What is Attention-Deficit/Hyperactivity Disorder?
Inattentive, hyperactive & impulsive to excessive degree compared with their peers.
For more info, download the presentation.
Babatunde Idowu Ogundipe M.D. M.P.H.
Comprehensive Clinical Services P.C.
October 7 2011
Topic 8 - Treatment for ADHD.
Autism, Asperger's and ADHD.
The views expressed in this presentation are those of the individual Simon Bignell and not University of Derby.
Topic 8 - Treatment for ADHD.
Autism, Asperger's and ADHD.
The views expressed in this presentation are those of the individual Simon Bignell and not University of Derby.
Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes produces 2 episodes each week and offers CEUs based on the podcast at AllCEUs.com/counselortoolbox
Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes produces 2 episodes each week and offers CEUs based on the podcast at AllCEUs.com/counselortoolbox
The term ADHD refers to Attention Deficit Hyperactivity Disorder, a condition that makes it difficult for children to pay attention and/or control their behavior. Learn more about about the causes, diagnosis and treatment of ADHD.
This poster was presented to highlight the following mental health conditions in adolescent patients: attention deficit/hyperactivity disorder (ADD/ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).
Mental Health is a very important aspect of public health. Although mental health assessment is vital within all populations, it is especially vital to assess mental health within our vulnerable populations (e.g. adolescents)
CCS would like to encourage your attendance for the 2012 Latino Mental Behavioral Health Conference: Changing the Paradigm from Stigma to Wellness on Friday, October 19th at the Chicago School of Professional Psychology.
Come listen to Psychiatrist Dr. Daniel Martinez discuss the neuroanatomical basis of brain disorders, focusing on the biopsychosocial medical model, areas of the brain affecting emotions and psychiatric disorders with a clear medical basis.
What is Depression?
(1)Major depressive disorder: Combination of symptoms interfering with person’s ability to work, sleep, study, eat, & enjoy once-pleasurable activities. Disabling & prevents person from functioning normally. Often recurs in persons life.
(2)Dysthymic disorder: Long-term (> 2 years) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well.
(3)Psychotic depression: Severe depressive illness accompanied by some form of psychosis, such as break with reality, hallucinations, & delusions.
(4)Postpartum depression: When new mother develops major depressive episode within one month after delivery. Estimated that 10-15% women with postpartum depression after giving birth.
(5)Seasonal affective disorder (SAD): Depression during winter months, when less natural sunlight, that lifts during spring and summer. Half of these cases do not respond to light therapy alone but responsive to combo antidepressants, light, and psychotherapy.
(6)Bipolar disorder: Aka manic-depression. Cycling mood changes from extreme highs (mania) to extreme lows (depression).
DAY ONE: NOVEMBER 4, 2011, 12:00 – 3:00 pm
The History and Practice of Occupational Psychiatry
-Evolution and relevance in today's workplace
-Core elements of the practice and evaluations
-Disability and Impairment
-Fitness for Duty
DAY TWO: NOVEMBER 11, 2011, 12:00 – 3:00 p.m.
The How-To of Independent Medical Examinations
-Practice and Theory
-Basic templates
-Medical examinations for legal purposes
-Do's and Don'ts
-Reviews of basic terminology
OCCUPATIONAL PSYCHIATRY WORKSHOPS
DAY ONE: NOVEMBER 4, 2011, 12:00 – 3:00 pm
The History and Practice of Occupational Psychiatry
-Evolution and relevance in today's workplace
-Core elements of the practice and evaluations
-Disability and Impairment
-Fitness for Duty
DAY TWO: NOVEMBER 11, 2011, 12:00 – 3:00 p.m.
The How-To of Independent Medical Examinations
-Practice and Theory
-Basic templates
-Medical examinations for legal purposes
-Do's and Don'ts
-Reviews of basic terminology
TO BE HELD AT:
THE UNIVERSITY OF ILLINOIS AT CHICAGO
This presentation is a Grand Rounds for the Dept. of Pediatrics at Mt. Sinai Hospital in Chicago. Presented by child psychiatrist, Daniel B. Martinez, M.D. February 9, 2011
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. What is Attention-Deficit/Hyperactivity Disorder?
• Inattentive, hyperactive & impulsive to
excessive degree compared with their
peers.
• Prevalence as high as 3%-10% of children
& 1%-6% adults in the U.S.
