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1

role of psyD in treating individuals with intellectual disabilities

1. complete eval (karyotype)
2. make sure appropriate interventions occur
3. ensure other dx are found as 35-40% have another psych disorder
4. provide adequate tx
5. coordinate care

2

psychological assessments for intellectual capacities

Wechsler scales (the Wechsler Preschool and Primary Scale of Intelligence, the Wechsler Intelligence Scale for Children, and the Wechsler Adult Intelligence Scale) and the Stanford-Binet Scale

3

prevalence of intellectual disability is approximately ? of the population

1%
males being more affected than females

4

Two pieces of information are needed to make a diagnosis of intellectual disability:

Evidence of deficits in intellectual functioning both clinically and via standardized testing AND evidence of deficits in adaptive functioning

5

typical symptoms of ASD

difficulty with social reciprocity, poor peer interaction, poor language development, and repetitive and odd play

6

Asperger's disorder

old terminology for a type of ASD that describes individuals who display social impairment and restricted interests and behavior (stereotyped behavior) but have normal language and cognitive skills.

7

Rett disorder

old term for a type of ASD that describes individuals who show a type of childhood developmental disorder of unknown etiology in which the patient develops progressive encephalopathy, loss of speech capacity, gait problems, stereotyped movements, microcephaly, and poor social interaction skills. The child must have shown normal development in early infancy, and only females are affected.

8

ASD findings:
MRI
fMRI
others

increased cortical thickness that may relate to abnormalities in cortical connectivity

less activation of the prefrontal regions indicating a dysfunction of the frontostriatal networks

abnormalities in glutamate/glutamine physiology, particularly in the limbic areas

9

ASD characteristics

failure to develop relationships
lack of social reciprocity
impairment in nonverbal behaviors
impairments in communication: delay/failure in learning spoken language
exhibit repetitive behaviors and strict adherence to mannerisms
preoccupation with specific objects

10

what previous diagnoses have been consolidated into the term autistic spectrum disorder (ASD)?

autistic disorder
Rett disorder
childhood disintegrative disorder
Asperger disorder
pervasive developmental disorder NOS

11

ASD vs schizophrenia

the onset of childhood schizophrenia usually occurs later, there is a family history of schizophrenia, and the child is less impaired in the area of intellectual functioning

12

approach to managing ASD

family education, behavior shaping, speech therapy, occupational therapy, and educational planning

13

recent studies indicate a role for ? in the etiology and treatment of ASD

oxytocin (the neuropeptide)
shown a likely benefit in improving nonverbal communication behaviors

14

other medications used in ASD

low-dose Risperdal (risperidone)
aripiprazole may also be of benefit with the irritability symptoms of ASD

15

look for these comorbid disorders in ASD

ADHD), OCD, behavior disorders, and psychotic disorders

16

the best predictor of future outcome in autistic disorder

Language development

17

symptoms seen in ADHD inattentive type

Making careless mistakes
Having difficulty focusing one's attention
Often seeming not to listen
Often failing to follow directions
Having difficulty in organizing tasks
Avoiding tasks requiring sustained mental effort
Often losing things
Often becoming distracted by other stimuli
Being forgetful
girls > boys

18

first line treatment of ADHD inattentive

stimulants: Adderall (dextroamphetamine and amphetamine), Ritalin (methylphenidate) (Concerta is XR), Focalin (dexmethylphenidate)

or Strattera (Atomoxetine) (NE reuptake inhibitor-NRI)

19

what ADHD patients should use Strattera over stimulants?

individuals/families with substance abuse problems, individuals with tics (does not cause or worsen tics as stimulants do), or patients with comorbid anxiety disorders

20

second-line choices for ADHD

clonidine (Kapvay) 0.1 mg at bedtime max 0.4
and guanfacine (Intuniv) 1 mg per day max 4
a2 antagonists
(low-dose often used to help with sleep disturbances/agitated behavior after on a stable dose of stimulant)

21

diagnostic criteria of ADHD

6+ symptoms of inattention or hyperactivity/impulsivity before 12 in more than one setting and there is clinically significant impairment

22

ADHD hyperactive symptoms

Fidgeting or squirming
Often leaving one's seat
Running or climbing excessively and inappropriately
Difficulty playing quietly
Often being "on the go"
Talking excessively

23

ADHD impulsive symptoms

Often blurting out on answer before a question is completed
Difficulty waiting for one's turn
Often interrupting others

24

third-line choices for ADHD

Bupropion (Wellbutrin)
-may worsen tics (Dopamine)
Imipramine (Tofranil)
-blood levels and EKG should be followed because of QT prolongation

25

ADHD etiology may involve

decreased DA and NE tracts in several areas of the prefrontal cortex
-dorsal anterior cingulate gyrus is involved in selecting what an individual focuses
-dorsolateral prefrontal cortex is involved with sustaining attention and various executive functions

26

Impairment in the ? appears to account for the hyperactivity
Decreased activity in the ? is involved with impulsive actions

prefrontal motor cortex
orbitofrontal cortex

27

common comorbid disorders with ADHD

oppositional defiant disorder (ODD) or conduct disorder
failing to recognize leads some physicians to attempt to medicate away purposeful disruptive behavior

28

medications for ADHD can only

(1) help the child sit still-if the child wants to sit still
(2) help the child to focus his or her attention-if the child wants to pay attention
(3) help the child to think before he or she acts-but will not affect whether the child makes a good decision or not

