ADHD Diagnosis and Treatment Flashcards
(40 cards)
1
Q
What did the age range for diagnosis change from DSM IV to DSM 5?
A
- DSM IV - symptoms before age 7
- DSM 5 - several symptoms before age 12
2
Q
Where do symptoms need to be present in order to accurately diagnose ADHD?
A
- Multiple/2+ settings:
- School
- Home
- Social situations
- Etc.
3
Q
What are the three types of ADHD?
A
- Inattentive
- Hyper/Impulsive
- Mixed (both 1 & 2 above)
4
Q
What is the most common type of ADHD in boys and girls?
A
Boys - Mixed ADHD
Girls - Inattentive
5
Q
What is the least common type of ADHD?
A
Hyper/Impulsive only
6
Q
What are three possible family/genetic/developmental factors that could lead to ADHD symptoms?
A
- In utero exposures
- Nicotine, Alcohol, Cannabis
- Birth trauma
- nuchal chord (cord wrapped around neck)
- Frontal lobe trauma
- TBI
- Lead, mercury, & other heavy metal exposure
7
Q
What is the differential diagnosis for ADHD symptoms?
A
- Learning disorders
- Behavioral disorders
- Oppositional Defiant, Conduct disorder
- Anxiety disorders
- trauma (PTSD), OCD, GAD, Social Phobia
- Mood disorders
- Depression, Bipolar, Dysthymia
- Psychotic (rare)
8
Q
What medical etiologies must be ruled out in work up for ADHD?
A
- Neuro
- seizures, TICS (transient blinking), Tourettes, migrains
- Endocrine
- thyroid dysfunction
- diabetes
- Sleep Disorders
- Drugs (chronic)
9
Q
What testing is used in diagnosing ADHD?
A
- Formal Cognitive Processing Tests
- self report, from parents, from teachers
- Practical Testing (video games/movies)
- mildly helpful in distinguishing types, but not stand alone diagnosis
- Executive funcitoning tests & Learning Disorder screens
- Positive screen when their executive function is below their actual IQ
- Wisconsin Card Sort
- fucking preserverance!
10
Q
What are the 5 ADHD Algorithm Options Dr. Bauer talked about in class?
A
- ADHD
- ADHD with Depression
- ADHD with Anxiety
- ADHD with Aggressive Behaviors
- ADHD with TIC Disorders
11
Q
What are the guidelines for Stage 0 treatment of ADHD?
A
- Nonpharmacological
- Special education
- Parent education
- Group support
- Behavior modification
- Individual therapy
12
Q
What are the guidelines for Stage 1 treatment of ADHD?
A
- Methylphenidate or Amphetamine
- Pharmacotherapy → ½ hour to hour before starts to work, watch minimal effective dose
- Examples: Methylphenidate, dextroamphetamine, amphetamine, dexmethylphenidate
- Risks: CV, tics, anxiety/depression, psychosis, mania
- Pharmacotherapy → ½ hour to hour before starts to work, watch minimal effective dose
13
Q
What are the guidelines for Stage 2 treatment of ADHD?
A
- “The Other”
- Long Acting Psychostimulants
- Biphasic → coat half pills in something that takes longer to dissolve
- Adderall XR
- Ritalin LA/SR
- Metadate
- Focalin
- Biphasic → coat half pills in something that takes longer to dissolve
- “Continuous” → harder to do
- Daytrana = patch, peel off hour before bed
- Long Acting Psychostimulants
14
Q
What are the guidelines for Stage 3 treatment of ADHD?
A
- A. Non Stimulants → Atomoxetine (Strattera)
- selective norepinephrine reuptake inhibitor
- Adverse Rxns: nausea, agitation
- B. Atomoxetine + Stimulant
15
Q
What are the guidelines for Stage 4 treatment of ADHD?
A
- Atypical Antidepressants
- Buproprion (Wellbutrin/Zyban)
- mild norepinephrine/dopamine inhibitor
- Venlafaxine (effexor), Duloxetine (Cymbalta)
- Norepinephrine/Serotonin reuptake inhibitor
16
Q
What are the guidelines for Stage 5 treatment of ADHD?
A
- Tricyclic Antidepressants
- Desipramine
- Imipramine
- Amitriptyline
- Mirtazepine
- ***can cause cardiac arrythmias and cholinergic side effects like: dry mouth, constipation, sedation, and orthostatic hypotension
17
Q
What are the guidelines for Stage 6 treatment of ADHD?
A
- Alpha-2 Agonists
- Blood pressure agents used to calm hyperactivity, impulsivity, & little focus
- Ex. Clonidine (Catapres) & Guanfacine (Tenex)
18
Q
How should you treat ADHD with Anxiety?
A
Use stimulant to treat ADHD first, then add an SSRI if anxiety symptoms do not resolve with successful treatment of ADHD
19
Q
How should you treat ADHD with Depression?
A
Tx whichever disorder is most severe first, then add Tx for the second if monotherapy does not result in remission of both disorders
20
Q
How should you treat ADHD with TIC Disorders?
