Kk&s Ch.43 Adhd

Front 1

DSM Criteria for ADHD?

Back 1

Key number is 6
1. 6 sx (or more) for at least 6 mo maladatpive and nondevelopmental
Innattention
a. poor attention to details, careless
b. sustaining attention impaired
c. listening poor when spoken to directly
d. follow through of instructions/school work poor
e. organizing poor
f. effort sustained avoided
g. loses task things
h. distracted
i. forgetful often
2. six or more hyperactive-impulsive sx
a. fidgets, squirms
b. sitting is unstained
c. climbs, runs excessively, inappropriately
d. quiet leisure difficult
e. on the go, driven by a motor
f. talks ++
Impulsiviity:
g. blurts out
h. turn waiting difficult
i. interrupts others
Sx onset six and under (below 7)
Impairment in >=2 settings (home most reliable,then school for Conners)
Dysfxn
Sx not occuring only during course of: PDD, Sz, Psychotic DS
or better accounted for by Mood, Anxiety, Dissociative, or Personality Ds

Front 2

DSM Specifiers?

Back 2

combined type,
predominantly inattentive
predominantly hyper-active-impulsive p

Front 3

ADHD DDX?

Back 3

Temperment (hard to sort out before 3)
Seizure Ds (must get EEG, i.e., absence spells)
Anxiety Ds
Mood (Bipolar)
Conduct Ds
LD

Front 4

ADHD Bio Tx?

Back 4

STIMULANT MEDS

Methylphenidate preparations:
1. Ritalin 3 to 4 duration
2. Concerta 12 hour duration dose: 18mg up to 54mg
3. Methylphenidate CR (or Biphentin)

Dextroamphetamine preparations
Dexedrine

Dextroamphetamine and amphetamine salt preperations
Adderall
Adderall XR

NONSTIMULANT MEDS
Strattera (atomoxetine) ... but 2nd line

Front 5

Atomoxetine, line of evidence, mechanism?

Back 5

2nd line
NE uptake inhibitor

Front 6

Other agents beside stimulants, atomoxetine use?

Back 6

bupropion
clonidine/guanfacine : a-adrenergic receptor agonists

Front 7

FDA approved drugs by age?

Back 7

3 and older dextroamphetamine
6 and older methylphenidate

Front 8

methylphenidate moa?

Back 8

increase tone of NE and DA in prefrontal cortex by blocking NE Transoporter and DA Tranporter
(amphetamines and other short acting increase pulsatile NE, DA)

Front 9

Methylphenidate Side fx?

Back 9

common: headaches, stomaches, nausea, insonia,
can exab tics
growth suppression, make up in summer

Front 10

Atomoxetine side fx?

Back 10

diminished appetite, abdominal discomfort, dizziness, and irritability. In some cases, increases in blood pressure and heart rate have been reported. Atomoxetine is metabolized by the cytochrome P450 (CYP) 2D6

Front 11

Atomoxetine benefits?

Back 11

can also be used for low mood

Front 12

Along with atomoxetine, what other drugs can be used for ADHD?

Back 12

modfinil

Front 13

How manage methylphenidate insomnia?

Back 13

Suggestions for the management of insomnia in such a case include the use of diphenhydramine (25 to 75 mg), low dose of trazodone (25 to 50 mg), or addition of an α-adrenergic agent, such as guanfacine

Front 14

Paremeters to measure pre-rx start? and how often?

Back 14

PE
BP
Pulse
Weight
Height

check q season and physical qyearly

Front 15

How do stimulants help?

Back 15

Reduce sx: In most patients, stimulants reduce overactivity, distractibility, impulsiveness, explosiveness, and irritabilit
Not fix learning but allow learning
kids feel better about self

Front 16

Psychosocial Tx of ADHD

Back 16

Education (not crazy)
Work with teacher, Advocate
Parental support:
- Continue with reasonable expectations (not exemptions)
- + reinforcement
-

Front 17

ADHD Epidemiology?A conservative figure is about ? percent of prepubertal elementary school children have ADHD

Back 17

3 to 7%

Front 18

ADHD is more prevalent in boys than in girls, with the ratio ranging from ? to 1 to as much as ? to 1

Back 18

2 to 9X

Front 19

The suggested contributory factors for ADHD include?

Back 19

prenatal toxic exposures,
prematurity, and
prenatal mechanical insult to the fetal nervous system

Front 20

siblings of hyperactive children have about ? the risk of having the disorder as those in the general population

Back 20

twice

Front 21

Children with ADHD are at higher risk of developing ? disorders, and ? disorders and ? personality disorder are more common in their parents than in those in the general population.

Back 21

Children with ADHD are at higher risk of developing conduct disorders, and alcohol use disorders and antisocial personality disorder are more common in their parents than in those in the general population.

Front 22

What factors along with genetics may be at play on ADHD etiology?

