Community: ADHD Flashcards
ADHD affects what percentage of children?
3-5%
Under diagnosed
Symptoms persist into adulthood in what percentage of cases?
2/3
What symptoms do adults have more of?
Emotional volatility/ anxiety
Does it commonly occur with other neurodevelopmental difficulties?
50% of those with ADHD have dyslexia
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
What type of condition is ADHD?
Neurodevelopmental
What age do symptoms need to start between?
Between ages 6 and 12 and not appropriate for age
What causes ADHD?
Environment
Genetics - child with a sibling with ADHD more likely to develop it themselves
It is thought that ADHD is linked to low levels of what neurotransmitters?
Dopamine
Noradrenaline
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
According to DSM5, ADHD split into 3 types…
Inattentive
Hyperactive/ impulsive
Both (most common)
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
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
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
The severity of symptoms must…
Negatively impact social and academic/ occupational activities
Several symptoms must be present before the age of…
12
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
How is ADHD managed?
Multimodal Mild-moderate: parental and school intervention first Behavioural psychotherapy Severe: medication Treat comorbidities
What medications can be used?
Methylphenidate (ritalin) - short or long acting stimulant Lisdexamphetamine Dexamphetamine Atomoxetine Guanfacine
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
