Next CME lecture is on ADHD...seems like they are making a lot of progress in genetics and figuring out the emotional processing and wiring differences. Mostly pre-clinical work at this point.
Kids with ADHD have lower activation of the inferior right frontal cortex which is where inhibition lives. Also stronger links between amygdala (the “fear” center) and the cortex.
ADHD kids need stronger motivation to attend to a task whereas controls will attend to the task for the sake of the task itself. The default mode and task-oriented networks in ADHD brains are not in sync the same way as control brains.
We have a daydreaming “default mode” network and a task-oriented attention network. In ADHD the intranetwork communication within both networks is weak, but the internetwork communication is stronger than normal, which is...well, confusing and makes it harder to attend.
Different children with different genetics and environment will have different deficits in these networks so personalized therapy based on brain network analysis may be in our future.
Stimulants stimulants stimulants are the mainstays of treatments...there are a couple dopamine/norepinephrine reuptake inhibitors in phase II trials. Behavioral treatment and combined treatment have different results in different populations.
Here's a big data review of ADHD medication use and risk of substance abuse related events ajp.psychiatryonline.org/doi/10.1176/ap…
Here's data about ADHD medication and crime from Sweden ncbi.nlm.nih.gov/pubmed/23171097
Adolescence, ADHD, and driving... ncbi.nlm.nih.gov/pubmed/28604931
Another big data set showing significant decrease in motor vehicle accidents with ADHD+medication use vs unmedicated ncbi.nlm.nih.gov/pmc/articles/P…
(there is also data from controlled driving simulation experiments showing benefit of stimulant medication and driving with ADHD)
Okay...also some findings that ADHD kids score lower on empathy ratings, but it seems to be due to not paying attention to social cues, whereas in autistic spectrum lack of empathy is more related to neurological deficits and inability to understand social cues.
It is interesting I never saw any of these huge studies in the media (the big multimodal treatment study I've seen frequently but has limited practical value considering what it actually measured) nimh.nih.gov/funding/clinic…
Okay, wow, the lecturer says there has never been a proper study of a well-known clinical anecdotal experience of rebound when the medicine wears off!!
Now onto behavioral management: key is understanding the frontal lobe is not firing on all cylinders, so normal social reward or punishment will not be as effective in reinforcing good behavior.
These kids live in the short term so behavioral management has to be geared toward short term (in general this will improve with age, as with all kids, ADHD tends to be more delayed)
"you're grounded until you pass your spelling test" in three weeks won't work. Immediate behavioral rewards for doing homework, following rules, not fighting with sister, etc. works much better.
tying weekly allowance to a nightly points system totaled each week for specific behaviors the kid is working on improving, for example...and more immediate rewards every night (allowed to use phone or video games), consistency (can be hard as ADHD highly heritable)
over time short term success at good behavior can add up for a bigger reward, something to work for and to help exercise that frontal lobe and delayed gratification.
here is a recommended book: amazon.com/Taking-Charge-…
Okay I hate CME questions. A number of studies suggest the prevalence of personality disorders in the US is around 10%, variation being from 6.1-13.4% (according to Sansone and others) 
NIMH says prevalence is 9.1%. So of course the answer in this exam is 10-20% 🙄
