1: ADHD

Question 1

prevalence and impact of ADHD

Answer 1

• prevalence rate: 6-10%

- male more than females

Question 2

diagnostic criteria for inattention symptoms of ADHD

Answer 2

need at least 6 of the following:

• fails to give close attention to details/ makes careless mistakes
• difficulty sustaining attention
• doesn’t seem to listen when spoken to directly
• doesn’t follow through on instructions/fails to finish work
• difficulty organizing tasks and activities
• avoids tasks requiring sustained mental effort
• loses things necessary for tasks/activities
• easily distracted by extraneous stimuli
• forgetful in daily activities

Question 3

diagnostic criteria for hyperactivity-impulsivity symptoms of ADHD

Answer 3

need at least 6 of the following:

• difficulty playing/engaging in activities quietly
• always on the go or acts as if driven by a motor
• talks excessively
• blurts out answers
• difficulty waiting in lines or awaiting turn
• interrupts or intrudes on others
• runs about or climbs inappropriately
• fidgets with hands or feet or squirms in seat
• leaves seat in class/situations when expected to sit

Question 4

general diagnostic criteria for ADHD

Answer 4

• symptoms present before age 12
• clinically significant impairment in social or academic/occupational functioning
• symptoms that cause impairment in 2 or more settings
• not due to another disorder

Question 5

three subtypes of ADHD

Answer 5

• combined type
• predominantly inattentive subtype
• predominantly hyperactive/impulsive subtype

Question 6

describe the combined type of ADHD

Answer 6

• clinical levels of both inattention and hyperactivity/impulsivity
• most common subtype

Question 7

describe the predominantly inattentive type of ADHD

Answer 7

• clinical levels of inattention only
• often not identified until middle school
• sluggish cognitive tempo

Question 8

describe the predominantly hyperactive/impulsive type of ADHD

Answer 8

• clinical levels of hyperactivity/impulsivity only

- more common among very young children prior to school entry

Question 9

associated peer problems

Answer 9

• inattentive sx -> ignored
• hyperactive/impulsive sx -> actively rejected
• not deficient in social reasoning/understanding, but rather the execution of appropriate social behavior

Question 10

associated family dysfunction/parental issues

Answer 10

• no clear causal relationship b/w family problems and ADHD

- family probs can impact the severity and developmental course/outcomes of ADHD

Question 11

associated problems with self-esteem

Answer 11

• inflated: positive illusory bias (Hoza)

- low self esteem associated with co-morbid depression

Question 12

developmental course of ADHD

Answer 12

• persistent across lifespan in most cases
• inattention remains stable
• hyperactivity declines with age
• adult outcomes including psychiatric comorbidity (conduct disorder or depression or anxiety)

Question 13

etiological factors of ADHD: heritability

Answer 13

.80-.85 (extremely high)
-environmental factors are not the cause, but may contribute to the expression, severity, course, and comorbid conditions

Question 14

etiological factors of ADHD: prefrontal lobe dysfunction

Answer 14

• involved in inhibition, executive functions

- abnormal brain activation during attention and inhibition tasks

Question 15

etiological factors of ADHD: genes involved in dopamine regulation

Answer 15

• dopamine transporter DAT1 gene implicated
• 7 repeat of dopamine receptor gene DRD4 implicated
• gene x environment interactions

Question 16

etiological factors of ADHD: possible differences in size of brain structures

Answer 16

• prefrontal cortex
• corpus callosum
• caudate nucleus

Question 17

ADHD differences in brain structure and function

Answer 17

• diffs in brain maturation, structure, fxn - particularly in frontostriatal circuitry (prefrontal cortex, basal ganglia, cerebellum)
• these areas are associated with executive fxn abilities:
  
  • attention, spatial working memory, short term memory
  • response inhibition and set shifting

Question 18

what neurotransmitters are different in ADHD?

Answer 18

• *dopamine
• norepi (mostly a dopamine prob, but dopa makes norepi)
• epi
• serotonin

dopamine associated with approach and pleasure-seeking
norepi role in emotional/behavioral regulation

Question 19

executive functioning deficits

Answer 19

deficits in cognitive processes which activate, integrate, and manage other brain functions (sx overlap with ADHD, but not all kids with ADHD have EF deficits)

• cognitive: working memory, planning, organizing strategies
• language: verbal fluency, communication
• motor: response inhibition, motor coordination
• emotional: self-regulation of emotion, frustration tolerance

Question 20

what is the basis of executive functioning deficits in ADHD?

Answer 20

behavioral disinhibition - a performance, rather than knowledge, deficit

Question 21

evidence-based assessment of ADHD

Answer 21

• teacher and parent-completed questionnaires (Connor scales)
• structured clinical interview with parent(s)
• IQ/achievement testing to screen for learning disabilities (50% comorbidity)
• behavioral observations at home and school
• no medical screen, cognitive test, or brain imaging technique can detect ADHD
• kids with ADHD can focus long enough to watch TV, play video games or sit still at doc’s office

Question 22

well-established ADHD treatments

Answer 22

• stimulant meds
• behavioral interventions
  
  • behavioral parent training
  • behavioral classroom management
  • intensive summer treatment programs

Question 23

what are the best known stimulant meds for ADHD?

Answer 23

methylphenidate

• Ritalin
• Concerta
• metadate

dextroamphetamine
-Adderall

Question 24

how do these stimulant meds reduce ADHD symptoms (mechanism of action)?

Answer 24

• block reuptake of norepi, dopamine and facilitate their release
• enhances norepi, dopamine availability in certain brain regions: prefrontal cortex, basal ganglia

Question 25

how do these stimulant meds reduce ADHD symptoms (visible behavior changes)?

Answer 25

- extremely effective short term - decrease disruption in class - increase academic productivity and on-task behavior - improve teacher ratings of behavior

Question 26

common side effects of ADHD stimulant meds

Answer 26

- insomnia | - decreased appetite

Question 27

what is an alternative non-stimulant medication for ADHD?

Answer 27

strattera/atomoxetine - non-stimulant alternative - could need 4-6 weeks to work - hasn't been studied as long as the stimulants - smaller effect size relative to stimulants

Question 28

limitations of stimulant treatment

Answer 28

- individual differences in response (80% respond) - limited impact on domains of fxnal impairment - does not normalize behavior (managed, but not cured) - family problems beyond scope of medication - no long-term effects established - long-term use rare - limited parent/teacher satisfaction - some families not willing to try meds

Question 29

ADHD behavioral treatment components

Answer 29

- psychoeducation about ADHD - structure/routines - clear rules/expectations - attending/rewards - planned ignoring - effective commands - time out/loss of privileges - point/token systems - daily school-home report card - intensive summer treatment programs

Question 30

multi-modal treatment study for ADHD (MTA) - describe the set up/parameters

Answer 30

- 6 sites - 579 kids, 7-9 y/o - ADHD, combined type - assigned to 14 months of: - med management - intensive behavior therapy - combined treatment - treatment as usual in the community (TAU)

Question 31

MTA results

Answer 31

- all groups showed reduced ADHD over time - meds alone + combined therapy did better than behavior therapy alone and TAU - combined tx was often not better than meds alone - higher med doses were needed in meds alone group relative to combined tx group