ADHD

Question 1

Case 1: Cody is an 8-year-old boy referred to paediatrics clinic from general practitioner because of disruptive behaviour at home and school. His mother recalls that Cody has been hyperactive since a toddler. Teacher reports that he does not sit still in class and interrupts frequently. Discuss approach to management.

Case 2: A 9-year-old boy attends for interview with his mother. She reports that his school complains that he gets into fights at school, and is disruptive in class. Mother also reports that he is aggressive towards his 2 younger brothers. How would you approach the assessment of this child’s mental health and what diagnoses would you consider likely?

Answer 1

Impression
Given reports of behavioural disturbance and hyperactivity, likely this represents attention deficit hyperactivity disorder.

Ddx to consider:

• oppositional defiant disorder, conduct disorder (behavioural)
• Autism spectrum disorder
• learning and language disorders
• psychiatric (depression, anxiety, etc)

Want to take full medical, developmental, and psychosocial assessment. Typically requires information from several sources (parents, teachers, etc)

Question 2

ADHD - History

Answer 2

History

• Inattention; difficulty organising tasks, can’t follow instructions, easily distractible, doesn’t follow through with instructions,
• Hyperactivity; difficulty focusing, poor listener, makes careless mistakes, on the go, gets out of seat inappropriately, interjects in conversation inappropriately
• Risk factors: Fam hx, low birth weight, smoking in family, male gender
• Paediatric history: obstetric complications, developmental milestones
• Characterise functional impairment (home, school)
• Age of onset
• Screen psychiatric conditions
• PMHx - ask about organic symptoms
• Medications

Question 3

ADHD - Examination

Answer 3

Examination

• general appearance = anthropometric measurements (in consideration of starting medications
• observation in play

Question 4

ADHD - Investigations

Answer 4

Investigations

• no formal laboratory or imaging for ADHD specifically
• referral to paediatrician for complete assessment and care
• Utilise Connors 3 test for parents, other carers, and school to complete to verify sx across domains of life.
• formal hearing, vision, IQ tests, psychometric testing,
• further work-up for organic causes (TFT, FBC, UEC, LFT, etc)

Question 5

ADHD - Management

Answer 5

Management
- referral to paeds/psychology for official diagnosis.

Psychosocial treatment (Not necessarily first line in ADHD)

• Behavioural interventions: essentially enhanced parenting skills - operant conditioning: goal based and positive reinforcement
• create low-stimulus effective environments: daily schedules, minimise distractions, small target goals, positive reinforcement
• social skills training/vocational training when older

Biological
1) stimulants: methylphenidate (ritalin, concerta), or dexamphetamines (Adderall).
- can up titrate, also alter depending on requirement (short actings vs long-actings)
A/E: decrease appetite, insomnia, HTN, tachycardia, decreased growth velocity. May require sleeping assistance (melatonin).
- stimulants are widely used and highly effective in paediatric patients

Then treatment of co-morbid psychiatric disorders (tic, tourettes, etc).

• Clonidine, Atomoxetine (2nd line treatments)
• Tic disorder - Risperidone (also for significant behavioural component)
• Ongoing review