ADHD Flashcards Preview

SPRING16 N833 Adv Pedi > ADHD > Flashcards

Flashcards in ADHD Deck (124):
1

What are some sources of school failure?

  • Health issues
  • Emotional issues
  • Learning issues
  • Attention issues

*try to distinguish where coming from -- cognitive ability specific to subject? auditory or visual? Emotional changes? Etc.

2

What are the risks to untreated adhd?

cascade of negative consequences: poor self esteem --> poor academic performance --> risk taking, substance abuse, etc. --> poor employment options, poor health outcomes, poor relationships

3

3 characteristics of adhd

  1. inattentiveness
  2. hyperactivity
  3. impulsivity

4

Definition / diagnostic criteria ADHD

 

  • Interferes w/functioning across settings: home, school, work
    • Behaviors > signifcant than peers
  • Triad of behaviors beyond range of accepted for "normal"
  • At least 6 months
  • Symptoms before 12 years of age

5

3 subtypes of adhd

6

Neurobiology: structural differences associated w/adhd

Chronic neurobehavioral disorder 

smaller frontal lobes

A image thumb
7

Neurobiology: functional differences associated w/adhd

•Lower blood flow
•Response to meds
  • Alteration of neurochemical transmission 

Chronic neurobehavioral disorder 

A image thumb
8

ADHD: genetics vs environment

•Very high incidence in twin studies

•75% variance in phenotype is genetic, not environmental

9

Specific genes associated with adhd

•Dopamine receptor gene
–Cognition, memory, exploratory behaviors
•Dopamine transport gene
–Site of action of stimulants
•Similar genes linked to other mental health issues

10

prenatal/parinatal factors associated with adhd

  • Pregnancy complications
  • Prematurity/SGA
  • Hypoxemia
  • Hypoperfusion: – low cerebral blood flow associated with increased dopamine receptor availability in adols with ADHD
  • Maternal smoking

11

psychosocial factors associated with adhd

  • Maternal depression
  • parenting skills/stress

12

biologic factors associated with adhd

  • Lead exposure: even low lead levels showed hyperactivity in preschoolers
  • Iron deficiency
  • Obstructive sleep apnea

13

diet factors associated with adhd

  • food additives
  • sugar

*may be triggers in genetically susceptible child - make better or worse

14

prevalence of adhd in u.s.

~11%

15

Preschool age: prevalence, type, male vs female

adhd

  • Prevalence: 2-5%
  • Type: 48% hyperactive/impulsive
  • 1:1 female to male

16

School age: prevalence, type, male vs female

adhd

  • Prevalence: 3-11%
  • Type: many combined, many inattentive/impulsive
  • 1:4 female to male

17

High School age: type, diagnosis

adhd

  • Type: more inattentive, esp girls
  • Diagnosis: ?? other DOs- ODD, CD, "adolescence", also difficulty w/APA criteria (before 12y)

18

Characteristics of inattentiveness in ADHD

  • Easily distracted
  • Poor listening skills
  • Poor attention to details
  • Forgetful
  • Disorganized
  • Poor sustained attention to play or tasks
  • Fewer activities requiring sustained attention
  • Loses items
  • Needs redirection

19

Characteristics of hyperactivity in ADHD

  • Most troublesome for preschoolers/early school age
    • “On the go”,   “Driven by a motor”
    • Driven to interact with the environment (restlessness in adolescents)
    • Unable to remain seated, even briefly
    • Difficulty settling to play
    • Fidgety
    • Excessive talking

20

Characteristics of impulsivity in ADHD

  • Takes risks
  • Disregards physical boundaries
  • Unable to cooperate with peers or adults
  • Interrupts
  • Difficulty waiting turns
  • Unable to delay gratification, even briefly

21

Characteristics of preschoolers w/ADHD

  • Lack of rhythmicity
  • Poor adaptability
  • Sleep disturbances
  • Moodiness/irritability
  • Demanding of attention
  • Slower language development

22

Preschoolers: behavioral risks associated w/adhd

  • Poor impulse control
  • Expelled from preschool settings
  • More disruptive
  • Less cooperative
  • Less opportunity to develop social skills
  • Increased risk of injury

