Child and Adolescent Psych - ADHD / Conduct Disorders Flashcards
When do symptoms of ADHD generally first appear, and when is the diagnosis made?
Start appearing by age 3, diagnosis is generally not made until child enters school and requires selective attention
What are a few things which have been linked to ADHD (non-genetic neurobiological factors)?
Perinatal stress, maternal smoking, lead poisoning
What areas of the brain seem to have lower activity in ADHD? What neurotransmitters are affected?
Prefrontal cortex (impulse control) Caudate & Globus pallidus (basal ganglia, motor control) Neurotransmitters include dopamine and NE
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)
Inattentive subtype Hyperactive / impulsive subtype Need at least 6 for children and 5 for adults
When must symptoms present before for an ADHD diagnosis? Why does it need to occur in 2+ settings?
Must present before age 12 Occurs in 2+ settings because it cannot simply be occurring at school or at home, should be happening everywhere
How long must symptoms in ADHD be present, and how do they relate do your development level?
Must be present at least 6 months, and be maladaptive / inconsistent with your developmental level (not age)
What things are commonly cormorbid with ADHD?
ODD/CD Learning disability Anxiety / Mood disorders
What are ADHD rating scales useful for doing?
Monitoring treatment response -> not diagnosis
What is one important thing that must be done to rule out a cognitive delay as a reasoning for ADHD?
Cognitive assessment of ability & achievement -> assess developmental level
What are some conditions which may be mis-diagnosed at ADHD (on the differential)?
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
Do people with ADHD tend to remain symptomatic into their teens and adult years? Why? What predicts a worse prognosis longterm?
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
What are the basics of treatment for ADHD?
Psychoeducation of parents / child School resources / special ed Behavioral therapy Psychopharmacology
What types of school interventions can be done for ADHD kids?
Sit near front of classroom to lessen distractions Take untimed tests Do daily reportcards from teachers and use planners
How must the parents be involved in treatment of ADHD?
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
When would behavioral therapy + pharmacotherapy be preferable to just pharmacotherapy alone? Generally, which is more effective?
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)
What are the three stages of pharmacotherapy for ADHD?
Dose titration - optimize dosing / frequency Maintenance - routine monitoring Termination - Can go off medication for a while to see if symptoms are better
What are first line, second line, and third line pharmacotherapies for ADHD?
First line: Stimulants - Methylphenidate and dextroamphetamine Second line: Alpha-2 agonists - Guanfacine, Clonidine NRI - Atomoxetine Third line: TCAs, Bupropion
What is the mechanism of action of stimulants? What should be done if one doesn’t work?
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
What are the important side effects of stimulants?
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
What are the contraindications of stimulants?
History of substance abuse (addictive) BPAD -> will cause mania Active psychotic disorder
What are the drug interactions of concern with stimulants?
MAOIs/ TCAs
In children with heart problems / remarkable physical exam, what should be done before starting a stimulant?
Obtain an EKG / Echo
Other than long-release formulations via oral route, what is one way to get extended release stimulants?
Transdermal patch applied to hip
What are some other indications for stimulants?
Exogenous obesity and binge-eating disorder (appetite suppressant) Adjunct for Obstructive Sleep Apnea Narcolepsy (treats insomnia via keeping you awake)
What is the onset of action of stimulants vs atomoxetine? Why is the latter used?
Stimulants - near instant after absorption Atomoxetine - NRI which will have full effects by 4-6 weeks, less effective than stimulants (used in contraindication)
What are atomoxetine’s drug interactions of concern?
Metabolized by CYP2D6 - increased levels with paroxetine, fluoxetine, and TCAs
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?
Suicidal ideation
What are alpha-2 agonists used off-label to treat? Are they approved for ADHD?
Tourette’s disorder / tic disorder ADHD PTSD / stress Aggression Only the XR formulations are approved for ADHD
What is the mechanism of action of alpha agonists in ADHD?
Enhance NE input from locus coeruleus and stimulate post-synaptic alpha 2A receptors -> improves functional connectivity of prefrontal cortex networks
What are the side effects of alpha-2 agonists? What can happen in discontinuation? How long do they take to work?
Drowsiness / sedation Decreased BP / pulse -> discontinuation = rebound hypertension, tachycardia, anxiety / panic attacks Take 4-6 weeks to work (same as Atomoxetine)
Can you combine stimulants and atomoxetine / guanfacine / clonidine?
Yes, well tolerated
What are the two kinds of disruptive behavior disorders (DBD)?
- Oppositional defiant disorder (ODD) 2. Conduct disorder (CD)
Give a couple key biological, individual, family, and social/school risk factors for development of DBDs?
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
As oppositional behavior normal in development?
Yes, it normally peaks around age 2 (the terrible two’s)
What psychological factors could contribute to ODD?
Insecure attachment and social learning from having an antagonistic parent
What are the three categories for ODD diagnosis? How long must it be present?
For >6 months - pattern of negativistic / hostile / defiant behavior 1. Angry / Irritable Mood 2. Argumentative / Defiant Behavior 3. Spiteful / Vindictive
How does ODD appear at school and do children feel their actions are warranted?
The behavior starts at home and later displayed in school, where they will do poorly Children feel their actions are justified
When does ODD start, and what do many children go on to develop?
Usually before age 8, many children will develop conduct disorder later in life
What is the treatment for ODD? What is most important?
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***
What are some protective features against conduct disorder?
Anxiety (fear of punishment) Impulse control
When is conduct disorder diagnosed and what is it generally?
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
What are the four categories of misconduct in conduct disorder?
- Aggression towards people & animals 2. Destruction of property 3. Deceitfulness or theft 4. Serious violations of rules (parental or school)
What are three specifiers of conduct disorder?
- 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
How might CD be sometimes a precursor to schizophrenia?
Prodromal psychosis -> voices make you do bad things
Can CD co-occur with ADHD / ODD?
ODD - yes -> although it is often just a stepping stone ADHD - frequently comorbid
Do most CD adolescents develop into ASPD? How are they related?
No, but a diagnosis of conduct disorder between age 15 is required for ASPD diagnosis
What are the three evidence-based psychosocial treatments for CD and which one shows a long-term reduction in arrest / incarceration?
- 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.
When would pharmacotherapy be used for CD?
Only for extreme aggression or in combination with psychosocial treatment for comorbid psychiatric illnesses
What conditions are most frequently comorbid with ODD / CD?
ADHD (10x) Major Depression (7x) Substance Abuse (4x) -> although behavior must not be CAUSED by substance use
How old must you be for a true ASPD diagnosis?
18 years
Comprehensive list of adverse events for methylphenidate (6 common/17)
5 absolute & 3 relatives
Contraindications to psychostimulant use
Health Canada approved treatment for ADHD
1/2ab/3ab/4/5
Suggested Pharmacological algorith for ADHD
4 MPH/ 4 AMPH
Brand & Generic names for ADHD medication (MPH & AMPH)
