Module 3: ADHD & Autism

Question 1

Neurodevelopmental Definition

Answer 1

1. Having to do with the way the brain affects emotion, behavior, & learning
2. This affects:
   - Academic achievement
   - Well-being
   - Social interactions

Question 2

ADHD Pathogenesis

-Genetic Factors

Answer 2

1. Evidence for a genetic basis of ADHD is supported by twin studies that demonstrate concordance as high as 92% in monozygotic twins and 33% of dizygotic twins
2. Neuroanatomy — There is a structural difference in brain imaging between those with and without ADHD
3. Malfunction in catecholamine metabolism in cerebral cortex may be at play in ADHD
4. Catecolamines include
   - Epinephrine
   - Norepinephrine
   - Dopamine

Question 3

ADHD

-3 Types

Answer 3

1. Hyperactive/Impulsive Type
2. Inattentive Type
3. Combined Type

Question 4

ADHD

-Hyperactive/Impulsive Type

Answer 4

1. Fidgets and talks a lot
2. Hard to sit still for long (meals and homeword)
3. Smaller children may run, jump or climb constantly
4. Individual feels restless and has trouble w/ impulsivity
5. May interrupt others a lot, grab things from people, speak at inappropriate times
6. It is hard for a person to wait their turn or listen to directions
7. May have more accidents and injuries than others

USUALLY DIAGNOSED AROUND 6-7 YRS OLD**

Question 5

ADHD

-Inattentive Type

Answer 5

1. Hard for the individual to organize or finish a task, to pay attention to details, or follow instructions or conversations
2. Person is easily distracted or forgets details of dialy routines

USUALLY DIAGNOSED AROUND AGE 9-10 yrs**

Question 6

ADHD

-Combined Type

Answer 6

1. Sx’s of the above two types are equally present in the Person

USUALLY DIAGNOSED AROUND AGE 6-7 YRS**

6 sx’s of hyperactivity and 6 sx’s of inatention

Question 7

DSM-V criteria Inattentive Subtype

Answer 7

6 or more sx’s of INATTENTION for children up to age 16
OR
5 or more for adolescents 17 and older on the following slide have persisted for AT LEAST 6 MONTHS. To a degree that is MALADAPTIVE and inconsistent w/ developmental level

NEED TO PERSIST FOR AT LEST 6 MONTHS OR GREATER
AND
MUST BE MALADAPTIVE

Question 8

Additional Criteria for ADHD Dx

Answer 8

1. Several inattentive or hyperative-impulsive sx’s were present prior to age 12
2. Several “ sx’s are present in TWO or more settings
3. Clear evidence that sx’s interfere w/ or reduce quality of social academic or occupational functioning
4. Sx’s do not occur exclusively during the course of schizophrenia or another psychotic disorder

Question 9

ADHD Differential Diagnoses

Answer 9

1. Cognitive problems
2. Environmental factors
3. Various medical conditions such as
   - Visual impairment, lead poisoning, asthma, fetal alcohol syndrome, thyroid abnormalities, sleep disorder and seizure disorder
4. Seizures are included because some seizure medications can be SEDATING -
   - Also some seizures make it appear child is NOT paying attention
5. Asthma — Pt’s may be on steroids which may cause ADHD sx’s
   - SABA use can cause anxiety and increased HR sx’s which can appear to be ADHD

Do sx’s fluctuate with the underlyning disease or are they PERSISTENT and PERVASIVE which would lead more towards ADHD

Question 10

Co-Morbid Disorders W/ ADHD

Answer 10

1. Inattentive Type ADHD have comorbid — Anxiety And/or Depression
2. Hyperactive/Impulsive ADHD have comorbid — Oppositional defiant disorder and/or conduct disorder
3. Co-Morbid disorders can be primary or secondary
4. The vanderbilt Assessment scale assesses for all of the above co-morbid conditions