23

Preschoolers: Social risks associated w/adhd

  • Problematic parent/child relationship
  • Family stress
  • Limited activities /experiences
  • Focus on discipline
  • Poor social skill development
  • 89% - significant impairment in at least one relationship

Intrusive, in your face, no boundaries, first in line, taking turns, sharing

24

Preschoolers: academic risks associated w/adhd

  • Poor pre-academic skill development
  • Delayed emergent literacy
  • Parents don’t extend and expand language
  • Disrupted phonological awareness
  • Lower scores
  • Working memory
  • Planning
  • Cognitive flexibility

25

Preschoolers: comorbidities associated w/adhd

  • 35-50% Oppositional Defiant Disorder
  • 15% Anxiety
  • 13% Depression
  • 19% >1 comorbidity

26

Challenges to diagnosing adhd in preschoolers

  • high energy level: may be nl
  • non-compliant behavior
  • day-to-day variability in behavior
  • situational response to environment
  • Neurologic immaturity
  • Child-environment mismatch
  • Adult expectations of behavior: may be unrealistic for age
  • Co-morbidity: e.g., dvptl problems

27

General Characteristics of adhd in school-age children

  • Issues with peers
    • Emotionally immature
    • Prefer younger children or adults
  • Emotional lability
  • Procrastination
  • Disorganization
  • Distractibility

28

Characteristics of adhd in EARLY school-age children

boys vs girls

Boys:  high activity level
Girls:  “good”, no trouble

29

Characteristics of adhd in LATER school-age children

boys vs girls

Boys:  increasing oppositional behavior
Girls:  more social, talkative

30

risks for school-age child with adhd

  • Family stress
  • Family relationships
  • Social issues
  • Academics

31

challenges in diagnosis of adhd in school age children

  • Normal development
  • Learning disabilities
  • Medical issues
  • Comorbidities

32

Course of adhd in adolescents

  • Previously
    • Maturational lag
    • Outgrown in adolescence
  • Currently
    • 65% persist with symptoms at least into adolescence, often adulthood
    • Some not diagnosed until adolescence

33

Characteristics of adhd in adolescents

  • Hyperactivity declines
  • Inattentiveness more obvious
  • School struggles
    • Multiple teachers
    • Multiple expectations
  • Cognitive demands increase
    • Memory
    • Higher level thinking
  • Independence expected

34

Comorbidities associated with adhd in adolescents

ODD, anxiety, depression, substance abuse DO, personality DO, learning disabilities**

35

Characteristics suggestive of ODD or conduct DO in adolescents

  • Argumentative
  • Negative
  • Easily frustrated
  • Conflicts at school
  • School refusal

36

Characteristics suggestive of anxiety in adolescents

  • Restlessness
  • Difficulty concentrating
  • Irritability

37

Characteristics suggestive of depression in adolescents

  • Social isolation
  • Irritability
  • Boredom
  • Reckless behavior
  • Academic underachievement

38

Principles of assessment of adhd

  • Multiple sources
  • Good tools
  • Recurring themes
  • Connections to school and life outside of school
  • Profile of strengths and weaknesses

39

Components of ADHD assessment: History

  • History
    • Past medical
      • Birth
      • Chronic illness
      • Acute illness
      • Trauma
      • Development
  • Social history
    • Family stressors
    • Out-of-home care
    • Family structure
  • Family Medical
    • Genetics
    • Sibs, cousins

40

Components of ADHD assessment: PE

  • Affect/emotional response
  • Dysmorphic features
  • Behavior
  • Communication skill

41

Components of ADHD assessment: Medical Screenings (as indicated)

  • Sensory
  • Lead
  • Iron
  • Thyroid

42

Components of ADHD assessment: Developmental / neurodevelopmental screening

  • Language/linguistics
  • Memory
  • Personal-social
  • Motor

43

Why are parent interviews important in adhd? 

  • Home less structured
  • Different expectations
    • Appropriate
    • Inappropriate
  • Unaware of full range of behaviors
    • School behavior
    • Social interactions

44

What to look for in interview w/preschool teacher: adhd

  • Normative perspective
  • Structured and unstructured samples of behavior

45

Important concepts w/elementary/HS teacher interview: adhd

  • May have no knowledge of outside classroom behavior
  • poor interrater reliability among teachers
  • Parent-teacher agreement =74%

46

Characteristics of students perspectives on adhd symptoms

  • Under report symptoms
  • Under rate level of impairment

47

Who should be involved in adolescent interviews for adhd and why?

