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Psychiatry > Child and Adolescent Psych - ADHD / Conduct Disorders > Flashcards

Child and Adolescent Psych - ADHD / Conduct Disorders Flashcards

1
Q

When do symptoms of ADHD generally first appear, and when is the diagnosis made?

A

Start appearing by age 3, diagnosis is generally not made until child enters school and requires selective attention

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2
Q

What are a few things which have been linked to ADHD (non-genetic neurobiological factors)?

A

Perinatal stress, maternal smoking, lead poisoning

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3
Q

What areas of the brain seem to have lower activity in ADHD? What neurotransmitters are affected?

A 
Prefrontal cortex (impulse control)
Caudate & Globus pallidus (basal ganglia, motor control)

Neurotransmitters include dopamine and NE

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4
Q

What are the two subtypes of ADHD, and how many symptoms do you have to have in that category in order to qualify for that subtype (or combined = affected by both)

A

Inattentive subtype
Hyperactive / impulsive subtype

Need at least 6 for children and 5 for adults

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5
Q

When must symptoms present before for an ADHD diagnosis? Why does it need to occur in 2+ settings?

A

Must present before age 12

Occurs in 2+ settings because it cannot simply be occurring at school or at home, should be happening everywhere

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6
Q

How long must symptoms in ADHD be present, and how do they relate do your development level?

A

Must be present at least 6 months, and be maladaptive / inconsistent with your developmental level (not age)

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7
Q

What things are commonly cormorbid with ADHD?

A

ODD/CD
Learning disability
Anxiety / Mood disorders

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8
Q

What are ADHD rating scales useful for doing?

A

Monitoring treatment response -> not diagnosis

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9
Q

What is one important thing that must be done to rule out a cognitive delay as a reasoning for ADHD?

A

Cognitive assessment of ability & achievement -> assess developmental level

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10
Q

What are some conditions which may be mis-diagnosed at ADHD (on the differential)?

A

Anxiety -> will be fidgety
Depression -> lack of motivation
BPAD -> looks like hypomanic symptoms
Conduct disorder -> playing with scissors might look like conduct disorder but actually be ADHD

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11
Q

Do people with ADHD tend to remain symptomatic into their teens and adult years? Why? What predicts a worse prognosis longterm?

A

Yes, up to 80% do in teen years, and 60% in adult years

-> adult follow-up becomes more difficult because symptoms change and people tend to choice career paths where their function is less impaired

Worse prognosis = more severe childhood symptoms

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12
Q

What are the basics of treatment for ADHD?

A

Psychoeducation of parents / child
School resources / special ed
Behavioral therapy
Psychopharmacology

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13
Q

What types of school interventions can be done for ADHD kids?

A

Sit near front of classroom to lessen distractions
Take untimed tests
Do daily reportcards from teachers and use planners

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14
Q

How must the parents be involved in treatment of ADHD?

A

They must come and learn how to control their children’s behaviors, how to use reward systems to manage their behavior, and properly socialize the kids

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15
Q

When would behavioral therapy + pharmacotherapy be preferable to just pharmacotherapy alone? Generally, which is more effective?

A

Those with anxiety disorders or high levels of socio-economic / family stress

(situations where stepping up the medication won’t fix psychosocial stressors)

Generally, medication is more effective than behavioral treatment according to the multimodal treatment study of ADHD children (MTA study)

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16
Q

What are the three stages of pharmacotherapy for ADHD?

A

Dose titration - optimize dosing / frequency
Maintenance - routine monitoring
Termination - Can go off medication for a while to see if symptoms are better

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17
Q

What are first line, second line, and third line pharmacotherapies for ADHD?

A

First line: Stimulants - Methylphenidate and dextroamphetamine

Second line: Alpha-2 agonists - Guanfacine, Clonidine
NRI - Atomoxetine

Third line: TCAs, Bupropion

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18
Q

What is the mechanism of action of stimulants? What should be done if one doesn’t work?

A

Block NET and DAT as well as reversing VMAT2 to increase NE/DA in the synapse

If one doesn’t work, try the other one

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19
Q

What are the important side effects of stimulants?

A

Appetite suppression / weight loss -> may lead to growth delay
Mood disturbance in withdrawal -> will realize they are hungry
Elevated HR / BP
Can cause insomnia if taken at night, also GI / headache

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20
Q

What are the contraindications of stimulants?

A

History of substance abuse (addictive)
BPAD -> will cause mania
Active psychotic disorder

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21
Q

What are the drug interactions of concern with stimulants?

A

MAOIs/ TCAs

22
Q

In children with heart problems / remarkable physical exam, what should be done before starting a stimulant?

A

Obtain an EKG / Echo

23
Q

Other than long-release formulations via oral route, what is one way to get extended release stimulants?

A

Transdermal patch applied to hip

24
Q

What are some other indications for stimulants?

A

Exogenous obesity and binge-eating disorder (appetite suppressant)

Adjunct for Obstructive Sleep Apnea

Narcolepsy (treats insomnia via keeping you awake)

25
Q

What is the onset of action of stimulants vs atomoxetine? Why is the latter used?

