Attention and learning disorders Flashcards
DDx attention difficulties
ADHD learning, developmental disability stressors sensory abnormalities psychiatric/emotional immaturity prenatal substance exposure hunger sleep disturbance/disorders
ADHD
“Developmental impairment in the brain’s executive functions”
centred in prefrontal cortex with other region involvement
- develops in early childhood through to adulthood
DSM5 for ADHD
A. persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, characterised by (1)inattention or (2)hyperactivity-impulsivity
B. Several hyperactive-impulsive or inattentive symptoms causing impairment present before 12 y
C. Several impairments from the symptoms is present in >=2 settings
D. Clear evidence that symptoms interfere with functioning
E. do not occur exclusively during the course of a Pervasive developmental disroder, schizophrenia/psychotic disorder, not better accounted for by another mental disorder
DSM5 ADHD Inattention criteria
> =6 for >=6 mo that is inconsistent with developmental level and negatively impacts social/academic/occupational activities
- often fails to give close attention to details, make careless mistakes
- difficulty sustaining attention in tasks/play
- does not seem to listen when spoken to directly
- does not follow through on instructions, fails to finish duties/work
- difficulty organizing tasks and activities
- often avoids/dislikes/reluctant to engage in tasks that require sustained mental effort
- often loses things necessary for tasks or activities
- often easily distracted
- often forgetful in daily activities
DSM5 ADHD hyperactivity-impulsivity criteria
> =6 for >=6 mo that is inconsistent with development, and negatively impacts social/academic/occupational activities
Hyperactivity
- fidgets with hands, feet, squirms
- leaves seat in classroom when expected to remain seated
- runs about/climbs excessively when inappropriate
- often has difficulty playing or engaging in leisure activities quietly
- “on the go” or acts as if driven by a motor
- talks excessively
Impulsivity
- blurts out answers before questions are completed
- difficulty awaiting turn
- interrupts/intrudes on others
types of ADHD in DSM5
ADHD combine presentation if both inattention/hyperactive impulsivity identified in the past 6 mo
ADHD predominantly inattentive presentation
ADHD predominantly hyperactive-impulsive presentation
Specify if in partial remission
Specify current severity (mild, moderate, severe)
Prevalence of ADHD
commonly diagnosed varies from country to country 8-15% of North American children Children on Medicaid: 14% incidence increasing over last decade Male: female 3:1
Proposed etiologies of ADHD
not proven
Genetic: increased incidence in family esp in father
- increased incidence of conduct disorders, learning disabilities, ADHD in siblings
- specific variant of genes identified but no consistent results
- 1 parent with ADHD: may have as high as 50% chance of having ADHD
Neurochemical pathways
- Low dopamine
-NE? (affects attention and alertness)
Serotonin?
Environmental injury - insults, traumatic brain injury, toxins, developmental lag
Pathophysiology of ADHD
neuroanatomical differences on MRI
small decreases in size of certain brain areas
loss of normal asymmetry
no consistent findings
functional imaging studies implicate prefrontal cortex, anterior cingulate and striatum
Phase I Tx of ADHD
education for parent, child and teacher psychological support behavioural modification/management lifestyle mindfulness exercises
Phase II Tx of ADHD
medical therapy - stimulant
Long term outcomes of ADHD
significant persistence into young adulthood, esp in children from low SES
can remit in childhood/early adolescence
family adversity increases risk of persistence
no long term outcome studies confirming that treatment with medication changes functional outcome
Specific learning disorders
DSM5: specific deficits in an individual’s ability to perceive/process information efficiently and accurately
Difficulties in learning reading and/or writing and/or math
performance well below what would be predicted for age or acceptable performance or is only achieved with extraordinary effort
NO intellectual disability
discrepancy model - discrepancy between intellectual ability and achievement (Ministry of Education)
Learning disability prevalence
BC: 3% of children with severe learning disability based on statistical differences in test scores
actual # probably 10%
common, tend to co-occur with ADHD
Dx of learning disabilities
need a full psychoeducational assessment
strong suspicion clinically
can’t complete cognitive testing until child is at least 4.5
can’t get accurate information about achievement until child is in school
Consider LD in these children:
behavioural problems diagnosed with ADHD isn't achieving in school speech/language delay family history of LD delayed in learning alphabets/numbers
Office screening for learning disabilities
language tasks: following directions, reading
non-verbal tasks: memory game, puzzles
school achievement: reading samples, math, writing, drawing a picture
LD interventions
Multimodal teaching strategies individualized education plans specialized schools - \$\$$ but effective recreation parents think ahead to vocational/career planning
FASD prevalence
common: at least 1/100
expensive: 1.5 mil/child lifetime
devastating
preventable
FASD
lifelong condition characterized by abnormalities in growth, face, brain
increased dose, more severe effects
Growth deficiency in FASD
low birth weight if drinking in late pregnancy
postnatally less than adequate weight gain despite adequate caloric intake
disproportionately low weight compared to height
FASD facial presentation
short palpebral fissures
flattened philtrum
thin upper lip
Functional impairments in FASD
often invisible
most common diagnosable cause of intellectual handicap, but majority have normal to just below avg intelligence
85% adults with FASD cannot live independently due to weak adaptive skills and poor exectuvei functions
Possible mechanisms of teratogenesis of alcohol
increased cell death and reduced neural crest cell numbers (apoptosis): FAS craniofacial features
oxidative stress
accumulation of fatty acid ethylesters
stress and hormonal mediation
effects on serotonin: important NT with neurotrophic effects
NMDA receptor
Epigenetic effects of perinatal stress, maternal emotional stress, neglect, poor nutrition
