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BD > Lecture 18: Autism Spectrum Disorder and ADHD > Flashcards

Lecture 18: Autism Spectrum Disorder and ADHD Flashcards

1
Q

What must be present for ADHD?

A
  • Persistent pattern of diminished sustained attention AND high levels of impulsivity or hyperactivity
  • Present prior to age 12.
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2
Q

What are the 3 specifier types for ADHD?

A
  • ADHD-PH, predominantly hyperactive/impulsive
  • ADHD, combined type
  • ADHD-PI, predominantly inattentive
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3
Q

What characterizes ADHD-PH?

A
  • Excessive fidgeting/restlessness
  • Hyperactivity
  • Difficulty remaining seated and waiting
  • Impulsivity
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4
Q

What characterizes ADHD-PI?

A
  • Disorganized
  • Forgetful
  • Easily distracted
  • Daydreamers
  • Difficulty completing tasks
  • AKA ADD.
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5
Q

What gender is ADHD more common in?

A

Males.
ADHD-PH is 4:1.
ADHD-PI is 2:1.

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6
Q

What are the contributing factors to ADHD?

A
  • Biological
  • Environmental (Controversial)
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7
Q

What are the biological components of ADHD?

A
  • Impaired catecholamine metabolism in the brain
  • Genetics (Increased risk with FHMX and 92% for identical twins)
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8
Q

What is the DSM-TV-R criteria for an ADHD diagnosis?

A

6+ symptoms from at least one category (inattentive or hyperactive) for at least 6+ months)
* Maladaptive and INCONSISTENT with developmental level.
* Some symptoms must be present prior to age 12.
* CLEAR FUNCTIONAL IMPAIRMENT IN 2+ SETTINGS. (home and school)

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9
Q

What symptoms fall under inattentiveness?

A
  • Poor attention to detail or careless mistakes.
  • Difficulty sustaining attention
  • Does not seem to listen
  • Does not follow instructions; fails to finihs tasks
  • Poor organization
  • Avoids or dislikes tasks needing sustained mental effort
  • Loses necessary materials for tasks
  • Easily distracted
  • Forgetful
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10
Q

What symptoms fall under Hyperactivity/Impulsivity?

A

Hyperactivity
* Fidgets or squirms
* Leaves seat when remaining seated is expected
* Active in inappropriate situations
* Teens/adults: subjective restlessness
* Difficulty playing or engaging in leisure activities
* Always on the go
* Excessive talking

Impulsivity
* Blurts out answer before question is finished
* Difficulty waiting turn
* Often interrupts or intrudes on others.

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11
Q

What are the 3 non-pharmacological therapies for ADHD?

A
  • Behavioral interventions
  • Cognitive therapy (psychotherapy)
  • Dietary modifications
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12
Q

When is behavioral intervention best for treating ADHD?

A

Preschoolers

It is only adjunct for older children because alone, it does NOT improve core symptoms.

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13
Q

When is cognitive therapy used for ADHD?

A

Adjunctive therapy for those with comorbid psych diagnoses.

It is NOT recommended as monotherapy.

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14
Q

What are the dietary modifications for ADHD?

A
  • Elimination Diets (not routinely recommended)
  • Fatty Acid supplementation (Not routinely recommended)
  • Megavitamins, chelation, detox, mineral/herbal supplements. (no proven efficacy)
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15
Q

What are the pharmacological treatment options for ADHD?

A
  • Stimulants (usually for younger children)
  • Non-stimulants (Atomoxetine, Clonidine/Guanfacine/Antidepressants)
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16
Q

What is the criteria for RX therapy in children with ADHD?

A
  • Confirmed diagnosis
  • 6+ yrs old
  • School cooperation
  • No hx of substance abuse in family
  • No hx of allergies, seizures, pervasive developmental delay, or tourette’s
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17
Q

What is the first-line therapy for ADHD?

A

Pharmacologic treatment!

Must prevent loss of learning for children!

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18
Q

What medications fall under methylphenidates?

A
  • Ritalin
  • Focalin
  • Concerta
  • Quillivant
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19
Q

What medications fall under amphetamines?

A
  • Adderall
  • Vyvanse
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20
Q

What drug schedule are stimulants?

A

Schedule 2!

No refills allowed.

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20
Q

What is the MOA of a stimulant?

A

Increases intrasynaptic levels of catecholamines (esp. dopamine.)
Methylphenidates block reuptake.
Amphetamines block reuptake AND stimulate dopamine release.

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21
Q

What is the ideal formulation for a stimulant?

A

ER (extended release), which will reduce adverse SE at the peak and reducing the crash at trough.
Reduces tachyphylaxis (reducing rapid tolerance)

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22
Q

What do stimulants not treat in terms of ADHD?

A
  • Emotional problems
  • Defiant behavior
  • Learning impairment
  • Reduced social skills.
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23
Q

How do we dose stimulants?

