ADHD Flashcards
1
Q
What are some sources of school failure?
A
- 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
Q
What are the risks to untreated adhd?
A
cascade of negative consequences: poor self esteem –> poor academic performance –> risk taking, substance abuse, etc. –> poor employment options, poor health outcomes, poor relationships
3
Q
3 characteristicsof adhd
A
- inattentiveness
- hyperactivity
- impulsivity
4
Q
Definition / diagnostic criteriaADHD
A
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
Q
Neurobiology: structural differences associated w/adhd
A
Chronic neurobehavioral disordersmaller frontal lobes
6
Q
Neurobiology: functional differences associated w/adhd
A
•Lower blood flow•Response to meds
* Alteration of neurochemical transmissionChronic neurobehavioral disorder
7
Q
ADHD: genetics vs environment
A
•Very high incidence in twin studies•75% variance in phenotype is genetic, not environmental
8
Q
Specific genes associated with adhd
A
•Dopamine receptor gene–Cognition, memory, exploratory behaviors•Dopamine transport gene–Site of action of stimulants•Similar genes linked to other mental health issues
9
Q
prenatal/parinatal factors associated with adhd
A
- Pregnancy complications
- Prematurity/SGA
- Hypoxemia
- Hypoperfusion:– low cerebral blood flow associated with increased dopamine receptor availability in adols with ADHD
- Maternal smoking
10
Q
psychosocial factors associated with adhd
A
- Maternal depression
* parenting skills/stress
11
Q
biologicfactors associated with adhd
A
- Lead exposure: even low lead levels showed hyperactivity in preschoolers
- Iron deficiency
- Obstructive sleep apnea
12
Q
dietfactors associated with adhd
A
- food additives
- sugar
- may be triggers in genetically susceptible child - make better or worse
13
Q
prevalence of adhd in u.s.
A
~11%
14
Q
Preschool age: prevalence, type, male vs femaleadhd
A
- Prevalence: 2-5%
- Type: 48% hyperactive/impulsive
- 1:1 female to male
15
Q
School age: prevalence, type, male vs femaleadhd
A
- Prevalence: 3-11%
- Type: many combined, many inattentive/impulsive
- 1:4 female to male
16
Q
High School age: type,diagnosisadhd
A
- Type: more inattentive, esp girls
* Diagnosis: ?? other DOs- ODD, CD, “adolescence”, also difficulty w/APA criteria (before 12y)
17
Q
Characteristics of inattentiveness in ADHD
A
- 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
18
Q
Characteristics of hyperactivity in ADHD
A
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
19
Q
Characteristics of impulsivity in ADHD
A
Takes risks Disregards physical boundaries Unable to cooperate with peers or adults Interrupts Difficulty waiting turns Unable to delay gratification, even briefly
20
Q
Characteristics of preschoolers w/ADHD
A
- Lack of rhythmicity
- Poor adaptability
- Sleep disturbances
- Moodiness/irritability
- Demanding of attention
- Slower language development
21
Q
Preschoolers: behavioral risks associated w/adhd
A
- Poor impulse control
- Expelled from preschool settings
- More disruptive
- Less cooperative
- Less opportunity to develop social skills
- Increased risk of injury
22
Q
Preschoolers: Social risks associated w/adhd
A
- 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
23
Q
Preschoolers: academic risks associated w/adhd
A
- 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
24
Q
Preschoolers: comorbidities associated w/adhd
A
- 35-50% Oppositional Defiant Disorder
- 15% Anxiety
- 13% Depression
- 19% >1 comorbidity
25
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
26
General Characteristics of adhd in school-age children
Issues with peers
* Emotionally immature
* Prefer younger children or adults
* Emotional lability
* Procrastination
* Disorganization
* Distractibility
27
Characteristics of adhd in EARLY school-age childrenboys vs girls
Boys: high activity levelGirls: “good”, no trouble
28
Characteristics of adhd in LATER school-age childrenboys vs girls
Boys: increasing oppositional behaviorGirls: more social, talkative
29
risks for school-age child with adhd
* Family stress
* Family relationships
* Social issues
* Academics
30
challenges in diagnosis of adhd in school age children
* Normal development
* Learning disabilities
* Medical issues
* Comorbidities
31
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
32
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
33
Comorbidities associated with adhd in adolescents
ODD, anxiety, depression, substance abuse DO, personality DO, learning disabilities**
34
Characteristics suggestive of ODD or conduct DO in adolescents
* Argumentative
* Negative
* Easily frustrated
* Conflicts at school
* School refusal
35
Characteristics suggestive of anxiety in adolescents
* Restlessness
* Difficulty concentrating
* Irritability
36
Characteristics suggestive of depression in adolescents
* Social isolation
* Irritability
* Boredom
* Reckless behavior
* Academic underachievement
37
Principles of assessment of adhd
* Multiple sources
* Good tools
* Recurring themes
* Connections to school and life outside of school
* Profile of strengths and weaknesses
38
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
39
Components of ADHD assessment: PE
* Affect/emotional response
* Dysmorphic features
* Behavior
* Communication skill
40
Components of ADHD assessment: Medical Screenings (as indicated)
* Sensory
* Lead
* Iron
* Thyroid
41
Components of ADHD assessment: Developmental / neurodevelopmental screening
* Language/linguistics
* Memory
* Personal-social
* Motor
42
Why are parent interviews important in adhd?