1. Adolescent alone

  • Confidentiality
  • Concerns
  • Perception of school and family issues
  • Sensitive topics
    • Use of ETOH, drugs
    • Driving habits

2. Parents alone

  • Perceptions of issues
  • Contact with school
  • Approaches tried
  • Expectations from evaluation

3. Adolescent and parents together

  • Shared concerns?

48

Rating scales in adhd: why, disadvantes, types

  • Attempt to objectify behavior
  • Some normed to age and gender
  • Impressionistic, subjective
  • Some specific to ADHD, others to range of  emotional/behavioral problems

49

Specific provider rating tools for adhd, recommended

  • Vanderbilt (AAP)
    • ADHD
    • Comorbidities
  • Connors
  • McCarney (ADDES) short / long forms
  • Brown ADD Diagnostic Form for Adolescents – Revised

50

Self-assessment tools for adhd

  • Pediatric Symptom Checklist
  • ANSER Self-Report  ( >9 years)
  • Brown ADD Scales for Adolescents
  • Conners-Wells Adolescent Self Report Scale

51

other adhd assessment tools

  • Early Childhood Inventory IV
  • SNAP-IV
  • Child Behavior Checklist
  • Preschool Age Psychiatric Assessment
  • Behavior Assessment System for Children
  • ANSER system

52

academic information used to assess adhd mgmt

  • Report cards
  • School progress- teachers’ comments
  • Standardized testing
  • Psychoeducational testing
  • Neuropsychological testing

53

Differentials to adhd for preschoolers: medical

  • Normal exuberance
  • Medical disorders
    • Seizures
    • Significant lead poisoning
    • Sensory deficit
    • OSA
    • Iron deficiency
    • Chronic OM

54

Differentials to adhd for preschoolers: developmental DOs

  • Language delay
  • Fragile X syndrome
  • Intellectual disability
  • Autism spectrum
  • FAS

55

Differentials to adhd for preschoolers: psychiatric DOs

  • Depression
  • Anxiety
  • ODD

56

Differentials to ADHD for school age and adolescents

  • Learning disability
  • Mental health issues
  • Chronic conditions
  • Sensory deficit
  • Parental expectations

57

What are the components of learning, according to PRK's slides?

  • Attention
    • mental energy controls
    • processing controls
    • production controls
  • Temporal - sequential ordering
  • Spatial ordering
  • Memory
    • short term
    • active working
    • long term

Language

  • receptive
  • expressive
  • written  

Neuromotor functions

  • gross motor
  • fine motor

Social Cognition

Higher  order cognition

Levine, M,  A Mind at a Time

58

Components of a student profile of a child w/adhd

  • Strengths
    • What works best?
    • Affective resources
    • Coping styles
  • Needs
    • Where does the breakdown happen?
    • What makes it better?
  • Environmental influences
  • How can school facilitate success?
  • Affinities
  • Motivators

59

Inattentive

Hyperactive/impulsive

combined

60

What are the goals of adhd mgmt?

Develop self-regulatory behaviors:

  • maintain self esteem
  • develop social skills
  • foster learning behaviors
  • improve family functioning

 

61

General mgmt guidelines

  • Chronic condition
    • Long term management
    • Ongoing evaluation of treatment options
    • Careful planning
    • Support for child, caregivers, teachers
  • Identification of target outcomes

62

mgmt of adhd: education of parents, dhild, adolescent

  • Demystify
    • Chronic condition
    • Symptoms manageable
    • Outcomes good
  • Destigmatize
    • Not associated with intelligence
    • Not associated with being “bad kid”

63

Environmental mgmt of adhd

  • Safe, appropriate boundaries
  • Sense of order and control
  • Consistent expectations/routines
  • Active involvement
  • Collaboration and cooperation
  • Reduced stimuli – TV, music, and computer, phones

64

behavioral mgmt training for adhd: goals

  • Goals
    • Decrease core symptoms
    • Improve parent-child interaction
    • Improve peer interaction
    • Decrease oppositional behaviors
    • Generalize to other settings
  • Much research about use with preschoolers

difficult for disorganized families to implement

Focus on immediate issues

65

Components of behavior mgmt for adhd

  • Positive reinforcement
  • Token system
  • Time out
  • Response contingency: withdrawal of attn
  • Limit setting
  • Appropriate commands and reprimands
  • Group social skills
  • Cognitive/ behavioral self control training
  • Anger management
  • “report card”
  • Overcorrection
  • Minimize negative feedback

