Rogers- ADHD Flashcards
ADHD is characterized by developmentally inappropriate levels of the core symptoms of ,
, impulsivity, and inattention that adversely affect behavioral, emotional, cognitive, academic, occupational, and social functions
hyperactivity
What are some coexistent issues with ADHD?
sleep disorders,
anxiety,
conduct disorders
What are some concurrent childhood onset neurodevelopment disorders associated with ADHD?
language disability,
learning disability,
autism spectrum disorder,
tic disorders
What are some psychiatric comorbities associated with ADHD?
mood disorders,
depressive disorders,
anxiety disorders
Affects 5% to % of school-aged children, more commonly in males/females
9
males
As concerning a diagnosis of ADHD
At least several inattentive or hyperactive-impulsive symptoms occur before age years
12
Prevalence of disease is up to 5% to 9% of children, 2% to 6% of , and 2% of
school-aged
adolescents
adults
What is the ratio male to female for ADHD?
3:1 to 4:1
At what age should a parent see symptoms of ADHD?
see symptoms by age 4
to fold higher in children of parents with attention-deficit/hyperactivity disorder and/or siblings with attention-deficit/hyperactivity disorder
2 to 8
Up to % of first-degree relatives of children with attention-deficit/hyperactivity disorder are affected
33
What is the definitive genetic inheritance of ADHD?
non-Mendelian multifactorial
Though non-Mendelian multifactorial is the definitive inheritance of ADHD, some may have what other kind of genetic inheritance?
autosomal dominant for some
Some/Multiple genes contribute to the attentiondeficit/hyperactivity disorder phenotype
multiple
What are 2 canditate genes associated in the development of ADHD?
dopamine transporter gene (DAT1)
dopamine 4 receptor gene (DRD4)
Psychosocial family stressors can also contribute to or exacerbate the symptoms of ADHD
• These include poverty, exposure to violence, and undernutrition or malnutrition
injury also increases the risk of ADHD
Brain
Describe the abnormal levels of neurotransmitters in those with ADHD?
abnormal catecholamine metabolism, particularly dysregulation of dopamine and norepinephrine
- Reduced dopamine activity in the prefrontal-striatalthalamocortical and cerebellar circuits
- Abnormally low serotonin activity; serotonin is a modulator for dopamine
There is reduced activity in the prefrontal-striatalthalamocortical and cerebellar circuits
dopamine
Abnormally low serotonin activity; serotonin is a for dopamine
modulator
Howmany of the DSM-5 ADHD criteria must be met for diagnosis of ADHD?
What is the pervasivness criteria that must be met for ADHD diagnosis?
example:
at home and at school
Symptoms must persist for at least months in 2 or more settings and must be present before age 12 years
6
What are some diagnostic screeners for ADHD? And what kind of evidence is documented?
Rating scales
Connor’s Rating Scale, Vanderbilt ADHD Diagnostic Rating Scale, ADHD Rating Scale 5, Swanson, Nolan, and Pelham Checklist (SNAP), and the ADD-H: Comprehensive Teacher Rating Scale (ACTeRS)
subjective evidence
Teachers, caregivers, and observers who provide supportive information to complete standardized behavior rating scales should have regular contact with individual for a minimum of months
4
How to distinguish ADHD from central nervous system disease?
Central nervous system disease in patients whose clinical presentation includes more than subtle neurologic soft signs (eg, hypertension, papilledema, ataxia, neurologic deficits)
How to distinguish hyperthyroidism from ADHD?
