Troubles neurodéveloppementaux Flashcards
what is “global developmental delay”
a diagnosis for individuals UNDER AGE OF 5
used when clinical severity level cannot be reliably assessed during early childhood
given when child fails to meet expected developmental milestones in SEVERAL areas of intellectual functioning
applies to individuals who are unale to undergo systematic assessments of intellectual functioning (including children who are too young to participate in standardized testing)
requires reassessment after a period of time
what is the prevalence of ADHD in kids and teens
5-9%
list 3 neuropsychological/psychoeducational evaluation tools that may be helpful in assessing ADHD
Wide Range Assessment of Learning and Memory
California Verbal Learning Test
Wisconsin Card Sort Test
list 3 computerized cognitive assessments that were specifically designed to assess attention and response inhibition, and can be useful in assessing ADHD
Conners Continuous Performance Test
Test of Variables of Attention
Gordon Diagnostic System
what differences might be seen on EEG in kids with ADHD vs teens/adults
increased theta waves
decreased alpha/beta waves
what questionnaire should be given to parents/teachers for ADHD assessment of a child
SNAP-IV
what is a tool to assess functional impact of a mentalhealth concern
Weiss Functional Impairment Rating Scale
What are the 3 most common comorbidities with ADHD in CHILDHOOD
ODD, learning disabilties (often language), anxiety–> early childhood
anxiety and tic disorders more prominent in middle childhood
What are the 3 most common comorbidities with ADHD in TEENS
learning disabilities
mood disorders
SUDs
What are the most common comorbidities with ADHD in ADULTHOOD
anxiety, depression, SUD, borderline PD
(+ learning disability still)
list common medical conditions wiht overlap with ADHD
hearing/vision impairment
thyroid function
hypoglycemia
severe anemia
lead poisoning
sleep disorders
FASD
neurofibromatosis
list 2 medications with psychomotor side effects that may resemble or worsen ADHD
mood stabilizers (cognitive dulling)
decongestants, beta agonists (psychomotor agitation)
what factor confers worse prognosis for comorbid CD and ADHD
if onset of CD is before age 10
CD + ADHD has poorer outcome than ADHD or CD alone
what is a treatable risk factor for ASPD
ADHD
what are the main goals of treatment in comorbid ADHD and borderline PD
stabilizing impulsive behaviours
optimizing emotional regulation
what are the principles of management of ADHD + addictions
specific intervention for addictive behaviour + specific intervention for ADHD
ideally CONCURRENTLY
what are the principles of management of ADHD + addictions
specific intervention for addictive behaviour + specific intervention for ADHD
ideally CONCURRENTLY
do people with ADHD have higher risk for substance abuse/misuse
yes–> about 2x risk
?underlying poor self esteem + impulsivity
what % of teens with SUD have ADHD
50%
what % of adults with SUD have ADHD
about 25%
what is the most commonly abused agent in ADHD
cannabis
why do we care about substance use problems in ADHD
can increase severity of ADHD sx
can also mimic ADHD
why might early stimulant treatment for ADHD be important
reduces or delays SUD–> protective effect may be lost in adulthood
which class of stimulant has lower abuse potential
methylphenidate
–> slower dissociation from site of action
–> slower uptake into the striatum
–> slower binding/dissociation with DAT (vs cocaine)
–> oral admin, decreases likability of a substance
–> not associated with euphoria if used parenterally
*also long acting meds have less abuse liability
what % if kids have ADHD + anxiety? adults?
children–> 33%
adults–> 50%
what ADHD stimulants can be used in the case of comorbid anxiety
any of them
atomoxetine is also beneficial and guanfacine is well tolerate
what antidepressants may be preferentially considered if treating comorbid depression and ADHD
those with catecholamine activity–> i.e BUPROPRION
what ADHD meds have most risk of drug interactions with which SSRIs
atomoxetine + amphetamines
interact with
fluoxetine, paroxetine
due to 2D6
how should you approach treatment of comorbid ADHD + bipolar disorder
treat BIPOLAR FIRST
–reduce or stop stimulants in order to most effectively treat bipolar
then once mood stabilized, can cautiously restart stimulants
small risk of switch with psychostimulants
are stimulants safe in bipolar + ADHD
yes, once bipolar stabilized
safe + effective
what treatment “shows promise” in treating comorbid tics + ADHD
alpha 2 adrenergic agonists (clonidine, guanfacine)
what medication to use if stimulants exacerbate tics
atomoxetine
name 2 non pharmacological treatments for tics
habit reversal therapy
CBIT (comprehension behavioural intervention for tics)
*considered first line when available
ADHD increases the risk of what eating disorder
bulimia nervosa–> especially in girls
what % of kids with autism are suggested to have ADHD
about 30-70% are suggested to meet ADHD criteria
what are some medication considerations in treating ADHD in those with ASD
- may be MORE sensitive to side effects
–irritability, hyper focus, stereotypies - lower response rate to methylphenidate if have ASD (50% vs 70-80%)
however–> treating ADHD in ASD is very effective and helps functioning but may have lower effect sizes
is there evidence that psychostimulants worsen seizures if stable
no
what differences in sleep are seen in those with ADHD
more restless sleep than peers
