ADHD and differential diagnoses

Question 1

internalising presentations

Answer 1

emotional, thinking or somatic difficulties
fearfullness, sadness, withdrawal, abdominal pain, suicidal thought s

Question 2

externalising presentations

Answer 2

behaviour problems
deliquency, disobedience (oppositional defiance), attentional problems, aggression, tantrums

Question 3

most presentations are

Answer 3

mixed

Question 4

ADHD is an

Answer 4

externalising problem

Question 5

names for ADHD

Answer 5

attention deficit hyperactivity disorder - DSM-5, DSM-4
hyper kinetic disorder - ICD10
attention deficit disorder - DSM-3

Question 6

why is hyperkinetic disorder different

Answer 6

requires hyperactivity for diagnosis
ADHD as per the DSM-5 is with or without hyperactivity

Question 7

ADHD phenotype

Answer 7

DSM-5 contains 18 items (core phenotype)
- 9 for inattention and 9 for hyperactivity/impulsivity
there are non-DSM phenotypes as well (peripheral phenotype)

Question 8

non-DSM phenotypes of ADHD

Answer 8

emotional hyper-reactivity
mood lability
low tolerance of frustration
explosive dyscontrol
ceaseless mental activity (ego-dystonic)
initial insomnia
inertia/procrastination
hyper-focusing

Question 9

inattention (disorganisation) phenotypes

Answer 9

details/mistakes
sustain attention
not listen
not follow-through
disorganised
avoid tasks
loses things
distracted
forgetful

Question 10

hyperactive/impulsive phenotypes

Answer 10

fidgets
leaves seat
runs around
noisy
‘on the go’
talks
blurts out
can’t wait
interrupt

Question 11

DSM-5 diagnostic criteria for ADHD

Answer 11

B. several inattentive or hyperactivity-impulsive symptoms were present before 12 years of age
C. several symptoms present in two or more settings (home, school, work, friends, family, other activities)
D. symptoms interfere with, or reduce the quality of, costal, academic or occupational functioning
E. symptoms don’t occur exclusively during a psychotic disorder, and are not better explained by another mental disorder eg. mood, anxiety, dissociative, personality, substance

Question 12

what to you need to fill criterion A of the DSM-5 criteria of ADHD

Answer 12

6/9 items or inattention (A1)
additionally, 6/9 items of hyperactivity/impulsivity if A2

Question 13

what type of rewards work best for children with ADHD

Answer 13

immediate rewards
complicated reward systems/charts that provide only long term rewards don’t work

Question 14

common medical differential diagnoses

Answer 14

hearing, vision, sleep, pain, iron, foetal alcohol spectrum disorder

Question 15

what is likely the genetic cause of ADHD

Answer 15

dopamine D4 receptor polymorphisms

Question 16

structural brain abnormalities in ADHD

Answer 16

studies show reduced volumes in:
dorsolateral prefrontal cortex
caudate, globus pallidum
corpus collosum
cerebellum

but also inconsistent findings

Question 17

hypothetical circuits from the cortex to the corpus striatum basal ganglia to the thalamus back to the cortex:

Answer 17

cortico-striatal-thalamic-cortical loops
‘sit still and concentrate loop’

Question 18

parts of the cortex and what they control

Answer 18

dorsal anterior cingulate cortex regulates selective attention
dorsolateral prefrontal cortex regulates sustained attention and problem solving
prefrontal motor cortex regulates motor hyperactivity
orbital frontal cortex regulates impulsivity

Question 19

common comorbidities in ADHD

Answer 19

specific learning disorder
language disorder
developmental coordination disorder
autism spectrum disorder
Tourette disorder and tic disorder
obsessive compulsive disorder
oppositional defiant disorder
conduct disorder
depression
anxiety disorder

Question 20

side effects of stimulants

Answer 20

headache
stomach ache
loss of appetite
nervousness
moodiness, tearfulness, depression

short lived and resolve 1-2 weeks

Question 21

first line treatment

Answer 21

methylphenidate (lower seizure threshold)
dexamphetamine (epileptic subjects, non-responders)

Question 22

second-line treatment ADHD

Answer 22

atomoxetine 80-100mg
start at 20mg and then increase every 5/7 and wait for response for 4/52

Question 23

side effects of atomoxetine

Answer 23

nausea, dry mouth, agitation, vivid dreams
useful for anxious, panicky individuals

Question 24

refractory cases or third-line treatment

Answer 24

modafinil
clonidine
risperidone
imipramine
bupropion, reboxetine, venlafaxine, SSRI