Autism Spectrum Disorder and ADHD - Exam 3 Flashcards
What is ADHD characterized by? What age of must the s/s start before?
Characterized by a persistent pattern of diminished sustained attention and high levels of impulsivity or hyperactivity
present before age 12
What are the 3 different types?
Predominantly Hyperactive/Impulsive
Predominantly Inattentive
Combined
excessive fidgeting and restlessness, hyperactivity, difficulty remaining seated and waiting turns, impulsivity is which kind of ADHD?
ADHD, Predominantly Hyperactive/Impulsive
disorganization, forgetful, easily distracted, daydreamers, difficulty completing tasks is which kind of ADHD?
Predominantly Inattentive
previously ADD
ADHD- Hyperactive is ratio male to female is _____. ADHD-Inattentive it is ____
4:1 in males
2:1 in males
ADHD is believed to be due to a combo of _____ and ____factors. What is the chemical imbalance in the brain?
biological and environmental
impaired catecholamine (norepinephrine and dopamine) metabolism in the brain
genetics
**What is the DSM criteria for ADHD?
6+ symptoms from one category (inattentive or hyperactive), or 6+ from each, for 6+ months
Maladaptive and inconsistent with developmental level
**Clear functional impairment from symptoms present in 2+ settings
What is the non-pharm treatment of ADHD?
behavioral interventions
cognitive therapy
dietary modifications
**______ is the preferred treatment for preschool ADHD pts. What are common ways to help small children?
behavioral intervention
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 the tx for ADHD?
non-preschool aged kids answer is meds and therapy!
preschool aged kids is behavioral interventions
cognitive therapy may be useful as adjunct!
What is the videogame therapy for ADHD?
Endeavor Rx
What are stimulants for ADHD? Non-stimulant options?
Methylphenidate (Ritalin, Focalin, Concerta, Quillivant)
Amphetamines (Adderall, Vyvanse)
__________
Atomoxetine (Strattera)
Alpha-2 Adrenergic Agonists:
-Clonidine (Kapvay)
-Guanfacine (Intuniv)
Antidepressants
What are the criteria for starting therapy in children with ADHD?
- Full diagnostic assessment and dx confirmed
- Child is at least 6!
- school will be compliant with medication
- pharm is first line tx**
______ generally considered first-line for children 6 yo and up with functional impairment due to ADHD.
Stimulants
_______ known to increase intrasynaptic levels of catecholamines (______ and _______)
________ blocks reuptake
________ blocks reuptake and stimulate dopamine release
Stimulants
norepinephrine and dopamine
Methylphenidate - blocks reuptake
Amphetamines - blocks reuptake, stimulate dopamine release
_____ can help reduce adverse SE, reduce crash and reduce _____.
Extended release forms
reduce tachyphylaxis
**Do stimulants help with emotional problems?
These medications do not treat emotional problems, defiant behavior, learning impairment, reduced social skills
______ must be activated by stomach acid aka cannot be crushed or snorted
Vyvanse
What is the dosing schedule for stimulants? How do you discontinue?
start at lower doses and gradually titrate up
May reassess need for stimulants over time
If discontinued, taper down on dose
______ may be able to miss doses on weekends, vacations
drug holidays
What are 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
Peripheral vasculopathy is also known as _____
Raynaud’s
priapism is very rare but is associated with ______
methylphenidate
What do you do if your patient develops a tic with a stimulant?
trial of different dose or changing medication to non-stimulant
What do you do if your patient develops mood lability?
XR formulations; evaluation for comorbid psych disorders
What are some CI to stimulants?
**History of substance abuse
Hyperthyroidism
Glaucoma
moderate to severe hypertension
arrhythmias or heart failure
motor tics/Tourette syndrome
anxiety
agitated states
use within 14 days of MAOI
______ is the methylphenidate transdermal patch. When is the drug class preferred?
Daytrana
methylphenidate:
**Preferred for preschool-age children requiring meds
Generally better tolerated with regard to side effects
Associated with slightly less weight loss
_______ blocks catecholamine reuptake (norepinephrine, dopamine) → increased intrasynaptic levels
Methylphenidate
What are the brand names for methylphenidate?
Ritalin, Focalin, Concerta, Methylin
______ prodrug of dextroamphetamine that only becomes activated after orally ingested
Lisdexamfetamine (Vyvanse)
______ blocks catecholamine reuptake (norepinephrine, dopamine); also increases dopamine release → increased intrasynaptic levels
amphetamines
_____ has more SE and is associated with more weight loss. NOT associated with priapism
amphetamines
______ is a selective norepinephrine reuptake inhibitor. Not controlled substance. When is it mainly used? Is it first line? How long does it take to go into effect?
Atomoxetine (Strattera)
Used mainly if stimulants can’t be used (need to avoid stimulants, hx of tic disorder, abuse of stimulants)
not first-line
May see delay of 1-2 weeks to clinical efficacy
What are the CI for Atomoxetine (Strattera)?
use within 14 days of MAOI; glaucoma; pheochromocytoma; severe cardiovascular disease (heart failure, arrhythmia, etc.)
