria for ADHD predominantly inattentive type but whose age at onset is 7 years or after
Individuals with clinically significant impairment who present with inattention and whose sx pattern does not meet the full criteria for the disorder but have behavioral pattern marked by sluggishness, daydreaming and hypo activity.
KEYS TO DIAGNOSIS
Symptoms must:
- Be present in more than one setting (eg, school and home)
- Persist for at least six months
- Be present before the age of seven years
- Impair function in academic, social, or occupational activities
- Be excessive for the developmental level of the child
Etiology
- May run in some families
- no evidence of any single gene that determines ADHD type.
- Although most cases occur in typically developing children
- Also seen in children who have developmental disorders like
- Fetal alcohol syndrome
- Down syndrome
- Brain injury
- Most commonly, there is no identified cause
- Likely that the symptoms are a final common pathway of diverse causes, including
- Genetic
- Organic
- Environmental etiologies
Epidemiology
- Prevalence in U.S. school-age community populations: 8%-10%
- 2-3M:1F
- Girls are more likely inattentive-type ADHD
- Symptoms of ADHD persist into adolescence in 60% to 80% of patients
- Many continue to have symptoms into adulthood
Clinical Manifestations
- The diagnosis of ADHD is made by history
- Open-ended questions focused on specific behaviors
- ADHD-specific rating scales
- Conners
- Vanderbilt
- A physical examination is essential to rule out underlying medical or developmental problems
- Observation of the child and the parents and their relationship
- Office environment behavior means little
History
HPI
- Onset of symptoms
- Frequency, duration of problem behaviors
- Situations that increase or decrease behaviors
- Previous treatments
Family History
- Medical syndromes
- Developmental Delays
- Cognitive Limitations, learning disorders
- Mental illness – ADHD, mood/anxiety, bipolar
- Ask about school performance
Interview the child
- Concerns about his/her own behavior
- Family relationships
- Peer relationships
- School
- Strengths and Difficulties
- Goals
- Delusional thinking/Suicidal ideation
- Observation of attention during the encounter
- Language skills
- Social skills
Examination
Comprehensive
- Baseline height, weight, BP, Pulse
- Hearing and visual acuity
- Cardiovascular status
- Note dysmorphic features (fetal alcohol, fragile X)
- Neurologic
- Mental status – affect, communication skills
- Developmental screen
- Tics
- Gross and fine motor coordination
Clinical Manifestations
- Laboratory and imaging studies unnecessary, but may help r/o other conditions as indicated by H&P
- Thyroid function studies
- Blood lead levels
- Karyotyping
- Brain imaging studies
Differential Diagnosis
- Normal developmental variation (giftedness, intellectual diability)
- Hyperthyroidism
- Lead intoxication
- Hearing or visual impairment
- Chaotic living situations
- If only in one setting – problems with emotional maturity or feelings of well-being there
- Speech-language delay and learning disabilities can occur with ADHD
- Psychiatric conditions more common in children with ADHD
- Conduct disorder
- Depression
- Anxiety disorder
Treatment
- ADHD is a chronic condition
- Strategies should minimize adverse effects on learning, school functioning, social relationships, and family life
BEHAVIORAL APPROACHES
- Structure
- Routine
- Appropriate behavioral goals
- Counseling: Social skills, Self-esteem
STIMULANT MEDICATION
- Effective for mgmt of inattention, -hyperactivity, and distractibility
- DO not treat comorbid conditions or improve intelligence
MEDICATION Management
Stimulants
- Methylphenidate: Short, medium, and long-acting
- Dextroamphetamine: Long-acting
- Side-effects – appetite suppression, sleep disturbance: Manage with dosage adjustment timing
- Lionear growth disturbance – growth slows in 1st 2 years, does not affect ultimate height
Non-stimulants
- Atomoxetine – may be helpful for non-responders to stimulant
- Alpha agonists – Clonidine, Guanfacine hydrochloride: Also helpful, esp kids with sleep disorders
Management Principles
Preschool
- First-line treatment is behavior therapy
- Methylphenidate (off-label) if behavioral interventions unsuccessful AND moderate to severe continuing disturbance in function
Elementary School
- FDA-approved meds AND/OR behavior therapy
- Preferably BOTH
- Stimulants preferred over atomoxetine, guanfacine, clonidine
- School environment must be part of the treatment plan
Adolescents (12-18 yrs)
- FDA-approved meds with patient assent
- May consider behavioral therapy, both preferred
Dosage
- Unlike most dosages in pediatrics, we titrate UP from a common starting point rather than rely on per kilogram dosing
- Re-evaluate every 2-4 weeks and adjust to
- Maximum benefit
- Minimum side-effects
- Use follow-up surveys provided by the evaluation tool
Referral INDICATIONS
- Intellectual disability (mental retardation)
- Developmental disorder (eg, speech or motor delay)
- Learning disability
- Visual or hearing impairment
- History of abuse
- Severe aggression
- Seizure disorder
- Coexisting learning and/or emotional problems
- Chronic illness that requires treatment with a medication that interferes with learning
Complications
- Academic underachievement
- Difficulties in interpersonal relationships
- Poor self-esteem
- Increased incidence of suicide in adults
Prevention
Child-rearing practices may help
- Calm environment
- Opportunities for increasing length of focus on age-appropriate activities
- Limiting TV and rapid-response video games (reinforce short attention span)
Prevention of secondary disabilities
- Education of medical and educational professionals
- Most appropriate behavioral and pharmaceutical interventions
- Appropriate evaluation of learning disorders
- Needed accommodations