• High prevalence, global impairment, &
chronicity has lead CDC to identify it as
serious public health problem since
1999.
• Areas impairment children:
• Academic dysfunction.
• Social dysfunction & skills deficits.
• Areas impairment adults:
• Occupational & vocational dysfunction.
healthresource4u.com
• Social impairment.
• High rates of motor vehicle accidents.
4. Etiology Attention-Deficit/Hyperactivity Disorder
• Validity ADHD been established by
research on neurobiological features:
• Functional MRI studies- activity in
frontal striatal networks in ADHD vs
activity in anterior cingulate gyrus
those without ADHD.
• Positron Emission tomography –
decreased frontal cortical activity
affected adults + indicated
methylphenidate increases
extracellular dopamine levels by medscape.org
blocking dopamine transporter
(DAT), particularly in striatum. Adults
with ADHD been found to have two-
fold increase in DAT-binding potential.
5. Attention-Deficit/Hyperactivity Disorder
Developmental Course
• Preschool: Children have difficulty with quiet, focused activities.
Trouble cooperating with other children, engage in less play than peers
& have difficulty managing transitions. More noncompliant with adult
requests + are less socially skilled than children of same age.
• Elementary School: Continued conflict with peers. Trouble organizing
school-related tasks (i.e. doing homework & keeping desk in order) +
underachieve in school even when with intellectual potential to do
well.
• Adolescence: At school inattentive, hyperactive & impulsive behaviors
difficulties completing projects & homework thus do not achieve
academic potential. At home have more conflict with parents than do
those without ADHD. Tend to be immature, get into trouble when
unsupervised, have poor social skills & engage in high-risk activities
(i.e. reckless driving, cigarette smoking, unprotected sex, marijuana
use).
6. Attention-Deficit/Hyperactivity Disorder Diagnosis
Steps in the diagnosis of attention-deficit
hyperactivity disorder (ADHD) in adults
1. Assess current ADHD symptoms (within the last 6 months) using rating scales
with adult norms.
2. Establish a childhood history of ADHD.
3. Assess functional impairment at home, work and school and in relationships.
4. Obtain developmental history, including during prenatal, childhood and school
years.
5. Obtain psychiatric history: rule out other psychiatric disorders or establish
comorbid diagnoses (e.g., learning disabilities, mood and anxiety
disorders, personality disorders and substance abuse, especially marijuana
abuse).
6. Obtain family psychiatric history, especially concerning learning
problems, attention and behavior problems, ADHD and tics. Enquire about all
first-degree relatives (parents, siblings and offspring).
7. Perform physical examination: rule out medical causes of symptoms
(e.g., serious head injury, seizures, heart problems, thyroid problems) or
contraindications to medical therapy (e.g., hypertension, glaucoma).
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
7. Attention-Deficit/Hyperactivity Disorder Diagnosis: Assessment
Ask the patient to indicate how often, using a 4-point scale (0 = “never or not at all,”1 = “sometimes or
somewhat,” 2 = “often or pretty much” or 3 = “very often or very much”), he or she has experienced the
following symptoms of ADHD in the past 6 months and whether they have persisted for at least 6 months:
(1) Inattention
• Does not pay close attention to what he or she is doing and makes careless mistakes
• Has trouble paying attention to tasks
• Has trouble following verbal instructions
• Starts things but does not finish them
• Has trouble getting organized
• Tries to avoid doing things that require a lot of concentration
• Misplaces things
• Is easily distracted by other things going on
• Is forgetful
(2) Hyperactivity–impulsivity
• Fidgets with hands or feet
• Has trouble sitting still
• Feels restless and jittery
• Has trouble doing things quietly
• Is a person who is “on the go”
• Talks too much
• Acts before thinking things through
• Gets frustrated when having to wait for things
• Interrupts other people’s conversations
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
8. Attention-Deficit/Hyperactivity Disorder Diagnosis: Assessment
Diagnosis
All of the following criteria must be met for a diagnosis of ADHD:
A. Six or more of the symptoms of either (1) or (2) above are rated as “often or
pretty much” or “very often or very much” and have persisted for at least 6
months. (For adults over the age of 50 years, only 3 or more symptoms rated
“often” or “very often” are required to meet diagnostic thresholds.)
B. Some symptoms of inattention or hyperactivity–impulsivity that caused
impairment were present in childhood.
