Neurodevelopmental/ADHD 1 Flashcards
1
Q
ASD Symptoms and Signs: Social reciprocity (7)
A
- Give and take of social interaction—must recognize another person’s perspective
- Trouble establishing relationship with peers
- May not empathize well
- Joint attention or ability to attend to an activity with another person is lacking
- Can’t point to an object (protoimperative pointing)
- Pointing to draw something to the attention of another (Protodeclarative point) more important
- Looks at mouth, not eyes; Lack of good eye contact
2
Q
ASD DSM V Criteria
A
- Restricted, repetitive pattern of behavior, interest, or activities as manifested by:
A. Stereotyped or repetitive motor movements, echolalia, idiosyncratic phrases
B. Insistence or sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behavior
C. Highly restricted, fixed interests that are abnormal intensity or focus
D. Hypo or hyper reactivity to sensory input
3
Q
ASD DSM V Criteria Severity
A
Severity is based on the degree of social communication impairment (A) and restricted, repetitive patterns of behavior (B)
c) Symptoms must be present in early development (may become more manifest as social demands exceed capacity)
d) Symptom cause significantly different impairment in social, occupational or other important areas of current functioning
e) These disturbances are not better explained by intellectual developmental disability
4
Q
Assessing development (6)
A
- Make sure there is a clear way of triaging children in primary care that belong in the ED
- Assess severity of all symptoms—functional impairment is key
- Emphasize the child’s functioning –if severe belongs with a mental health professional
- Assess sleeping pattern
- Identify what are the environmental factors that may have precipitated any change
- The Safe Environment for Every Kid (SEEK questionnaire)
5
Q
Inattention/Impulsivity (3)
A
- Symptoms that do not rise to a level of disorder
- Occur commonly in children
- Child’s teacher may observe symptoms of:
a. Excitability, impatience, angry outburst (more than seen in peers)
b. Wandering attention (Greater than is seen in peers)
c. Difficulty with behaviors at home or in classroom
d. Academic difficulties
e. Parent and teacher assume this is ADHD
6
Q
Inattention/Impulsivity vs ADHD
A
For some children, impulsivity and inattention limit adaptability to normal peer and family situations but extremes of these behaviors warrant attention for ADHD disorder
7
Q
Treatment of Mild Inattention and Impulsivity (5)
A
- Reinforcement of good behavior
- Reinforce the strengths of the child. (Strength based approach)
- Build trust and develop a plan of care using shared decision making
- Reduce stress on the child—consider parental mental health.
- Symptoms of inattention are generally worse under stress
8
Q
Four types of learning disorders
A
- Reading Disorder
- Mathematics disorder
- Disorder of written expression
- Learning disorder not otherwise specified
9
Q
Testing for Learning Disability (5)
A
- Intelligence tests
- Achievement tests
- Full psychoeducation evaluation; done by psychologist or by school psychologist
- School placement and special services
- Individualized educational program is already in place
10
Q
Management of Learning Disability (5)
A
- Engage child and family in care
- Encourage healthy habits—sleep, exercise, and diet
- Reduce stress
a. Is the parent punitive or critical?
i. Encourage them not to compare with siblings or peers
ii. Nurture nonacademic gifts
iii. Provide positive social experiences - Ask about homework battles?
- Are school authorities proceeding with assessments within the child’s rights
a. Individuals with disabilities act
b. Section 504 rehabilitation act
11
Q
Guidelines for PNP to Help Parents with Homework Battles (12)
A
- Establish a regular routine
- Identify another student your child can call to clarify homework assignments
- Limit distractions (TV, phones)
- Assist child in getting started (read directions together, watch child do first item)
- Monitor without taking over
- Do not insist on perfection*; Don’t over pressure the child
- Offer incentives
- Help child study for tests
- Do not force the child to spend extra or excessive time on homework.
- If child tried but wasn’t able to do it give praise to the child and write a note to the teachers
- If child did not turn it in after completing it, develop a plan with the teacher
- Ask for a tutor, if homework time is getting to be a battle.