66

Considerations when initiating pharm mgmt

  • Seldom should be only treatment but often is only treatment
  • Consider co-morbid conditions
  • Informed consent/assent of adolescents
  • Risk/benefits

67

Monitoring pharm mgmt of adhd

  • Side effects: occurrence, monitoring
  • Toxicity: abuse, cardiac, liver
  • Periodic assessment

68

What is the most commonly used category of medications for adhd?

stimulants (1.5 million)

69

What is the most successful category of medication used for adhd?

stimulants: 80% will improve

70

What areas do stimulants improve in adhd?

  • concentration (mental energy, focus and processing controls)
  • behavior (decreased impulsiveness)
  • socialization (reduced activity and intrusiveness)

71

MOA of stimulants for adhd

  • Enhance neurotransmitter in brain pathways involved in inhibition
  • Activate brain stem arousal

72

How to dose stimulants

until effectiveness w/o side effects

73

What are the categories of stimulants?

methylphenidates, amphetamines

74

Methylphenidates used for adhd

  • Ritalin ( S & L): capsule you can empty
  • Focalin ( S & L): isomer of ritalin (5mg=10mg of ritalin)
  • Methylin ( S & L )
  • Metadate ( S & L): capsule you can empty
  • Concerta ( L): must be swallowed whole
  • Daytrana – patch (L)
  • Quillivant XR 25mg/5ml (L): liquid

75

Stimulant that has less abuse potential

Vyvanse - needs to get into stomach to work, less abuse potential

76

Which stimulant is good for afternoon overactivity?

Methadate

77

amphetamines used for adhd

  • Dexedrine (S & L)
  • Adderall ( S & L)
  • Vyvanse ( L)

78

Characteristics of short-acting stimulants

A image thumb
79

Characteristics of long-acting stimulants

E.g., concerta is good for older students - steady period of action, ~12h duration

A image thumb
80

What is unique about Daytrana?

 

  • Apply 2 hours before needed on alternating hips (can be annoying)
  • Remove in 9 hrs.
  • Prior use of stimulants recommended
  • Same safety/ risk profile as oral

81

What is the newest stimulant and how is it dosed?

  • Quillivant 25/5ml
  • Liquid
  • Long acting
  • Start at 20mg ?!
  • Same safety and SE profile as others

82

Potential side effects of stimulants

•Appetite suppression

•Weight loss

•Headaches

•Increased heart rate

•Increased blood pressure

•Tics

•Delayed sleep onset

•Rebound phenomenon

•Growth suppression ? unclear data

•Moodiness

•Sadness

•Lowering of seizure threshold

83

How to manage appetite suppression/wt loss on stimulants

eat breakfast before medication

If on ER, will happen around lunch. They can have snacks before school.

amphetamines seem to have more appetite suppression

84

What are some cautions with stimulants

  • Significant anxiety, tension, agitation
  • Allergies to components
  • Glaucoma
  • Current or recent use of MAOI
  • Motion or verbal tics or family history
  • Structural cardiac defects
  • Abuse potential

85

Is routine cardiovascular monitoring needed before starting stimulants?

Previously it was

in 2008, AAP recommended no ECG: no increased risk of SCD and questionable S/S of ECG in predicting SCD

86

When should CV monitoring be done before starting on stimulants?

+ FMH or + personal history of cardiomyopathy, WPW, arrhythmia, long QT, other functional, structural heart issues

**Also screen adopted kids who don’t know family Hx

87

What CV history do you need before starting stimulants?

  • Careful evaluation before starting stimulants
  • Child’s history
  • Family medical history
    • Early events
    • Cardiomyopathy
    • Long QT syndrome

88

What CV f/u is needed on stimulants?

  • Vital signs
  • Symptoms referable to CV system- syncope, palpitations ( butterfly in my chest), SOB, “heart pain”

89

State of the evidence on medicating preschoolers for ADHD

  • Previous studies in preschoolers
    • Few
    • Short duration
  • Increase in off-label use of stimulants (3-fold increase during 90s)
    • Many medications not approved for <6 year olds
    • Few long term outcomes or safety data
  • Newer study: Pre-school adhd treatment study (pats)

90

What is PATS?

