Chapter 8: ADHD Flashcards

1
Q

Incidence of ADHD

A

diagnosis increased dramatically from 6% of children in 1997 to 10% of children in 2017

Reasons for increased diagnosis:
* increased awareness
* more expansive definition of ADHD
* increased environmental exposures & societal stressors
* misdiagnosis d/t inadequate evaluation

Comorbid OCD or conduct disorder (CD) in 50% of cases or hyperactive / combined type
Comorbid anxiety/ depression in 45% of cases of inattentive/ combined type

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2
Q

diagnostic criteria of ADHD (DSM-V)

A

Inattention type: At least 6 of following (5 if 17yrs+) for 6 months that interferes with social, academic, occupation:
* fails to pay attention to details, makes mistakes
* difficulty sustaining attention in tasks or play
* doesnt seem to listen when spoken to directly
* doesnt follow through, doesnt finish work
* difficulty organizing tasks/ activities (includes messy)
* dislikes tasks requiring sustained mental effort
* loses necessary things

Hyperactive/ Impulsive type: (same # and timeline)
* fidgets, taps, squirms
* leaves seat at inappropriate times
* runs/ climbs when inappropriate
* unable to play quietly
* “on the go” - uncomfortable being still, restless
* talks a lot
* blurts answer before question is done
* difficulty waiting turn
* interrupts/ intrudes on others

Features present before age 12
Features present in two or more settings
Symptoms interfere with function
Not better explained wit hother mental disorder
Symptoms not due to deliberate disobedience or lack of understanding instructions
There is also a combined type (with inattention and hyperactivity)

Persists into adulthood 35-65% of the time!

People with ADHD often have significant strengths and successes - creativity, empathy, innovation

Behavioral scales are used to diagnose but should be taken in context of thorough eval otherwise they likely misdiagnose (scales alone have poor specificity and are very subject to bias).

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3
Q

Pathophysiology and risk factors for ADHD

A
  • MRI differences in brain volume, cortical thickness, white matter
  • Mostly in basal ganglia, prefrontal cortex, corpus callosum
  • differences in neural activity hemodynamics in studies
  • catecholamine metabolism plays key role
  • genetic predisposition is present/ inheritability
  • Risks: male sex, IUGR, excess screen time, early tobacco/smoke, phthalates/ phenols, pesticides, food additives
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4
Q

Stimulants for ADHD

A
  • Methylphenidate and dextroamphetamine
  • good in the short term, but studies show no effect after longer durations of treatment (good at 14 months, no change between treated in untreated kids at 3 yrs and 6 yrs)
  • 70% of kids will respond. Kids often respond much better to one agent than the other
  • SIDE EFFECTS: appetite loss, insombia, GI upset, palpitations, headache, dizziness, anxiety, aggression. Also subtle changes - “Kids are just not themselves, lost their joy”
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5
Q

Non-stimulant pharmaceuticals for ADHD

A

Atomoxetine (Strattera)
* similar to an SSRI
* Also effective in short term, usually second-line

Guanfacine
* clonidine derivative
* effective as an adjunct to psychostimulants

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6
Q

AAP recommendations for screen time

(ADHD chapter)

A
  • 6 yrs and older: 2 hrs max per day of digital media
  • 3-5 yrs: 1 hour max per day
  • 2 and under: no screens (exception FaceTime)

Types of screen time may be better (ie family movie time) or worse (video game alone in room)

Some data that kids with developmental delays spend more time exposed to television.

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7
Q

Sleep disorders in kids with ADHD

A
  • longer sleep latency
  • more sleep cycles
  • circadian rhythm abnormalities

ADHD symptoms can be improved by increasing quantity and quality of sleep! Avoid screen 1 hour before bed, avoid caffeine 6 hours before bed

Consider melatonin! Can be safe in kids for up to 52 weeks continuously.

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8
Q

What is the ideal room temp for sleep

A

Cool, between 65 - 70 degrees.