C. Some impairment from the symptoms is present in 2 or more settings (e.g., at
work, at school, at home, during leisure activities, when driving a car).
D. There must be clear evidence of clinically significant impairment in
social, academic or occupational functioning.
E. The symptoms do not occur exclusively during the course of a pervasive
developmental disorder, schizophrenia or other psychotic disorder and are not
better accounted for by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder or personality disorder).
The symptoms and diagnostic criteria are modified from the DSM-IV.
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
9. A single 36-year-old woman is referred for a psychiatric evaluation to explore
occupational and personal problems in her life. She reports that she has “always” had
problems concentrating on her work, felt restless and acted impulsively (e.g., made
comments to people that she later regretted). She describes herself as chronically
disorganized. She currently works as a computer technician and says that her work
evaluations have indicated that she has often been late for meetings, made careless
errors and disrupted her coworkers with her constant chatter. As for personal
relationships, she reports having had few friends. She suspects that she “burnt out”
her friends with her high energy level and admits that her mind wanders during
serious conversations, leaving her friends feeling that she is selfish or does not care.
Beyond these difficulties, the woman is in good physical health, with no history of
serious childhood illnesses. When asked about her childhood, she admits that she
frequently got into trouble for “acting before thinking.” Her report cards indicated
that she was working below potential and that she had “atrocious handwriting.” She
was eventually placed in a special class because she talked constantly and “would not
sit in her seat.”
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
10. The patient reports that she has experienced 6 of the inattention symptoms and 7 of the
hyperactivity–impulsivity symptoms of ADHD “often” or “very often” over the past 6 months.
She reports having experienced all 18 symptoms in her childhood. Her roommate is asked to
rate her current behavior using the Adult Inventory–4; this collateral information indicates that
the patient's behaviors are consistent with ADHD. No collateral informant is available to assess
the patient's behavior in childhood; however, teachers' comments on her report cards clearly
indicate a long-standing history of attention problems and disruptive behavior in school. The
patient had a prior history of depression, although she is not depressed at the time of
assessment. Her presenting problems associated with ADHD existed before and after the onset
of her depression. Given the results of the assessment, her physician diagnoses ADHD–
combined type (symptoms of both inattention and hyperactivity–impulsivity) and chooses a
combination of medication and support to manage her symptoms. A trial of methylphenidate
(15 mg orally, every 4 hours, 4 times during waking hours) is effective in reducing the severity
of her symptoms, with mild appetite suppression and irritability as each dose wanes. The
patient is switched to dextroamphetamine (15 mg orally twice daily) to improve compliance. At
work, the patient requests assignments that are interesting but challenging, instead of rote
tasks that she finds boring and tedious. Socially, she monitors the physical distance between
herself and others so that she can behave more appropriately. To improve her organizational
skills, she learns how to use an electronic planner. Two years after the diagnosis, the patient is
proud that she is still employed with the same company and is better able to form and maintain
friendships.
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
11. Assessment of patient’s developmental history
Prenatal
• Did your mother use drugs, nicotine or alcohol when she was pregnant with you?
• Do you know if there was difficulty during pregnancy or childbirth such as diabetes, eclampsia, cord around the neck, breech delivery or lack of
oxygen?
Childhood
• Were you described as a very active or impulsive child?
• Did your parents complain that you were difficult?
• Did you have any accidents requiring hospital treatment as a child?
• Were you exposed to any physical, verbal or emotional abuse? Were you neglected?
• Did you have any serious trauma, exposure to violence or losses as a child?
• Did you have any medical illnesses as a child?
• Did you ever lose consciousness?
School
• How did you do academically in elementary school? In high school?
• Were you ever enrolled in college or university? Did you drop out? Why?
• Did you ever fail a grade?
• Did you ever have psychological testing or were told you had a learning disability?
• Did you receive learning assistance or were you ever placed in a special class?
• Were you ever suspended or expelled from school?
• Did you have any special problems with reading? Arithmetic? Writing?
• Did teachers complain that you were not achieving your potential or were not trying your best?
• Was your performance at school variable or unpredictable?
Family psychiatric history
Have your parents, siblings or children had any of the following problems?
