Autism/ADHD Flashcards
Characterized by a persistent pattern of diminished sustained attention and high levels of impulsivity or hyperactivity
Attention-Deficit/Hyperactivity Disorder (ADHD)
at what age does ADHD must be present by?
12
3 major specifiers for ADHD
- ADHD, Predominantly Hyperactive/Impulsive (ADHD-PH)
- ADHD, Combined Type
- ADHD, Predominantly Inattentive (ADHD-PI)
which ADHD type is excessive fidgeting and restlessness, hyperactivity, difficulty remaining seated and waiting turns, impulsivity
ADHD, Predominantly Hyperactive/Impulsive (ADHD-PH)
which ADHD type is disorganization, forgetful, easily distracted, daydreamers, difficulty completing tasks
ADHD, Predominantly Inattentive (ADHD-PI) aka Attention Deficit Disorder (ADD)
what is the epidemiology of ADHD
- 2-18% of children; 3-5% of adults*
- males MC
- 4:1 for ADHD-PH, 2:1 for ADHD-PI* - Comorbidities - conduct disorders, anxiety, depression, learning disorders
biological causes of ADHD
- Impaired catecholamine (norepinephrine, dopamine) metabolism in the brain
- Genetics - increased risk in pts with (+) family history of ADHD, up to 92% for monozygotic twins
environmental causes of ADHD
- Intake of food additives or refined sugar
- Deficiency of fatty acids, iron or zinc
- Prenatal tobacco or alcohol exposure
- Screen time exposure
- Prematurity, low birth weight
criteria for ADHD
6+ symptoms from one category (inattentive or hyperactive), or 6+ from each, for 6+ months
1. Maladaptive and inconsistent with developmental level
2. Some symptoms must have been present before age 12
3. Clear functional impairment from symptoms present in 2+ settings
4. Symptoms not better accounted for by another disorder
5. symptoms
- inattentiveness
- Hyperactivity
- Impulsivity
what are the non-pharm tx for ADHD
- Behavioral Interventions
- Cognitive Therapy
(Psychotherapy) - Dietary Modifications
what is the preferred tx over medication for preschool ADHD pts
Behavioral Interventions
Reported to improve behavior in preschool-age pts
what tx is an adjunct for older children and teens and alone, does not improve core ADHD s/s in school-age pts
Behavioral Interventions
common interventions of behavioral interventions
- Daily schedule
- Using charts and checklists
- Minimal distractions
- Limiting choices
- Specific and logical storage places
- Rewarding positive behaviors
- Using calm discipline, such as time-out
common interventions of behavioral interventions
- Daily schedule
- Using charts and checklists
- Minimal distractions
- Limiting choices
- Specific and logical storage places
- Rewarding positive behaviors
- Using calm discipline, such as time-out
what is not recommended as monotherapy
cognitive therapy
No major improvement in core symptoms of ADHD
Any improvement noted is unlikely to transfer to practical settings (ex. school, home)
what are 3 dietary modifications that could help ADHD
- Elimination Diets
- not recommended - Fatty Acid Supplementation
- not recommended - Other Alternative Therapies
- Megavitamins, chelation, “detox”, herbal or mineral supplements
- No solid evidence to support efficacy
- Can have harmful side effects and setback in improvement
which dietary modifications must you closely monitor to ensure adequate nutrition for children when tx ADHD?
elimination diets
what are the pharm tx of ADHD
- Stimulants
- Methylphenidate
- Amphetamines - non-stimulants
- Atomoxetine (Strattera)
- Alpha-2 Adrenergic Agonists
- antidepressants
Ritalin
Methylphenidate
Focalin
Methylphenidate
Concerta
Methylphenidate
Quillivant
Methylphenidate
adderall
amphetamine
Lisdexamfetamine
amphetamine
(vyvanse)
Clonidine (Kapvay)
Alpha-2 Adrenergic Agonists
Guanfacine (Intuniv)
Alpha-2 Adrenergic Agonists
what is the criteria for pharm tx of ADHD
- Full diagnostic assessment has been completed and confirms dx
- Child is at least 6 years old¹
- School will cooperate in administration and monitoring of rx
- No concerns about substance use in household members
- No history of…
- Sensitivity or allergy to chosen medication
- Uncontrolled tachycardia
- Uncontrolled hypertension
- Uncontrolled anxiety
- Seizures
- Pervasive developmental delay
- Tourette syndrome
what is the 1st line tx for ADHD?
