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Three subtypes of ADHD

Predominately inattentive type (ADHD-I)
6 inattentive symptoms and <6 HI symptoms

Predominately hyperactive-impulsive type (ADHD-HI)
6 HI symptoms and <6 I symptoms

Combined type (ADHD-C)
6 or more HI AND 6 or more I


ADHD: Diagnostic Criteria inattention

Inattention for 6+ months that negatively impacts social, academic, vocational activities:


ADHD: Diagnostic Criteria hyperactivity and impulsivity

Hyperactivity and impulsivity for 6+ months that negatively impacts social, academic, vocational activities:


ADHD: Diagnostic Criteria age of onset, area where symptoms happen, comorbid

Age of onset prior to 12

Symptoms present in more than one setting

Not exclusively part of another more serious mental health condition:
Personality Disorder
Substance Abuse
Dissociative Disorder


ADHD: Associated Features

memory, language, motor, social

Mild delays in language, motor, social development
Difficulties with memory and executive functions


ADHD: Associated Features

increased risk with?

Increased risk of TBI, suicide attempt by early adulthood


adhd in preschool

adhd as adult

Course: more common to see hyperactivity in preschool ages; inattention and impulsivity still problematic by adulthood


ADHD: Risk Factors?

Gender: 2-1 ratio males to females

Environmental factors:
very low birth weight
Lead exposure
Teratogenic substances in utero

Genetic and physiological:
Highly heritable
Common in TBI, epilepsy, sleep disorders, etc.


examples of genetic syndromes known to be associated with intellectual disability:

Down syndrome (Trisomy 21)
Fragile X syndrome
Prader-Willi syndrome
Angelman syndrome
Williams syndrome
Tuberous sclerosis complex


Most common genetic disorder associated with intellectual disability, usually in the mild to moderate range (1 in 800 newborns diagnosed); not typically inherited

Down Syndrome


A.k.a. Trisomy 21 due to genetic etiology
Associated physical features and medical complications
Behavioral challenges common
High rates of co-occurring disorders

Down Syndrome


downs Associated physical features include:

flattened face and nose bridge, prominent upper eyelid fold, upward slanting eyes, small ears, short neck, large tongue, Brushfield spots on irises, small hands and feet, single palmar crease, small pinky fingers curving towards thumb, hypotonia (i.e., low muscle tone), short stature


downs Associated medical problems are possible:

congenital cardiac abnormalities (in about 50%), digestive abnormalities, gastroesophageal reflux, orthopedic abnormalities, hearing loss, airway obstruction (obstructive sleep apnea), vision problems, endocrine problems, higher risk of autoimmune diseases, higher risk of acute leukemia, anemia, skin-related problems


downs Behavioral features may include:

limitations in language and communication skills, limitations in cognition and nonverbal problem-solving skills, impulsive and disruptive behaviors, inattention, stubborn or oppositional behavior, increased anxiety/ruminative thinking, social deficits, chronic sleep problems, regression of skills with increased age


downs Higher rates of co-occurring disorders including

autism spectrum disorder, anxiety disorder, obsessive-compulsive disorder, depression, early onset dementia (usually starting around 50 years of age)


Most common inherited genetic disorder associated with intellectual disability (1 in 4,000 males and 1 in 8,000 females), with males being more severely affected than females with this disorder

Fragile X


FMR1 gene mutation, inherited X-linked dominant pattern

Higher rates of co-occurring disorders including:
autism spectrum disorder, ADHD, anxiety, mood disorders

Fragile X


fragile x Associated physical features include

long and narrow face, prominent jaw and forehead, large ears, very flexible fingers, flat feet, high-arched palate, and enlarged testes in males after puberty


Prader-Willi Syndrome Associated physical/medical features include

early feeding difficulties and failure to thrive, developmental delays, delayed puberty, infertility, short stature, small hands and feet, obesity due to hyperphagia, and distinctive facial features such as narrow forehead, almond-shaped eyes, and triangular mouth


Loss of gene function in region of chromosome 15 (not typically inherited)

Prader-Willi Syndrome


Prader-Willi Syndrome Associated clinical features usually include:

most are in mild to moderate range of ID or have learning disability, insatiable appetite, sleep disturbance, irritability, repetitive skin picking, compulsive behaviors


Genetic cause: Loss of UBE3A gene function (most cases involve a segment deletion on chromosome 15, with other mutations occurring as well); most cases are not inherited

Angelman Syndrome


Angelman Syndrome Associated physical/medical features include:

microcephaly, ataxic movements, “coarse” facial features, epilepsy


Angelman Syndrome
Associated clinical features usually include:

most present with severe to profound ID, absent or limited expressive language, significant developmental delays by 6-12 months of age, frequent smiling or bouts of laughter (happy, excitable demeanor), stereotyped/repetitive mannerisms, sleep difficulties, inattention


Medication Management for ADHD Psychostimulants

Adderall XR


Medication Management for ADHD Non-stimulants

Intuniv (guanfacine)
Strattera (atomoxetine)
Less common:
Wellbutrin for adults