* Home less structured
Different expectations
* Appropriate
* Inappropriate
Unaware of full range of behaviors
* School behavior
* Social interactions
43
What to look for in interview w/preschool teacher: adhd
* Normative perspective
| * Structured and unstructured samples of behavior
44
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%
45
Characteristics of students perspectives on adhd symptoms
* Under report symptoms
| * Under rate level of impairment
46
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?
47
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
48
Specific provider rating tools for adhd, recommended
Vanderbilt (AAP)
* ADHD
* Comorbidities
* Connors
* McCarney (ADDES) short / long forms
* Brown ADD Diagnostic Form for Adolescents – Revised
49
Self-assessment tools for adhd
Pediatric Symptom Checklist
ANSER Self-Report ( >9 years)
Brown ADD Scales for Adolescents
Conners-Wells Adolescent Self Report Scale
50
other adhd assessment tools
* Early Childhood Inventory IV
* SNAP-IV
* Child Behavior Checklist
* Preschool Age Psychiatric Assessment
* Behavior Assessment System for Children
* ANSER system
51
academic information used to assess adhd mgmt
* Report cards
* School progress- teachers’ comments
* Standardized testing
* Psychoeducational testing
* Neuropsychological testing
52
Differentials to adhd for preschoolers: medical
* Normal exuberance
Medical disorders
* Seizures
* Significant lead poisoning
* Sensory deficit
* OSA
* Iron deficiency
* Chronic OM
53
Differentials to adhd for preschoolers: developmental DOs
* Language delay
* Fragile X syndrome
* Intellectual disability
* Autism spectrum
* FAS
54
Differentials to adhd for preschoolers: psychiatric DOs
* Depression
* Anxiety
* ODD
55
Differentials to ADHD for school age and adolescents
Learning disability
* Mental health issues
* Chronic conditions
Sensory deficit
* Parental expectations
56
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 CognitionHigher order cognitionLevine, M, A Mind at a Time
```
57
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
58
3 subtypes of adhd
- Inattentive
- Hyperactive/impulsive
- combined
59
What are the goals of adhd mgmt?
Develop self-regulatory behaviors:
* maintain self esteem
* develop social skills
* foster learning behaviors
* improve family functioning
60
General mgmt guidelines
Chronic condition
* Long term management
* Ongoing evaluation of treatment options
* Careful planning
* Support for child, caregivers, teachers
Identification of target outcomes
61
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”
62
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
63
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 implementFocus on immediate issues
64
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
65
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
66
Monitoring pharm mgmt of adhd
* Side effects: occurrence, monitoring
* Toxicity: abuse, cardiac, liver
* Periodic assessment
67
What is the most commonly used category of medications for adhd?
stimulants (1.5 million)
68
What is the most successful category of medication used for adhd?
stimulants: 80% will improve
69
What areas do stimulants improve in adhd?
concentration (mental energy, focus and processing controls)
behavior (decreased impulsiveness)
socialization (reduced activity and intrusiveness)
70
MOA of stimulants for adhd
* Enhance neurotransmitter in brain pathways involved in inhibition
* Activate brain stem arousal
71
How to dose stimulants
until effectiveness w/o side effects
72
What are the categories of stimulants?
methylphenidates, amphetamines
73
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
74
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
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
79
Characteristics of long-acting stimulants
E.g., concerta is good for older students - steady period of action, ~12h duration
80
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
81
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
82
How to manage appetite suppression/wt loss on stimulants
eat breakfast before medicationIf on ER, will happen around lunch. They can have snacks before school.amphetamines seem to have more appetite suppression
83
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
84
Is routine cardiovascular monitoring needed before starting stimulants?
