Community: ADHD Flashcards by Kirsty Sutherland

ADHD affects what percentage of children?

3-5%

Under diagnosed

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Symptoms persist into adulthood in what percentage of cases?

2/3

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What symptoms do adults have more of?

Emotional volatility/ anxiety

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Does it commonly occur with other neurodevelopmental difficulties?

50% of those with ADHD have dyslexia

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What is diagnosis made on?

History and observation in DIFFERENT SETTINGS - must be pervasive
Diagnostic rating scales from multiple settings e.g Conner’s questionnaire, Dundee Difficult Times of the Day Scale (D-DTODS), SNAP-IV (for teachers and parents), Strengths and Difficulties questionnaire - useful as part of initial assessment, monitor medication effectiveness and to monitor symptoms over time

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What type of condition is ADHD?

Neurodevelopmental

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What age do symptoms need to start between?

Between ages 6 and 12 and not appropriate for age

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What causes ADHD?

Environment

Genetics - child with a sibling with ADHD more likely to develop it themselves

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It is thought that ADHD is linked to low levels of what neurotransmitters?

Dopamine

Noradrenaline

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What are the key features of ADHD?

Poor attention and concentration
Physical over activity
Impulsivity
Needs to occur in more than one environment
Diagnosis after 6 years, but symptoms present before

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According to DSM5, ADHD split into 3 types…

Inattentive
Hyperactive/ impulsive
Both (most common)

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What are the symptoms DSM5 associates with inattention?

Makes careless mistakes/ lacks attention to detail
Difficulty sustaining attention
Does not seem to listen when spoken to directly
Fails to follow through on tasks and instructions
Exhibits poor organisation
Avoids/dislikes tasks requiring sustained mental effort
Loses things necessary for tasks/activities
Easily distracted
Forgetful in daily activities

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What are the symptoms DSM5 associates with hyperactivity/impulsivity ?

Fidgets with or taps hands or feet, squirms in seat
Leaves seat in situations when remaining in seat is expected
Experiences feelings of restlessness
Difficulty engaging in quiet, leisurely activities
Is “on the go” or acts as if driven by motor
Talks excessively
Blurts our answers
Difficulty waiting their turn
Interrupts or intrudes on others

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How many of the symptoms must be present for diagnosis?

6 or more symptoms of inattention and/ or 6 or more symptoms of hyperactivity/ impulsivity persisting for more than or equal to 6 months

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The severity of symptoms must…

Negatively impact social and academic/ occupational activities

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Several symptoms must be present before the age of…

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What differentials are there?

General developmental delay
SE of medications e.g AEDs
Poorly disciplined - lacks boundaries at home 
Sleep disorders
Hearing or visual impairment 
Thyroid disorders 
Emotional abuse or neglect
ASD

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How is ADHD managed?

Multimodal 
Mild-moderate: parental and school intervention first 
Behavioural psychotherapy
Severe: medication 
Treat comorbidities

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What medications can be used?

Methylphenidate (ritalin) - short or long acting stimulant 
Lisdexamphetamine
Dexamphetamine 
Atomoxetine
Guanfacine

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How does the methylphenidate work?

CNS stimulant

Dopamine/ noradrenaline reuptake inhibitor

What factors are thought to have a possible role in ADHD?

Premature birth
Low birth weight
Smoking or alcohol abuse during pregnancy

Is it more common in those with learning difficulties?

Yes

Can ADHD occur in people of any intellectual ability?

Yes, although more common in people with learning difficulties

What is often the first treatment offered to adults with ADHD?

Medication

Psychological therapies e.g CBT may also help

The symptoms associated with ADHD can cause significant problems in a child’s life such as...

Underachievement in school Poor social interaction with other children and adults Problems with discipline

What conditions can coexist ?

``` Anxiety Oppositional defiant disorder Conduct disorder Depression Sleep problems - difficult to get to sleep, irregular sleep pattern ASD Epilepsy Tourette’s syndrome Learning difficulties e.g dyslexia ```

Can ADHD develop in adults without first appearing in childhood?

No, it is a developmental disorder

Who can the child be referred to for a formal assessment?

Child psychiatrist Paediatrician Learning disability specialist, social worker or occupational therapist with expertise in ADHD

Why do the symptoms need to be seen in 2 different setting?

To rule out the possibility that the behaviour is just a reaction to certain teachers or to parental control

What beneficial effects can the medication have?

Not a permanent cure, but can help concentrate better, less impulsive, feel calmer, learn and practice new skills

Are treatment breaks recommended?

Yes to assess whether medication still needed

What is the most commonly used medication?

Methylphenidate - offered to adults, teenagers and children over 5 IR - small doses taken 2 to 3 times a day MR once a day in morning

What are some common side effects of methylphenidate?

Small increase in BP and HR Loss of appetite, nausea, vomiting Insomnia Headaches Anxiety, agitation, restlessness Euphoria Reduced threshold for seizures and tics Decreased growth rate - weight and height should be monitored every 6 months Rare: cardiac arrest, angina pectoris, neuroleptic malignant syndrome, sudden cardiac death Important to discuss side effects of medication prior to starting treatment

When might lisdexamfetamine be offered?

Teenagers and children over 5 if at least 6 weeks of treatment with methylphenidate has not helped. Adults may be offered it first line.

How does atomoxetine work?

SNRI

What does psychoeducation involve?

Encouragement to discuss ADHD and it’s effects | Helps child/teenage/adult make sense of the diagnosis

What is behaviour therapy?

Support for child, carers and can involve teachers | Involves behaviour management - system or rewards to encourage child to try and control their ADHD

What can be offered before formal diagnosis?

Parent training and education group programmes | 10-16 meeting

What is social skills training?

Involves child taking part in role play situations and aims to teach them how to behave in social situations by learning how their behaviour affects others

What tips can be given to parents?

Plan the day so child knows what to expect e.g getting ready for school - break it down into steps Set clear boundaries and reinforce positive behaviour If boundaries overstepped follow through with consequences Be positive and give specific praise e.g you washed the dishes really well, thank you Give brief instructions and be specific e.g please put the books on the shelf Incentive scheme - points or start chart Targets should be immediate, intermediate and long term Intervene early - if they look frustrated intervene sooner Lots of physical activity throughout the day - improve sleep quality Watch diet and see if behaviour linked to certain foods, can keep a diary Stick to a routine for bedtime, avoid overstimulation before bedtime

Is ADHD more common in boys or girls?

Boys 4:1

Following presentation, what approach should be taken?

A 10 week watch and wait period to observe whether symptoms change or resolve. If they persist then a referral to secondary care required - normally to paediatrician with special interest in behavioural disorders or to local CAMHS.

When should dexamphetamine be started?

Those who have benefited from lisdexamphetamine, but can not tolerate side effects

All of the drugs are potentially...

Cardiotoxic - perform baseline ECG before starting treatment

Who is ADHD under recognised in?

Girls and women - less likely to be referred for assessment, more likely to have undiagnosed ADHD and more likely to receive incorrect diagnosis of another MH condition

What are some long term consequences associated with ADHD?

Impaired educational and occupational performances | Higher rates of substance use and personality disorders

Difficulties with attention are more often seen in...

Preterm children

The side effects of stimulant medication can lead to what blood results?

Leukopenia Pancytopenia Hepatic coma So useful to do baseline normal function e.g FBC, LFTs

The diagnosis of ADHD requires multidisciplinary input from who?

The community paediatrician or child psychiatrist SALT Educational psychologist