ADHD + Learning disabilities Flashcards
What is the definition of ADHD?
characterized by an early onset,
persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a
comparable stage of development, and are present in more than one situation. Children may present with difficulties at school
and at home
What are neurodevelopmental conditions defined as?
DSM - V - group of conditions with onset in developmental period and can persist throughout individuals lifetime
Typically manifest early in development, before child enters elementary school and is characterised by developmental deficits that produce impairments of personal, social, academic or occupational functioning
What is the aetiology of ADHD?
Genetic: Twin and adoption studies indicate a genetic predisposition (concordance rate of 82% for
monozygotic twins). The DRD4 and DRD5 genes are thought to play a role.
Neurochemical There are reports of a link between hyperkinetic disorder and the genes coding for the
dopamine system, suggesting an abnormality in the dopaminergic pathways.
Neurodevelopmental: Neurodevelopmental abnormalities of the pre-frontal cortex are hypothesized based on
symptoms of recklessness, inattention and learning difficulties.
Social: There is an association with social deprivation and family conflict as well as parental cannabis
and alcohol exposure.
Epidemiology of ADHD
Male Males are three times more likely to be affected than females.
Family history Family history is a strong determinant of hyperkinetic disorder with twin studies reporting about
70% heritability.
Environmental risk
factors
Social deprivation and family conflict as well as parental cannabis and alcohol exposure.
RFs of ADHD
Preterm
LAC
ODD/CD
Mood Disorders (Anxiety/ Depression)
Close family members with ADHD
Epilepsy
Neurodevelopmental Conditions
Mental Health
Substance Use Disorder
Youth Justice/ Adult Criminal Justice System
Acquired Brain Injury
What are the 3 core features of ADHD
Inattention
Hyperactivity
Impulsivity
What are the 3 DSM-IV recognised categories of ADHD?
predominantly inattentive type;
predominantly hyperactive-impulsive type; and
combined type.
How can we diagnose ADHD in adults?
Did the person have ADHD or ADHD symptoms as a child?
To what extent do they still have symptoms
To what extent are the problems described better explained by another diagnosis?
What are the features of inattention?
Not listening when spoken to
Highly distractible
Reluctant to engage in activities that require persistent mental effort eg school work
Forgetting or regularly losing belongings
Features of hyperactivity
Restlessness and fidgeting or tapping with hands or feet
Recklessness
Running and jumping around in inappropriate places
Difficulty engaging in quiet activities
Excessive talking or noisiness
Features of impulsivity
Difficulty waiting for their turn
Interrupting
Prematurely blurting out answers
Temper tantrums and aggression
Disobedient
Running into the street without looking
ICD-10 criteria for ADHD
A. Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child.
B. Demonstrable abnormality of attention and activity at school or nursery (if applicable), for the age and developmental level
of the child.
C. Directly observed abnormality of attention or activity. This must be excessive for the child’s age and developmental level.
D. Does not meet criteria for a pervasive developmental disorder, mania, depressive or anxiety disorder.
E. Onset before the age of 7 years.
F. Duration of at least 6 months.
G. IQ above 50.
DSM-V ADHD definition in those younger <17 years
6/9 Inattentive
6/9 Hyperactive/ Impulsive symptoms
Present before 12 years
Developmentally inappropriate
Several symptoms in 2 or more settings
Clear evidence symptoms interfere/reduce quality of social/academic/occupational function
What is poor emotional regulation in ADHD
Immediate and situation specific
Identifiable trigger
Short lived
Understandable but over the top
If there is impairment of at least moderate clinical +/- psychosocial significance in > 1 domains
E.g. Self-care, Travelling Independently, Making/ Keeping Friends, Achieving In School, Forming Positive Relationships In Family, Positive Self Image, Avoiding Criminal Activity, Avoiding Substance Misuse, Emotional States Free of Excessive Anxiety and Unhappiness, Understanding Risk and Avoiding Common Hazards
Adolescence/Adult
Occupational Underachievement, Dangerous Driving and Problems In Intimate Relationships e.g. Excessive Discord and Jealousy
History for ADHD?
History:
‘Do you find that your child…’
1. Inattention: ‘…is reluctant to engage in activities which need sustained mental effort, such as schoolwork?’, ‘…
often leaves play activities unfinished?’,
‘…regularly loses their possessions?’, ‘…does not listen when spoken to?’
