ADHD Exam 4 Mod 13 Mental Health PDF

ADHD • • • • ADHD Prevalence in Kids o Rates of children varies from 2 to 18 percent depending upon the diagnostic criteria and the population studied (e.g., primary care versus referral) o The prevalence in school-age children is estimated to be between 8 and 11 percent o In the 2011 National S...

ADHD • • • • ADHD Prevalence in Kids o Rates of children varies from 2 to 18 percent depending upon the diagnostic criteria and the population studied (e.g., primary care versus referral) o The prevalence in school-age children is estimated to be between 8 and 11 percent o In the 2011 National Survey of Children's Health (NSCH), the prevalence of a parent-reported diagnosis of ADHD (ever) among children aged 4 to 17 years of age in the United States was estimated to be 11 percent o A 42% increase from the estimated prevalence of 7.8 percent in 2003. o Approximately 1/3 of children are diagnosed with ADHD before age six years. o ADHD is more common in boys than girls (male to female ratio 4:1 for the predominantly hyperactive type and 2:1 for the predominantly inattentive type) o In the 2011 NSCH, the prevalence was 15.1% in boys and 6.7 % in girls. o The prevalence of ADHD may increase with increasing age (7.7 % in 4- to 10-yearolds; 14.3 % among 11 to 14-year-olds; and 14.0 % in 15- to 17- year-olds). ADHD Prevalence in Adults o 4.4 % among 18 to 44 year olds in US o 3.4 % aged 18 to 44 years in ten countries in the Americas, Europe and Middle East, according to a World Health Organization survey o Lower-income countries (1.9 %) o Higher-income countries (4.2 %) Neuropathophysiology o Not fully understood à lack in the part of the brain that slows them down o Reduced global activation and reduced local activation in the area of the basal ganglia and anterior frontal lobe o Imbalance between the norepinephrine and dopamine systems in the prefrontal cortex § Decrease in inhibitory dopaminergic activity and increase in norepinephrine activity § Patients with ADHD have an increase in dopamine transporter density (which may clear dopamine from the synapse too quickly) compared to healthy controls, methylphenidate increases extracellular dopamine in the brain o A genetic imbalance of catecholamine metabolism in the cerebral cortex § illustrated by structural and functional brain imaging, animal studies, and the response to drugs with noradrenergic activity: methylphenidate Other Associated Factors o Prenatal exposure to tobacco o Prematurity and low birth weight • o Prenatal exposure to alcohol o Head trauma in young children § NO STRONG evidence to suggest diet or food plays any role in ADHD ADHD Comorbidities o ODD – 50 to 80%; more common in combined or hyperactive/impulsive subtype o Conduct disorder – possibly 1/3 of kids with ADHD o Anxiety – 20 to 40%; more common with inattentive subtype o Depression – 1/3 of cases; more common with inattentive subtype o Learning disabilities – 20 to 60%; more common with inattentive and combined types o Tics o Sleep disorders • Complications of ADHD o Kids § Educational difficulties § problems with self-esteem § significantly impaired family and peer relationships o Adults § Higher rates of occupational difficulties, criminal activity, substance abuse problems, traffic accidents and motor vehicle citations compared to adults without ADHD § ADHD-related impairments from childhood are believed to underlie or contribute to these behavioral problems of adults. • ADHD Core Symptoms o ADHD is a syndrome with TWO categories of care symptoms § Hyperactivity/ Impulsivity § Inattention o Hyperactivity/Impulsivity (DSM5 six or more) § Excessive fidgetiness (e.g., tapping the hands or feet, squirming in seat) § Difficulty remaining seated when sitting is required (e.g., at school, work, etc.) § Feelings of restlessness (in adolescents) or inappropriate running around or climbing in younger children § Difficulty playing quietly § Difficult to keep up with, seeming to always be "on the go" § Excessive talking § Difficulty waiting turns § Blurting out answers too quickly § Interruption or intrusion of others o Inattentiveness (DSM5 six or more) § Failure to provide close attention to detail, careless mistakes Difficulty maintaining attention in play, school, or home activities Seems not to listen, even when directly addressed Fails to follow through (e.g., homework, chores, etc.) Difficulty