Attention Deficit Hyperactivity Disorder

Question 1

Define Attention Deficit Hyperactivity Disorder

Answer 1

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
Requires the following (ICD-10):
- 6 months duration
- Onset < 7 years
- Pervasive across different situations
- Inattention and/or hyperactivity-impulsivity
- Significant distress or social impairment

Question 2

Define inattention

Answer 2

wandering off task, lacking persistence, having difficulty in sustaining focus and being disorganised

Question 3

Define hyperactivity

Answer 3

extreme restlessness or wearing others out with their activity
(In children = excessive motor activity when not appropriate e.g. running around, or excessive fidgeting, tapping, or talkativeness)

Question 4

Define impulsivity

Answer 4

Hasty actions that occur in the moment without forethought and have a high potential for harm for the individual e.g. running across the street without looking. It may be social intrusiveness (interrupting excessively), or making decisions without considering long-term consequences (quitting jobs or taking them without consideration)

Question 5

What are the three types of ADHD

Answer 5

Inattentive subtype accounts for 20% to 30% of cases
Hyperactive-impulsive subtype accounts for around 15% of cases
Combined subtype accounts for 50% to 75% of cases

Question 6

What are the risk factors for ADHD

Answer 6

Epilepsy
Acquired brain injury
Perinatal:
- LBW
- Maternal smoking
- pre-term delivery
- Lead, iron, or alcohol exposure during pregnancy
- Adverse maternal mental health

Question 7

What is the epidemiology of ADHD

Answer 7

global prevalence 5%, UK prevalence 3-4%
Boys > girls (2-5:1)

Question 8

What are the symptoms of ADHD

Answer 8

Inattention:
- little attention to detail
- Careless mistakes in work/activities
- difficulty maintaining concentration in tasks/activities
- Failing to follow instructions or finish tasks
- Difficulty organising
- Reluctance/dislike/avoidance of tasks requiring sustained mental effort
- Easy distraction

Hyperactivity-impulsivity
- Fidgeting, tapping, squirming, restlessness
- Leaving seats when it is expected to sit
- Running or climbing in inappropriate situations
- Inability to play or engage in activities quietly
- Feeling that they are ‘on the go’ or ‘driven by a motor’
- Excessive talking
- Blurting out answers, inability to wait their turn, interrupting or intruding

Question 9

What are the differentials for ADHD

Answer 9

Learning or language disorder
Autism Spectrum disorder
Intellectual disability
Oppositional defiant disorder, conduct disorder
Depression, anxiety
Bipolar affective disorder
Psychosis
iron deficiency anaemia

Question 10

What investigations should be done for ADHD in adults

Answer 10

Refer to specialist for diagnosis

Bedside: Conners rating scales, ADHD rating scale, Brown attention deficit disorder scale
Urine drug screen

Question 11

What is the management for ADHD in children

Answer 11

mild symptoms/little daily impact → watchful waiting for up to 10 weeks + self-help + behaviour management advice
+ group-based ADHD-focused support

Severe/waiting unacceptable/large impact → refer to CAMHS/paediatrician/child psychiatrist

Bio (third line): methylphenidate
Psycho: Group-based support, parent training in behaviour management (PTBM), psychoeducation ± behavioural classroom intervention ± CBT (fourth line)
Social: Educational support, self-help groups, support groups, healthy diet and regular exercise

Question 12

Who may be in the MDT for ADHD

Answer 12

Paediatrician
Psychiatrist
ADHD Specialist nurses
Mental health and learning disability trusts
CAMHS,
Parent groups
Social care workers
School/college and school nurses

Question 13

What monitoring should be done for methylphenidate

Answer 13

Monitor effectiveness and adverse effects to treatments
Response with symptom rating scales (e.g. Conner’s)
Development of tics after taking stimulant medication
Sexual dysfunction, seizures, sleep disturbance and worsening behaviour

Weight
- ≤ 10 years- every 3 months
- > 10 years- 3 months, 6 months and every 6 months thereafter treatment started
Height: Every 6 months in children and young people
BP and HR: Before and after every dose change, Routinely every 6 months
ECG

Question 14

What alternative medications can be given for ADHD (excluding methylphenidate)

Answer 14

Dexamfetamine/lisdexamfetamine: stimulant
Atomoxetine: non-stimulant, little/no insomnia, no increase in tics, useful for co-morbid depression, reduced likelihood of abuse
Guanfacine: non-stimulant, can reduce tics

Question 15

What are the side effects of methylphenidate

Answer 15

Growth restriction
Cardiac: palpitations, arrhythmias, HTN
GI: abdo pain, N&V, diarrhoea, dypepsia, decreased appetite
CNS: headache, insomnia, tics

Question 16

What are the complications of ADHD

Answer 16

Obesity
T2DM
Sleep problems
STIs
Substance use disorder
Accidental injury
Suicidal behaviours
Premature death

Question 17

What is the prognosis for ADHD

Answer 17

Over time, inattentive symptoms tend to persist and hyperactive-impulsive symptoms tend to recede.
associated with increased risks of psychiatric disorders, including oppositional defiant disorder (ODD), conduct disorder, substance abuse, and possibly mood disorders, such as depression and mania.
Untreated: 90% develop conduct disorder
15% retain full ADHD diagnosis at the age of 25

Question 18

What is the management for ADHD in adults

Answer 18

First line: Environmental modifications

Second Line: Medication
- 1st Line: Lisdexamfetamine OR Methylphenidate

• 2nd Line: Dexamfetamine OR Atomoxetine
  Third Line: Non-pharmacological Treatment (in combination with medication)
• Structured supportive psychological intervention focused on ADHD
• Regular follow up in person or by phone
• CBT- elements or full course