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Attention-deficit/hyperactivity disorder (ADHD)
types, dx criteria
- Inattentive type ADHD (6 or more of the following... persistent >6 months, problematic and inconsistent with development level)
- -impairment in two or more settings (school, work, home...)
- -Onset before the age of before the age of 7 years
- 1. Fails to attend to details
- 2. Fails to focus attention
- 3. Fails to listen if spoken to
- 4. Fails to follow through
- 5. Fails to organize
- 6. Avoids concentration
- 7. Loses things
- 8. Distracts easily
- 9. Forgets
- *Inattentive type is the most common
- -leads to academic and social problems
- -present at a later age (not disruptive, easier to miss)
Hyperactive-impulsive type ADHD ( 6 or more... hyperactive 1-6, impulsive 7-9)
- 1. Fidgets/squirms
- 2. Leaves seat
- 3. Runs/climbs
- 4. Does not play quietly
- 5. On the go
- 6. Talk excessively
- 7. Blurts answers
- 8. Does not wait turn
- 9. Interrupts
-presents earlier (easier to see)
- Combined type ADHD
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meets criteria for both (less common)
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ADHD
epidemiology
- Prevalence in young and school-aged children: 6%
- Male>female (3:1)
- Genetics contribute ~70% of the risk
- -Dopamine transporter genes, dopamine receptor genes
- Environmental risk factors:
- -Fetal alcohol syndrome
- -prematurity
- -Lead toxicity, nutritional deficiencies
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ADHD
clinical course, evaluation and treatment
- Clinical course:
- -dx in grades 1 through 6
- -hyperactivity decreases with age
- -60% have some persistence of symptoms into adulthood
- Evaluation:
- -assess current situation/risk factors
- -Rule out alternative causes (thyroid disorders, medications, absence epilepsy, hypoglycemia
- Treatment:
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Non-pharmacologic (education, behavior modification...)
- Pharmacological Tx:
- -Stimulants (know that AEs: decreased sleep, decreased appetite, irritability, anxiety, GI pain, headache, slow growth)
- -ADHD does not predict risk for substance abuse (non-conduct disorder ADHD)
- -Dose: dose only when needed (at school, not on the weekends); start low dose
- Stimulants
- -Methylphenidate (Ritalin)
- -Dexmethylphenidate (Concerta)
- -Mextroamphetamine (Dexedrine)
- -Dextroamphetamine plus amphetamine (Adderall)
- Non-stimulants:
- -Atomoxetine (Strattera)
- -Bupropion (Wellbutrin)
- -Tricyclics such as nortriptyline (Pamelor)
- -Clonidine (Catapres)
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Conduct disorder
- -Repetitive and persistent pattern of violating rules or societal norms.
- - "Childhood form of Antisocial Personality Disorder"
- - >3 of the following within the last year... that cause impairment
- 1. Bully
- 2. Fights
- 3. Weapon
- 4. Cruel
- 5. Animal cruelty
- 6. Steal/confront
- 7. Forced sex
- 8. Fires
- 9. Vandalism
- 10. Break-ins
- 11. Lies
- 12. Stealing
- 13. Curfew (onset <13 years)
- 14. Runaway (more than once)
- 15. Truant (onset <13 years)
*Onset: prior to age of 10-13 (puberty)
- Prevalence: ~6%
- -Males > females (5:1)
- -Genetic and environmental
- -decreased function of the prefrontal cortex
- Clinical course:
- -physical aggression often decreases with age
- -puberty can bring on increased violence in some
- -40% go on to develop ASPD
- -80% develop substance abuse disorder
- -individuals who have or had conduct disorder die earlier
- Tx:
- mostly behavioral, education of family, structural changes
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Oppositional defiant disorder
pattern of negative, hostile and defiant behavior lasting at least 6 months... >4 of the following
- 1. Temper
- 2. Argues
- 3. Refusals
- 4. Annoys
- 5. Blames
- 6. Annoyed
- 7. Anger/resentful
- 8. Vindictive
- Prevalence and causes:
- -~10% prevalence; Males = females
- -etiology not well studied
- Course and Treatment:
- -onset in age is 6 to 8 years
- -30% develop conduct disorder, 10% go on to develop ASPD
- -60% improve within 3 years
- -Tx: education, early, problem solving (worst first)
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Pervasive developmental disorders
early onset of impaired communication, interaction, and interest:
- Autism: impaired social interactions (>2 from group 1), impaired communication (>1 criteria from group 2), and restricted behavior or interests (>1 criteria from group 3). Total of 6 or more criteria.
- -Pt has delays or abnormal functioning with onset before age 3 years in one of the following: social interaction, language as used in social communication, or symbolic or imaginative play
- 1a. Decreased use of nonverbal cues (such as eye contact)
- 1b. Decreased peer relationships
- 1c. Decreased shared interests
- 1d. Decreased social response
- 2a. Decreased development of language
- 2b. Decreased conversations
- 2c. Idiosyncratic/repetitive
- 2d. Decreased social play
- 3a. Preoccupied, restricted interests
- 3b. Nonfunctional routines, rituals
- 3c. Repetitive movements
- 3d. Preoccupied with objects
- Asperger's disorder: impaired social interactions and restricted/repetitive behaviors or interests ( >2 group 1 and >1 group 3 symptoms - No group 2)
- -No language delay, no delay in cognitive development
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Depressive disorders in childhood
- Same criteria as for adults
- Onset: rare before puberty
- Incidence is increased if there is family hx of MDD or bipolar disorder
- Males = females (incidence)
- Clinical course is same as adult onset MDD
- Evaluation/tx is same
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Anxiety disorders of childhood
- 1. Separation anxiety: fear of leaving home and/or possible harm to parents
- -seen in 4% of school aged children; onset is age 6 to 9
- -disorder improves with age
- 2. Post-traumatic stress disorder (PTSD):
- -occurs in 8% of children
- -improves with age
- -tx is CBT and sometimes SSRIs
3. Obsessive compulsive disorder, gerealized anxiety disorder, and social phobia MAY start in childhood
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