Hyperthyroidism in patients with clinical signs concerning for elevated thyroid hormone levels (eg, weight loss, hypertension, resting tachycardia, goiter, exophthalmos, weakness, diaphoresis); exclude diagnosis with T₄ and TSH assay
High levels in patients with risk factors for lead toxicity (eg, inhabitant of substandard housing, exposure to old paint, housing in close proximity to a highway) can also lead to can lead to symptoms similar to ADHD
lead
ADHD is a diagnosis of inclusion/exclusion
exclusion
People with genetic syndromes (Down’s) can also have signs and symptoms similar to ADHD
congenital
Sudden/gradual manifestation development without previous history should prompt serious consideration for other conditions
sudden
For example: head trauma, physical or sexual abuse, neurodegenerative disorder, central nervous system tumor, substance use, mood or anxiety disorders, depression, major psychological stress in family or school
sleep disorders in patients with ADHD like symptoms (eg, snoring, pauses in breathing while asleep, daytime sleepiness) and risk factors (eg, obesity, adenotonsillar hypertrophy) for primary sleep disorders
Primary
children who don’t sleep well can appear to be hyperactive and lose concentration
untreated use disorder needs to be addressed before to fully addressing manifestations that may be related to attention-deficit/hyperactivity disorder
substance
(especially in adolescents)
List of psychosocial factors on differential diagnosis of ADHD
List if Diagnoses associated with ADHD behaviors
List of medical and neurologic condtions on differential diagnoses of ADHD
Review the chart of age-specific issues that could affect those with ADHD
Review the chart of ADHD associated behaviors
Predominantly inattentive type
- Only criteria for are present
- More common in
- Often includes impairment
inattention
females
cognitive
Predominantly hyperactive/impulsive type
- Only criteria for are present
- More common in
hyperactivity/impulsivity
males
Combined type
- Criteria for both and hyperactivity/impulsivity
- More common in
inattention
males
Symptoms interfere with life should include quality of social, academic, or occupational functioning
reduced
Broad clinical exists, rendering variable clinical presentations of disease
heterogeneity
Hyperactivity/impulsivity symptoms usually appear by age years and peak by age years
4
7 or 8
Prominent symptoms are motor and disruptive
restlessness
behavior
Inattention symptoms usually appear by age years
8 or 9
Adolescents and adults
•Typically exhibit; hyperactivity is less pronounced
inattention
older adolescents and adults
•Older patients report more restlessness or inability to settle down rather than motor hyperactivity
inner
•Disorder continues into adulthood in up to % of affected children
40
Symptom manifestations can be gender dependent/independent
dependent
Girls are more likely to have more issues with and they experience fewer issues with hyperactivity and behavioral disturbances
attention
High prevalence of comorbid psychiatric disorders contribute to clinical of presentation
heterogeneity
Presents with and inability to maintain attention during mundane and repetitive tasks, however, can hyperfocus on things they love
distraction
Review the DSM-5 criteria for inattention
must have 6 and 9
- Lack of attention to detail
- Difficulty sustaining attention
- Difficulty with listening skills
- Difficulty with task completion
- Difficulty with organizational skills
- Difficulty with tasks requiring sustained attention
- Frequently loses belongings
- Easily distracted
- Forgetful
What is expressed as restlessness, excess motor activity, fidgeting with hands and feet, or excessive talking?
hyperactivity
What is expressed as tendency to act without thinking about consequences and social interference (eg, interrupting conversation or games during play)
impulsivity
Review DSM-5 criteria for Hyperactivity and Impulsivity
must have 6 out of 9
- Fidgeting and squirming
- Stands when sitting is expected
- Runs around inappropriately
- Difficulty with quiet play
- Inability to relax and remain still
- Excessive talking
- Blurts out answers
- Difficulty waiting for turn
- Interrupts
Review comorbid neuropsychiatric Disorders with ADHD
Oppositional defiant disorder (up to 60% of patients)
Mood disorder (up to 50% of patients)
Anxiety disorder (eg, generalized anxiety disorder, separation anxiety, panic disorder; up to 33% of patients
Developmental language or learning disability (eg, dyslexia or dyspraxia; up to 30% of patients)
Conduct disorder (up to 26% of patients)
Autism spectrum disorder (up to 20% of patients)
Depressive disorders (up to 18% of patients)
Tics or tic disorders (eg, Tourette syndrome; up to 7% of patients
What are the top 3 comorbid neuropsychiatric disorders and at what % do they show up in those diagnosed with ADHD?
Oppositional defiant disorder (up to 60% of patients)
Mood disorder (up to 50% of patients)
Anxiety disorder (eg, generalized anxiety disorder, separation anxiety, panic disorder; up to 33% of patients
More common features of ADHD other than criteria
Emotional lability (38% to 75% of children)
- Clumsiness is very common
- Sleep disorders or sleep problems
- Frequent accidental injuries
• Chronic academic and/or social failure can lead to loss of motivation and learned
helplessness
Increased likelihood to be a of child abuse
victim
What are the 2 subtle neurocognitive deficits?
- Memory impairment
- Calculation impairment
What are the 3 subtle neurologic soft motor findings?
- Mild dysdiadochokinesia (eg, difficulty with finger to nose or rapid alternating movements)
- Difficulty with certain tasks such as finger tapping, skipping, tracing a maze, or cutting paper
- Mixed laterality (i.e. ambidexterity)
Variable/similar structural and functional brain abnormalities are noted in children with attention-deficit/hyperactivity disorder
variable
•Evidence of delayed cortical and of the frontal subcortical circuits exists
maturation
dysregulation
What are the 5 Specific areas of the brain affected by deficits?
frontal lobes,
inferior parietal cortex,
basal ganglia,
corpus callosum, and
cerebellar vermis
Which areas have widespread small-volume reduction in the brain?
prefrontal cortex,
caudate,
and cerebellum
Children with ADHD have variable deficits in cognitive processing, attention, planning, and of processing responses
motor
speed
What are the 4 treatment goals for those with ADHD?
