ADHD Flashcards

Question

Preschoolers: comorbidities associated w/adhd

Answer 1

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

Answer 2

* 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*

Answer 3

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

Answer 4

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

Answer 5

Boys: increasing oppositional behavior Girls: more social, talkative

Answer 6

* Family stress * Family relationships * Social issues * Academics

Answer 7

* Normal development * Learning disabilities * Medical issues * Comorbidities

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

* Restlessness * Difficulty concentrating * Irritability

Answer 13

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

Answer 14

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

Answer 15

* 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

Answer 16

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

Answer 17

* Sensory * Lead * Iron * Thyroid

Answer 18

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

Answer 19

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

Answer 20

* Normative perspective * Structured and unstructured samples of behavior

Answer 21

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

Answer 22

* Under report symptoms * Under rate level of impairment

Answer 23

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?

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

* Depression * Anxiety * ODD

Answer 32

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

Answer 33

* _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_

Answer 34

* 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

Answer 35

Develop self-regulatory behaviors: * maintain self esteem * develop social skills * foster learning behaviors * improve family functioning

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

* Goals * Decrease core symptoms * Improve parent-child interaction * Improve peer interaction * Decrease oppositional behaviors * Generalize to other settings * Much research about use with preschoolers ## Footnote * difficult for disorganized families to implement* * Focus on immediate issues*

Answer 40

* 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

Answer 41

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

Answer 42

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

Answer 43

stimulants (1.5 million)

Answer 44

stimulants: 80% will improve

Answer 45

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

Answer 46

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

Answer 47

until effectiveness w/o side effects

Answer 48

methylphenidates, amphetamines

Answer 49

* 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*

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

* 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

Answer 54

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

Answer 55

* 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

Answer 56

eat breakfast before medication If on ER, will happen around lunch. They can have snacks before school. amphetamines seem to have more appetite suppression

Answer 57

* 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

Answer 58

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

Answer 59

+ 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

Answer 60

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

Answer 61

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

Answer 62

* 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)

Answer 63

* 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

Answer 64

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

Answer 65

no long term safety / efficacy impact

Answer 66

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

Answer 67

•Dependence –Abused at high doses –Possibly psychological * Abuse * Marketable * SAD: Conflicting reports –Well managed students, less SAD –Potential in non-prescribed students for SAD

Answer 68

Not responding to stimulants or high abuse potential –Mood stabilizing effect if comorbidity

Answer 69

–First non-stimulant for ADHD –Norepinephrine reuptake inhibitor

Answer 70

–2-6 weeks before effects seen –24 hour period of action

Answer 71

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

Answer 72

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

Answer 73

* 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

Answer 74

Interacts with receptors in prefrontal cortex guanfacine - a BP med Central alpha-2 adrenergic agonist

Answer 75

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

Answer 76

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

Answer 77

Kapvay / Clonadine

Answer 78

MOA unknown in ADHD May involve prefrontal cortex activity like Intuniv

Answer 79

* 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!

Answer 80

* Similar to Intuniv * Bradycardia * Somnolence, etc.

Answer 81

BID as opposed to Intuniv which is QD. Also good for hyperactivity. Like Intuniv, Combine w/stimulant for attention

Answer 82

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

Answer 83

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

Answer 84

* 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

Answer 85

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

Answer 86

* 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

Answer 87

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

Answer 88

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

Answer 89

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

Answer 90

* 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*

Answer 91

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

Answer 92

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

Answer 93

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

Answer 94

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

Answer 95

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)

ADHD Flashcards

(124 cards)