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Behavioral Dynamics > Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder > Flashcards

Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder Flashcards

1
Q

What are the characteristics of ADHD?

A
  • Diminished sustained attention and high levels of impulsivity or hyperactivity
  • Must be present before age 12
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2
Q

What are the 3 specifiers for ADHD?

A
  • ADHD, predominantly hyperactive/impulsive
  • ADHD, predominantly inattentive
  • ADHD, combined type
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3
Q

what is the epidemiology of ADHD?

A

2-18% of children, 3-5% of adults, varies with study and criteria, increasing over time

Gender: more common in males

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4
Q

What are comorbidities with ADHD?

A

conduct disorders, anxiety, depression, learning disorders

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5
Q

What biological factors impact the development of ADHD?

A

impaired catecholamine (norepinephrine, dopamine) metabolism, increased risk with + family history

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6
Q

how is ADHD diagnosed?

A

6+ symptoms from either inattentiveness or hyperactive or 6+ from each, for 6+ months:

-Maladaptive and inconsistent with developmental level
-Some symptoms must have been present before age 12
-Clear functional impairment from symptoms present in 2+ settings
-Not accounted for by another disorder

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7
Q

What are non-pharm treatments of ADHD?

A

behavioral interventions
cognitive therapy
dietary modifications

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8
Q

In which populations are behavioral interventions preferred over medication for ADHD?

A

preschool

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9
Q

Behavioral interventions are used as an adjunct for which ADHD patients?

A

older children and teens

(Do not improve core ADHD s/s in school-age pts but often helpful to improve parent-child relationship)

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10
Q

what are behavioral interventions for ADHD?

A

modify environment, using rewards to reinforce behavior

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11
Q

How is cognitive therapy used in ADHD?

A

It is not recommended as monotherapy but may be useful as a adjunct

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12
Q

What dietary modifications are used in ADHD?

A

Elimination diets: make sure has adequate nutrition for children
Fatty acid supplementation: not routinely recommended
Other alternative therapies: megavitamins, chelation, detox, herbal or mineral supplements but no solid evidence and can have harmful side effects

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13
Q

What is a new alternative therapy for ADHD?

A

EndeavorRx (FDA approved)

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14
Q

What is pharmacological treatment of ADHD?

A

Stimulants: Methylphenidate, amphetamines

Non-stimulants:
-Atomoxetine
-Alpha-2 adrenergic agonists: clonidine, guanfacine
-Antidepressants

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15
Q

What is criteria for starting prescription therapy in children with ADHD?

A

Full diagnostic assessment has been completed and confirms diagnosis
Child is at least 6 years old
School will cooperate in administration and monitoring of rx
No concerns about substance use in household members

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16
Q

What historical factors mean you should not receive pharmacological treatment for ADHD?

A

Sensitivity or allergy
uncontrolled tachycardia
uncontrolled hypertension
uncontrolled anxiety
seizures
pervasive developmental delay
tourette syndrome

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17
Q

What is the first line mode of treatment for ADHD?

A

pharmacologic treatment

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18
Q

What is first line pharm for ADHD 6yo+?

A

Stimulants

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19
Q

What schedule are stimulants?

A

II

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20
Q

What is the mechanism of action of stimulants?

A

increases intrasynaptic levels of catecholamines

Metylphenidate: blocks reuptake
Amphetamines: blocks reuptake, stimulate dopamine release

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21
Q

Why might an extended release form of stimulant be helpful?

A

reduce adverse SE at peak levels of drug
reduce crash SE when drug is cleared

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22
Q

Many stimulants come with special release formulations to manage ____ and reduce ____

A

symptoms, tachyphylaxis

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23
Q

What symptoms of ADHD do stimulants not treat?

A

emotional problems, defiant behavior, learning impairment, reduced social skills

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24
Q

How are stimulants dosed?

A

Start low go slow and titrate up until 40-50% improvement in symptoms

Adjust dosing schedule based on symptoms, activities, and functional impairment

May reassess need for stimulants over time, if discontinued tapered down

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25
Q

can patients on stimulants receive drug holidays?

A

yes, helpful to schedule for weekends or vacations because reduces dependence

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26
Q

What are common side effects of stimulus?

