1 . According to the 2016 National Survey of Children's Health, what percentage of children 4 to 17 years of age had ADHD in 2011–2012?
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EPIDEMIOLOGYThe exact prevalence of ADHD is unknown. The 2016 National Survey of Children's Health (NSCH) found that 6.1 million children in the United States have ever been diagnosed with ADHD. This includes 388,000 children 2 to 5 years of age, 2.4 million children 6 to 11 years of age, and 3.3 million adolescents 12 to 17 years of age [2]. The percent of children 4 to 17 years of age ever diagnosed with ADHD increased from 7.8% in 2003 to 11.0% in 2011–2012 [2]. Note: Because the 2016 NSCH survey used different methods, estimates are not directly comparable with estimates based on previous NSCH data. Also, due to the increased focus on ADHD in younger children, the age ranges surveyed were expanded to include children 2 to 17 years of age [2]. Click to Review2 . Which of the following statements regarding the epidemiology of ADHD is TRUE?
EPIDEMIOLOGYIn children, ADHD is more than twice as common in boys (11.7%) as in girls (5.7%) [3]. In 2016–2018, 13.8% of children 3 to 17 years of age had ever been diagnosed with either ADHD or a learning disability. Non-Hispanic Black children (16.9%) were more likely than non-Hispanic White (14.7%) or Hispanic (11.9%) children to be diagnosed with either condition, although the reason is not clear [3,4]. The prevalence of ADHD among children with family incomes less than 100% of the poverty level was 10% from 1998 to 2009 and 11% for those with family income from 100% to 199% of the poverty level [5]. Click to Review3 . Which of the following is NOT true regarding adults with ADHD?
EPIDEMIOLOGYIn children, ADHD can lead to educational difficulties, social difficulties, injuries and accidents, and family problems. Adults with a childhood history of ADHD are more likely to exhibit antisocial and criminal behavior, are more prone to injuries and accidents, and have more health problems than the general population [9]. They also have more employment and marital difficulties and are more likely to have children out of wedlock. In a community sample of 500 adults with self-reported ADHD and 501 community-based controls, the adults with ADHD were significantly less likely to have graduated from high school (83% vs. 93%), less likely to have obtained a college degree (19% vs. 26%), and less likely to be currently employed (52% vs. 72%). They were more likely to have had job changes (5.4 vs. 3.4 jobs over 10 years), to have been arrested (37% vs. 18% of controls), and to have been divorced (28% vs. 15%). They were also less likely to be satisfied with their professional, family, and social lives [10]. Click to Review4 . According to the DSM-5 criteria, how many symptoms must be present for a child to be diagnosed with either the inattentive or hyperactive form of ADHD?
DIAGNOSTIC CRITERIAAccording to the DSM-5 criteria for ADHD, one of the following groups of symptoms must be present [11]:
5 . Which of the following is NOT a symptom of inattention found in people with ADHD?
DIAGNOSTIC CRITERIAAccording to the DSM-5 criteria for ADHD, one of the following groups of symptoms must be present [11]:
6 . An individual whose symptoms and impairment no longer meet the full criteria for ADHD would be diagnosed with
DIAGNOSTIC CRITERIAImpairment from the symptoms must be present in two or more settings (e.g., at school [or work] and at home). There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. For a diagnosis of ADHD, the symptoms may not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder or be better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder). For individuals (especially adolescents and adults) who have symptoms that no longer meet full criteria, "in partial remission" should be specified. The category unspecified ADHD is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the full criteria for ADHD [11]. Click to Review7 . Which of the following is typical of adults with ADHD?
AGE AND CHANGING SYMPTOMSThere are several changes in symptoms as patients approach adulthood. There appear to be fewer overt symptoms of hyperactivity (e.g., running and climbing, inability to remain seated), but these may be replaced with or confined to fidgetiness, jitteriness, or restlessness. Restlessness may lead to difficulty participating in sedentary activities and even avoiding sedentary occupations. Impulsivity may manifest as a tendency to make decisions without thinking them through [19]. Patients may start on projects without reading or listening to instructions. An adult with ADHD may also have a tendency to speed when driving. Other typical adult ADHD symptoms include having trouble getting organized, planning ahead, or preparing for events [19]. These patients may appear inefficient, failing to do tasks in the order that makes the most sense. Inattention may manifest as failure to persist in uninteresting tasks or daydreaming instead of concentrating. Click to Review8 . Which of the following is a set of criteria for assessing ADHD in adults?