A

Stimulants - near instant after absorption

Atomoxetine - NRI which will have full effects by 4-6 weeks, less effective than stimulants (used in contraindication)

26
Q

What are atomoxetine’s drug interactions of concern?

A

Metabolized by CYP2D6 - increased levels with paroxetine, fluoxetine, and TCAs

27
Q

Other than things you would expect for stimulant-like drugs (i.e. mild appetite suppression, increased HR/BP), what is the black-box warning for atomoxetine?

A

Suicidal ideation

28
Q

What are alpha-2 agonists used off-label to treat? Are they approved for ADHD?

A

Tourette’s disorder / tic disorder
ADHD
PTSD / stress
Aggression

Only the XR formulations are approved for ADHD

29
Q

What is the mechanism of action of alpha agonists in ADHD?

A

Enhance NE input from locus coeruleus and stimulate post-synaptic alpha 2A receptors -> improves functional connectivity of prefrontal cortex networks

30
Q

What are the side effects of alpha-2 agonists? What can happen in discontinuation? How long do they take to work?

A

Drowsiness / sedation
Decreased BP / pulse -> discontinuation = rebound hypertension, tachycardia, anxiety / panic attacks

Take 4-6 weeks to work (same as Atomoxetine)

31
Q

Can you combine stimulants and atomoxetine / guanfacine / clonidine?

A

Yes, well tolerated

32
Q

What are the two kinds of disruptive behavior disorders (DBD)?

A
  1. Oppositional defiant disorder (ODD)

2. Conduct disorder (CD)

33
Q

Give a couple key biological, individual, family, and social/school risk factors for development of DBDs?

A

Biology - male sex, perinatal complications, genetic

Individual - Below average IQ, reading problems, aggression / ADHD

Family - Parental antisocial behavior, single parent w/ lack of supervision, excessive control, early motherhood

Social - Peer rejection / being bullied / victimized, low SES, exposure to media violence

34
Q

As oppositional behavior normal in development?

A

Yes, it normally peaks around age 2 (the terrible two’s)

35
Q

What psychological factors could contribute to ODD?

A

Insecure attachment and social learning from having an antagonistic parent

36
Q

What are the three categories for ODD diagnosis? How long must it be present?

A

For >6 months - pattern of negativistic / hostile / defiant behavior

  1. Angry / Irritable Mood
  2. Argumentative / Defiant Behavior
  3. Spiteful / Vindictive
37
Q

How does ODD appear at school and do children feel their actions are warranted?

A

The behavior starts at home and later displayed in school, where they will do poorly

Children feel their actions are justified

38
Q

When does ODD start, and what do many children go on to develop?

A

Usually before age 8, many children will develop conduct disorder later in life

39
Q

What is the treatment for ODD? What is most important?

A

There is NO pharmacotherapy

  • > Early treatment via psychosocial therapies MUST involve parents
  • > Individual or family therapy NOT effective
  • -> Parent Management Training or Problem Solving Collaboration / Communication therapy is indicated*
40
Q

What are some protective features against conduct disorder?

A

Anxiety (fear of punishment)

Impulse control

41
Q

When is conduct disorder diagnosed and what is it generally?

A

Repetitive & persistent pattern of behavior in which basic rights of others or major age-appropriate societal norms / rules are violated

Diagnosed until 18, or after age 18 if criteria for antisocial personality disorder are not met

42
Q

What are the four categories of misconduct in conduct disorder?

A
  1. Aggression towards people & animals
  2. Destruction of property
  3. Deceitfulness or theft
  4. Serious violations of rules (parental or school)
43
Q

What are three specifiers of conduct disorder?

A
  1. Childhood onset -> at least one criteria before age 10
  2. Adolescent onset -> absence of criteria before age 10
  3. With limited prosocial emotions -> lack of remorse, guilt, empathy, shallow affect, and unconcern about performance
44
Q

How might CD be sometimes a precursor to schizophrenia?

A

Prodromal psychosis -> voices make you do bad things

45
Q

Can CD co-occur with ADHD / ODD?

A

ODD - yes -> although it is often just a stepping stone

ADHD - frequently comorbid

46
Q

Do most CD adolescents develop into ASPD? How are they related?

A

No, but a diagnosis of conduct disorder between age 15 is required for ASPD diagnosis

47
Q

What are the three evidence-based psychosocial treatments for CD and which one shows a long-term reduction in arrest / incarceration?

A
  1. Parent Management Training
  2. Probleming-Solving Skills Training
    (First two are same as ODD)
  3. Multisystemic Therapy (MST) -> leads to a reduction in re-arrest. Includes involvement of school, home, justice system, etc.
48
Q

When would pharmacotherapy be used for CD?

A

Only for extreme aggression or in combination with psychosocial treatment for comorbid psychiatric illnesses

49
Q

What conditions are most frequently comorbid with ODD / CD?

A 
ADHD (10x)
Major Depression (7x)
Substance Abuse (4x) -> although behavior must not be CAUSED by substance use
50
Q

How old must you be for a true ASPD diagnosis?

A

18 years

Psychiatry (23 decks)

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