12
Q
Prevalence and Impact of ADHD (6)
A
- Prevalence rate of 5% of Children and 2% of adults
- More prevalent in males than females
- Male: female ratio is 2:1 in epidemiological samples
- Ranges from 3:1 - 9:1 in clinical samples 50% of children referred to mental health clinics are referred for ADHD-related problems
- Preschoolers tend to have more hyperactivity
- Annual societal cost of illness for ADHD estimated to be between $36 - 52 billion $12,005 – $17,458 annually per individual
13
Q
Comorbidities Associated with ADHD (6)
A
- ODD (50-60%) – primary or secondary
* Opposition defiant disorder - Mood and anxiety disorders (20-40%) – chicken and egg; if having problems at school, may become anxious
- Learning disorders / language disorder (25-35%) – if having developmental disorders, often travel together
- Substance abuse disorders (15%)
- If you have ADHD, 15% chance you also have substance abuse disorder
- Untreated ADHD increases risk of substance abuse
14
Q
Criteria A1: Inattentive Symptoms of ADHD (9)
A
- Often fails to give attention to details or makes careless mistakes in schoolwork, at home, at work or in other activities
- Often has difficulty sustaining attention in tasks or play activities (difficulty staying with reading, listening during lectures)
- Often does not seem listen when spoken to directly in the absence of obvious distractions
- Often does not follow through on instructions and fails to finish schoolwork, shoes or duties in the workplace
- Often has difficulty organizing tasks and activities
- Often avoid, dislikes or is reluctant to engage in tasks that require sustained mental effort
- Often loses things necessary for tasks or activities
- Is often distracted by extraneous stimulus (may include unrelated thoughts for adolescent or adult)
- Is forgetful in daily activities
15
Q
Criteria 2a: Hyperactive Symptoms of ADHD (9)
A
- Hyperactivity
- Squirms and fidgets with hands or feet
- Leaves seat in situations when remaining seated is important
- Often unable to play or engage in leisure activities quietly
- Blurts out an answer before a question has been completed (cannot wait for turn
- Runs and climbs excessively
- Difficulty waiting his turn
- Talks excessively
- On the go/driven by a motor
16
Q
ADHD DSM V: Diagnostic Criteria (6)
A
- 6 or more symptoms of inattention
- 6 or more symptoms of hyperactivity-impulsivity
- Some symptoms present before 12 years of age
- Some impairment present in 2 or more settings (school, home, socially)
- Clinically significant functional impairment
- Symptoms not better accounted for by another dx –PDD, schizophrenia, mo
17
Q
DSM V and ADHD - types of presentation (3)
A
- Combined presentation: Both criteria A 1 (inattention) and A2 (hyperactivity/impulsivity is not met for six months
- Predominantly inattentive presentation: Criteria A1 is met but Criteria A2 is not met for 6 months
- Predominantly hyperactivity/impulsivity presentation: Criteria A2 is met but Criteria A1 is not met
18
Q
Level of Functional Impairment: mild, moderate, severe
A
Mild: Symptoms of functional impairment present as a mild impairment in two or more settings
Moderate: Symptoms of functional impairment present as a moderate and severe impairment in two or more settings
Severe: Many symptoms in excess of those required to make the diagnosis or several symptoms are particularly severe are present and result in marked social impairment
19
Q
Associated Features that Support Diagnosis of ADHD (4)
A
- Mild language, motor or social development problems
- Low frustration tolerance, irritability or labile mood
- Cognitive problems on tests of attention, executive function or memory
- ADHD is associated with suicide risk by adolescence especially when comorbid with mood, conduct or substance use
20
Q
Potential Non-Genetic Causes of ADHD (5)
A
- Perinatal stress
- Low birth weight
- Traumatic brain injury
- Maternal smoking during pregnancy
- Severe early deprivation (extreme)
21
Q
ADHD Etiologic Factors (5)
A
- Average heritability of .80 - .85
a. Environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions - Dysfunction in prefrontal lobes