• ADHD
• Depression
• Anxiety (worrying, fears, extreme embarrassment in front of people, repetitive behaviors that do not make sense)
• Psychosis (hearing voices, seeing things, or having fixed, wrong ideas)
• Tics (involuntary and repetitive movements or sounds)
• Substance abuse or alcoholism
• Learning disability
• Behavior problems or problems with the law
• Suicide attempt or self-destructive behavior
Weiss, Margaret. Assessment and Management of Attention-Deficit
Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
12. Attention-Deficit/Hyperactivity Disorder Management
• Treatment c/o 3 parts:
• (1)Education on ADHD +
psychological support to the patient
& family.
• (2) Medication.
• (3) Follow up and continued support.
• Medication 1st line for ADHD &
effective & safe in adults & children: drugs-expert.com
• First Line:
• Stimulants
• Second Line:
• Tricyclic Antidepressants
• Bupropion
• Atomoxetine
13. Medication Dose Durati Schedule Rate Adverse Events ADR management
on (h) titration
First Line: Start at 5- 3.5 3-4 x/day 0.5- Decreased appetite, Discuss dietary needs
Methylphenidate 10mg PO BID, 1.0mg/kg insomnia, Decrease late day dosing;switch to
max 80mg/d daily long acting medication;discuss sleep
hygiene.
Headache (few wks only) If headache severe consider change of
dose or switch to another
Dextroamphetam Start at 5mg 5 2-3x/day 0.5mg/kg stimulant/med
ine PO once daily or 5mg nervousness/dysphoria Consider use of antidepressant; r/o
daily BID, qweek. comorbid disorder
max 40mg/d
Second Line: Start at 24 Every 25-50mg Constipation High-fiber diet
Desipramine or 50mg/d, max night every week Dry mouth Advise no drinks sweetened with sugar
Imipramine 200mg/d + get regular dental check ups.
(response after 4
weeks) Postural hypotension Advise to get up slowly
Tachycardia /arrhythmia Lower dose
Drowsiness(1st few days)
Bupropion SR Start at 12 2x daily 50mg every Seizures Keep doses within recommended max,
(response after 5 100mg in am, (8h apart) week ensure max 8h between doses; avoid
weeks) max 15om use in patients at risk seizures i.e.
BID eating disorder, alcohol abuse, h/o
seizure
Insomnia Take earlier in day/ single dose in am
Headache Adjust dose
Atomoxetine daily Decreased appetite/wgt
loss (early only)
14. References
• FIRST AID for the USMLE 3, Tao Le, Vikas Bhushan, Robert W.
Grow, Veronique Tache.
• Psychiatry History Taking. Third Edition. A Current Clinical
Strategies medical book. Alex Kolevzon, Craig L.Katz.
• Barkley, Russell. A. Adolescents with Attention-
Deficit/Hyperactivity Disorder: An Overview of Empirically Based
Treatments (2004). Journal of Psychiatric Practice, 10:1, 39-56.
• Weiss, Margaret. Assessment and Management of Attention-
Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-
722.
• Spencer, Thomas J.et al. Overview and Neurobiology of Attention-
Deficit/Hyperactivity Disorder (2002). Journal of Clinical
Psychiatry, 63, 3-9.
• Brown, Ronald T. et al. Treatment of Attention-
Deficit/Hyperactivity Disorder: Overview of the Evidence (2005).
Pediatrics, 115, 749-757.
Editor's Notes
Academic-as children with ADHD mature academic failures demoralization & poor self-esteem. Other areas children: high rates injuries, cigarette smoking, & substance abuse. In subgroup there is risk delinquency. Symptoms adults mirror those in children & associated with significant educational, occupational, & interpersonal difficulties.Like other psych disorders no objective tests.Epidemiology:Clinically significant symptoms equally prevalent among men & women in adults vs children more prevalent in boys than girls.
