Disruptive... Flashcards
Etiology of ADHD
Dopamine and NE
Frontal and prefrontal cortices, basal ganglia
Anterior cingulate activation
Slower cortical thinning
High probability if parents or siblings have ADHD
MSE of ADHD: appearance, affect/mood, speech/thought processes
Appearance: Most often, appointments are difficult to structure and maintain d/t hyperactivity and distractibility. Children with ADHD may present as fidgety, impulsive, and unable to sit still, or they may actively run around the office. Adults with ADHD may be distractible, fidgety, and forgetful.
Affect/mood: Affect usually is appropriate and may be elevated, but it should not be euphoric. Mood usually is euthymic, except for periods of low self-esteem and decreased (dysthymic) mood. Mood and affect are not primarily affected by ADHD, although irritability may be associated with ADHD
Sppech/thought processes: Speech is of normal rate but may be louder d/t impulsivity. Thought processes are goal-directed but may reflect difficulties staying on a topic or task. Evidence of racing thoughts or pressured speech should not be present.
MSE of ADHD: hallucinations or delusions, thought content/suicide, cognition
Hallucinations or delusions: Not present
Thought content/suicide: Content should be normal, with no evidence of suicidal/homicidal or psychotic sx
Cognition: Concentration and storage into recent memory are affected. Pts with ADHD may have difficulty with calculation tasks and recent memory tasks. Orientation, remote memory, or abstraction should not be affected.
DSM-5 criteria for ADHD: inattention
Six or more (five or more in age 17 or older) of the following sx have persisted for at least 6 mos to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
DSM-5 criteria for ADHD: hyperactivity and impulsivity
Six or more (five or more in ages 17 or older) of the following sx have persisted for at least 6 mos to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Often fidgets with or taps hands or feet or squirms in seat
Often leaves seat in situations when remaining seated is expected
Often runs about or climbs in situations where it is inappropriate (in adolescents and adults, may be limited to feeling restless)
Often unable to play or engage in leisure activities quietly
Is often “on the go”, acting as if “driven by a motor”
Often talks excessively
Often blurts out an answer before a question has been completed
Often has difficulty waiting his or her turn
Often interrupts or intrudes on others
DSM-5 criteria for ADHD: general
B. Several inattentive or hyperactive-impulsive sx were present prior to age 12 yrs
C. Several inattentive or hyperactive-impulsive sx are present in two or more settings
D. There is clear evidence that the sx interfere with, or reduce the quality of, social, academic, or occupational functioning
E. The sx do not occur exclusively during the course of schizophrenia or another psychotic d/o are are not better explained by another mental d/o
Workup for ADHD: labs
Please note that it's very important to take a thorough hx and physical to exclude other reasons for these sx Serum CBC with diff Electrolyte levels LFTs (before beginning stimulants) Thyroid function tests
Workup for ADHD: other tests
Connors Parent-Teacher Rating Scale Barkley Home Situations Questionnaire Wender Utah Rating Scale WHo Adult ADHD Self-Report Scale Continuous Performance Tests -Test of Variable Attention -Low sensitivity and specificity and should not be the sole basis for diagnosis Vision and hearing should be checked
Tx for ADHD: pharm
Stimulants are first-line
Atomoxetine second-line
TCAs- do an EKG first
Clonidine and guanfacine have mixed reports of efficacy
Tx for ADHD: psychotherapy and other
Cognitive therapy to counter anxiety and depressive sx and work on time management
Work with parents and school
For adults, work to establish ways of decreasing distractions and improving organizational skills
Behavioral parent training and behavioral classroom management
Exercise!
Pathophysiology of autism spectrum d/o: hypotheses
Frontal and temporal lobe, cerebellar abnormalities
More neurons present in prefrontal cortex
Reduced or atypical connectivity in frontal brain regions, thinning of corpus callosum
Reduction of GABA receptors
Acetylcholine, glutamate anomalies
Serotonin elevations
Reduction in serum biotinidase
Decrease in plasma levels of cysteine, gluthathione, and methionine
Reduced ratio of SAM to SAH
Decreased ratio of reduced to oxidized gluthathione
Etiology of autism spectrum d/o: hypotheses
Obstetric complications: don't know whether it's the chicken or the egg Prenatal valproate use Prenatal exposure to SSRIs Rubella exposure during pregnancy Genetic linkage Environmental toxins Advancing parental age- either parent
Behavioral and developmental features that suggest autism
Developmental regression
Absence of protodeclarative pointing- the use of the index finger to indicate an itme of interest to another person
Abnormal reactions to environmental stimuli
Abnormal social interactions
Absence of symbolic play
Repetitive and stereotyped behavior
Screening for autism spectrum d/o
CHAT MCHAT QCHAT AQ Pretend play Gaze monitoring Protodeclarative pointing Body movement Head and hand features Following directions Assessing stereotypes Self-injurious behaviors Evaluate for abuse Examine siblings
DSM-5 criteria for autism spectrum d/o: deficits in social communication
A. Persistent difficulties in social communication and social interaction across multiple contexts, as manifested by the following, currently or by hx:
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of nl back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and non-verbal communication
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers
DSM-5 criteria for autism spectrum d/o: patterns of behavior
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by hx:
- Stereotyped or repetitive motor movements, use of objects, or speech
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
- Highly restricted fixated interests that are abnormal in intensity or focus
- Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment
DSM-5 criteria for autism spectrum d/o: general
Sx must be present in the early developmental period
Sx cause clinically significant impairment in social, occupational, or other important areas of current functioning.