A
- Stage 1 - stimulant monotherapy
- Stage 2 - stimulant required for ADHD, but if tics persist add alpha agonists
- Stage 3 - add atypical antipsychotic
- Stage 4 - add pimozide or haloperidol only after failure of several atypical antipsychotics
21
Q
How should you treat ADHD with Aggression?
A
- Stage 1 - Tx ADHD, determine if aggression resolves
- Stage 2 - add behavior intervention to the stimulant
- Stage 3 - add an atypical antipsychotic to stimulant (he doesn’t like this though)
- Stage 4 - add lithium or divalproex sodium to stimulant
- Stage 5 - add additional agent that was not used in stage 4
22
Q
What are some common characteristics of ADHD according to Dr. Weber (fast talker)?
A
- characterized by hyperactivity, impulsivity, inattention
- Disorders of executive function
- Disorders of self regulation
- Specific learning disabilities
- math and reading common
- Male > Female
- Most common diagnosed child disorder
23
Q
What parts of the brain are affected/dysfunctional in ADHD?
A
- Prefrontal - delayed 2-3 years
- Dorsolateral prefrontal
- Prefrontal motor
- Orbital frontal cortex
- Basal ganglia - volume reduced
- Dorsal anterior cingulate cortex (is less than optimal)
- Cerebellum - Small volume with ADHD
24
Q
What area of the brain is delayed in ADHD and regulates sustained attention, problem solving, executive function, mental effort, following through, and the sustained attention circuit?
A
Dorsolateral Prefrontal Cortex
DLPFC → top of caudate → thalamus → DLPFC
25
What area of the brain is delayed in ADHD and functions to regulate motor hyperactivity and the hyperactivity circuit, which results in children fidgeting, leaving their seat, running/climbing, and always on the go?
## Footnote
:
Prefrontal Motor Cortex
PFMC → Putamen → Thalamus → PFMC
26
What area of the brain is delayed in ADHD and functions to regulate impulsivity, social and emotional responses, which results in talking excessively and not waiting?
Orbital Frontal Cortex
OFC → bottom of caudate → thalamus → OFC
27
What area of the brain is reduce in volume in ADHD and functions to regulate the selection of appropriate behaviors, voluntary motor control, and emotional functions?
## Footnote
Basal ganglia
28
What area of the brain functions less than optimally in ADHD and normally regulates the selective attention circuit, which results in little attention to detail, careless mistakes, and frequently losing things?
Dorsal Anterior Cingulate Cortex
ACC → bottom of striatum → thalamus → ACC
29
What area of the brain is small volume-wise in ADHD and is implicated in motor problems like handwriting, clumsiness, and delays in achieving motor milestones?
Cerebellum
30
What three neurotransmitters are important in ADHD?
* Dopamin
* Norepinephrine
* Serotonin
31
What change in neurotransmitters is thought to occur in ADHD?
* Lower quantity of NT
* Low rate of firing
* Possibly fewer receptors
32
What kind of family environment exacerbates inattentive, impulsive, and hyperactive child behaviors to a significant degree?
Chaotic & Unresponsive
If child is neurologically slow AND the family is chaotic, then the brain doesn't get trained in the correct way = results in ADHD!
33
What kind of parenting teaches children to self regulate skills and thus serves as a protective factor that may minimize ADHD symptoms?
Responsive & Sensitive
If child is neurologically slow but the family model is supportive, then child can do ok and **not** get diagnosed with ADHD!
34
What are some alternative environmental factors that may exacerbate symptoms of ADHD?
* lack of sleep (fidget to stay awake)
* light from electronics (cause lack of sleep)
* lack of exercise
* school curriculum (everyone learns differently)
* food allergy
35
What is the prevalence of adult ADHD?
* Prevalence of ADHD in childhood is 5% → many children grow out of it
* Prevalence of residual ADHD in adulthood 3-4%
* Less likely to include hyperactivity, more likely to include inattentiveness
* Male: female in adulthood 1:1
36
**T/F** Adult ADHD *without* comorbidity is RARE.
True
Commonly:
* Mood disorders, depression, manic, anxiety, dementia, delirium, sleep apnea, insomnia, hyperthymic personality
37
Do more people with bipolar disorder also have ADHD or do more people with ADHD also have bipolar disorder?
More people with bipolar disorder have ADHD.
* 20-25% with bipolar also have ADHD
* 6-7% with ADHD also have bipolar
38
T/F 84% of parents who had childhood Hx of ADHD had at least one child with ADHD.
True
Why?
* Shared genetics?
* Parenting practices?
* Psychological?
39
What are three major liability issues in pharmacotherapy of ADHD?
* Dependence on medication
* Prescriptions to recovering substance abusers - Strattera, Tenex, Clonidine, antidepressant
* Diversion (give, trade, sell) - lifetime rates ~30%
40
What are six behavioral treatments of ADHD?
* IEP (individual education plan) at school
* Self control skills → stop, think, act
* Family Education
* Parenting classes
* behavioral management, social skills, monitor height and weight, consistence and structure
* Mindfulness training and self monitoring
* Environmental accommodations
* charts, beepers (reminds to take medications, stop/start studying), notes, limits
* EXERCISE!!!!