No single etiology ADHD. Multifactorial hypothesis, as with all neuropsychiatric conditions complex combination environmental, genetic, & biological factors. Also prenatal & Perinatal risk factors with ADHD. Prenatal & Perinatal risk factor: Results from Logistic Regression Model of Odds ratio’s for Prenatal & perinatal risk factors show increased odds ADHD with cigarette exposure, alcohol exposure, low birth weight, & parental ADHD( 8 fold increase).Heritability: Studies of dizygotic & monozygotic twins that have grown up in same environment. Heritability=0 no genetic input, =1 characteristic/disorder completely determined by genetics. Mean heritability ADHD = 0.75 75% etiologic contribution genetic vs depression (0.39), GAD (0.32), breast cancer (0.27), asthma (0.39).Candidate Genes: Once genetic contribution ADHD was revealed researchers began trying to identify candidate genes. Gene association most widely confirmed = 7-repeat allele D4 dopamine receptor gene (DTD4*7) genetic polymorphisms in D4 receptor, a defective gene found in 30% general population & 50%-60% ADHD population. + distinct pattern neuropsychological deficits (difficulty with working memory & executive function) compared with healthy controls.Also found Susceptibility genes: dopamine receptor gene D2 + DAT gene. Other research D4 receptor shown that in addition to dopamine, both epinephrine & norepinephrine agonists at DRD4*7 thus medications affecting either of these catecholamine's could also affect this dopaminergic system.Model of Executive Dysfunctions: Located in prefrontal cortex, explains cognitive & behavioral deficits associated with ADHD (Barkley, ADHD & the Nature of Self Control) Attention, impulsivity, & hyperactivity. 5 major executive functions enable individuals to recognize & control their actions to achieve a goal: (1) Response inhibition-delays & interrupts responses & controls interference to allow individuals to control verbal & motor impulses. (2) Nonverbal working memory-enables person to have sense of the past & future & a cognitive awareness of self (3) Verbal working memory- gives people ability to internalize receptive & expressive language for self questioning, self-description, & establishing rules for behavior. Together nonverbal + verbal working memories provide ability for reading comprehension & moral conduct. (4) Self-regulation of emotion & motivation. By internalizing visual & verbal stimuli, 2 working memories lead to development of the self-regulation of emotion & motivation that provides individuals the ability to control their emotions & the motivation & persistence necessary to meet their goals. (5) Reconstitution-form of play allowing individuals to analyze the experiences in their working memories to synthesize new responses, which they accept or reject based on the likelihood that the response can help them to achieve their goal. Of 5 executive functions response inhibition most obviously deficient in individuals with ADHD impairments observed in psychological & social abilities associated with other 4 executive functions.
Functional & structural magnetic resonance imaging has documented differences brains individuals with & without ADHD:Circuits controlling attention smaller & less active in individuals with ADHD than in controls. Circuits: parts prefrontal cortex controlling working memory, alerting, & response inhibition. These areas rich in catecholamine receptors- shows norepinephrine & dopamine involvement in ADHD.
ADHD with distinct pattern of challenges at each stage of development.Elementary School: Also activities of daily living i.e. grooming + hygiene may be struggle. Often have associated problems i.e. messy handwriting, difficulty with sleep, oppositional behavior, increased risk of accidents & enuresis.Longitudinal studies have shown 80% children with ADHD still exhibit symptoms in adolescence, period of particular stress & impairment.Adults: higher risk than those w/o ADHD of dropping out of school, being fired from their jobs & having marital problems. Typically with fewer years of schooling, lower occupational achievement & poor social skills thus experience higher levels anxiety & depression than general population. Recent research shows increased risk poor medical health, serious motor vehicle crashes, cigarette smoking, & drug abuse.Research: adults with ADHD attracted to occupations that are exciting & busy with an element of risk (i.e. sales, stock-broking, entrepreneurial ventures).Other: frequent changes in employment, poor planning abilities (i.e. organizing finances, handling college coursework), messiness, dangerous driving, unstable relationships/social isolation, + engagement in leisure activities that are highly absorbing or stimulating (i.e. downhill skiing, high-contact sports, surfing the internet). Difficulty organizing their homes (i.e. cooking regular meals, cleaning) & managing their children (i.e. packing lunches, getting them to appointments on time).
Document current & past symptoms & establish that these impairment via obtaining developmental & psychiatric history + performing physical exam.One must assess current symptoms of ADHD (next 2 slides)+ those in childhood (i.e. before age 7). Obtaining childhood history of ADHD essential to assessment. Self report rating scales help assess presence of ADHD symptoms in childhood. Problem is patient may have poor insight /have difficulty remembering symptoms in childhood thus important to also gather info from school records, report cards for objective evidence childhood ADHD. i.e. look for comments in records about patients attention (i.e. “daydreams,” “can’t focus”), activity level (i.e. “always up from her desk,”, “can’t sit still”) & impulsive behavior (i.e., “interrupts students when they’re working, “ “needs to learn to wait his turn or raise hand before answering”). + other sources i.e. teachers/parents.Physical exam: Helps to r/o medical causes of the symptoms i.e. neurological problems & thyroid abnormalities. Is seeming inattention/impulsivity due to visual/auditory impairment?To screen for problems that are consequence of having ADHD i.e.smoking, illicit drug use, fractures, poor nutrition, poor sleep hygiene.To identify contraindications to treatment with stimulant medication i.e hypertension, glaucoma.To record patients baseline weight which may change with treatment.Electronic testing(i.e. continuous performance tests) & neuropsychological tests may contribute to clinicians overall impression but neither with good sensitivity/specificity on their own for diagnosis.