2. Hyperactivity: ‘…is constantly fidgeting, jumping or running around?’, ‘…is unable to remain still?’, ‘…is difficult to
engage in quiet activities?’
3. Impulsivity: ‘…cannot wait their turn when playing in groups?’, ‘…blurts out answers to questions before the
question has been completed?’
MSE for a child with ADHD
EAppearance
&
Behaviour
Fidgety. Unable to sit still. Running around, jumping or climbing inappropriately. If toys offered, will flit
from one to another. If parents are asked a question, the child replies with the answer before the
parents can.
Speech Talks loudly, even at inappropriate times and makes excessive noise.
Mood Normal but may be low if co-morbid depressive disorder.
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Thought No disorders of thought.
Perception No hallucinations.
Cognition Poor attention levels. Lack of concentration.
Insight Poor.
What are the tests done for ADHD?
Clinical interview
ADHD nurse classroom observation
QB test
Questionnaires
What is used for the diagnostic interview for a patient with suspected ADHD?
Young DIVA-5 - Diagnostic Interview for ADHD 5-17 YEARS
Complete with Young Person and Parent
Based DSM5
1 hour to complete
What is the SHORT Questionnaire
Swanson Noland And Pelham IV
As a benchmarking tool
18 Questions available CADDRA
Score 0-54
<27 ‘Clinical Response’
<18 Optimisation
Investigations for ADHD
x NOTE: As problem behaviours vary in different settings, it is important to obtain information from teachers, as well as
the parents and the child. For adults seeking a diagnosis, school reports are usually reviewed and a collateral history
from parents is helpful.
Blood tests including TFTs (to rule out thyroid disease).
Hearing tests: Examine middle/inner ear with an otoscope and consider a pure tone audiogram.
Rating scales: e.g. Conners’ rating scale and the Strengths and Difficulties questionnaire.
Differential Diagnoses for ADHD
Learning disability/Dyslexia
Oppositional defiant disorder (see Key facts 1)
Conduct disorder (see Key facts 1)
Autism
Sleep disorders
Mood disorders (particularly bipolar)
Anxiety disorder
Hearing impairment
How can we differentiate from ADHD
- Symptoms of ADHD - longitudinal history with onset in childhood and persisting into adulthood
- Overlapping additional neuro-developmental conditions, specific and general learning difficulties
- Co-occurence of another condition or mental health disorder which mimic symptoms of ADHD
Co morbidities of ADHD
70% of hyperkinetic disorder patients have co-morbidities including learning difficulties (e.g. ASD, dyslexia), dyspraxia,
Tourette’s syndrome and mood/anxiety disorders.
Conduct disorder (co-exists in 50% of hyperkinetic children) is a repetitive and severe pattern of antisocial behaviour
including aggression, destruction of property, deceitfulness (or stealing) and major violations of age-appropriate social
expectations. Risk factors include being male, abuse as a child, poor socioeconomic status and parental psychiatric
disorders. It is the most common psychiatric disorder of childhood.
Oppositional defiant disorder is defiant and disruptive behaviour against authoritative figures but is less severe than
conduct disorder, in that violations of law and physical abuse of others are far less common.
What did the Russell Barkley Milwaukee Study of 2008 show about people with ADHD and workplace, driving and substances?
Workplace
Fired 2-4xmore
18 x more disciplinary actions
22 days more absenteeism
Monthly income 20-40% less
Driving
2-4x more likely in car crash
2-4x banned from driving
Substances
2-3x more likely abuse tobacco
3-8x more likely abuse alcohol
8x more likely drug dependence
What did the Russell Barkley Milwaukee Study of 2008 show about people with relationships and education?