29

ddx ADHD

ODD/conduct: but intentional
learning disabilities
bipolar: may be restless/distractible but +affective
Lead intoxication can lead to hyperactivity
petit mal seizures (Absence)

30

How many kids with ADHD will respond to stimulant medications?
adverse effects

70% to 80%, rapid, wear off by end of day
decreased appetite (sometimes with subsequent slowed growth rate), initial insomnia, irritability, dysphoria, and headache, development or worsening of tics

31

Strattera (Atomoxetine)

potent selective inhibitor of the presynaptic norepinephrine transporter
not a stimulant or a controlled substance
gradual onset of action: 2-3 weeks with 24-hour length of action
may cause decreased appetite, sedation, does not worsen tics

32

the only medications with FDA approval to treat Tourette's
but why not utilized?

haloperidol (EPS) and pimozide (prolonged QT)
instead a2 antagonists and atypical antipsychotics are used

33

symptoms consistent with Tourette disorder

combination of multiple motor and vocal tics occurring for at least 1 year

34

strong relationship between Tourette disorder and ?

OCD and ADHD, and these disorders run in families

35

imbalances in Tourettes

decreased GABA and increased dopamine in the caudate nucleus

36

tic disorder ddx

Huntington chorea, Wilson disease, and stroke, tardive dyskinesia, stimulant use, PANDAS (strep, worse in winter/spring), OCD compulsions, schizophrenia

37

Transient tic disorders timeframe
Patients with a chronic motor or vocal tic disorder can have it for more than ? but there is an absence of ?

4 weeks but for no longer than 1 year

1 year
multiple motor tics and/or motor and vocal tics occurring simultaneously (as the combo would be Tourette's)

38

first line pharmacotherapy for Tourettes

a2 agonists: Clonidine, Guanfacine
also good for ADHD symptoms in kids who have tics

39

MOA for Clonidine in Tourettes

Clonidine: alpha-adrenergic agonist that is believed to activate presynaptic autoreceptors in the locus ceruleus to reduce norepinephrine release that may reduce tics

40

MOA for Guanfacine in Tourettes

Guanfacine binds to postsynaptic prefrontal alpha-adrenergic cortical receptors to enhance functioning in the prefrontal cortex

41

In practice most clinicians utilize ? for Tourettes/tics
MOA?
most common one used?

atypical antipsychotics
block dopamine and serotonin receptors, decreasing input from the substantia nigra and ventral tegmentum to the basal ganglia
Risperdal: 1 to 3.5 mg/d with weight gain, lipid abnormalities, and sedation as the most common side effects
(next: haloperidol or pimozide)

42

psychotherapy with the strongest empirical evidence for effectiveness in Tourettes/tic

Habit reversal training:
teaching awareness of the aversive sensation or buildup of tension called a premonitory urge that is relieved by the tics, then helped build a competing response to that urge without engaging in tic behavior (+social support)

43

depression that responds to antidepressant but evidence of paranoia after mood symptoms resolved think?

schizoaffective disorder

44

treatment for schizoaffective

atypical antipsychotic: risperidone first,
if bipolar type, treat with mood stabilizer i.e. lithium, carbamazepine, and valproic acid
if depressive type, add antidepressant (SSRI) ONLY if antipsychotic alone not affective

45

Schizoaffective d/o

> 2 weeks of hallucinations or delusions without major mood episode (major depression or mania), plus periods of concurrent major mood episode with schizophrenic symptoms
**psychotic episodes occur during the mood episodes, but the mood symptoms do not always occur during the psychotic episodes

46

always ask about ? if considering schizoaffective

manic symptoms, as schizoaffective may be depressive type or bipolar type

47

brain matter abnormalities in schizophrenia/schizoaffective d/o

white matter pathology hypotheses of frontotemporal dysfunction and abnormalities in left-hemisphere lateralization in the pathophysiology of these illnesses

48

schizoaffective ddx

substance-induced mood disorder: cocaine or amphetamine intoxication (manic symptoms), cocaine withdrawal (depressive symptoms), and prescribed meds including steroids and antiparkinsonian medications

49

schizoaffective vs schizophrenia

symptoms can appear similar, but the mood symptoms in schizophrenia if present are generally brief in relation to the total length of the illness while in schizoaffective mood symptoms occur during significant portions of their illness

50

schizoaffective vs mood disorders

(*mood first then +/- psychosis)
bipolar disorder, mania, generally have had mood symptoms (euphoria, irritability) before development of the psychoses, as have patients with major depression with psychotic features (a depressed mood predating the onset of psychosis)

51

other treatment for schizoaffective (correlates with schizophrenia as well)

hospitalization (if suicidal or unable to care for self/psychotic)
social support
TMS: transcranial magnetic stimulation

52

What age group with schizoaffective disorder may exhibit more severe symptomatology

Younger patients

53

DSM V for schizoaffective

Patients must exhibit psychotic symptoms consistent with the acute phase of schizophrenia.
Psychotic symptoms are accompanied by prominent mood symptoms (mania or depression) during part of the illness.
At other points in the illness, the psychotic symptoms are unopposed; that is, no mood symptoms are present. Periods of illness in which there are only psychotic symptoms, and no mood symptoms, must last for at least 2 wk.
The disorder cannot be caused by a substance or by another medical condition.