Current ADHD symptoms can be assessed using standardized rating scales. Here are 18 ADHD symptoms from DSM-IV each rated on its frequency in past 6 months with 4 point scale (0=never/not at all – 3=very often/very much).Patient will meet diagnostic criteria for ADHD-inattentive type if with significant difficulty ( score of 2 or 3) for > 6 of 9 items inattentive symptoms.Patient will meet diagnostic criteria for ADHD-combined type if with significant difficulty ( score of 2 or 3) for > 6 of 9 items hyperactive/impulsive symptoms.Rare for adults to meet criteria ADHD-hyperactive/impulsive type w/o meeting threshold for inattentive symptoms.
Adults with ADHD may id problems associated with ADHD (i.e. procrastination, lack of motivation, mood lability, low self-esteem) as primary concern rather than core symptoms.Assessing comorbid conditions & differential diagnoses is necessary as adults with ADHD with high rates mood, anxiety, learning & personality disorders, & substance use & abuse. Comorbid conditions may require treatment, may provide relative contraindication to use stimulants, or may alter expected outcome of treatment.ADHD distinct disorder & its impairments present in absence comorbid conditions.Differential diagnosis: Certain conditions may mimic (or more commonly coexist) with ADHD:Conduct disorder-differ from ADHD, exhibit persistent antisocial behavior (lying, cheating, stealing)Oppositional defiant disorder-easily annoyed, hostile, defiant, spiteful, and negative.Major depressive disorder-as with ADHD may show signs inattention + become easily upset (must have also had 2 weeks depressed mood or loss of interest/pleasure in most activities, + c/o easy fatigue, loss of energy, but not hyperactivity).Bipolar disorder-mild/fluctuant cases, especially in children difficult to distinguish from ADHD (if substantial Bipolar ssxs clear mood impairments: elation, grandiosity, severe irritability & anger, decreased need for sleep, hypersexuality, racing thoughts).Anxiety disorders- hyperactive behaviors i.e.fidgeting & inattentive behaviors i.e.off-task behaviors accompanied by persistent fears & worries.Substance-related disordersLearning disabilities- like ADHD learning disorders may impair academic/occupational functioning & frequently comorbid with ADHD. However characterized by specific learning impairment as evidenced by significant discrepancy individuals performance on standardized test in reading, math, or written expression & their education & intelligence.Medical conditions, especially endocrine disorders i.e. hypothyroidism & hyperthyroidism sxs similar to ADHD (rare in children)Sleep disorders-r/o as cause attentional problems before diagnosis ADHD made.Medication/illegal substance/alcohol sxs inattention, hyperactivity & impulsivity?Mental retardation- impairment adaptive functioning more severe than social, academic, & occupational impairment associated with ADHD, occurring with impairment in general intellectual functioning (i.e. IQ < 75).Pervasive Developmental disorders (autism & asperger’s)- may exhibit hyperactivity or fidgeting + impaired social, academic, & occupational functioning. Also exhibit disinterest or inability to participate in social interaction or limited & stereotyped behavior, interests, & activities.
Are the woman's symptoms and history consistent with adult attention-deficit hyperactivity disorder (ADHD)? What steps should be taken to confirm or rule out a diagnosis of ADHD? If the woman does have the disorder, what can be done to manage her symptoms?
When assessing adults as with children beneficial to have > 1 informants complete standardized rating scales.i.e someone who knows patient well (spouse, close friend, parent, sibling) & someone who knew patient well enough as child to rate their childhood behavior (i.e. parent, aunt, uncle).Issue is question over reliability patient self-report.ADHD familial so important to screen for family psychiatric history of ADHD. Also inquire whether 1st degree relatives have had problems with tics, drug use & criminal behavior. Not uncommon in ADHD-helps identify risks for patient.
