ADHD Flashcards
Define
Characterised by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood.
- The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation for age and level of intellectual functioning and significantly interferes with academic, occupational or social functioning.
NICE definition requires that symptoms:
- Start < 12 years of age
REMEMBER IF YOU ARE SEEING THESE SYMP/ SIGNS AT AN OLDER AGE AND WASN’T THERE AS A CHILD, IT IS SOMETHING ELSE
- Occur in ≥ 2 settings
- Interfere with, or reduce the quality of social, academic or occupational functioning
- Do not occur exclusively during the course of a psychotic disorder and are not better explained by another mental disorder
Inattention: manifested by wandering off task, lacking persistence, having difficulty in sustaining focus and being disorganised
Hyperactivity: Child- excessive motor activity when not appropriate or excessive fidgeting, tapping or talkativeness
Adult- extreme restlessness or wearing others out with their activity
Impulsivity: act in response to immediate stimuli, without deliberation or consideration of the risks and consequences
Epidemiology
More common in boys than girls (3:1)
Three different subtypes:
- Inattentive (20-30%)
- Hyperactive-impulsive (15%)
- Combined subtype (50-75%)
Comorbidity
- ODD/CD
- Anxiety/ Depression
- LD inc reading difficulties
- Soft neuro signs (motor coordination etc)
Aetiology
Exact cause is unknown but involves the interplay of multiple genetic and environmental factors that are thought to lead to altered brain neurochemistry and structure
Genetic contribution
Environmental factors most strongly associated:
- Low birth weight
- Maternal smoking during pregnancy
Risk factors: preterm delivery, LBW, epilepsy, acquired brain injury, lead exposure, iron deficiency, alcohol exposure during pregnancy (FAS), psychosocial adversity, adverse maternal mental health
Symptoms
Inattention symptoms:
- Failing to give close attention to detail or making careless mistakes in schoolwork, work or other activities
- Difficulty in maintaining concentration when performing tasks or play activities
- Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction
- Failing to follow through on instructions or finish a task
- Difficulty in organising tasks and activities
- Reluctance, dislike or avoidance of tasks that require sustained mental effort
- Losing items necessary for tasks or activities e.g. pencils, mobile phones or wallets
- Easy distraction by extraneous stimuli
- Forgetfulness with regards to daily activities
Hyperactivity symptoms:
- Fidgeting with or tapping hands or feet, or squirming when seated
- Leaving the seat where remaining seated is expected, such as in a classroom
- Running about or climbing in situations where inappropriate. In adolescents or adults, this may be limited to a feeling of restlessness
- Inability to play or engage in leisure activities quietly
- Being ‘on the go’ or acting as if ‘driven by a motor’
- Talking excessively
- Blurting out an answer before a question has been completed
- Difficulty waiting his or her turn
- Interrupting or intruding on others
Management
MDT-focussed:
MDT: paediatrician, psychiatrist, ADHD SNs, mental health and learning disability trusts, CAMHS, parent groups, social care workers, school/college and school nurses
1st line in all cases if there is a negative impact on child’s/young person’s development of family life:
- Consider period of watchful waiting for up to 10 weeks (self-help, simple behavioural management)
- Group-based ADHD-focused support for parents
- Refer to specialist if… severe symptoms, >10w
Children <5 years: [AFTER A 10w WATCH AND WAIT]
1st line: offer ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral
Children >5 years: [AFTER A 10w WATCH AND WAIT]
1st line: offer ADHD-focused group parent-training programme to parents and carers
- 10-16 meetings in a group of 10-12 participants
- Education on ADHD, parenting strategies, environmental changes
2nd line: specialist service referral and medications if ADHD persists:
- 1st line (6 weeks) = methylphenidate à trial for 6 weeks
- Pharmacokinetics: CNS stimulant (DA, NA reuptake inhibitor)
- SEs: abdominal pain, nausea, dyspepsia
· 2nd line (monitor SEs) = lisdexamphetamine à 3rd line if side effects
· 3rd line = dexamphetamine
· 4th line = atomoxetine (NARI) or guanfacine
Side effects:
- Loss of appetite
- Palpitations
- Mood changes
- Tics
3rd line: CBT if problems in… social skills, self-control, active listening, dealing with expressing feelings
Other medications:
- Clonidine -> sleep disturbance, rages or tics
- Antipsychotics -> aggression and irritability
- Monitoring Medication: appointments every 3m (if <10yo; dose changes)
- Baseline height, weight, HR, BP and ECG appointments every 6m (if >10yo)
Monitor:
· Response with symptom rating scales (e.g. Conner’s)
· Development of tics after taking stimulant medication
· Sexual dysfunction, seizures, sleep disturbance and worsening behaviour
-Measure weight (BMI for adults) every 3 months (<10yo) or 6 months (>10yo)
-Measure height, HR and BP every 6 months (may suppress appetite and cause growth impairment)
· Include plotting on a growth chart
· If interruptions to growth -> referral and a planned break to allow catch-up growth
Dietary Advice – n.b. no dietary interventions are particularly evidence-based
- Stress importance of balance diet and regular exercise
- Explore foods that seem to influence behaviour (recommend keeping a food diary)
- Dietician referral if relationship with certain foods is observed in the diary
Complications / Prognosis
Side effects from medications
- Methylphenidate: growth retardation in children, alopecia, reduced appetite, GI discomfort, headaches, hypertension, arrhythmias, sleep disorders, reduced weight, anxiety, depression
- Lisdexamfetamine: abdominal pain, anxiety, reduced appetite, GI disturbance, dyspnoea, headache, hyperhidrosis, insomnia, altered mood, tachycardia, tremor, reduced weight
Deterioration in symptoms- worsening of behaviour, sexual dysfunction, seizures, sleep disturbance
Prognosis
- Over time, inattentive symptoms tend to persist and hyperactive-impulsive symptoms tend to recede
- ADHD associated with increased risks of psychiatric disorders including oppositional defiant disorder, conduct disorder, substance abuse, mood disorders (depression and mania)
- Overall prognosis depends on severity and management of any comorbid disorders
Outcome:
- Some may grow out of it
- 90% get conduct disorder if untreated
- 15% have ADHD as an adult