Relationships
10x risk of unwanted pregnancy
4x risk more risk of std’s
Fewer close friends
Higher risk extra marital affairs
Education
30-40% SEN
Lower reported grades below C
50% of adults need additional tutoring
3.5x less likely to enter college
What are the NICE guidelines of 2018 about medication for ADHD from 5-17 years
Meet full criteria for ADHD
ADHD…Significant impact In at Least One Domain of Everyday Life After Environmental Modification
Stress Importance of Balanced Diet/Regular Exercise
Mental Health
Educational enivronment
Social circumstances
Neurodevelopment co morbidity
Secondary School ADHD in girls
Underage pregnancy
Detentions
Self harm
Bing eating
Poor organisation
Hyperfocus
Meltdowns
Social rejections
Cyberbullying
Zoning out
Overwhelmed
ADHD in Primary School girls
Sleep difficult
Giggles
Fidgets
Bites nails
Hair play
Not achieving full academic potential
Friendship difficulties
Talks too much
Moody
Meltdowns
Looses it
General management of ADHD
Hyperkinetic disorder is diagnosed by specialists and treatment depends on whether the patient is pre-school, school-age or
adult, as well as the severity of symptoms.
Support for parents and teachers is crucial. Support groups include add+up and ADDISS.
If there is a clear link between food or drink consumed and behaviour, parents should be advised to keep a food diary and a
referral to a dietician can be made if appropriate.
Pre-school management of ADHD
Parent-training and education programmes (psychoeducation) are first-line.
Parent-training is behavioural with parents being helped to reinforce positive behaviour and to find alternative ways of
managing disruptive behaviour.
Drug treatments are not recommended.
School goer management of ADHD
Psychoeducation and CBT (and/or social skills training) should be provided.
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In severe hyperkinetic disorder in school-age children, drug treatment is first-line with the CNS stimulant methylphenidate
(Ritalin) being the usual choice.
Atomoxetine (and if this fails, dexamfetamine) is the alternative when methylphenidate has been ineffective. Side effects
should be monitored for.
Side effects of CNS stimulants include headache, insomnia, loss of appetite and weight loss.
Recent studies show no clear link between extended stimulant use and growth retardation.
What are the types of medication used for ADHD
Ritalin
Elvanse
Strattera
Intuniv
What is the definition of Learning disabilities?
Learning disability (LD) is a state of arrested or incomplete development of the mind. It is characterized by impairment of
skills manifested during the developmental period, and skills that contribute to the overall level of intelligence.
ICD-10 divides LD into four categories depending on the severity (see ICD-10 box).
A triad must exist to constitute a learning disability. This includes (1) Low intellectual performance (IQ below 70). (2) Onset
at birth or during early childhood. (3) Wide range of functional impairment including social handicap due to reduced ability to
acquire adaptive skills (activities of daily living).
What is the ICD-10 Criteria for the diagnosis of LD?
Mild → IQ = 50–70 (Mental age = 9–12)
Moderate → IQ = 35–49 (Mental age = 6–9)
Severe → IQ = 20–34 (Mental age = 3–6)
Profound → IQ = <20 (Mental age <3 years)
What is the pathophysiology/ aetiology of learning disabilities?
Perinatal: Birth asphyxia, intraventricular haemorrhage, neonatal sepsis.
Neonatal: Hypoglycaemia, meningitis, neonatal infections, kernicterus.
Postnatal Infection (e.g. meningitis, encephalitis), anoxia, metabolic (e.g. hypothyroidism, hypernatraemia), cerebral
palsy.
Environmental: Neglect/non-accidental injury, malnutrition, socioeconomically deprived.
Psychiatric: Autism, Rett’s syndrome.
Antenatal: Congenital infection (rubella, CMV, toxoplasmosis), nutritional deficiency, intoxication (alcohol, cocaine,
lead), endocrine disorders etc
Genetic: Down’s syndrome, fragile X syndrome, Cri du chat, Prader–Willi etc
Epidemiology and RFs for Learning disabilities
The prevalence of LD is 2%: 85% of these are mild, 10% moderate and 5% severe or profound.
The ♂ to ♀ ratio is 3:2.
The most common risk factor is a positive family history of LD.
Clinical features of LD
Mild LD: Usually identified at a later age when the child starts school. They have adequate language abilities,
social skills and self-care. There may be difficulties in academic work. Most live independently but may
need some support in housing and employment.
Moderate LD:
Able to communicate but language is limited. May need supervision for self-care but able to do simple
work.
Severe LD:
There is a marked degree of motor impairment. Little or no speech in early childhood but may eventually
use simple communication. May be able to perform simple tasks under supervision. They may have
associated physical disorders.
Profound LD:
Severe motor impairment and severe difficulties in communication. Have little or no self-care. Frequently
have physical disorders and require residential care.