A

Lower doses and titrate slowly.
Drug holidays

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24
Q

What are the common SE of stimulants?

A
  • Reduced appetite
  • Insomnia/nightmares
  • Emotional lability
  • Weight loss and decreased height
  • Tic development
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25
Q

What are the less common SE of stimulants?

A
  • HTN
  • Tachycardia
  • Palps
  • Raynaud’s
  • Priapism (methylphenidates only)
  • HA
  • Dizziness
  • N/V/D
  • Psychosis or mania
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26
Q

What are some ways we manage stimulant SE?

A
  • Taking with food
  • Monitoring BP/HR
  • Earlier dosing
  • Different dosing
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27
Q

What are the CIs to stimulants?

A
  • Allergy
  • Hx of substance abuse
  • Hyperthyroidism
  • Glaucoma
  • CV
  • Neuro/psych (Tourette’s, use within 2 weeks of MAOI)
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28
Q

When are methylphenidates preferred?

A

Preschool age with better SE tolerance and less severe weight loss
Rarely has priapism.

About the same efficacy as an amphetamine.

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29
Q

What is the main difference in MOA between methylphenidates and amphetamines?

A

Amphetamines also increase dopamine release.

A for additional dopamine.
A for additional age (can’t be used in preschoolers)

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30
Q

Who do we avoid amphetamine use in?

A

Preschool aged children.

31
Q

What SE does amphetamine generally lack?

A

Priapism.

32
Q

What is the MOA of atomoxetine?

A

SNRI. (Not a controlled substance)

33
Q

When is atomoxetine indicated?

A
  • Intolerable to stimulants.
  • History of tic disorder
  • Risk of diversion with stimulants.
34
Q

What is the main concern with atomoxetine?

A

4-6 weeks to start showing effect.

35
Q

What are the SE of atomoxetine?

A
  • Decreased appetite, N/V, abd pain, dyspepsia, weight loss
  • CV
  • Priapism
  • Psychosis/SI/tics
  • Hepatotoxic
36
Q

What are the CIs of atomoxetine?

A
  • Allergy
  • MAOI within 14 days
  • Glaucoma
  • Pheo
  • Severe CVD
37
Q

When are alpha-2 adrenergic agonists indicated for ADHD?

A

Intolerable/failed stimulants AND atomoxetine.

38
Q

What are the 2 alpha-2 adrenergic agonists used for ADHD?

A
  • XR Clonidine
  • XR Guanfacine

2 weeks to take effect.
MUST BE XR version!

39
Q

What are the general SE of XR clonidine?

A

Sedating SE.
Hypotension (taper if d/cing)

40
Q

Which alpha-2 adrenergic agonist has less SE?

A

XR Guanfacine

41
Q

When are TCAs used for ADHD and what are the concerns?

A

4th line.
Cardiotoxicity could occur, so a pediatric cardiology consult may be required.

Can be used in a child with comorbid psych disorders.

42
Q

Why is bupropion used for ADHD and what are the concerns?

A

Reduce aggressiveness and hyperactivity
SE: insomnia, anorexia, tics, SEIZURES

43
Q

What is the MOA of bupropion?

A

Blocks reuptake of NE and dopamine.

44
Q

What characterizes autism spectrum disorder?

A
  • Deficits in social interaction and communication.
  • Restricted repetitive patterns of behavior, interests and activities
  • Must be present in early development
45
Q

What disorders fall under autism spectrum disorder?

A
  • Autistic disorder
  • Asperger’s disorder
  • Childhood disintegrative disorder
  • Pervasive developmental disorder - NOS

Rett syndrome is NOT part of ASD.

46
Q

What gender is ASD most common in?

A

Males

47
Q

What is the general consensus regarding ASD etiology?

A

Altered brain development.
Family history tends to match ASD as well.

48
Q

What is the epigenetic theory for ASD?

A

Abnormal gene is turned ON early in development that influences other genes.

49
Q

What is usually seen in terms of structural brain abnormalities for ASD?

A
  • Accelerated head growth in infancy
  • Increased brain size
  • Different neuronal firing patterns
  • Abnormal serotonin synthesis
  • Abnormal structure/organization
50
Q

What environmental factors may affect ASD?

A
  • Increased parental age
  • Overall poorer perinatal/neonatal health
  • Maternal metabolic conditions (DM, HTN)

No vaccine association.

51
Q

When is ASD usually recognized by?

A

Age 2

52
Q

What is the common factor in ASD patients?

A

Impaired social skills.

53
Q

What are the common social difficulties ASD patients face?

A
  • Delays and deviations in language
  • Lack of social reciprocity (unaware of others)
  • Lack of joint attention (don’t feel a need to share achievements with anyone)
  • Non-verbal communication
  • Poor social relationships (fail to develop and maintain peer relationships)
54
Q

What are the restricted/stereotyped/repetitive behaviors in ASD?