a. Involved in inhibition, executive functions - Genes involved in dopamine regulation
a. Dopamine transporter (DAT1) gene implicated
b. 7 repeat of dopamine receptor gene (DRD4) implicated
c. Gene x environment interactions - Possible differences in size of brain structures
a. Prefrontal cortex, Corpus callosum, caudate nucleus - Abnormal brain activation during attention & inhibition tasks
22
Q
ADHD Brain Structure and Function (3)
A
- Increased knowledge about the development of the prefrontal cortex (particularly abnormalities in frontostriatial):
a. Prefrontal cortex
b. Basal ganglia
c. Cerebellum - These areas of the brain are associated with executive function abilities
a. Attention, spatial working memory, and short-term memory - Response inhibition and set shifting
23
Q
Neurotransmitters involved in ADHD (4)
A
- Dopamine: Associated with pleasure seeing behaviors
- Norepinephrine: Associated with emotional and behavioral regulation
3 Epinephrine
- Serotonin
24
Q
ADHD Executive Functioning (7)
A
Most children with ADHD have impairments in executive functioning, including:
- Difficulty inhibiting responses
- Poor organizational skills leading to planning difficulties
- Working memory
- Impulsivity
- Verbal fluency
- Emotional differences with low frustration, difficulty with emotional self-regulation
- But not all children with ADHD have problems with executive functioning; executive function problems are also associated with other disorders like Turners syndrome**
25
Conner’s Rating Scale (4)
1. Conners 3rd Edition: Long form for parents, teachers and for self reporting
* Takes approximately 20 minutes
2. Short length forms for parents, teachers and for self reporting: Takes approximately 10 minutes
3. Conners 3 ADHD Index (Conners 3AI™)
a. Used for large scale screening
b. Used to monitor results of therapy
4. Conners 3 Global Index (Conners 3GI™)
a. Fast and effective measure of general psychopathology
b. Monitoring treatment and intervention.
26
Conner's Scale Assesses....(5)
a. Inattention
b. Hyperactivity/impulsivity
c. Learning problems/executive functioning
d. Aggression
e. Peer relations
27
Vanderbilt Scale (4)
1. Vanderbilt Assessment Scales includes ADHD, oppositional defiant disorder, conduct, anxiety, depression/mood disorder, + academic and behavioral impairment
2. Teacher Version
3. Parent Version
4. Time 10 minutes
28
Snap IV-C (5)
1. Freely available on the web (see appendix)
2. Takes 10 minutes to fill out
3. 90 items in English and Chinese
4. SNAP-IV is based on a 0 to 3 rating scale: Not at All = 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3.
5. SNAP-IV includes the 10 items of the Swanson, Kotkin, Agler, Mylnn, and Pelham (SKAMP) Rating Scale.
29
Narrow Band Screening Tools for ADHD (2)
1. ACTeRS: Parent version for 6-14 years old
| 2. School Situations Questionnaire for 6-11 years old
30
ADHD Dx Positive Screen (5)
1. Confirm with discussion and clinical judgment
2. Consider non-specificity of some symptoms
3. Consider alternative psychiatric diagnoses – ask about psychomotor agitation as opposed to fidgeting/impulsiveness that have inherent diagnostic bias (mania, anxiety, OCD, tourette’s)
4. Consider family history (76% heritable)
5. Lab and neurological screening/testing not indicated if history and exam are unremarkable
31
When to consider ADHD and Neuropsychological Testing (3)
1. Academic abilities are poor, even with one-on-one instruction
2. Deficits in expressive and receptive coordination or difficulty grasping fundamental math concepts is observed
3. With ADHD treatment, no improvement in academic performance 1-2 months following improvement of ADHD symptoms (if improved ADHD symptoms but not academics, want to optimize ADHD treatment prior to testing)
32
ADHD Differential Diagnosis: Psychiatric (8)
1. Mood and/or Psychotic Disorder
2. Anxiety Disorder
3. Learning Disorder
4. Mental Retardation/Borderline IQ
5. ODD/Conduct Disorder
6. Pervasive Developmental Disorder
7. Substance Abuse
8. Psychosocial History (e.g., abuse, parenting, etc.)