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9
Q

What types of exercise are good for kids with ADHD

A
  • moderate-to-intense exercise
  • martial arts
  • yoga
  • swimming
  • 30-60 min per day. Even in bursts (like during school)
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10
Q

school accomodations for ADHD

A
  • 504 plan (section 504 of rehabilitation act of 1973) or individualized education plan (IEP)
  • ADHD falls under definition of “disability” for both of them
  • kids sit at front and away from windows
  • nonverbal cues from teachers to stay on track so as to not felt called out
  • extra time to complete tasks
  • rewards systems

Teachers that are the best fit: has inherent structure (with some flexibility) with at endency towards giving generous amount of positive feedback

Note - not all adults with ADHD qualify as having a disability under the Americans with Disabilites Act (ADA)

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11
Q

what is an ADHD coach

A

An ADHD coach helps individuals improve executive functioning with skills and strategies to combat the core impairments of ADHD, such as planning, time management, goals setting, organization, and problem solving. Although further research is needed, several small studies done in college students have shown improvements in measures of time management, anxiety, self-efficacy, and study skills through ADHD coaching.38

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12
Q

true or false: studies have shown significant improvements in driving in adolescents with treatment of ADHD

A

True!

Kids with ADHD are at greater risk for injury

Teens with ADHD are more likely to get into MVCs

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13
Q

does the type of environment outdoors matter for symptom improvement in ADHD

A

Yes. Greenspaces are more beneficial for ADHD symptoms as opposed to nongreen spaces (either indoors or built outdoor settings)

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14
Q

What is the role of sugar consumption and ADHD

A
  • Many studies show NO association between consuption and hyperactivity, and no association between consuption over time and risk of ADHD
  • One study showed sugar-sweetened beverages increased risk of ADHD
  • Another showed eating low-glycemic breakfast can improve cognitive function –> for the authors this is very important!
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15
Q

Role of food additives in ADHD

A
  • links between artificial colors, artificial flavors, and preservatives on hyperactivity
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16
Q

what percentage of kids with ADHD respond to dietary interventions

A

33%

17
Q

What is a practical yet effective elimination diet for ADHD? How can you prescribe it?

A
  • Oligoantigenic diet can be very restrictive and impractical for families
  • Use a modified elimination diet instead: eliminate common food allergens (wheat, dairy, corn, soy, chocolate, nuts, citrus, and artificial additives - colors, flavors, preservatives)
  • Do it for at least 3 weeks
  • If ADHD sx improve, reintroduce foods one by one
  • Most kids don’t need actual IgE food allergy testing unless there are signs pointing to this
  • Not much evidence for IgG food sensitivity testing
18
Q

What is the role of pesticides in ADHD?

A
  • likely have biggest role when exposed at critical stages of neurodevelopment
  • Concentration of pesticides (dioxin and dibenzofurans) higher in kids with ADHD and learning disabilities
  • Kids with higher urinary levels of organophosphate metabolites (like the 4-dimethylaminopyridine or DMAP metabolite called dimethylthiophosphate) were more likely to have ADHD
  • Organic foods have significantly higher levels of micronutrients
19
Q

Can caffeine be helpful in ADHD

A
  • People with ADHD may tend toward caffeine
  • Teens with ADHD have higher consumption later in the day, and also have poor sleep
  • Caffeine may help kids who can’t tolerate psychostimulants
  • Green tea may be better because it also has L-theanine which can improve attention and relax the mind.
20
Q

Omega-3 Fatty Acids and ADHD

A
  • Relationship is well established
  • Omega-3 levels blood levels are lower in kids with ADHD
  • Supplementation improves sx in all groups, even those already getting stimulants
  • DOSAGE: fish oil 500mg-2000mg EPA+DHA daily (depending on kids size). Ideally the EPA to DHA ratio should be 2:1.
21
Q