pharm
Generally considered first-line tx for children 6 yo and up with functional impairment due to ADHD
Stimulants
what schedule are Stimulants
schedule II
which pharm tx is known to increase intrasynaptic levels of catecholamines (norepinephrine, dopamine)
stimulants
which stimulant blocks reuptake of catecholamines
Methylphenidate
which stimulant blocks reuptake and stimulate dopamine release?
amphetamines
benefits of extended release forms of stimulants
helpful due to need to treat ADHD in multiple settings
1. Reduce adverse SE at peak levels of drug
2. Reduce “crash” SE when drug is cleared
Many stimulants come with special release formulations to manage symptoms and what else?
reduce tachyphylaxis
Partial immediate-onset, partial delayed-onset
Some have capsules that can be opened, some must be swallowed whole
what medications do not treat emotional problems, defiant behavior, learning impairment, reduced social skills
stimulants
may be able to miss doses on weekends, vacations
drug holiday
how do you adjust dosing schedules?
based on symptoms, activities and functional impairment
Start at lower doses and gradually titrate up until:
40-50% improvement in symptoms
SE become intolerable or max dose reached
common SE of stimulants
- Reduced appetite
- Insomnia or nightmares
- Feeling “on-edge” or “jittery”
- Emotional lability
- Weight loss and/or decreased height
- Routine monitoring of growth in pediatric pts - Development of tics
- Usually mild and correctable with dose adjustments
less common SE of stimulants
- CV - Increased HR, increased BP, palpitations; peripheral vasculopathy (Raynaud’s)
- Priapism - seen with methylphenidate; very rare
- Neuro - Headache, dizziness
- GI - N/V/D
- Psych - psychotic symptoms, manic symptoms
- Diversion or Misuse
pt is experiencing decreased appetite while on stimulants, how could you fix this?
dose at or following a meal; emphasize nutrient-dense foods
pt is experiencing poor growth while on stimulants, how could you address this?
drug holiday or change in therapy if substantial deceleration
pt is experiencing dizziness while on stimulants, what can you do?
monitor BP and HR; adequate fluids; XR formulations
pt is experiencing sleep disturbances, what could you do?
normal bedtime routine; earlier dosing or decrease/omit last dose of day
pt is experiencing mood lability while on stimulants, what could you do?
XR formulations; evaluation for comorbid psych disorders
pt is experiencing rebound while on stimulants, what could you do?
Increased dose or adding another dose later in the day
pt is experiencing tics while on stimulants, what could you do?
trial of different dose or changing medication to non-stimulant
pt is experiencing psychosis while on stimulants, what could you do?
discontinue stimulant; psych referral if needed
you discover your pt is misusing/diversion stimulants, what could you do?
formulations with decreased abuse potential; discussion with patient and parents; changing to non-stimulant therapy
CI for stimulants
- Allergic
- hx of substance abuse
- Hyperthyroidism
- Glaucoma
- CV
- Symptomatic CV disease
- Moderate-severe HTN
- Arrhythmias or HF - Neuro/Psych
- Motor tics or Tourette syndrome
- Agitated states
- Anxiety
- Use within 14 days of MAOI
which stimulant is a transdermal patch?
daytrana - methylphenidate
which stimulant is preferred for preschool-age children requiring meds
Methylphenidate
which stimulant is generally better tolerated with regard to side effects
Associated with slightly less weight loss
Rarely associated with priapism
Methylphenidate
which stimulant is not preferred for preschool-age children requiring meds
Amphetamines
which stimulant is less tolerated with regard to side effects
Associated with slightly more weight loss
Not associated with priapism
Amphetamines
which medication is a Selective norepinephrine reuptake inhibitor
Atomoxetine (Strattera)
which medications are not a controlled substance for ADHD
- Atomoxetine (Strattera)
- Alpha-Adrenergic Agonists
- XR Clonidine (Kapvay)
- XR Guanfacine (Intuniv)
which medicaiton is used mainly if stimulants can’t be used - not first-line
Atomoxetine (Strattera)
- Intolerable SE to stimulants
- Desire to avoid stimulant therapy
- History of tic disorder or development of tics
- Risk of diversion/abuse of stimulants
SE of atomoxetine (strattera)
- GI - decreased appetite, N/V, abdominal pain, dyspepsia, weight loss
- CV - rare; may see increased BP and HR, arrhythmias, peripheral vasculopathy
- Priapism
- Neuro/Psych - psychosis, suicidal thoughts, tics
- Liver Injury
CI for atomoxetine (strattera)
allergy to drug; use within 14 days of MAOI; glaucoma; pheochromocytoma; severe cardiovascular disease (heart failure, arrhythmia, etc.)