Question 11

Diagnostic tools — Vanderbilt Assessment Scales

Answer 11

1. Diagnoses and tracks ADHD sx’s over time (High frequency is key) as well as screen for the following comorbid problems
   - Conduct disorders, oppositional defiant disorders, anxiety and depression
2. NICHQ - Parent and Teacher Informant
3. Follow-up Scales
   - NichQ Parent and teacher informants
4. These scales will NOT pick up learning disabilities, suicidal behaviors, bipolar disorders, alcohol and drug use or tics

Make sure there is a HIGH FREQUENCY of sx’s to make ADHD diagnosis and not just mild or transient sx’s

Question 12

ROS for ADHD

Answer 12

1. Prenatal exposures
2. Perinatal complications or infections
3. CNS infection
4. Head trauma
5. Recurrent otitis media
6. Medications
7. Family hx of similar behaviors
8. Sleep disturbances — Amphetamines can cause sleep changes — may need melatonin
9. Dietary hx - picky eating? Amphetamines can suppress appetite
10. Cardiac baseline and possible EKG prior to starting medications

Question 13

ADHD Physical Exam?

Answer 13

1. The physical Exam of children with ADHD is usually NORMAL
2. Exam is necessary to r/o
   - Neurofibromatosis —These children have higher incidence of ADHD — Look for cafe o’le spots or nodules
   - Dysmorphic features — might be a congenital or genetic disorder

Question 14

ADHD treatment Guidelines set by AAP

Answer 14

1. ADHD is a chronic condition
2. Collaboration between provider, school and family to guide outcomes
3. Clinician should recommend stimulant medication and/or behavioral therapy
4. Re-evaluate situation if child w/ ADHD has not met target outcomes — Look at original diagnosis
5. Periodically follow-up to make sure child is tolerating medications and that things are working

Question 15

Treatment Goals for ADHD

Answer 15

1. Improved relationships with parents, teachers, siblings, or peers
2. Improved academic performance
3. Improved rule following

Question 16

ADHD Treatment Ages 4-5 yrs

Answer 16

1. Behavioral therapy is recommended as the FIRST LINE of treatment
2. Methylphenidate if behavior interventions do not provide significant improvement (No FDA approved meds under age 6)
   - Concerta
   - Focalin
   - Metadate
   - Methylin
   - Ritalin

Question 17

ADHD Treatment Ages 6-11 years

Answer 17

1. Best treatment is Behavioral therapy in conjunction w/ medications
2. Stimulants are FDA approved medications
   - Amphetamines - Adderall
   - Methylphenadate
3. Atomoxetine (Straterra) Is a NON-STIMULANT medication for ADHD, especially for high risk drug behavior or selling of meds
4. Alpha-2 adregnergic agonists — Only used if stimulatns and Straterra fail
   - Clonidine (extended release ONLY)
   - Guanfacine

Question 18

ADHD Treatment Ages 12-18 years

Answer 18

1. Same as group 6-11 EXCEPT that patient must agree to take the medication as an adolescent
2. High potential for abuse in this group — Giving medications to friends

Question 19

Summary of PCP role in ADHD

Answer 19

1. Synthesize and interpret information about child’s behavior
2. ID other medical or psychosocial problems that might be causing sx’s
3. Refer for further evaluation where needed
4. Provide appropriate medical treatment
5. Monitor progress
6. Suppport parents in their role as advocates for the child

Question 20

AUTISM LECTURE NEXT

Answer 20

AUTISM LECTURE NEXT

Question 21

Autism Definition

Answer 21

1. Neurodevelopmental disorder like ADHD
   - Deficits in social communication and social intenraction
   - Restrictive repetitive patterns of behavior, interests, and activities
   - Sx’s MUST be present in early development
2. If a 5 year old is being evaluated, ask parents what the child was like at 1, 2, 3 years old. Usually these children are VERY good infants because they do not need social Interactions

Question 22

Autism Stats

Answer 22

1. Male to Femal ratio is 4:1 - Look at genetic factors in females who present with autistic like sx’s
2. Prevalence is 1-2 per 1000
3. 3-10% increased risk in siblings
4. Increased incidence of epilepsy and intellectual diability