______ stimulation of alpha-2 adrenergic receptors in the central nervous system. When are they commonly used? Is it controlled? What are the 2 names?
Alpha-Adrenergic Agonists
Mainly used for pts who fail to respond to or cannot tolerate stimulants or atomoxetine
not controlled :)
XR Clonidine (Kapvay)
XR Guanfacine (Intuniv)
What is important to remember about Alpha-Adrenergic Agonists?
only the XR version is approved for ADHD the IR version is NOT!!
would not use in PCP setting, only psych
not first line!
____ and ____ are 3rd-line monotherapy or adjunct to stimulants
XR Clonidine (Kapvay) and XR Guanfacine (Intuniv)
What is a SE of XR Clonidine (Kapvay)? What do you need to do in order to d/c?
Sedating side effects
may be helpful in agitated, aggressive or highly active pts
If discontinued, taper to avoid rebound HTN
Of the Alpha-Adrenergic Agonists, which ones works better?
XR Guanfacine (Intuniv) works better than XR Clonidine
____ are used for 4th line therapy. ______ blocks reuptake of norepinephrine and dopamine; stimulant SE. What is it shown to help reduce?
TCAs (concerned about cardiotoxicity)
Bupropion (Wellbutrin)
shown to help reduce aggressiveness and hyperactivity
What is autism spectrum disorder characterized by?
Deficits in social interaction
and communication
Restricted repetitive patterns of behavior, interests, and activities
Must be present in early development
What is the pt population for autism? Pt with autism have a higher risk of _____ is more severe intellectual disability
males
seizures
What are 3 genetic and metabolic conditions that as associated with autism?
Angelman syndrome, mitochondrial abnormalities, Fragile X syndrome
What is the thought process behind autism?
Genetic etiology alters brain development → abnormal social and communication development → restricted interest and repetitive behavior
Name some ASD brain/head abnormalities
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
ASD has been shown to increase risk with what 3 pregnancy related states?
Increased parental age (mother or father)
Overall poorer perinatal/neonatal health
-Preterm delivery
-Low birth weight
Maternal metabolic conditions (DM, HTN)
What age does autism typically present at? What are some signs? Is older onset better or worse?
2 years old
no eye contact
sitting in abnormal position
limited verbal capacity
impaired social skills
older onset is harder social skills
Autism usually presents with _____ in other
unaware of other children
uninterested in imitating others
Little/no desire to share enjoyment, interests, or achievements with other people
prefer solitary play, little interest in friendships
What are some stereotyped behaviors for ASD? ______ can be seen in ASD with cognitive impairment
Hand flapping or twisting, rocking, swaying
Lining toys up in an exact manner, counting
self- injurious
ASD has major difficulty with _____ and do better with???
difficulty with change
need identical daily routines and struggle with transitions
ASD pts have ____ interests or persistent preoccupation with inanimate objects
narrowed interest
Intellectual impairment often stronger in _____ and markedly deficient in _____
nonverbal tasks and verbal cognition
Pts with ASD abilities improve with _____ and ____. Verbal abilities are relatively intact in ______
early detection and intervention
Asperger disorder
What are some screening 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
What are the screening tools for ASD?
M-CHAT-R/F - young children (16-30 mo)
One of the most universally used tests for ASD
(Earlier/Later) detection → better outcomes. Why?
earlier detection has better outcomes
Earlier education planning
Provisions of family support
More appropriate medical care
What happens next after a child screens positive for ASD?
Be referred to a specialist who is familiar with autistic disorders
Undergo a hearing screening and serum lead level screen
Possibly undergo genetic testing
What is the tx for ASD?
Educational and Behavioral Interventions
-social, language and adaptive skills
Routine Screening and Preventative Care
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 stimulant is used to treat ASD symptoms? What two antipsychotics are used to treat ASD symptoms?
Methylphenidate
**risperidone or aripiprazole
_____ is an SSRI that is helpful in ASD pts with anxiety or repetitive behaviors
fluoxetine
What are good prognosis factors for ASD? What are poor prognosis factors?
higher cognitive abilities, less severe symptoms, early identification, functional play skills
IQ <70, lack of joint attention by age 4 or functional speech by age 5, seizures or other comorbid conditions, severe symptoms
What is Rett disorder? What gender? What gene mutation? What age do they survive to?
born normal and slowly lose social and verbal skills
almost exclusively in FEMALES
sporadic mutation in MECP2 gene
typically survive to 45 years old
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
What is the initial presentation of Rett disorder? What does later present like?
loss of interest in surroundings, little purposeful hand movements (may persist with stereotypic movements)
some recovery of nonverbal communication with improved eye contact, followed by slow deterioration of gross motor functioning
What are some 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
What is the tx of Rett disorder?
**no specific treatment
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