organizing tasks, activities, and belongings Avoids tasks that require consistent mental effort Loses objects required for tasks or activities (e.g., school books, sports equipment, etc.) § Easily distracted by irrelevant stimuli § Forgetfulness in routine activities (e.g., homework, chores, etc. o Specify whether: § 314.01 (F90.2) Combined presentation: • If both Criterion A1 (inattention) and Criterion A2 (hyperactivityimpulsivity) are met for the past 6 months. § 314.00 (F90.0) Predominantly inattentive presentation: • If Criterion A1 (inattention) is met but Criterion A2 (hyperactivityimpulsivity) is not met for the past 6 months. § 314.01 (F90.1) Predominantly hyperactive/impulsive presentation: • If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. o Specify if: § In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning. o Specify current severity § Mild: • Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning. § Moderate: • Symptoms or functional impairment between “mild” and “severe” are present. § Severe: • Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning. ADHD Assessment o History is key o Rating Scales § Adults • Connors Adult ADHD Rating Scales - $$$ • Adult ADHD Self-Report Scale § Kids: § § § § § § • • • • NICHQ Vanderbilt Assessment Scales (4yo or highter) Conners Comprehensive Behavior Rating Scales (<4yo) - $ ADHD Treatment o Must have coordinated care § Parents and children § Child, school, and parents o Goals of treatment – realistic, achievable, and measurable § Improved relationships with parents, teachers, siblings, or peers (e.g., plays without fighting at recess) § Improved academic performance (e.g., completes academic assignments) § Improved rule following (e.g., does not talk back to the teacher) o Behavior Interventions § Positive reinforcement § Time-Out § Response cost • Withdrawing rewards or privileges when unwanted or problem behavior occurs § Token economy • A combo of positive reinforcement and response cost o Lifestyle § Maintaining a daily schedule § Keeping distractions to a minimum § Providing specific and logical places for the child to keep his schoolwork, toys, and clothes § Setting small, reachable goals § Rewarding positive behavior (e.g., with a "token economy") § Identifying unintentional reinforcement of negative behaviors § Using charts and checklists to help the child stay "on task" § Limiting choices § Finding activities in which the child can be successful (e.g., hobbies, sports) § Using calm discipline (e.g., time out, distraction, removing the child from the situation) o Pharmacology § Stimulants – gold standard • Methylphenidate • Amphetamines § Non-stimulants – not all can tolerate stimulants, good for younger kids • Alpha agonists : G & C • Strattera § Combination therapy — Combination therapy may be warranted in children (and adults) who do not respond to behavioral interventions. • Combination therapy with medications and behavior/psychological therapy is superior to behavior/psychological therapy alone o Stimulants § Work in the prefrontal cortex by increasing levels of available dopamine and norepinephrine § § WARNINGS: • Sudden death associated with cardiac abnormalities or other serious heart problems • Baseline ECG/ echo and collaboration with cardiologist or PCP • Hx of heart defects or heart disease • Reports of murmur, syncope, chest pain, HTN or arrhythmias • Family hx of heart disease < 40 years old • Rates of unexpected sudden death on stimulants 0.19-0.5 in 100,000 patient years and 1.3- 1.6 in 100,000 patient-years in general population • Caution in adults with preexisting heart conditions and HTN • Use with caution in: patients or patients with family members with history of SUDs • patients with psychotic or bipolar disorders • patients with tics or Tourette’s Common SE with Stimulants • Decreased appetite and weight loss • Slowed growth rate (poorly documented) • Headache • Abdominal pain • Delayed sleep onset • New onset tics • Rebound crankiness and tearfulness • Overstimulation • • • • • • Nervousness Picking at skin/nail biting Behavioral changes Irritability Aggression Depressed mood § Less Common but Serious SE • Sudden death – do good cardiac hx and workup • Adverse cardiac events o Angina o Tachycardia o Palpitations o HTN • Tactile and visual hallucinations • Seizures • Activation of hypomania or mania § Monitoring Patients on Stimulants • Height/Weight • BP • HR • Rating Scales § Clinical Pearls • May have greater effect on behavior than attention symptoms • If no improvement in target symptoms when dose is increased, drop back down • Therapeutic doses will not cause addiction in those with ADHD o Actually a protective factor for SUDs • If causes or increases nail biting, chewing or picking at skin consider baseline obsessive/anxiety features • If they cause aggression/irritability consider comorbid mood d/o’s, but stimulants do tweak mood • Little evidence of tolerance to stimulant effect • But may need to increase with growth • Take with food o Appetite suppression o Absorption and bioavailability may increase after meal • Immediate release o Can crush or break in half • • Capsules o Can open up and sprinkle § Stimulant Non-Responders: • Pt factors: o Is it really ADHD? § Anxiety, Depression, PTSD o Is there a comorbid diagnosis? o Are side effects interfering with a response? o Adherence? • Medication factors: o Is patient over/underdosed? o Is there a time of day when med is not effective? o Interactions affecting the response? • Family Factors: o Family conflict or family mental illness? o Do care givers disagree on giving patient the med? NONSTIMULANTS o Atomoxetine, Clonidine, Guanfacine, Bupropion*, TCAs* § Typically used when: • Inadequate response to stimulants o Monotherapy o Adjunct treatment § Unable to tolerate stimulants § Tic disorder § Patient or family history of SUDs § Caregiver or patient preference § Comorbid disorders o Alpha 2 Agonists: Clonidine, Guanfacine § Side Effects: • sedation, dizziness, orthostatic hypotension, dry mouth, bradycardia, irritability, sleep disturbance, syncope § Caution: • Documented sudden unexpected deaths in children taking clonidine • Rebound HTN associated with missed doses • Antihypertensive treatment § Monitoring • BP, pulse o Additional Indications for Adjunctive Pharmacotherapies § Partial response • Add alpha 2 agonist or atomoxetine to stimulant u § § • Breakthrough symptoms • Add am or afternoon immediate release formulation to long acting formulation Rebound Symptoms • Irritability, whining, crankiness, tearfulness • Typically when stimulant wears off in afternoon or evening o alpha 2 agonists o another dose of stimulant ADHD Overview o ADHD is very common, we’re likely to see more people come forward needing treatment o Hyperactivity is easiest to spot, inattentiveness is trickier o Impulsivity can have long lasting consequences o Treatment is effective and safe… unit its not à Sub Abuse o Always consider the need for continued treatment o Have a network of psych providers for consultation and referral Depression • • Depression Disorders o Depressive Disorders o Disruptive Mood Dysregulation Disorder o Major Depressive Disorder o Persistent Depressive Disorder (Dysthymia) o Premenstrual Dysphoric Disorder o Substance/Medication – Induced Depressive Disorder o Depressive Disorder Due to Another Medical Condition o Other Specified Depressive Disorder Major Depressive Disorder: Diagnostic Critera o A. § Five (or more) of the following symptoms have been present during the same 2 - week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. • Note: Do not include symptoms that are clearly attributable to another medical condition. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood) o B. § o C. The episode is not attributable to the psychological effects of a substance or to another medical condition. Medical Rule Outs o Endocrine Disorders: hypothyroidism, diabetes, hyperaldosteronism, Cushing or Addison’s disease o Neurological Disorders: Parkinson’s, dementing illness, epilepsy, cerebrovascular disease, tumors, multiple sclerosis, fibromyalgia, sleep apnea o Cardiac Disorders: MI, CHF, HTN o Infectious Disease: mononucleosis, HIV/AIDS, pneumonia, TB o Nutritional Disorders: anemia, Vit D, Folate, Thiamine, B12 Common Screening Tools o PHQ-9 o PhQ-2 o HAM-D Treatment o Should be client -centered o Psychotherapy o Pharmacotherapy o Neurostimulation o Phototherapy o Diet/Exercise § • • • Symptoms must represent change from previous functioning and produce impairment in relationships or activities and cause significant distress or impairment in social, occupational, or important areas of Functioning. • • Most Common Treatments o Psychotherapy and Pharmacotherapy o Several trials support the combination of Psychotherapy and Pharmacotherapy