Question 23

Autism Pathogenesis

Answer 23

1. General consensus that there is a GENETIC etiology

2. Brain abnormalities supported by autopsy studies and MRI

Question 24

Autism Clinical Manifestations

Answer 24

1. “Spectrum” — Children may have delays in first year all the way to children with frank regression after typical development
2. Most children diagnosed present w/ delayed acquisition of language skills
3. Regression of language milestones is NEVER normal and is a characteristic of autism

Question 25

Autism Clinical Manifestation of (Social Communication)

Answer 25

1. Social reciprocity — Unaware of others, lack of empathy, no interest in imitation 2. Joint attention — Sharing of interest, amusement or apprehension of an objective w/ friends or caregivers 3. Non-verbal communication — DIfficulty reading non-verbal emotional cues 4. Social relationships — prefer solitary play over social play **Children with Autism lack joint attention but not protoimperitive pointing — Meaning this child will still point at an object that they want

Question 26

Autism Clinical Manifestations (Restricted/Repetitive Behaviors

Answer 26

1. Stereotyped behaviors — Hand or finger flapping or twisting, rocking ,swaying, dipping, walking on tip toes 2. Insistence on sameness — Focus on routine, difficulty w/ transitions 3. Restricted interests — Interest that is abnormal in either intensity or focus - Can be difficult to differentiate between Primary Autism and Secondary OCD - Young kids can focus on peculiar sensory arrousal. Older kids may focus on weather, dates, schedules, license plates, pokimon etc. 4. Sensory perception — Over-responsiveness, under responsiveness, and paradoxical responses to environmental stimuli - Visual inspection of objects out of the corner of their eyes, Only eating certain textures of food

Question 27

Diagnosis of Autism

Answer 27

1. Diagnosis should be made by an experience professional (ie developmental pediatrician, psychologist, psychiatrist etc) 2. Diagnosis is made based on DSM V criteria Previous slides 3. Firther classified into disease severity in each of the 2 categories based on level of suport required 4. Added specifiers - Intellectual disability - Language impairment - Known medical or genetic condition - Catatonia

Question 28

Role of PCP with Autism

Answer 28

1. Listen to concerns of parents 2. Routine surveillance/screening 3. Obtain history 4. Complete physical exam 5. R/O other disorders 6. Identify and refer to specialits 7. Connect w/ early intervention services

Question 29

Review Hx in Autism

Answer 29

1. Review of early developmental Hx 2. Parental concerns regarding hearing, vision, and speech/language 3. Specific info regarding early communicative behaviors — Pointing, eye contact, response to name 4. Hx of repetitive, ritualized, or stereotyped behaviors - hand flapping 5. Preoccupation with parts of toys 6. Frequent tantrums, trouble tolerating change or transition 7. Possible seizures 8. Self-injury 9. Significant disturbance in eating (including pica) or sleep

Question 30

Autism Physical Exam

Answer 30

1. Growth Parameters — Examine head circumfrance which is in 97th percentile in most with autism 2. Exam skin to r/o tuberous sclerosis 3. Examination of dysmorphic features- ie - Fragile x syndrome — long face, large ears, large testicles - Angleman Syndrome — Ataxic gate, broad mouth, persistent smile, language delays, seizures - Smith-Lemli-Oplitz syndrome — microcephaly, soft cleft palate, bifid uvula, low-set posteriorly ears, failure to thrive 4. Examination of muscle tone and reflexes — Look for hypotonia

Question 31

Autism Ancillary Testing

Answer 31

1. Vision and hearing assessment 2. Speech, language, and communication assessments 3. Developmental/intelligence testing w/ separate estimates for verbal and nonverbal skills 4. Assessment of adaptive skills - Ie: intellectual disability 5. Neuropsychologic and or achievement testing 6. Sensorimotor and or occupational therapy eval

Question 32

Autism Management

Answer 32

1. NO medications to treat ASD 2. Behavioral therapies — Applied behavioral analysis (ABA) 3. Education — IEP, lower teacher student ratios, offering of therapies 4. Medications to treat sx’s of - ADHD - Agression, outbusts and self injury - Anxiety/depression - OCD, rigidity, and repetitive behaviors - Sleep dysfunction