These disturbances are not better explained by intellectual disability
Workup for autism spectrum d/o
EEG to r/o seizure d/o, Landau-Kleffner syndrome, biotin-responsive infantile encephalopathy, etc.
Do genetic testing for fragile X if:
-The child has mental retardation
-Mental retardation cannot be excluded
-There is FHx of fragile X or undiagnosed mental retardation
-Dysmorphic features are present
Tx of autism spectrum d/o
Special education
Speech, behavioral, occupational, and physical therapies
Dietary consultation
Consider meds, but the jury is out that benefits outweigh the risks
-Risperidone and aripiprazole for challenging and repetitive behaviors, irritability
-Serotonergic drugs for behavior, but monitor closely for serotonin syndrome
-Ziprasidone for aggression, irritability, and agitation
Risk factors/etiology of oppositional defiant d/o
Environmental risk factors: harsh or neglectful parenting and highly authoritarian parenting
Children with ADHD are particularly vulnerable
DSM-5 criteria for oppositional defiant disorder: criterion A
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mos (<5 yo: the behavior should occur on most days. 5 yrs or older: the behavior should occur at least once per week) as evidenced by at least four sx from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling
DSM-5 criteria for oppositional defiant d/o: angry/irritable mood
Often loses temper
Is often touchy or easily annoyed
Is often angry and resentful
DSM-5 criteria for oppositional defiant d/o: argumentative/defiant behavior
Often argues with authority figures or, for children and adolescents, with adults
Often actively defies or refuses to comply with requests from authority figures or with rules
Often deliberately annoys others
Often blames others for his or her mistakes or misbehavior
DSM-5 criteria for oppositional defiant d/o: vindictiveness
Has been spiteful or vindictive at least twice within the past 6 mos
DSM-5 criteria for oppositional defiant disorder: general
B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context or it impacts negatively on social, educational, occupational, or other important areas of functioning
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar d/o. Also, the criteria are not met for disruptive mood d/o
Tx of oppositional defiant d/o
Assess for ADHD and learning d/os
If ADHD is present, guanfacine or stimulates may be very useful
Parent management training
Group tx
Etiology of conduct d/o
Genetic differences in DNA methylation, which result in deficits in the perception of emotions and impairment in affect regulation
Decreased dopamine response to reward and increased risk-taking behaviors related to abnormally disrupted frontal activity in the anterior cingulate cortex, orbitofrontal cortices and dorsolateral prefrontal cortex
Amygdala and insula abnormalities
DSM-5 criteria for conduct d/o: intro
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 mos from any of the categories below, with at least one criterion present in the past 6 mos
DSM-5 criteria for conduct d/o: aggression to people and animals
Often bullies, threatens, or intimidates others
Often initiates physical fights
Has used a weapon that can cause serious physical harm
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity
DSM-5 criteria for conduct d/o: destruction of property
Has deliberately engaged in fire setting with the intention of causing serious damage
Has deliberately destroyed others’ property (other than by fire setting)
DSM-5 criteria for conduct d/o: deceitfullness or theft
Has broken into someone else’s house, building, or car
Often lies to obtain goods or favors or to avoid obligations
Has stolen items of nontrivial value without confronting a victim
DSM-5 criteria for conduct d/o: serious violations of rules
Often stays out at night despite parental prohibitions, beginning before age 13 years
Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period
Is often truant from school, beginning before age 13 yrs
DSM-5 criteria for conduct d/o: general
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
If the individual is age 18 years or older, criteria are not met for antisocial personality disorder
Tx for conduct d/o
Stimulant medication Anticonvulsants as second line Parent management training Group tx has mixed results Social skills training Academic support