AGE AND CHANGING SYMPTOMSThe Utah criteria are a set of diagnostic criteria developed specifically to identify adults with ADHD [22]. Although they do not match the DSM-5 definition, they may be useful in assessing adult patients. The Utah criteria include [22]:
9 . Which of the following genes has been found to reliably predict ADHD?
PATHOPHYSIOLOGYThere have been several genes associated with ADHD, including the dopamine-beta-hydroxylase gene, the dopamine transporter gene, and the dopamine receptor gene [5,24]. However, no gene has been found that reliably predicts ADHD. Click to Review10 . Which of the following is considered a first-line treatment for ADHD?
TREATMENTStimulant medications, including amphetamine and methylphenidate, are considered first-line therapy in the treatment of ADHD [5,28]. However, other medications, such as atomoxetine, may be considered [5]. Behavior modification has a role in the overall treatment plan of ADHD, and cognitive-behavioral therapy (CBT) may be helpful for adults, although the evidence for stimulant medications is stronger. Click to Review11 . In a review of studies in which subjects underwent a trial of both amphetamine and methylphenidate, what percentage of children responded to treatment?
TREATMENTStimulant medications appear to be effective in treating ADHD, and most children with ADHD will respond to at least one of them [13]. In a review of studies in which subjects underwent a trial of both amphetamine and methylphenidate, about 85% of children responded to one or both of these medications [32]. Forty-one percent responded equally to both classes, and 44% responded preferentially to one or the other. Stimulants are also effective in adults. One systematic review and meta-analysis sought to estimate the comparative efficacy and tolerability of amphetamines (including lisdexamfetamine), methylphenidate, modafinil, atomoxetine, bupropion, clonidine, and guanfacine with each other or placebo for ADHD in children, adolescents, and adults [33]. Efficacy was defined as the change in severity of ADHD core symptoms based on teachers' and clinicians' ratings. For ADHD core symptoms rated by clinicians in children/adolescents closest to 12 weeks, all drugs included in the review were superior to placebo, whereas only methylphenidate was superior to placebo based on teachers' ratings [33]. In adults, amphetamines, methylphenidate, bupropion, and atomoxetine were superior to placebo according to clinicians' ratings. With respect to tolerability, amphetamines were inferior to placebo in all three age groups; guanfacine was inferior to placebo only in children and adolescents; and atomoxetine, methylphenidate, and modafinil were less well tolerated than placebo only in adults. In head-to-head comparisons of the drugs, differences in efficacy, not tolerability, were found (according to clinicians' ratings). Amphetamines were favored over modafinil, atomoxetine, and methylphenidate in all three age groups at 12 weeks [33]. Click to Review12 . Which of the following is TRUE regarding the mechanism of action of methylphenidate in ADHD?
TREATMENTThe effect of stimulants is thought to be mediated primarily though their actions on dopamine and norepinephrine transmission. Stimulants have been shown to increase the concentration of these neurotransmitters in the frontal cortex, midbrain, and brain stem, which may explain their effect of increasing attention span and the ability to concentrate [9]. Amphetamines and methylphenidate may differ in specific actions regarding dopamine release [34]. Methylphenidate is to a large extent a norepinephrine and dopamine reuptake inhibitor, while amphetamines promote dopamine and norepinephrine efflux from neurons [35]. Click to Review13 . Which of the following is NOT a common side effect of stimulants?
TREATMENTMany side effects associated with stimulant use are likely to resolve with time. Side effects that are reported commonly include insomnia, reduced appetite, headaches, stomachaches, and emotional lability [36]. Anorexia often resolves after a few weeks. In children, some height delay has been observed when treatment is initiated, but research shows this growth delay levels off by the end of adolescence [37,38,39]. Click to Review14 . Which of the following is TRUE about precautions with the use of stimulant medications to treat ADHD in children?