A

Reduced appetite
Insomnia or nightmares
Feeling “one-edge” or “jittery”
Emotional lability
Weight loss and/or decreased height
Development of tics
Usually mild and correctable with dose adjustments

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27
Q

What are less common side effects of stimulants?

A

Cardiovascular: increased HR, increased BP, palpitations, peripheral vasculopathy
Priapism: seen with methylphenidate, very rare (be careful if taking viagra)
Neuro: headache, dizziness
GI: N/V/D
Psych: psychotic symptoms, manic symptoms
Diversion or misuse

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28
Q

What are contraindications to stimulants?

A

allergy to medication
history of substance abuse
hyperthyroidism
glaucoma
cardiovascular: symptomatic cardiovascular disease, moderate to severe …. come back to this slide

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29
Q

What is the mechanism of action of methylphenidate?

A

blocks catecholamine reuptake to increase intrasynaptic levels

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30
Q

What is the use of methylphenidate vs amphetamines?

A

Relatively equally effective
Preferred for preschool-age children
Better tolerated with regard to weight loss and rarely associated with priapism

31
Q

What is the mechanism of action of amphetamines

A

blocks catecholamine reuptake, also increases dopamine release to increase intrasynatpic —– come back to this too

32
Q

What is the mechanism of action of atomoxetine?

A

selective norepinephrine reuptake inhibitor

33
Q

what is atomexetine mostly used?

A

if stimulants can’t be used due to intolerable SE, desire to avoid stimulant therapy, history of tic disorder or development of tics, risk of diversion/abuse of stimulants

34
Q

How long does atomoxetine take to kick in?

A

delay of 1-2 weeks for clinical efficacy

35
Q

What are side effects of atomoxetine?

A

GI: decreased appetite, N/V, abdominal pain, dyspepsia, weight loss
CV: may see increased BP and HR, arrhythmias, peripheral vasculopathy
Priapism
Neuro/Psych: …. come back to this

36
Q

What is the mechanism of action of alpha-adrenergic agonists?

A

stimulation of alpha-2 adrenergic receptors in the

37
Q

What is the 3rd line therapy for ADHD?

A

Clonidine

38
Q

what are the side effects of clonidine?

A

sedation, depression,

39
Q

What is the 3rd line monotherapy for ADHD?

A

guanfacine

40
Q

What is the 4th line therapy for ADHD?

A

TCAs

41
Q

Which antidepressant is commonly used for ADHD?

A

bupropion

42
Q

What are characteristics of autism?

A

Neurodevelopmental disorders characterized by:

-Deficits in social interaction and communication
-Restrictive repetitive patterns of behavior, interests, and activities
-Must be present in early development

43
Q

what is the epidemiology of autism spectrum disorder?

A

3-4x more common in males
… more on card

44
Q

What are ASD associated conditions?

A

Intellectual disability
ADHD
Seizures
Multiple genetic and metabolic conditions

45
Q

What is the general consensus of ASD etiology?

A

genetic etiology alters brain development causing abnormal social and communication development

46
Q

What is the epigenetic theory

A
47
Q

What abnormality seems to play an important role in ASD?

A

structural brain abnormality

48
Q

ASD patients have…

A

accelerated head growth
increased overall brain size
different patterns of connectivity
abnormal serotonin synthesis….

49
Q

What are environmental factors that may play a role in ASD?

A

Increased parental age
Overall poorer perinatal/neonatal health: preterm delivery, low birth weight
Maternal metabolic conditions (DM, HTN)

50
Q

What age do you most commonly see ASD by?

A

around 2

May manifest earlier or later, depends on social demands

51
Q

What are clinical findings of severe ASD?

A

signficant behaviorla problems, often mute; impaired social skills

52
Q

what are clinical findings of mild ASD?

A

verbal capacity, but unusual special interests; impaired social skills

53
Q

how does ASD manifest with social interaction?

A

delays and deviations in language
Social reciprocity
joint attention
nonverbal communication
social relationships: often fail to develop and maintain peer relationships

54
Q

What are characteristics of ASD restricted/repetitive behaviors?