- Improve core symptoms of inattention and hyperactivity/impulsivity
- Improve school performance and optimize functional performance
- Remove behavioral obstacles
- Monitor disorder and adjust treatment over time based on treatment goals
What is the treatment of choice for most patients is?
pharmacotherapy
Other than improving long-term outcomes, what 3 major short-term outcomes occur with treatment with medications?
short-term enhancement of
academic, social, and behavioral functioning
Treatment with medications decreases the likelihood of emergence of depression, oppositional defiant disorder, anxiety disorders, and substance use disorders;
treatment reduces aggression and antisocial behavior
stimulant
What is the first line treatment for preschool aged children (4-5ys old)
behavioral therapy
What is second line treatment for preschool (4-5) aged children if behavior interventions do not provide significant improvement and there is moderate to severe continuing disturbance in the child’s function?
methylphenidate
What is the first line treatment for elementary school-aged children (6-11 yrs old)?
Medications are first line
Stimulants are preferred - ritalin, methphenedate, dexamphetamine
What are the second line medications for Elementary school–aged children (aged 6-11 years)?
Atomoxetine, guanfacine, and clonidine are second line
Bipolar adults can have ADHD symptoms when younger and medications will not work
stimulant
Which medicine is an adjunct for an agry ADHD kid that will help with the anger symptoms?
guanfacine (BP medication)
What is the first line treatment for adolescents (12-18 yrs old)?
Medications are first line and consider behavior therapy; preferably both
What are the baseline measurements that should be taken and why?
Height, weight, blood pressure, and resting pulse rate
sleep patterns, appetite
Used to monitor effect and effectiveness of medications
What circumstance would indicate referral to a specialist before beginning stimulatnt medication?
Patient history, family history, or physical history exam suggestive of cardiac disease
When is taking a baseline ECG indicated?
abnormal personal history concerning for cardiac disease,
family history of cardiac disease, and
abnormal physical examination findings
No evidence exists that pharmacologic treatment in children or adolescents causes abnormal changes in , sudden cardiac death, acute myocardial infarction, or stroke
QT-interval
Stimulant medications are presynaptic agonists
dopamine
What are the 3 main groups of stimulants for treating ADHD?
methylphenidates
amphetamine salts
mixed preparation
What are the 2 types of methylphenidates?
Methylphenidate (eg, Ritalin, Concerta, Metadate, Methylin, Daytrana)
Dexmethylphenidate (eg, Focalin)
What are the 2 types of amphetamine salts?
Dextroamphetamine (eg, Dexedrine)
Dextroamphetamine prodrug lisdexamfetamine (eg, Vyvanse)
What is in the mixed stimulant preparation for treatement of ADHD?
Amphetamine and dextroamphetamine (eg, Adderall)
Short-acting methylphenidate preparation duration is up to hours
5
-acting methylphenidate (eg, Ritalin SR, Metadate ER, Methylin ER in the form of SR tablets) duration of action is 6 to 8 hours
Intermediate
-acting preparations (eg, Concerta osmotic release tablets, Ritalin LA beadfilled capsules, Metadate CD bead-filled capsules, Biphentin bead-filled capsules, Quillivant XR liquid, Daytrana transdermal patch) duration of action is up to 12 hours
Long
Long-acting preparations include dextroamphetamine SR (ie, Dexedrine Spansule) and lisdexamphetimine (ie, Vyvanse); lisdexamphetimine duration of action is over 10 hours
amphetamine
• Doses of stimulants are/are not weight-dependent; lower doses of stimulants may produce suboptimal effects when dosed and titrated on a mg/kg basis
are not
Start dose at low/high end of dosing range; titrate dose up every days until effective dose is achieved with minimal or no adverse effects
low
Most adverse effects are dose and diminish with a decrease in dose or wane with time
dependent
What % of patients will have an optimal response on low dose, medium dose, high dose, and will be unresponsive/unpalatable side effects?
25%
What is the biggest side effect for ADHD medications?
loss of appetite
By about how much will someone’s BP and HR increase on ADHD medication?
Small increase of 5mm/hg of BP
Small increase of heart rate 10 bpm
Review the most common adverse side effects?
Review the less common adverse side effects:
What are the 6 rare side effects of ADHD medications?
Rare:
priapism,
peripheral vasculopathy,
depression,
suicidal ideation, and
sudden unexpected death
What are the 2 Adverse effects at high doses:
headache and abdominal pain
Treatment of children with stimulant medications does/does not increase risk and may decrease the risk of developing a substance use disorder later in life
does not