  • Pre-school adhd treatment study (pats): 
  • a multi-site randoized control trial (3-5.5yrs)
  • Components: parent training, medication trial
  • Results: parent training alone not helpful, 85% with good response to methylphenidate

91

When are adhd medications recommended for preschoolers, and which ones, according to aap?

  • IF careful assessment and severe symptoms
  • Use methylphenidate
  • start low, titrate up to effectiveness w/o SEs (tmg)
  • Use short acting throughout day (TID)

92

Impact of stimulants on developing brain, preschoolers

no long term safety / efficacy impact

93

SEs of stimulants on preschoolers?

  • Question of growth suppression
  • Crabbiness, irritability, fatigue – diminished over time
  • Worry and anxiety -persisted over time
  • Sleep and appetite issues- persisted over time

94

Are dependence and abuse issues when prescribing stimulants?

•Dependence

–Abused at high doses

–Possibly psychological

•Abuse

•Marketable

•SAD: Conflicting reports

–Well managed students, less SAD

–Potential in non-prescribed students for SAD

95

Concerns with energy drinks and stimulants?

Synergy!

96

When might you Rx strattera?

Not responding to stimulants or high abuse potential

–Mood stabilizing effect if comorbidity

97

What is Strattera?

–First non-stimulant for ADHD

–Norepinephrine reuptake inhibitor

98

When should effects of Strattera be seen?

–2-6 weeks before effects seen

–24 hour period of action

99

SEs of Strattera

–GI upset –
•High protein foods
•Start low dose  (.5mg/kg)titrate upwards (1.2mg/kg)
–Liver toxicity
•Dark urine
•Itchy skin
•Jaundice
•RUQ pain

100

When is Intuniv recommended?

Non-stimulant! Good for high activity levels, issues w/stimulants

Recommended:

  • Core ADHD symptoms plus irritability, temper regulation
  • Intolerant of stim, tics or sleep issues
  • 6-17 year olds

101

Is Intuniv approved for use w/stimulants?

yes!

102

How should Intuniv be taken?

  • 1,2,3 and 4 mg tablet qd
    • Swallow only
    • No fatty foods
    • Effectiveness ~2-3 weeks
  • Taper by 1 mg q 3-7 days

103

Intuniv MOA

Interacts with receptors in prefrontal cortex

guanfacine - a BP med

 Central alpha-2 adrenergic agonist

104

Side effects of Intuniv

  • Fatigue, drowsiness
  • Lowers blood pressure:
    • Lightheadedness, syncope
  • GI:  Nausea, stomach pain, constipation,    appetite, dry mouth
  • Neuro: Irritability, headaches

105

Monitoring of Intuniv

BP and HR @beginning and with every ↑ and then q med check

106

What is the newest non stimulant for adhd?

Kapvay / Clonadine

107

MOA of Clonadine

MOA unknown in ADHD

May involve prefrontal cortex activity like Intuniv

108

Indications and dosing for Kapvay?

  • Age indication: 6-17 years old
  • 0.1- 0.4 mg/day (bid)
  • Swallow whole
  • Taper over 3-7 days
  • Mono or adjunct tx with stimulants!

109

SEs of kapvay

  • Similar to Intuniv
  • Bradycardia
  • Somnolence, etc.

110

Intuniv vs kapvay

BID as opposed to Intuniv which is QD. Also good for hyperactivity.

Like Intuniv, Combine w/stimulant for attention

111

What needs to be discussed when initiating medication for adhd?

  • Clear discussion parent and patient
  • Needs
  • Expectations
  • Targeted outcomes
  • Side effects
  • FMH
  • Personal history
  • Plan for follow up
  • Contract

112

Considerations when choosing a medication for adhd?

  • Subtype
  • Issues with  “quality of life”
  • Short acting vs long acting
  • Delivery method
  • Start low, titrate up

113

cautions when Rxing stimulants

  • Controlled substances
    • DEA number, 1mo supply, not called in
  • High risk behaviors
  • Other meds/drugs
  • Caffeine and energy drinks
  • Selling, sharing, abusing
  • Parental monitoring of meds

114

When / how to follow up after initiating adhd meds

  • Phone check:  2 weeks
  • Office visit: 1 month
  • Effectiveness
  • Side effects
  • Need for dose change or type  or class change
  • HR, BP, weight, neuro

115

How should regular f/u be conducted w/adhd on medication?

