ADHD Parts 1-3 Flashcards
What is the definition of ADHD in the DSM-5
A persistent patter of inattention and or hyperactivity-impulsivity that’s interferes with functioning or development, and negatively impacts on social, academic, occupation activities
How common is ADHD
3rd most common mental health disorder
- 3.4% of children and youth
Why does the ICD-10 have a lower ADHD prevelance than the DSM-5
ICD-10 requires both inattention and hyperactivity criteria to be met
What adverse effects is ADHD associated with?
- Educational problems - lower rates of high school and post-secondary graduation rates
- Difficult peer relationships
- Increased MVA injuries
- Increased substance misuse - esp. if comorbid CD
**increases overall mortality risk
What are predictors of persistent ADHD
- Combined ADHD
- Increased symptom severity
- Comorbid MDD,
- High comorbidity (>3 DSM-5 diagnoses)
- Parental anxiety
- Parental ASPD
What are ADHD gene variants important for in development?
- Brain development
- Cell migration
- Encoding catecholamine receptor and transporter genes
What neurological factors are implicated in ADHD pathogens is
- Alcohol or tobacco exposure in uterus
- BW <2.5kg
- HIE
- Epilepsy disorders
- TBI
What environmental factors increase ADHD risk
- Lead
- Organophosphate pesticides
- Polychlorinated biphenyls
- Exceptional early deprivation
How does cortical maturation differ between ADHD and controls
Delayed maturation, with peak cortical thickness attained at 10y instead of 7y
What rating scales can be used in preschool children?
Conner’s Comprehensive Behaviour Rating scale
ADHD Rating scales IV
What is first line treatment of ADHD in preschool children?
Parent training programs
Help develop age-appropriate developmental expectations and specific management skills
Why is diagnosing ADHD in teens difficult?
Less consistent observation in schools - multiple teachers
Parents observe behaviors less often
Less likely to exhibit overt behaviors
Adolescent minimize problematic behaviors
What should be on the differential for ADHD in teens?
Substance use
Depression
Anxiety
What is the most effective practice for evaluating ADHD symptomatology
Clinical impressions and use of standardized scales
How are rating scales helpful in ADHD
Not diagnostic!
Subjective impressions to help quantify degree to which behaviour deviates from norm, and helps evaluate effects of interventions
Are the following required in ADHD diagnosis?
- Lab work
- Genetic testing
- EEG, neuroimaging
- Psychological, SLP assessments
- Psychological, executive function tests
No! Only if indicated by history and physical
What is the DSM-5 criteria for ADHD
- Symptoms are severe, persistent (i.e., present before 12 years of age and continuing >6 months), and inappropriate for the patient’s age and developmental level.
- Symptoms are associated with impairment in academic achievement, peer and family relations and adaptive skills.
- If there is a discrepancy of symptoms across settings, it is important to identify why the discrepancy exists.
- Specify the type of ADHD presentation as per the DSM-5:
i) Combined presentation
ii) Predominantly inattentive presentation
iii) Predominantly hyperactive-impulsive presentation
- Specify current severity (mild, moderate or severe) based on the symptoms and degree of functional impairment.
What conditions are commonly misdiagnosed as ADHD
- Learning disorder
- Sleep disorder
- ODD
- Anxiety disorder
- Intellectual disability
- Language disorder
- Mood disorder
- Tic disorder
- Conduct disorder
- ASD
- DCD
What are psychiatric disorders on the differential for ADHD
- Externalising disorders
- ODD
- IED - Internalizing disorders
- Anxiety
- Depression
- Bipolar
- disruptive mood days regulation - Trauma and stress related
- reactive attachment disorder
- adjustment disorders
- PTSD - Cognitive development
- ID
- superior intellectual function
- specific learning disorder - Neurodevelopmental disorders
- ASD
- Tic disorder, Tourette’s
- Stereotypic movement disorder - Other
- personality disorders
- SUD - Medical
- OSA
- IBD
- sensory impairments
- chronic health conditions with ++school absenteeism
- epilepsy
- post concussion status
How is epilepsy associated with ADHD
- ADHD 2-3x more prevalent in pt with seizure disorders
- may be present prior to seizure or as a secondary cause
- complicated epilepsy, higher seizure frequency and earlier age onset = higher ADHD risk
Which AEDs are associated with ADHD
PHB, PHY, VPA
What genetic conditions have higher prevalence of ADHD
NF1 FXS Turners TSC Noonan (22q11 deletion syndrome)
What are ADHD comorbidities
- ODD/CD - up to 90%
- Anxiety - up to 30%, more fears, in attention, poorer social skills,++ severity symptoms, more difficult engaging in CBT
- Mood disorders (including BD)
- SUD - ?self-medicating
- Tic disorder
- DCD
- ASD
- Specific learning disorder - up to 33% (1/3)
- Eating disorder
Why is a shared care model important for treatment of ADHD
Need a shared understanding of identified treatment goals, preferences and accurate understanding of underlying etiology
Under what age is parent behavior training first line?
