Attention Deficit Hyperactivity Disorder (ADHD)

Question 1

What is attention deficit hyperactivity disorder (ADHD)?

Answer 1

Attention deficit hyperactivity disorder (ADHD) is at the extreme end of “hyperactivity” and inability to concentrate (“attention deficit“). It affects the person’s ability to carry out everyday tasks, develop normal skills and perform well in school.

Question 2

In what environments should children with ADHD demonstrate symptoms?

Answer 2

Features should be consistent across various settings. When a child displays these features only at school but is calm and well behaved at home, this is suggestive of an environmental problem rather than an underlying diagnosis.

Question 3

What is the other name for ADHD?

Answer 3

Hyperkinetic disorder.

Question 4

Briefly describe the genetic aetiology and pathophysiology of ADHD

Answer 4

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.

Question 5

Briefly describe the neurochemical aetiology and pathophysiology of ADHD

Answer 5

There are reports of a link between hyperkinetic disorder and the genes coding for the dopamine system, suggesting an abnormality in the dopaminergic pathways.

Question 6

Briefly describe the neurodevelopmental aetiology and pathophysiology of ADHD

Answer 6

Neurodevelopmental abnormalities of the pre-frontal cortex are hypothesized based on symptoms of recklessness, inattention and learning difficulties.

Question 7

Briefly describe the social aetiology and pathophysiology of ADHD

Answer 7

There is an association with social deprivation and family conflict as well as parental cannabis and alcohol exposure.

Question 8

How many children in the UK are thought to have ADHD?

Answer 8

2.4%.

Question 9

Which gender is commonly affected by ADHD?

Answer 9

It is three times more common in males than females.

Question 10

What is the age of onset of ADHD?

Answer 10

It is common between the ages of 3 and 7.

Question 11

What are the risk factors for ADHD?

Answer 11

• 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

Question 12

What are the 3 core features of ADHD?

Answer 12

1. Inattention
2. Hyperactivity
3. Impulsivity

Question 13

Briefly describe the ICD-10 Criteria of ADHD

Answer 13

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.

Question 14

What are the features of ADHD?

Answer 14

All the features of ADHD can be part of a normal spectrum of childhood behaviour. When many of these features are present and it is adversely affecting the child, ADHD can be considered:

• Very short attention span
• Quickly moving from one activity to another
• Quickly losing interest in a task and not being able to persist with challenging tasks
• Constantly moving or fidgeting
• Impulsive behaviour
• Disruptive or rule breaking

Question 15

How can a child demonstrate innattention?

Answer 15

• Not listening when spoken to
• Highly distractible (moving from one activity to the next)
• Reluctant to engage in activities that require persistent mental effort, e.g. school work which contains careless mistakes
• Forgetting or regularly losing belongings

Question 16

How can a child demonstrate hyperactivity?

Answer 16

• 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

Question 17

How can a child demonstrate impulsivity?

Answer 17

• Difficulty waiting their turn
• Interrupting others
• Prematurely blurting out answers
• Temper tantrums and aggression
• Disobedient
• Running into the street without looking

Question 18

What questions would you ask the parent of a child with ADHD?

Answer 18

Any three types of questions that cover the three core features of hyperkinetic disorder:

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?’

Question 19

Briefly describe the MSE for ADHD

Answer 19

Appearance & 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.

Thought: no disorders of thought.

Perception: no hallucinations.

Cognition: poor attention levels. Lack of concentration.

Insight: poor.

Question 20

What investigations should be ordered for ADHD?

Answer 20

• 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 Questionnaires.

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.

Question 21

What co-morbidities are linked to ADHD?

Answer 21

70% of hyperkinetic disorder patients have co-morbidities including learning difficulties (e.g. ASD, dyslexia), dyspraxia , Tourette’s syndrome and mood/anxiety disorders.

Question 22

What is conduct disorder?

Answer 22

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.

Question 23

What is oppositional defiant disorder?

Answer 23

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.

Question 24

Briefly describe the important general approach to managing ADHD

Answer 24

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.

Question 25

Briefly describe the management of pre-school treatment with ADHD

Answer 25

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.

Question 26

Briefly describe the management of school-age children with ADHD

Answer 26

Psychoeducation and CBT (and/or social skills training ) should be provided.

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.

Question 27

Give examples of medication used to treat ADHD

Answer 27

• Methylphenidate (“Ritalin“)
• Dexamfetamine
• Atomoxetine

Question 28

What class of drug are used to treat ADHD?

Answer 28

Contrary to what you might think, they are central nervous system stimulants.

Question 29

What are the side effects of medication used to treat ADHD?

Answer 29

Side effects of CNS stimulants include headache, insomnia, loss of appetite and weight loss.

Question 30

What differentials should be considered for ADHD?

Answer 30

• Learning disability and dyslexia
• Oppositional defiant disorder
• Conduct disorder
• Autism
• Sleep disorders
• Mood disorders (particularly bipolar)
• Anxiety disorder
• Hearing impairment