Back 22

Developmental factors (September babies exposed to infection during first trimester).
Brain damage: subtle damage during fetal/perinatal periods as higher rates of soft neuro signs
Neurochemical: too much peripheral epinephrine resets locus ceruleus to lower, less attention paying, level of stimulation
Neurophsiologic: maturational delay, hypoactive frontal lobes
Psychosocial factors: emotional deprivation in institutes, stressful life events may precip and perpetuate

Front 23

A recent study of quantitative EEGs in children with ADHD, in children with undifferentiated attentional problems, and in normal controls indicates that both groups with attentional problems e

Back 23

vince increased beta band relative percentages and decreased rare tone P3000 amplitudes. Increased beta band percentage or decreased delta band percentage is associated with increased arousal.

Front 24

ADHD PET findings?

Back 24

PET scans have also shown that adolescent females with the disorder have globally lower glucose metabolism than both normal control females and males with the disorder. One theory explains these findings by supposing that the frontal lobes in children with ADHD are not adequately performing their inhibitory mechanism on lower structures, an effect leading to disinhibition.

Front 25

Children with the predominantly ? type are more likely to have a stable diagnosis over time and to have concurrent conduct disorder than are children with the predominantly ? type.

Back 25

Children with the predominantly hyperactive-impulsive type are more likely to have a stable diagnosis over time and to have concurrent conduct disorder than are children with the predominantly inattentive type without hyperactivity

Front 26

What might you see on MSE of child with ADHD?

Back 26

The mental status examination may show a secondarily depressed mood, but no thought disturbance, impaired reality testing, or inappropriate affect. A child may show great distractibility, perseveration, and a concrete and literal mode of thinking. Indications of visual-perceptual, auditory-perceptual, language, or cognition problems may be present. Occasionally, evidence appears of a basic, pervasive, organically based anxiety, often referred to as body anxiety.

Front 27

ADHD Neurological exam?

Back 27

A neurological examination may reveal visual, motor, perceptual, or auditory discriminatory immaturity or impairments without overt signs of visual or auditory acuity disorders. Children may have problems with motor coordination and difficulty copying age-appropriate figures, rapid alternating movements, right-left discrimination, ambidexterity, reflex asymmetries, and a variety of subtle nonfocal neurological signs (soft signs).

Front 28

ADHD and character as infant?

Back 28

More commonly,
P.1209

however, infants with ADHD are active in the crib, sleep little, and cry a great deal.

They are far less likely than normal children to reduce their locomotor activity when their environment is structured by social limits.

Front 29

ADHD sx in order of frequency:

Back 29

hyperactivity,
perceptual motor impairment, emotional lability, general coordination deficit, attention deficit (short attention span, distractibility, perseveration, failure to finish tasks, inattention, poor concentration), impulsivity (action before thought, abrupt shifts in activity, lack of organization, jumping up in class), memory and thinking deficits, specific learning disabilities, speech and hearing deficits, and equivocal neurological signs and EEG irregularities

Front 30

About ? percent of children with ADHD show behavioral symptoms of aggression and defiance fairly consistently. But, whereas ? are generally associated with adverse intrafamily relationships, ? is more closely related to impaired performance on cognitive tests requiring concentration.

Back 30

75%

About 75 percent of children with ADHD show behavioral symptoms of aggression and defiance fairly consistently. But, whereas defiance and aggression are generally associated with adverse intrafamily relationships, hyperactivity is more closely related to impaired performance on cognitive tests requiring concentration.

Front 31

Inattention and impulsivity: difference in errors (ommission or commission?)

Back 31

Children with poor attention make errors of omission—that is, they fail to press the button, even when the sequence has flashed. Impulsivity is manifested by errors of commission, in which children cannot resist pushing the button, although the desired sequence has not yet appeared on the screen.

Front 32

he course of ADHD is variable. Symptoms have been shown to persist into adolescence or adult life in approximately ? percent of cases.

Back 32

50%

Front 33

? is usually the first symptom to remit, and ? is the last.

Back 33

Overactivity is usually the first symptom to remit, and distractibility is the last.

Front 34

Persistence of ADHD is predicted by:

Back 34

family history of the disorder,
negative life events, and
comorbidity with conduct symptoms, depression, and anxiety disorders.

Front 35

Children with the disorder whose symptoms persist into adolescence are at risk for developing ? disorder.

Back 35

conduct

Front 36

Children with both ADHD and conduct disorder are also at risk for developing ? disorder.

Back 36

a substance-related

The development of substance abuse disorders during adolescence appears to be related to the presence of conduct disorder rather than to ADHD alone.

Front 37

What type of stimulants are preferred in tx of adhd?

Back 37

once day because of each and less rebound

Front 38

Tricyclic drugs and pemoline (Cylert), previously used to treat ADHD, are no longer recommended because of potential adverse effects on ?

Back 38

liver function (pemoline) and potential cardiac arrhythmia effects (tricyclic drugs).

Front 39

Factors associated with early childhood emergence of ADHD include

Back 39

premature birth,
maternal use of nicotine during the pregnancy, and
increased serum lead levels