which drug is responsible for the stimulation of alpha-2 adrenergic receptors in the central nervous system
May take up to 2 weeks to see response
Alpha-Adrenergic Agonists
which medication is mainly used for pts who fail to respond to or cannot tolerate stimulants or atomoxetine
Alpha-Adrenergic Agonists
which medications are 3rd-line monotherapy or adjunct to stimulants
XR Clonidine (Kapvay)
XR Guanfacine (Intuniv)
which medication has sedating SE
helpful in agitated, aggressive, or highly active pts
help offset some SE of stimulants
XR Clonidine (Kapvay)
SE of XR Clonidine (Kapvay)
sedation, depression, bradycardia, low BP, HA
CI for XR Clonidine (Kapvay)
hypersensitivity
which medication Improves ADHD symptoms, but not as effective as stimulants
Once-daily dosing
Fewer side effects than XR clonidine
XR Guanfacine (Intuniv)
SE of XR Guanfacine (Intuniv)
sedation, HA, fatigue, abdominal pain
CI for XR Guanfacine (Intuniv)
hypersensitivity to drug
4th line therapy for ADHD
TCAs
Concern over SE, especially cardiotoxicity
May be helpful in children with comorbid mood disorders
which medication blocks reuptake of norepinephrine and dopamine; stimulant SE
Bupropion (Wellbutrin)
which medication is Shown to help reduce aggressiveness and hyperactivity
SE of insomnia, anorexia, tics, seizures
Not extensively studied for ADHD
Bupropion (Wellbutrin)
Group of neurodevelopmental disorders characterized by:
- Deficits in social interaction
and communication - Restricted repetitive patterns of behavior, interests, and activities
- Must be present in early development
ASD is 3-4x more common in ?
males
what is the general consensus of ASD etiology
Genetic etiology alters brain development → abnormal social and communication development → restricted interest and repetitive behavior
what is the Epigenetic theory for ASD etiology
abnormal gene is “turned on” early in development that influences other genes
what is the Epigenetic theory for ASD etiology
abnormal gene is “turned on” early in development that influences other genes
brain abnormalities seen in ASD
- Accelerated head growth in infancy
- Increased overall brain size (2-10%)
- Different patterns of connectivity, cognitive strategies and brain areas during social tasks or with visual/audio stimuli
- Abnormal serotonin synthesis
- Abnormal brain structure and organization
Increased ASD risk seen with what biological factors
- Increased parental age (mother or father)
- Overall poorer perinatal/neonatal health
- Preterm delivery
- Low birth weight - Maternal metabolic conditions (DM, HTN)
ASD most commonly recognized around age ?
2 yrs
- May be present earlier
- May manifest later, when social demands exceed limited capacities to cope
what is considered severe vs mild ASD
- Severe - significant behavioral problems, often mute
- Mild - children have verbal capacity, may show unusual special interests
Common factor - impaired social skills
what is a very common presenting complaint with ASD
Delays and deviations in language
- echolalia, pronoun reversal
what is social reciprocity in ASD
impaired; often unaware of other children, lack empathy, uninterested in imitating others
little/no desire to share enjoyment, interests, or achievements with other people in ASD
joint attention
difficulty using and interpreting nonverbal cues in ASD
Nonverbal communication
prefer solitary play, little interest in friendships is MC seen in what population of pts with ASD
younger
lack understanding of behavior being appropriate in one scenario and not another, do not grasp needs of others is MC seen in what population of pts with ASD
older
can involve complex or whole-body movements such as Hand flapping or twisting, rocking, swaying
is called what type of behavior
stereotyped behavior
can involve complex or whole-body movements
is called what type of behavior
stereotyped behavior
what % of ASD pts show stereotyped behavior
95
what % of ASD pts show stereotyped behavior
95%
lining toys up in an exact manner, counting is called what type of behavior in ASD
stereotyped rituals
what stereotyped behavior in ASD is seen more with cognitive impairment, such as head-banging, face slapping, self-biting
Self-injurious
major difficulty with changes; often need identical daily routines and struggle with transitions
Insistence on sameness
Either abnormal intensity or focus on a narrow area or persistent preoccupation with unusual (usually inanimate) objects
- Restricted interests
- Younger - peculiar sensory arousal
- Older - weather, dates, schedules, phone numbers, license plates, etc.
