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ADHD - Coggle Diagram
ADHD
Treatment
General
- Comprehensive, holistic, shared treatment
- Psych, behavioural, occupational/educational needs
- Consider: severity & impact, goals, resilience/protective, impact of other conditions
- Aim to reduce functional impairments
- With patients/families/educators
- Monitored/revised 6 monthly
School
- Less clutter, small class size, regular breaks, extra time
- Break down instructions, pacing help, positive reinforcement, timetable help
Medication
- 80% have medication
- Depends on access, cost, availability of other, culture
- Uncertain long-term effects
- Psychostimulant
** 70% have +ve response
** Amphetamine & methylphenidate
** More catecholamine activity, block reuptake of dopamine/noradren.
- Non-stimulant
** Atomoxetine (inhibit noradren. uptake) & clonidine/guanfacine (alpha-2 adrenergic agonist)
- Other
** Antidepressants, modafinil (wakefulness)
Non-Pharma
- Behaviour management: parent training, CBT, org skills, self-control, social skills
- No/uncertain evidence for dietary, EEG neurofeedback, cognitive training, mindfulness
Definition & Prevalence
-
Three presentation types
- Combined (> 6/9 symptoms in both in past 6m)
- Predominantly inattentive
- Predominantly hyperactive/impulsive
World-wide prevalence
- Just over 5%
- Reduction in symptoms, but 2/3 some symptoms, 2.5% full symptoms as adults
- Less than 1/2 identified - more if male, comorbidities, older child, more family impact; because stigma, no teacher training, medication concern
- Not new (1800s)
Neurobiology
Cognitive
* Varies between individuals
- Executive function (visuospatial & working memory, planning, vigilance, inhib control)
- Meta cognitive (self-talk, deduction, prediction), temporal processing / timing, processing speed, response time, motor control, attention allocation, 'sluggish cognitive tempo', reward dysregulation (prefer immediate)
Emotional dysregulation
- Intense reactivity (often aggressive)
- Irritability (20% have DMDD)
Neuroimaging
- Abnormality in size/structure/connection - ER areas (attention, working memory, response inhib, motor control)
- Thinner cortex, less volume - underdeveloped PFC, cingulate gyri, cerebellum, basal ganglia
- Dysconnectivity between DFM & ventral attentional networks
- Abnormality in dopamine & noradrenaline systems
Causes
Genetic
- Highly heritable
- Multifinality - present with diff disorders
- Cumulative vulnerability of genetic variants
Environmental
- No causal evidence + not specific to ADHD
- Embryopathic neurotoxins, premature/low birth weight, maternal stress, postnatal neurotoxins, severe early psychosocial deprivation, harsh/coercive parenting, nutritional deficiencies, dietary sensitivities, electronic media use
- But gene-environment interaction important
Assessment
Prevention
- Pregnancy health/AOD exposure/support
- Parental training, dev support, self-regulation intervention - early maternal scaffolding may help
Assessment
- Referred: difficulty learning/behaviour/social/emotional, or risk factors (premature, trauma, delayed language, sibling/parent with ADHD)
- Interview with parent/carer
- Behaviour rating scales - parents/teachers
Plus:
- Physical exam
- Other assessments: psych, allied health (speech, language, OT)
- Harder if trauma, separated parents, intellectual disability, intelligent older
Associated Conditions
Most have at least one
- ODD, conduct, DMDD, anxiety, depression, language, learning, ASD, chronic tic/Tourette + sleep
- Associated with more functional impairment
- Underidentified
Impairments
Affect individual/family -> classrooms/work/society
- Children: academic, peer, emotional
- Adults: job dismissal, low job status, low QoL
- Parents: mental health, marital problems, parent-child relationship, parental efficacy, stress
- Financial costs
Long-Term Outcomes
- Academic, dropout
- Depression, suicidal
- Substance, smoking
- Antisocial
- Early parenthood
- Poor occupational functioning
- Can be successful