<6 years old
What are nonpharmacologic interventions for ADHD
- Psychoeducation - provides accurate education and information for families, clears up misperceptions
- Shared decision making: share all info about dx and rx and identify treatment goals before implementing interventions
- Parent based training
- Classroom management
- Daily report card - to help with homework completion
- Behavioural peer interventions
- Organizational skills training - address executive functioning
- Exercise
What are potential non-pharmacological interventions
- Diet IF suspected deficiency, insufficiency, food allergy
- EEG neurofeedback
- Cognitive training
What intervention has not been proven effective for ADHD
Social skills training
Why are nonpharmacologic interventions helpful in ADHD
- > 50% have psychiatric and developmental comorbid items
- help with compliance, academic performance, quality of life
When should medication be used in ADHD
Pt with ADHD who’s learning, academic performance are impaired by attention difficulties, or whose behaviours and social interactions are impaired by impulsivity, hyperactivity
What are the benefits of stimulant medications
Improved academic achievement
Improved QoL
Lower rates of comorbid anxiety, depression in adulthood
Improved function - decision making, handwriting, school productivity
Better evening driving performance
Better math and reading scores
Fewer injuries, and fewer ER visits
Reduced morbidity, mortality associated with MVAs
What is the impact in adulthood of persistent ADHD symptoms
Greater difficulties with educational and occupational adjustments
Risky sexual behaviours
Psychiatric disorders
How should ADHD symptoms be monitored?
- Set specific goals focused on symptom reduction and improved function to guide treatment
- Use checklists to monitor response based on the goals
What stimulation should be started?
Can start with either the MPH or DEX subclass using an extended release formulation appropriate based on age
How long after starting a medication do you have to wait to assess if its effective?
2-4 weeks after initiation
Before deciding that a youth does not respond to stimulants what do you?
Switch to another medication in same subclass, or to the other subclass
When should IR medications be used
If child cannot tolerate ER medication
Individuals with short-term attention and behavioural targets
Should drug holidays be recommended?
No
What is the benefit of taking ER stimulants 7 days a week?
- Reduced risky behaviors
- Improve family and peer relationships
- Better attention for homework
How are ER stimulants taken
Once daily at breakfast.
Aim for effects to wean off at dinner time
Why might stimulants need to be uptitrated?
Upregulation by liver leading to tachyphylaxis
What are the most common adverse effects of stimulants
Low appetite Sleep difficulties Moodiness Irritability Tics (maybe...) Peripheral vasculopathic symptoms - Raynaud’s Priapism Slight increase in HR and BP
Who needs an ECG before starting a stimulant?
Youth at risk for stimulant-induced CVS adverse events based on H+P, FHx
Is final height affected by stimulant use?
Minimally - up to 2.5cm difference
How is BMI affected by stimulants
Slight overall reduction, especially if overweight when treatment started
Do stimulants affect puberty?
Sometimes delay pubertal growth spurt timing
What the two non stimulant medications approved by Health Canada for ADHD treatment? What age group are they approved in?
Atomoxetine
Guanfacine
6-17yo
Other than ADHD benefits - what are the potential benefits of atomoxetine?
Lower risk for weight loss
Lower risk for tic exacerbation
Improved anxiety
For individuals with ADHD and a history of SUD - what options are recommended, and why?
ER stimulant
Non-stimulant
Decreased risk for abuse and diversion
In what scenario is guanfacine beneficial?
Treating ADHD and comorbid ODD/CD
What are the adverse effects of
- Atomoxetine
- Guanfacine
- Appetite loss, upper abdominal pain, somnolence, HA, moodiness, irritability, slight increase in BP and HR, suicide related events, hepatic disorders
- Sedation, somnolence, fatigue, orthostatic hypotension, bradycardia, syncopated episodes
Raynaud’s can happen with both
Bother need BP and HR monitoring during treatment, esp. if dose increases UIKeyInputEnd
How should atomoxetine be started?
Metabolized by CYP2D6 with a half-life of 5-22h
can have extensive or slow metabolizes due to polymorphism
SSRIs can slow the metabolism
Start at 0.5mg/kg/day x 2-4 weeks before increaeeing
Can take up to 3mo to see effects
Can you stops guanfacine or clonidine immediately if its not working?