A
  • Hand flapping
  • Twisting
  • Rocking
  • Swaying

95% of ASD patients show this behavior!

55
Q

When is self-injurious behavior more common in ASD? Examples?

A

In cognitive impairment.
Involves
* Head-banging
* Face slapping
* Self-biting

56
Q

What kind of changes in interest do ASD patients show?

A
  • Insistence on sameness (difficult when chagning)
  • Restricted interests (very niche or extreme fixation of unusual objects or inanimate objects)
57
Q

How is sensory perception altered in ASD patients?

A
  • Aberrant sensory perception in up to 99% of ASD patients!!
  • Hyposensitivity, hypersensivitiy, or paradoxical responses.

Examples include
* Resistance to being touched
* Increased sensitivity to touch
* Refusal to eat foods with certain taste or textures
* Preoccupation with edges, spinning objects, etc.
* Visual inspection of objects with peripheral vision

58
Q

What intellectual impairment do ASD patients generally present with?

A

Markedly deficient in VERBAL cognition, but their abilities improve with early deteciton and intervention.

Savant behavior can also be observed.

59
Q

What language impairment tends to appear in ASD?

A

Receptive language is often delayed more.

Spoken language

60
Q

What motor deficits are often in seen in ASD?

A
  • Abnormal gait
  • Clumsiness
  • Hypotonia
61
Q

Missing what childhood milestones might suggest ASD?

A
  • No babbling by 9mos.
  • No pointing/gestures by 12mos.
  • Lack of orientation to name by 12mos.
  • No single words by 16mos.
  • Lack of pretend or symbolic play by 18mos.
  • No spontaneous, meaningful two-word phrases by 24mos.
  • Any loss of language or social skills at any age.
62
Q

What are the screening tools for ASD?

A

M-CHAT-R/F (16-30mos)

Modified checklist for autism in toddlers

63
Q

What are the next steps if a screening test for ASD is positive?

A
  • Specialist referral
  • Hearing Screening
  • Lead Screening
  • Genetic testing (maybe)
64
Q

What are the non-pharmacologic treatments for ASD?

A
  • Education/behavioral interventions
  • Routine screening and preventative care
  • Complementary/alternative medicine
65
Q

When are pharmacologic treatments indicated for ASD?

A

Treating the behaviors themselves, not ASD.

  • Stimulants (hyperactivity/inattentiveness)
  • Antipsychotics (Maladaptive behaviors)
  • SSRIs, alpha-adrenergics (Maladaptive behaviors)
  • SSRIs (anxiety or depression or dysregulated mood)
66
Q

What antipsychotics are most promising for ASD treatment of maladaptive behaviors?

A
  • Risperidone
  • Aripiprazole
67
Q

What factors might suggest a good prognosis for ASD?

A
  • Higher cognitive abilities
  • Less severe symptoms
  • Early identification
  • Functional play skills
68
Q

What factors suggest a poor prognosis for ASD?

A
  • IQ < 70
  • Lack of joint attention by age 4
  • Lack of functional speech by age 5
  • Seizures/comorbid psych disorders
  • Severe symptoms
69
Q

What is Rett Syndrome? Etiology?

A

Neurodevelopmental delay disorder caused by a sporadic mutation in MECP2 gene, resulting in growth deceleration, esp. brain tissue.

70
Q

Who is Rett Syndrome more common in? Average lifespan?

A

Female, almost exclusively.

Average lifespan is 45y.

71
Q

How does a classic case of Rett syndrome present?

A
  • Uneventful pregnancy with normal development up to 6 months.
  • Deceleration of head growth can appear starting at 2 months and by 12-18 months, loss of acquired fine motor, intellectual and communication abilities.
72
Q

How does Rett syndrome present initially?

A
  • Loss of interest in surroundings
  • Little purposeful hand movements
73
Q

How does Rett syndrome present later?

A
  • Some recovery of non-verbal communication with improved eye contact.
  • Followed by slow deterioration of gross motor functioning.
74
Q

What are some general clinical findings for Rett syndrome?

A
  • Loss of expressive language
  • Motor dysfunction (stereotypic hand movements, gait disturbance, bruxism, drooling, rigidity, dystonia)
  • Scoliosis
  • Growth failure
  • Epilepsy
  • Fractures
  • CV abnormalities
  • Weird wakeful breathing patterns
  • Sleep disorders
75
Q

How do we treat Rett syndrome?

A
  • Good nutrition
  • Checking for fractures
  • Antiepileptic drugs
  • QT interval monitoring
  • PT for scoliosis
  • Sleep hygiene
  • PT/OT for motor dysfunction.
76
Q

What are the two types of Rett syndrome?

A

Typical and atypical.
Typical: Motor dysfunction and standard symptoms.
Atypical: All the additional clinical findings.

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