ADHD/Learning Disorder

Question 1

subtypes of ADHD

Answer 1

hyperactive-impulsive

inattentive

combined

Question 2

criteria for diagnosis

Answer 2

symptoms present in more than one setting (i.e school and home)

persist for at least 6 months

present before age of seven years

impair function in academic, social or occupational activities

excessive for the developmental level of the child

must exclude other mental/medical disorders that could account for the symptoms

Question 3

how do you ask about the hyperactive-impulsive subtype

Answer 3

does the child seem excessively restless or has difficulty sitting still? difficulty waiting turns or interrupting?

Question 4

how do you ask about the inattentive subtype

Answer 4

are they easily distractable, forgetful or disorganized? do they often daydream? do they have difficulty completing tasks?

Question 5

what other conditions should you screen for

Answer 5

conduct disorder

anxiety/depression

oppositional defiant disorder

sexual abuse/physical abuse

tourettes or other tic disorder

learning disorder

vision or hearing impairment

Question 6

how do you screen for conduct disorder

Answer 6

has there been legal trouble? are they cruel towards people or animals?

Question 7

how do you screen for ODD

Answer 7

do they often argue with adults or lose their temper easily

Question 8

how do you screen for childhood anxiety/depression

Answer 8

do they excessively worry? ever expressed thoughts of self harm?

Question 9

what other questions to ask on history for ADHD

Answer 9

at what age behaviours first noticed? who has observed them? have they progressed?

are they the same behaviours noted outside of school? i.e at home or with peers

are these behaviours funtionally impairing the child?

any inappropriate sexual behaviour?

any repetitive vocal or motor tics?

any concerns with vision or hearing

any problems with bowel/bladder control, or bedwetting?

can we have school assessments that have been done?

Question 10

what should you ask about the childs PMHx when assessing ADHD

Answer 10

complications with pregnancy, early infancy, hospitalizations

exposures to toxins such as lead or EtOH

learning disability or psychiatric illness history

seizure or other brain disorder

have they met all developmental milestones

previous immunizaitons? nutrition?

Question 11

what medications might cause behaviour that mimics ADHD

Answer 11

bronchodilators
steroids
antihistamines
antipsychotics
anticonvulsants

Question 12

what physical exam should you do for ADHD

Answer 12

ruling out underlying medical disorders and look for signs of neglect and abuse

including screening for hearing and vision, neuro, MSE

cardiac exam before starting stimulants

Question 13

is diagnostic testing required for ADHD

Answer 13

not normally indicated unless you suspect other causes
*it is a clinical dx

before diagnosing, need to gather all info and consult DSM criteria

Question 14

medical ddx for ADHD

Answer 14

medication related
thyroid disease
infection
brain injury
lead toxicity
malnutrition
sensory impairment
seizure disorder
sleep disorder

Question 15

developmental ddx for ADHD

Answer 15

mental retardation
developmental delay
language disorder
learning disability

Question 16

psychiatric ddx for ADHD

Answer 16

anxiety
depression
conduct disorder
ODD
substance use
pervasive developmental disorder

Question 17

environmental ddx for ADHD

Answer 17

neglect or abuse
dysfunctional parenting or home life
history of bullying

Question 18

how do you manage ADHD

Answer 18

team approach

there are behavioural and pharmacological approaces

Question 19

behavioural approach to ADHD management

Answer 19

rewards for good behaviour and consequences to unwanted behaviour

maintain schedules and set routines, set small and reachable goals, charts and checklists to keep kids on task

support groups and parental skills training

teacher education with academic support

sleep and nutrition support

CBT and psychotherapy

involve school in care

Question 20

pharmacological approach to ADHD management

Answer 20

stimulants are first line
i.e methylphenidate (ritalin) and dextromethamphetamine

start at low dose and slowly titrate up over 2-4 weeks

Question 21

indications to start meds in ADHD

Answer 21

diagnostic assessment complete and it confirms aDHD

older than 6 years

parents accept meds as treatment

school on board with administering meds

no known sensitivities to the meds

normal vitals with no evidence of CV disease

no seizure d/o

no tourettes or autism d/o

no known substance abusers in the home

Question 22

side effects of stimulants

Answer 22

sleeping difficulties
appetite suppression
anxiety or irritability
tics
CV effects

*chronic use may DELAY growth

Question 23

what is a second line med for ADHD

Answer 23

strattera (atomoxetine)

use if stimulants fail, parents dont want stimulanta or concern over stimulant abuse

watch for SI

other second line are bupropion, TCAs, alpha agonists like clonidine

Question 24

when are TCAs especially useful with ADHD

Answer 24

when it is comorbid wtih depression and enuresis