NO, risk of rebound HTN, tachycardia, HTNive encephalopathy
Taper dose by 1mg q3-7d
Which stimulant medications are options if a young child cannot take pills?
Biphentin (beads) - 6-10h
Vyvanse (powder in a capsule) - 8-13h
Adderall (beads in capsule) - 6-8h
Which stimulant medications are options if a older child cannot take pills?
Concerts (capsule) - 8-12h
Vyvanse (powder in a capsule) - 8-13h
Adderall (beads in capsule) - 6-8h
What NDD can overlap or mimic ADHD?
ASD
ID
Prematurity
How many children with ASD meet criteria for ADHD
> 50%
How many children with ADHD have ASD traits
~50%
What are similarities between ADHD and ASD?
High heritability
High comorbidity
More common in males
Early onset
How do children with ASD+ADHD present?
More cognitive function impairment More severe behavior problems Greater psychopathology More pronounced ASD symptoms More difficulties with social and communication skills, self-care, adaptive and executive functioning More internalizing behaviors More common to have maladaptive disruptive behaviors, stereotypic or repetitive behaviors More comorbid psychiatric disorders More SLD
What genetic syndromes have ASD+ADHD features
FXS
TSC
22q11 deletion
Williams
What are the underlying genetics for ASD+ADHD
More common to have rare copy number variants, chromosomal deletions and duplications
Loci on chromosome 12, 16, 18 have been identified
16-25 single-nucleotide polymorphism identified
How is ADHD+ASD treated?
Stimulants = 1st line
Psychical activity - alleviated ADHD symptoms, and improve social skills
No studies on the efficacy of nonpharmacological or behavioral managements
BUT should still implement them
What are the most common adverse effects of stimulant medications in children?
Irritability with emotional outbursts
Increased stereotypic behaviours
Agitation
Dysphoria, psychotic symptoms
Is there a role for nonstimulant medications in ASD+ADHD?
Atomoxetine - maybe, but takes longer time
Guanfacine - yes
Is there a role for atypical antipsychotics or antidepressants in ASD+ADHD?
only if indicated by comorbidities
How many children over 5yo have ID
2-3%
How is ID characterized?
Developmental deficits in cognitive function, or in adaptive function such that the individual cannot meet standards for personal independence and social responsibility
IQ >2SD below the mean
Severity depends on level of adaptive functioning, NOT IQ
What is the prevalence of ADHD in ID?
3-4x general population
Why is diagnosing ADHD in ID difficult
Lower intellectual functioning can affect attention and behavior
Are there rating scales for ADHD in special populations?
No
How does ID+ADHD present?
ADHD symptoms tend to be more severe, and less likely to remit with age
Higher rates of agitation, aggressive and self-injurious behaviors, ASD traits, stereotypic behaviors, conduct problems
Impaired adaptive functioning
What conditions are associated with ID+ADHD
Klinefelters FXS Turners Aminoacidemias Phenylketonuria Galactosemia NF1 TSC Myotonic dystrophy
How is ID+ADHD treated
Optimize environment and academic interventions to meet needs
Use lowest dose medication possible -IR stimulants then nonstimulants
Physical exercise
Use atypical antipsychotic for behavioral problems
Does ID+ADHD respond well to stimulants?
Response rate to IR MPH of 45-66%
In ID+ADHD what predicts a poor response to stimulants?
IQ <50
Define the following terms:
- VLBW
- ELBW
- VPT
- EPT
- <1.5kg
- <1kg
- <30wk
- <26wk
Are premature infants surviving with more, the same or less rates of disability?
Less
What sequelae of prematurity have increased?
Milder CI
NDD
Mental health difficulties
What percent of EPT or ELBW have DD
~50%
What factors affecting premature babies affect educational achievement later in childhood?
CI
ADHD
Internalizing behaviour disorders - anxiety, depression
Social interaction difficulties
What is the most common disability in ELBW?
CI
- 25% have IQ 1-2 SD below the mean
- 20% have IQ 2 SD below the mean
What is the association between GA/BNW and cognitive scores by school age?
As GA increases >26 - impairments decrease linearly until past 32wk
Past 32wk = mean remains 5 SD lower than for NBW peers
What is the preterm behavioural phenotype
In VPT/EBLW - experience cluster of NDD and behaviours associated with:
- ADHD
- Internalizing disorders: anxiety, depression, withdrawal, somatic complaints
- Social difficulties
What is the rate of ADHD in ELBW children
2x
Also higher rates of anxiety, ID, and needs for IEP
How do the rates of ADHD differ between later preterm and term infants
They don’t
How should medications be used in prematurity and ADHD
The same - but pay attention to monitoring of treatment, and internalizing behaviour disorders