Iron and ADHD

A
  • kids with ADHD have low ferritin levels (but not anemia)
  • Degree of deficiency correlates with “bad behavior”
  • Stimulants may work partly by normalizing iron in the basal ganglia
  • kids with ADHD should be screened for iron deficiency (for low ferritin levels) and supplemented (at least 30 ng/dL), and eat iron-rich diet
  • supplementation may have effect size similar to stimulants
22
Q

Magnesium and ADHD

A
  • kids with ADHD have lower magnesium levels
  • Magnesium affects neuronal excitation via inhibiting the excitatory glutamate receptiors and promoting GABA reception –> reduces feelings of stress, anxiety, and mild sedating effect
  • Improved hyperactivity and sleep with magnesium
  • B6 increases bioavailability of Mg; combination supplements help normalize RBC magnesium
23
Q

Zinc, Copper, and ADHD

A
  • Zinc is involved in neurotransmitter regulation
  • Zinc levels are lower in kids with ADHD, degree of deficiency correlates with symptoms
  • Supplementation in kids with deficiency and with normal levels helps improve symptoms
  • Zinc helps maintain copper levels (so they dont go too high which can worsen ADHD sx)
  • Preferable to check an RBC zinc level
  • Supplement with 15-30 mg zinc/day
24
Q

Vitamin D and ADHD

A
  • significant correlation between low maternal Vitamin D and offspring risk of ADHD
25
Q

B Vitamins and ADHD

A
  • low B6 in adults associated with ADHD and cognitive impairment in older adults
  • Helps enhance magnesium absorption
  • works with zinc to produce serotonin
  • B2 and b9 also low in adults with ADHD
  • very little research on supplementation
26
Q

Gingko biloba and ADHD

A
  • most benefit when used as an adjunct to stimulants
  • DOSAGES: 80-120 mg/daily
27
Q

Ginseng and ADHD

A
  • modest beneefit in ADHD
  • very few studies, limited quality
  • of these studies, most is of Asian or Koren ginseng (Panax ginseng) as opposed to American ginseng (Panax Quinquefolium)
28
Q
A
29
Q

Pycnogenol

A
  • A plant extract that may help ADHD through dopamine and norepinephrine regulation
  • only a few studies
  • INSUFFICIENT IVIDENCE TO RECOMMEND
30
Q

Herbs that MAY help for ADHD

A
  • Nervines
  • Lemon balm
  • valerian root
  • chamomile
  • lavender
  • St John’s wort (if comorbid depression)
31
Q

EEG Biofeedback

A
  • real-time EEG measurements to teach self-regulation of brain acticity
  • Effective in multiple neurodevelopmental disorders
  • Improvement is sustained for months after treatment is complete
  • Studies may lack validity and good control groups
  • Costly and time-consuming (up to 40 sessions needed)
32
Q

Mind-body and ADHD

A
  • Yoga, tai-chi, qigong may be helpful in ADHD
  • Meditation may be helpful (4-16 weeks in studies, with a teacher)
  • Some studies show school-based meditation has better behavior, better grades, fewer fights
  • Massage is beneficial in ADHD (15-minute chair massage can improve testing)
33
Q

Parent Training in Behavior Management

A
  • positive parenting - caring but not permissive
  • parenting help can be just as important as medication!
  • Nurtured Heart Approach: shifts the focus on success and achievement
34
Q

TCM and ADHD

A

inconclusive evidence. Acupuncture is promising though

35
Q

Ayurveda and ADHD

A
  • ADHD characterized by predominance of Vata dosha
  • treatment: sleep before 10pm, get at least 8 hours, eat warm foods & beverages, avoid alcohol and caffeine
  • Bacopa monnieri (brahmi) herb may help
36
Q

Homeopathy and ADHD

A
  • lack of good evidence but many families anecdotally report benefit
37
Q

Equinotherapy

A

Horseback riding beneficial for kids with learning disabilities and difficulties in exectuive functioning

38
Q

video games and ADHD

A

video games are thought to be an exacerbating factor for ADHD. However one video game is approved by FDA for treatment of ADHD!