  • Appropriate, effective, well tolerated dose
  • See q 3 months
    • School and home info
      • Progress, efficacy, concerns
    • VS, HT, WT, neuro
    • Review expectations
  • Rescreen with Vanderbilt F/ U forms
  • Adjust management as needed

116

Why might med aherence be decreased in teens?

  • 48% adolescents stop meds
  • Deny problem
  • Issues of independence
  • Parents less willing to insist or administer
  • 4.5 Rx filled/year!!!

117

What might increase adherence in teens?

  • Better self concept
  • Stable family
  • Internal locus of control
  • Increased motivation
  • Simplified medication regimes
  • Fewer adverse effects
  • Use of motivational interviewing

118

Some CAM / alternative approaches to adhd?

  • Dietary changes
    • Additives
    • Sugars
    • Herbs
    • Omega 3 Fatty Acids
    • Zinc
    • Iron/vitamins
  • Relaxation training
  • Cerebellar training
  • Neuromapping
  • Optometry
  • Exercise
  • Outdoor activity

Chamomile and valerian  ok for restlessness, concentration and sleep issues.  Kava kava has adverse effects on CNS with chronic use

No support of megadose of vits/minerals – should treat iron deficiency

119

options for educational intervention in adhd?

  • Individuals with Disabilities Education Act (funding)
    • Services for disabilities that affect educational performance
  • 504 Sec of Rehabilitation Act ( no $)
    • Prohibits discrimination against anyone with disability
    • Regular class, spec services, (FAPE)
    • can be very creative to meet needs, motor breaks, etc

120

What is a 504 plan?

  • Provides accommodations, modifications in regular classroom
    • Preferential seating
    • Extended time
    • Modified assignments
    • Alternative test setting
    • Overflow activity
    • Motor breaks

121

What is an individualized education plan (IEP)?

 

  • Legal document (IDEA)
  • Updated annually at Planning and Placement Team (PPT)
  • Resource room
    • Resource support
    • Remedial help
    • Tutorials
    • Study skills training
    • etc.

122

Components of F/U for adhd

  • Criteria for efficacy
    • Educational
    • Behavioral
    • Social
    • Pharmacologic
    • Family
  • Communication
    • Parents
    • Teachers
    • Students
    • Other professionals
      • Phone
      • Office visits
      • Repeat checklists/rating scales

123

Outcomes of effective assessment and mgmt?

  • Improved self esteem
  • Improved learning outcomes
  • Improved family harmony
  • Improved social skills
  • Improved educational/
  •   vocational opportunities

124

Pediatrics: KAS from subcommittee on adhd

 

KASs:

1 – The PCC should evaluate for ADHD if 4-18yo w/academic or behavioral sx of inattention, hyperactivity, impulsivity (B)

2 – DSM-IV (now 5) criteria should be met for Dx. Info primarily from parents/guardians, teachers, other school and mental health clinicians involved in child’s care. R/O alternative cause (B)

3 – PCC should assess for coexisting conditions (anxiety, dep, ODD, CD, learning/language DO, neurodvptl do, tics, OSA) (B)

4 – PCC to recognize ADHD as chronic = special health care needs. Follow chronic care model and medical home (B)

5 – Tx varies by age. PCC recs:

  • Preschool (4-5yo): EB parent and/or teacher administered behavioral tx as 1st line (A), and Rx methylphenidate if no significant improvement and mod-severe continuing disturbance in child’s function. If EB behavioral tx not available, weigh risks of meds vs delay in tx (B)

   • Elementary (6-11yo): FDA approved med (A) and/or EB behavioral tx (B), preferably both. Evidence strong for stiulants, sufficient for atomexetine, ER guanfacine, ER conidine (in that order). The school, program, or placement is part of any tx plan.

   • Adolescents (12-18yo): FDA approved meds w/assent of adolescent (A), and maybe behavioral tx (C), preferable both

6 – titrate doses of meds for adhd to achieve maximum benefit w/minimum adverse effect (B)