ADHD_flashcards

Question 1

What is the definition of ADHD according to DSM-V?

Answer 1

ADHD is defined as a condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent.

Question 2

How many features of inattention or hyperactivity/impulsivity must be present for a diagnosis of ADHD in children up to 16 years old?

Answer 2

Six features of inattention or hyperactivity/impulsivity must be present for a diagnosis in children up to 16 years old.

Question 3

How many features of inattention or hyperactivity/impulsivity must be present for a diagnosis of ADHD in individuals aged 17 or over?

Answer 3

Five features of inattention or hyperactivity/impulsivity must be present for a diagnosis in individuals aged 17 or over.

Question 4

What is the prevalence of ADHD in the UK?

Answer 4

The prevalence of ADHD in the UK is 2.4%.

Question 5

At what ages are most children diagnosed with ADHD?

Answer 5

Most children are diagnosed with ADHD between the ages of 3 and 7.

Question 6

Is ADHD more common in boys or girls?

Answer 6

ADHD is more common in boys than in girls, with a ratio of 4:1.

Question 7

What are some diagnostic features of inattention in ADHD?

Answer 7

Diagnostic features of inattention in ADHD include: not following through on instructions, reluctant to engage in mentally-intense tasks, easily distracted, difficulty sustaining tasks, difficulty organizing tasks or activities, often forgetful in daily activities, often loses things necessary for tasks or activities, and often does not seem to listen when spoken to directly.

Question 8

What are some diagnostic features of hyperactivity/impulsivity in ADHD?

Answer 8

Diagnostic features of hyperactivity/impulsivity in ADHD include: unable to play quietly, talks excessively, does not wait their turn easily, spontaneously leaves their seat when expected to sit, is often ‘on the go’, often interruptive or intrusive to others, will answer prematurely before a question has been finished, and will run and climb in situations where it is not appropriate.

Question 9

What does NICE recommend as the initial approach to treating ADHD?

Answer 9

NICE recommends a holistic approach including a ten-week ‘watch and wait’ period to observe whether symptoms change or resolve.

Question 10

When should referral to secondary care be considered for ADHD?

Answer 10

Referral to secondary care should be considered if symptoms persist after the ‘watch and wait’ period.

Question 11

What is the first-line drug therapy for ADHD in children?

Answer 11

Methylphenidate is the first-line drug therapy for ADHD in children.

Question 12

What are the side effects of Methylphenidate?

Answer 12

Side effects of Methylphenidate include abdominal pain, nausea, and dyspepsia.

Question 13

What should be monitored in children taking Methylphenidate?

Answer 13

Weight and height should be monitored every 6 months in children taking Methylphenidate.

Question 14

What drug should be used if there is an inadequate response to Methylphenidate?

Answer 14

If there is an inadequate response to Methylphenidate, switch to Lisdexamfetamine.

Question 15

What should be done before starting drug therapy for ADHD due to potential cardiotoxicity?

Answer 15

Perform a baseline ECG before starting drug therapy due to potential cardiotoxicity.

Question 16

Why is a thorough history and clinical examination important in diagnosing ADHD?

Answer 16

A thorough history and clinical examination are important due to the overlap of ADHD with many other psychiatric and physical conditions.

Question 17

summarise

Answer 17

Attention Deficit Hyperactivity Disorder

March 2018 saw NICE issue new guidance around recognising and managing attention deficit hyperactivity disorder (ADHD). This condition can inflict significant morbidity on a child’s life and thus has consequences into adulthood, making good diagnosis and treatment vital.

DSM-V defines ADHD as a condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent. Like many paediatric conditions, there has to be an element of developmental delay. For children up to the age of 16 years, six of these features have to be present; in those aged 17 or over, the threshold is five features (Table below).

Epidemiology
ADHD has a UK prevalence of 2.4%, about twice that of autism, and is more common in boys than in girls (M:F 4:1);
Most children are diagnosed between the ages of 3 and 7;
There is a possible genetic component.

Diagnostic Features

Inattention Hyperactivity/Impulsivity
Does not follow through on instructions Unable to play quietly
Reluctant to engage in mentally-intense tasks Talks excessively
Easily distracted Does not wait their turn easily
Finds it difficult to sustain tasks Will spontaneously leave their seat when expected to sit
Finds it difficult to organise tasks or activities Is often ‘on the go’
Often forgetful in daily activities Often interruptive or intrusive to others
Often loses things necessary for tasks or activities Will answer prematurely, before a question has been finished
Often does not seem to listen when spoken to directly WIll run and climb in situations where it is not appropriate

Management

NICE stipulates a holistic approach to treating ADHD that isn’t entirely reliant on therapeutics. Following presentation, a ten-week ‘watch and wait’ period should follow to observe whether symptoms change or resolve. If they persist then referral to secondary care is required. This is normally to a paediatrician with a special interest in behavioural disorders, or to the local Child and Adolescent Mental Health Service (CAMHS). Here, the needs and wants of the patient, as well as how their condition affects their lives should be taken into account, to offer a tailored plan of action.

Drug therapy should be seen as a last resort and is only available to those aged 5 years or more. Patients with mild/moderate symptoms can usually benefit from their parents attending education and training programmes. For those who fail to respond, or whose symptoms are severe, pharmacotherapy can be considered:
Methylphenidate is first line in children and should initially be given on a six-week trial basis. It is a CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months
If there is inadequate response, switch to lisdexamfetamine;
Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects.

In adults:
Methylphenidate or lisdexamfetamine are first-line options;
Switch between these drugs if no benefit is seen after a trial of the other.

All of these drugs are potentially cardiotoxic. Perform a baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.

Like most psychiatric conditions, whether adult or paediatric, a thorough history and clinical examination are key, especially given the overlap of ADHD with many other psychiatric and physical conditions.

Question 18

A 10-year-old boy is referred to the paediatrics clinic due to behavioural and attention span concerns. His teacher has reported frequent inattentiveness and difficulty maintaining focus during lessons. The likely diagnosis leads the paediatrician to recommend training programmes for his parents to assist with managing his symptoms. Despite this intervention, after several months, the boy’s symptoms worsen. Consequently, the paediatrician initiates a trial of medication for six weeks.

What side effect is associated with this medication?

Hypersalivation
Hypohidrosis
Hypotension
Stunted growth
Weight gain

Answer 18

Stunted growth

A side effect of methylphenidate is stunted growth

Stunted growth is the correct answer. The likely diagnosis in this case is attention-deficit/hyperactivity disorder (ADHD). It is likely that the paediatrician has initiated treatment with methylphenidate, which is the first-line medication recommended for ADHD management. Stunted growth can be a potential side effect of methylphenidate, especially with prolonged use. This adverse effect may be due to the drug’s ability to suppress appetite and its possible influence on the secretion of growth hormone.

Hypersalivation is not correct. Patients taking methylphenidate are more commonly affected by dry mouth than hypersalivation.

Hypohidrosis is also incorrect. Methylphenidate typically causes an increase in sweating, known as hyperhidrosis, rather than a reduction in sweating or hypohidrosis.

Hypotension is incorrect. Contrary to causing low blood pressure, methylphenidate may lead to an increase in heart rate and blood pressure. While hypotension is not frequently observed with this medication, it remains important to monitor blood pressure regularly, particularly in individuals who have underlying cardiovascular conditions.

Weight gain does not represent a common side effect of methylphenidate use. On the contrary, stimulant medications such as methylphenidate typically reduce appetite and may contribute to weight loss in some patients.