Previously it wasin 2008, AAP recommended no ECG: no increased risk of SCD and questionable S/S of ECG in predicting SCD
85
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
86
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
87
What CV f/u is needed on stimulants?
* Vital signs
| * Symptoms referable to CV system- syncope, palpitations ( butterfly in my chest), SOB, “heart pain”
88
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
* Few long term outcomes or safety data
* Newer study: Pre-school adhd treatment study (pats)
89
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
90
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)
91
Impact of stimulants on developing brain, preschoolers
no long term safety / efficacy impact
92
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
93
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
94
Concerns with energy drinks and stimulants?
Synergy!
95
When might you Rx strattera?
Not responding to stimulants or high abuse potential–Mood stabilizing effect if comorbidity
96
What is Strattera?
–First non-stimulant for ADHD–Norepinephrine reuptake inhibitor
97
When should effects of Strattera be seen?
–2-6 weeks before effects seen–24 hour period of action
98
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
99
When is Intuniv recommended?
Non-stimulant! Good for high activity levels, issues w/stimulantsRecommended:
* Core ADHD symptoms plus irritability, temper regulation
* Intolerant of stim, tics or sleep issues
* 6-17 year olds
100
Is Intuniv approved for use w/stimulants?
yes!
101
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
102
Intuniv MOA
Interacts with receptors in prefrontal cortexguanfacine - a BP med Central alpha-2 adrenergic agonist
103
Side effects of Intuniv
* Fatigue, drowsiness
Lowers blood pressure:
* Lightheadedness, syncope
* GI: Nausea, stomach pain, constipation, appetite, dry mouth
* Neuro: Irritability, headaches
104
Monitoring of Intuniv
BP and HR @beginning and with every ↑ and then q med check
105
What is the newest non stimulant for adhd?
Kapvay / Clonadine
106
MOA of Clonadine
MOA unknown in ADHDMay involve prefrontal cortex activity like Intuniv
107
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!
108
SEs of kapvay
* Similar to Intuniv
* Bradycardia
* Somnolence, etc.
109
Intuniv vs kapvay
BID as opposed to Intuniv which is QD. Also good for hyperactivity.Like Intuniv, Combine w/stimulant for attention
110
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
111
Considerations when choosing a medication for adhd?
```
Subtype
Issues with “quality of life”
Short acting vs long acting
Delivery method
Start low, titrate up
```
112
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
113
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
```
114
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
115
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!!!
116
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
117
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 useNo support of megadose of vits/minerals – should treat iron deficiency
118
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
119
What is a 504 plan?
Provides accommodations, modifications in regular classroom
* Preferential seating
* Extended time
* Modified assignments
* Alternative test setting
* Overflow activity
* Motor breaks
120
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.
121
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
122
Outcomes of effective assessment and mgmt?
* Improved self esteem
* Improved learning outcomes
* Improved family harmony
* Improved social skills
* Improved educational/
* vocational opportunities
123
Pediatrics: KAS from subcommittee on adhd
1 – The PCC should evaluate for ADHD if 4-18yo
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
3 – PCC should assess for coexisting conditions (anxiety, dep, ODD, CD, learning/language DO, neurodvptl do, tics, OSA)
4 – PCC to recognize ADHD as chronic dz. Follow chronic care model and medical home
5 – Tx varies by age. PCC recs:
• Preschool (4-5yo): behavioral tx as 1st line and Rx methylphenidate if no significant improvement and mod-severe continuing disturbance in child’s function.
• Elementary (6-11yo): FDA approved med and/or behavioral tx, preferably both. Evidence strong for stimulants, 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, and maybe behavioral tx , preferable both
6 – titrate doses of meds for adhd to achieve maximum benefit w/minimum adverse effect