Psychological: scarcity controlled studies on efficacy psycho social treatments. Variety of psychological interventions used:Education on disorder, involvement in support groups, skills training (vocational, organizational, time management, financial), coaching. Support groups can provide support, social contacts, educate patient on ADHD & useful coping strategies & skills training (i.e. how to use day planner, developing routines for meal time, delegating challenging tasks).Medication: 9 double-blind placebo-controlled crossover studies using standardized methods diagnosis & outcome. Meta-analysis of findings showed weighted mean response rate of 57% to Methylphenidate, 58% to Dextroamphetamine, & 10% to placebo.Several studies suggest symptom reduction is dose dependent with higher response rates accompanying higher doses.Atomoxetine (strattera) first medication to receive approval by the US Food & Drug Administration for treatment of ADHD in adults.
Four classes psychotropic drugs have been proven useful in management ADHD symptoms: stimulants (most effective, with relatively benign side effects), noradrenergic reuptake inhibitors, tricyclic antidepressants, & antihypertensive agents. All more effective than placebo.Stimulants: most commonly prescribed are methylphenidate (MPH) (Ritalin, Concerta, Medadate CD, Focalin), d-amphetamine (AMP) (Dexedrine or Dextrostat), d- & 1-AMP combination (Adderall, Adderall XR). MPH slows down dopamine reuptake from extracellular space & amphetamines increase dopamine release. MPH & Amphetamines most commonly prescribed meds for ADHD. Concerta=miniature osmotic pump resembling capsule oozing liquid MPH while traversing gut x 10-12 hrs. Medadate CD (can also be sprinkled on food) & Ritalin LA are tiny MPH pellets & last about 8-12 hours.AMP/MPH sustained attention, impulse control, reduction of task-irrelevant activity, + diminishes noisy & disruptive behavior. Children become more compliant with parental/teacher instructions, & sustain compliance, & cooperate better with others. Also improvements seen with aggression, handwriting, academic productivity & accuracy, persistence of effort, working memory, peer relationships, emotional control, & participation in sports.Trial stimulant medication requires titrating doses while monitoring ADHD symptoms ( by means of serial administration of a rating scale) & side effects (hypertension, insomnia, headaches, weight loss). Monitoring requires that patient take medication daily x 1 week. Optimal dose = no further reduction in ADHD sxs occurs & side effects are manageable. Compliance better with long-acting stimulant.Noradrenergic reuptake inhibitors: Bupropion (Wellbutrin) & atomoxetine (strattera). Bupropion affects both NE & DA. Atomoxetine 1st nonstimulant medication to be developed specifically for treatment ADHD & to have been initially pilot tested in adults rather than children. Good alternative adults that cannot tolerate stimulants, do not respond to them, or require full day coverage. Potent & specific norepinephrine reuptake inhibitor.Atomoxetine- safe & efficacious for treatment ADHD children, adolescents, & adults & comparable in clinical response to MPH.When patient does not respond to or tolerate stimulant, treatment with an antidepressant may be considered:Double-blind placebo-controlled studies of the efficacy of bupropion, desipramine, & atomoxetine in management ADHD in adults shown these to be slightly less effective than stimulants but more effective than placebo.Antidepressant medication: TCA’s (imipramine, desipramine). Useful in short term treatment of children with ADHD only when stimulants or atomoxetine not effective (best to use atomoxetine first as alternative given more safety data)Treatment response TCA’s adults =children 50-66% with clinically significant response.Antihypertensive medication: Clonidine (catapres) & guanfacine (Tenex) alpha-2-adrenergic agonists. Research to date Clonidine less effective than stimulants in improving inattention & school productivity but equally efficacious in reducing hyperactivity & moodiness. Also useful vs sleep disturbance seen in some ADHD children. Side effects: drowsiness, weakness, dizziness, occasional sleep disturbance.In general:Side effects tend to decrease in severity & stablize within 1st 3 months treatment.Current practice guidelines: follow patients monthly until condition stable then every 3 months thereafter to monitor symptoms, adverse events, compliance, vital signs, dosage, & life stressors.Long acting stimulants include: 12 hour formulation of Methylphenidate (Concerta), 10 hour formulation Methylphenidate (Ritalin LA, Metadate CD), a 6 hour formulation dexmethylphenidate (Focalin), & 12 hour dextroamphetamine (Adderall XR)