Interventions. o Higher response and higher remission rates with combination than for either treatment alone. Antidepressants o Psychopharm Need to Knows § Goal is symptom remission § Usually take 3 - 4 weeks or longer to take action § SSRI’s most commonly used § SSRI’s and SNRI’s are first line treatment: • Prozac, Zoloft, Paxil, Celexa, Lexapro, Brintellix, Viibryd • Pristiq, Cymbalta, Effexor XR § 45-60% with uncomplicated depression who start treatment respond § Most common side effects include GI symptoms, Sexual dysfunction, Cardiovascular effects, insomnia, sedation, serotonin syndrome, sweating, and increased anxiety § Typically, don’t require routine labs Anxiety • • Types o Separation Anxiety Disorder • Selective Mutism • Specific Phobia • Social Anxiety Disorder (Social Phobia) • Panic Disorder • Panic Attack (specifier) • Agoraphobia • Generalized Anxiety Disorder Substance/Medication Induced Anxiety Disorder • Anxiety Disorder Due to Another Medical Condition • Other Specified Anxiety Disorder • Unspecified Anxiety Disorder Diagnostic Criteria for Diagnosis of GAD o A § Excessive anxiety and worry, occurring more days than not for at least 6 months § There is significant difficulty in controlling the anxiety and worry § Have three (or more) of the following six symptoms • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • • • § § o B § Symptoms must represent change from previous functioning and produce impairment in relationships or activities and cause significant distress or impairment in social, occupational, or important areas of Functioning. § The episode is not attributable to the psychological effects of a substance or to another medical condition. o C • • • • Irritability Muscle tension Sleep disturbance (falling or staying asleep) Focus of anxiety and worry is not confined to features of Axis I disorder (worried about gaining weight as in Anorexia Nervosa) Causes clinically significant distress or impairment in social, occupational, or other areas of life Medical Rule Outs o Hypertension • Thyroid Problems • Drug use/Withdrawal • Tumors • irritable bowel syndrome (IBS) Common Screenings o Beck Anxiety Inventory (BAI) o Hamilton Anxiety Rating (HAMA) o Burns Anxiety Rating (BAR) o Screening for Child Anxiety Related Disorders (SCARED) Most commonly used Psychotherapy o Cognitive Therapy o Relaxation o Mindfulness Pharm Interventions o SSRIs o Buspirone o Vistaril o Propranolol o Benzos Suicide • Statistics and Data o In 2020, 45, 979 people died in U.S. by suicide o Non-Hispanic America Indian and Alaskan Natives and non-Hispanic Whites have highest suicide rates o Suicide for males is 4 times that of females o People 75 years and older have highest suicide rates • • • o Firearms are used in more than 50% suicides § Ingestion of pesticide, hanging, and firearms are among the most common methods of suicide globally o Veterans, people who live in rural areas, sexual and gender minorities, middle aged adults, and tribal populations have higher risk factors Risk Factors and Warning Signs o Previous suicide attempt o History of depression and other mental illnesses o Serious illness such as chronic pain o Criminal/legal problems o Job/financial problems or loss o Impulsive or aggressive tendencies o Substance misuse o Current or prior history of adverse childhood experiences o Sense of hopelessness o Violence victimization and/or perpetration o Bullying o Family/loved one’s history of suicide o Loss of relationships o High conflict or violent relationships o Social isolation § Lack of access to healthcare § Suicide cluster in the community § Stress of acculturation o Community violence o Historical trauma o Discrimination § Stigma associated with help-seeking and mental illness § Easy access to lethal means of suicide among people at risk § Unsafe media portrayals of suicide Protective Factors o Effective coping and problem-solving skills o Reasons for living (for example, family, friends, pets, etc.) o Strong sense of cultural identity o Support from partners, friends, and family o Feeling connected to others o Feeling connected to school, community, and other social institutions o Availability of consistent and high quality physical and behavioral healthcare o Reduced access to lethal means of suicide among people at risk o Cultural, religious, or moral objections to suicide Assessment Tools o SAFE-T o CSSR-S o Stanley-Brown Safety Plan