A

-stereotyped behaviors: can involve complex or whole body movements
-hand flapping or twisting, rocking, swaying
-stereotyped rituals
-self-injurious-seen more with cognitive impairment head banging, face slapping, self-biting
-insistence on sameness
-restricted interests
-sensory perception deficits

55
Q

either abnormal intensity or focus on a narrow area or persistent preoccupation with unusual object

A

restricted interests

56
Q

what are features of ASD in addition to restricted/repetitive behaviors and social interaction impairments?

A

Intellectual impairment: often stronger in nonverbal tasks and markedly deficient in verbal cognition

Savant skills
Language impairment: delay in, or lack of, development of spoken language
Motor deficits: abnormal gait, clumsiness, toe walking, hypotonia
Macrocephaly

57
Q

What are early indicators for ASD?

A

No babbling by 9 months
No pointing or gestures by 12 months
Lack of orientation to name by 12 months of age
No single words by 16 months
Lack of pretend play
…

58
Q

How should children with potential ASD be screened?

A
59
Q

How is ASD treated?

A

Educational and Behavioral Interventions
Routine Screening and Preventative Care
Complementary and Alternative Medicine

60
Q

What are psychopharmacologic interventions for ASD?

A

If ADHD along with it, stimulants
Antipsychotics (or stimulants, SSRIs, alpha-adrenergic) for maladaptive behaviors
Anxiety or repetitive behaviors: SSRIs
Depressive symptoms: SSRI or SNRI
Dysregulated mood: atypical antipsychotic or SSRI

61
Q

What is ASD prognosis?

A

Lifelong condition
Many not able to function independently
Good prognosis if higher cognitive abilities, less severe symptoms, early identification, functional play skills
Poor prognosis if IQ <70, lack of joint attention by age 4 or functional speech by age 5, seizures or other comorbid conditions, severe symptoms

62
Q

What is etiology of Rett disorder?

A

Neurodevelopmental disorder due to sporadic mutation in MECP2 gene causing growth deceleration, especially in brain tissue

Almost exclusively in females

63
Q

what is the classic presentation of Rett disorder?

A

uneventful pregnancy and delivery, normal development for first part of life, deceleration of head growth …

64
Q

What is the initial presentation of Rett disorder?

A

loss of interest in surroundings, little purposeful hand movements (may persist with stereotypic movements)

65
Q

what are later clinical findings of Rett disorder?

A
66
Q

What are common findings with Rett disorder?

A

difficulty expressing self, dystonia, bruxism, drooling, scoliosis (very common), growth failure, epilepsy, bone mineral deficit and increased fracture risk, cardiac abnormalities, disordered wakeful breathing patterns

67
Q

What are helpful interventions for Rett disorder?

A

no specific treatment available
…

68
Q

A patient has ADHD, predominantly hyperactive/impulsive. How do you expect they will present?

A

Fidgety, hyperactive, difficulty remaining seated and waiting turns, impulsive

69
Q

A patient has ADHD, predominantly inattentive. What characteristics do you expect them to have?

A

Disorganized, forgetful, easily distracted, daydreaming, difficulty completing tasks

AKA ADD

70
Q

A patient was recently diagnosed with ADHD. What environmental factors may have contributed to their diagnosis?

A

Intake of food additives or refined sugar
Deficiency of fatty acids, iron, or zinc
Prenatal tobacco or alcohol exposure
Screen time exposure
Prematurity, low birth weight

71
Q

What sort of symptoms fall under inattentiveness in the ADHD DSM criteria?

A

Poor attention to detail or careless mistakes
Difficulty sustaining attention
Does not follow instructions; fails to finish tasks
Poor organization
Avoids or dislikes tasks needing sustained mental effort
Loses necessary materials for tasks
Easily distracted
Forgetful

72
Q

What sort of symptoms fall under hyperactivity in ADHD DSM criteria?

A

Fidgeting or squirming
Leaving seat when remaining seated is expected
Active in situations in which it is inappropriate
Difficulty playing or engaging in leisure activities quietly
Always “on the go” or acts as if “drive by a motor”
Excessive talking

73
Q

What falls into impulsivity for ADHD DSM criteria?

A

Blurts out answer before question is finished
Difficulty waiting turn
Often interrupts or intrudes on others

Behavioral Dynamics (6 decks)

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