aberrant sensory processing in up to 99% of ASD patients
Hyposensitivity, hypersensitivity, or paradoxical responses
Sensory perception
other common features of ASD
- Intellectual impairment - often stronger in nonverbal
tasks and markedly deficient in verbal cognition - “savant” skills
- Language impairment - delay in, or lack of, development of spoken language is common
- Motor deficits - may include abnormal gait, clumsiness, toe walking, hypotonia
- Macrocephaly - ¼ of children have head circumference > 97th percentile
how can intellectual impairment in ASD improve?
early detection and intervention
- Earlier education planning
- Provisions of family support
- More appropriate medical care
what are the important early indicators for ASD
- No babbling by 9 months
- No pointing or gestures by 12 months
- Lack of orientation to name by 12 months of age
- No single words by 16 months
- Lack of pretend or symbolic play by 18 months
- No spontaneous, meaningful (not repetitive or echolalic), two-word phrases by 24 months
- Any loss of any language or social skills at any age
M-CHAT-R/F is for what? for what age?
screen tool for ASD
young children (16-30 mo)
after a child is screened positive for ASD, what is the next step?
- Be referred to a specialist who is familiar with autistic disorders
- Undergo a hearing screening and serum lead level screen
- Possibly undergo genetic testing
ASD tx
- Educational and Behavioral Interventions
- Focus on social, language and adaptive skills
- May use manual signing, picture exchange - Routine Screening and Preventative Care
- Especially be aware of dietary intake and physical activity - Complementary and Alternative Medicine
- Melatonin, omega-3 fatty acids, probiotics, hyperbaric oxygen, IVIG, music therapy, yoga, massage, horseback riding - Psychopharmacologic Interventions
- Do not treat ASD but can help behaviors
what pharm tx can help with inattention/hyperactivity in ASD
stimulants
- Methylphenidate (most studied)
- other stimulants, alpha agonists, atomoxetine
what pharm tx can help with maladaptive behavior in ASD
Antipsychotics - especially risperidone or aripiprazole
Stimulants, SSRIs, alpha-adrenergics may also help
what pharm tx can help with anxiety or repetitive behavior in ASD
SSRIs (fluoxetine)
what pharm tx can help with Depressive symptoms in ASD
SSRI/SNRI
what pharm tx can help with dysregulated mood in ASD
atypical antipsychotic or SSRI
good prognosis of ASD
higher cognitive abilities, less severe symptoms, early identification, functional play skills
poor prognosis of ASD
IQ <70, lack of joint attention by age 4 or functional speech by age 5, seizures or other comorbid conditions, severe symptoms
Neurodevelopmental disorder
Almost exclusively in females
Most cases - sporadic mutation in MECP2 gene
Rett disorder
what is the classic presentation of Rett disorder
- uneventful pregnancy and delivery, normal development for first part of life (about 6 months)
- Deceleration of head growth - can appear as early as 2-3 mo
- 12-18 months - loss of acquired fine motor, intellectual and communication abilities - Can be gradual or rapid
initial findings of Rett disorder
loss of interest in surroundings, little purposeful hand movements (may persist with stereotypic movements)
later findings of rett disorder
some recovery of nonverbal communication with improved eye contact, followed by slow deterioration of gross motor functioning
additional common findings of rett disorder
Loss of expressive language
Motor dysfunction (stereotypic hand movements, gait disturbance, bruxism, drooling, rigidity, dystonia)
Scoliosis (50-85% by age 16)
Growth failure
Epilepsy
Bone mineral deficit and increased fracture risk
Cardiac abnormalities
Disordered wakeful breathing patterns
Sleep disorders
tx for rett disorder
- No specific treatment available
- Good nutrition (high-calorie, balanced diet)
— Assess oral motor function, GERD, delayed gastric emptying
- High index of suspicion of fractures
- Antiepileptic drugs for seizure patients
- Monitor QT interval
- Physical therapy for scoliosis
- Sleep hygiene and medication if needed
- PT and OT for motor dysfunction