may be differences in circadian rhythms
NO consistent differences in sleep variables like duration or architecture
stimulants can give shorter nights sleep
how do you treat sleep problems in ADHD
behavioural sleep interventions = first line
little evidence for pharma tx of sleep problems in ADHD–> maybe melatonin
is enuresis more common in kids with ADHD
yes–> 2-3x more likely to have eneuresis
kids with nocturnal eneuresis more likely to have ADHD
what is the first line treatment for PRESCHOOL ADHD (age 3-5)
NON pharmacological treatment
what psychosocial treatments are available for ADHD
CBT for ADHD
behavioural interventions
parent training
cognitive training
social skills training
what is the overall goal of psychosocial treatments for ADHD
educate and empower patients
per cochrane review, were there significant tx effects of social skills training on behaviour or symptoms of ADHD
no
what are the two focuses of CBT for ADHD
time management
organizational skills
who is CBT for ADHD effective for
effective for adults with ADHD–> functional effect on brain similar to stimulant meds
mixed results in kids and teens –> works better in those with ADHD + anx/dep vs those with ADHD + ODD
which areas of the brain show functional improvements after CBT for ADHD in adults
fronto-parietal network
cerebellum
what changes are seen in the brain of adults with ADHD after undergoing cognitive based therapy that includes mindful meditation
structural changes in amygdala
increased grey matter volume in hippocampus
what are the impacts of cognitive based therapy with mindfulness meditation in those with ADHD
reduces hyperactivity, impulsivity, inattention
increases self regulation and self directedness
** improvements are maintained over time
when should you consider trialling a second line med in ADHD
recommend trying long acting methylphenidate AND amphetamine formulations before moving to a second line agent
move to second line if suboptimal response, side effects or no access to first line
list the second line med agents for ADHD
- atomoxetine
- guanfacine XR
- shorter acting psychostimulants
what is one option for treatment if there is suboptimal response to first line long acting stimulants
can augment with non-stimulant second line meds
list the third line medication treatments for ADHD
buproprion
clonidine
imipramine
modafinil
AAPs
–> can also consider exceeding recommended maximum doses for other meds
when might you use a third line med for ADHD
treatment resistant cases
they are all off label use–> may have higher risk, more SEs, lower efficacy
list the specific medications (not just class) that are first line for ADHD
vyvanse/lisdexamfetamine (amphetamine)
adderall XR/mixed amphetamine
biphentin/multilayer methylphenidate beads
concerta/methylphenidate OROS
foquest/methylphenidate
list the specific second line meds (not just class) for ADHD
atomoxetine –NRI
guanfacine –alpha 2 agonist (selective)
dexedrine (dextroamphetamine) –short acting
ritalin (methylphenidate) –short acting
what ADHD meds cannot be stopped suddenly
the alpha 2 agonists due to risks of rebound HTN–> i.e clonidine, guanfacine
when should you do a cardia workup before initiating ADHD pharmacological therapy
history of suspected sudden cardiac death in family
if patient has hx of unexplained lightheadedness, SOB, cardiac sx
should NOT be used if there are structural cardiac abnormalities (i.e LV dysfunction, scarring, hypertrophy, valvular disease)
can you use psychostimulants if patients has long QT syndrome
one study showed no adverse outcomes with stimulants or beta blockers
suggest cardiology constult
what should you monitor for when prescribing psychostimulants
BP
HR
priapism
growth retardation
peripheral vasculopathy
what are CONTRAindications to using stimulant medications
- treatment with MAOI and up to 14 days after d/c
- hx mania/psychosis
- mod-severe HTN
- symptomatic CVD
- pheochromocytoma
- untreated hyperthyroidism
- narrow angle glaucoma
in which patients should you be cautious and take precautions when prescribing psychostimulants
anxiety
hx substance abuse
tic disorders
epilepsy
renal impairment
peripheral vasculopathy including raynauds
what are contraindications for atomoxetine
- treatment with MAOI and up to 14 days after d/c
- hx mania/psychosis
- mod-severe HTN
- symptomatic CVD, severe CVD
- pheochromocytoma
- untreated hyperthyroidism
- narrow angle glaucoma
- advanced arteriosclerosis
in which patients should you take precautions when prescribing atomoxetine
poor CYP2D6 metabolizers
asthma
peripheral vasculopathy
what should you monitor when prescribing atomoxetine
liver injury symptoms
urinary retention
growth retardation
peripheral vasculopathy
priapism
what is a contraindication to using alpha 2 agonists
inability to ensure regular daily dosing
in which patients should you use precaution when prescribing alpha 2 agonists
hepatic impairment
renal impairment
what should you monitor when prescribing alpha 2 agonists
sedation, somnolence
BP (risk of hypotension)
bradycardia
syncope
rebound increased BP/HR
Qtc interval if other contributing risks
what antibiotic should be avoided when prescribing amphetamines and methylphenidate
linezolid
*may increase HTN
how might amphetamines/methylphenidate interact with SSRIs, SNRIs
may increase risk of SEs of SSRI
increased risk of serotonin syndrome
how does methylphenidate affect warfarin
may increase warfarin levels–> monitor INR
how does methyphenidate interact with clonidine
may increase SEs of clonidine