TREATMENTStimulant medications are considered safe for use in most children and adults. However, there are areas of concern that should be considered prior to initiating treatment. Although the actual cardiac risk is not known, stimulant medications carry a warning against use in persons with certain cardiac abnormalities, due to sympathomimetic effects [41]. The AAP and the American Heart Association recommend that prior to starting a patient on ADHD medications, patient and family health histories should be obtained and a physical exam should be performed with a focus on cardiovascular disease risk factors [41]. This was a Class I recommendation with level of evidence C, meaning that the recommendation was strong although based primarily on expert consensus, case studies, and/or standard of care. Acquiring an electrocardiogram (ECG) prior to starting treatment was considered reasonable but not mandatory. It was also recommended that the blood pressure and heart rate of the patient be monitored, within 1 to 3 months of starting medication and every 6 to 12 months thereafter (also a IC recommendation) [41]. Later the same year, AAP released a statement supporting the use of careful history and physical exam to assess for cardiac abnormalities [42]. However, this statement noted a lack of evidence to support routine ECGs before prescribing stimulant medications. Cardiac risk should also be considered when prescribing stimulant medications for adults. This risk will be discussed in detail later in this course. Methylphenidate has been reported to lower seizure threshold in certain children; however, stimulants may be used safely in children who have epilepsy that is well-controlled [43,44,45]. Studies suggest that low doses of methylphenidate may also be safely used in children with difficult-to-treat epilepsy; in these instances, its use positively impacts the patient's quality of life [46,47]. Click to Review15 . Which of the following best characterizes atomoxetine?
TREATMENTAtomoxetine has been approved by the FDA for the treatment of ADHD in both children and adults; however, it may be less effective than stimulant medications. Atomoxetine is a noradrenergic reuptake inhibitor, and it has several important differences in comparison to stimulants [9,35]. Atomoxetine has different side effects than stimulant medication and is more likely to cause sedation and nausea. The treatment effect may be smaller than that observed with stimulant medications, and its effect may take longer to appear. Click to Review16 . Which of the following best characterizes the black box warning for atomoxetine?
TREATMENTAtomoxetine should be discontinued if symptoms of hepatic disease appear. This medication also carries cardiac warnings similar to stimulants. Lastly, atomoxetine carries a black box warning for suicidal ideation in children with ADHD, especially in the first month of treatment [35]. Click to Review17 . In studies of the use of clonidine for ADHD, which side effect was noted most prominently?
TREATMENTClonidine has been evaluated for the treatment for ADHD in children with co-existing conditions, especially sleep disturbance. In a double-blind, randomized, placebo-controlled study of 122 children given clonidine, methylphenidate, or both, the authors concluded that methylphenidate offered a better combination of efficacy and tolerability compared to clonidine [50]. Clonidine was efficacious but was also associated with increased sedation. Click to Review18 . What was the efficacy of behavioral therapy in the Multimodal Treatment Study of Children with ADHD?
TREATMENTThe Multimodal Treatment Study of Children with ADHD was a 14-month trial of specific medication management, intensive behavioral therapy (group and individual sessions, teacher consults, a classroom behavioral aide for 12 weeks, and a summer program), both medication and behavioral therapy, or ordinary community care [75]. This study revealed that combination treatment did not significantly differ from medication management alone on direct comparisons. Click to Review19 . What percentage of children with ADHD also have ODD?
COMORBIDITIES IN CHILDRENMultiple studies have shown that among children who have ADHD, 54% to 84% have ODD, 15% to 19% smoke or have other substance abuse disorders, and 25% to 35% have a learning or language problem [9]. Up to one-third of children with ADHD also have an anxiety disorder or depression, and approximately 16% meet the criteria for mania [9]. Click to Review20 . Based on data from the National Comorbidity Survey Replication, what is the estimated odds ratio for an adult with ADHD having any mood disorder, compared to the general population?
COMORBIDITIES IN ADULTSComorbidities are also common in adults with ADHD. Based on the National Comorbidity Survey Replication, the odds ratio of an adult with ADHD having any mood disorder is 5.0, any anxiety disorder is 3.7, any substance use disorders is 3.0, and intermittent explosive disorder is 3.7 [6]. Click to ReviewWhen ADHD is present the child will most likely exhibit which core symptoms?ADHD behavior usually appears by age 7, though symptoms behavior may appear before this. With ADHD, children can have trouble with impulsivity, hyperactivity, distractedness, following instructions and completing tasks.
What are the core symptoms of attention deficit disorders?Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities.
What are the 3 core symptoms of ADHD?ADHD is defined as Attention-Deficit/Hyperactivity Disorder. ADHD is a neurodevelopmental disorder found in children, teens, and adults. Its core symptoms are inattention, impulsivity, and hyperactivity.
What is the core attentional deficit in ADHD?Context A lack of inhibitory control has been suggested to be the core deficit in attention-deficit/hyperactivity disorder (ADHD), especially in adults. This means that a primary deficit in inhibition mediates a cascade of secondary deficits in other executive functions, such as attention.
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