Psychiatry - ADHD Flashcards
Defintion
Attention deficit hyperactivity disorder (ADHD) = behavioural disorder characterised by difficulty concentrating.
Epidemiology and Risk factors
One of the most common psychiatric disorders in children:
- Boys and men: may be due to under diagnosis of women
- History of neurodevelopmental disorder
- FHx of ADHD or other mental health disorders
- Premature birth
- Looked-after children
- Epilepsy
Types of ADHD
- Predominantly inattentive: difficulties with attention, but not with hyperactivity or impulsivity
- Predominantly hyperactive-impulsive: issues primarily with hyperactivity and impulsivity
- Combined presentation: significant problems with both attention and hyperactivity/impulsivity
Pathophysiology
It is thought to result from an imbalance in neurotransmitter systems within the prefrontal cortex, basal ganglia, and cerebellum , specifically involving dopamine and norepinephrine
Inattention symptoms
- Lack of attention to detail
- Difficult holding attention on tasks
- Easily distracted
- Difficulty listening to direct speech
- Difficulty following instructions
- Difficulty organising tasks and activities
- Avoidant of tasks that require mental effort
- Frequently loses things necessary for tasks, e.g. pen, phone, keys
- Forgetful in daily activities
Hyperactivity and impulsivity symptoms
- Fidgeting or squirming
- Leaves seat unexpectedly
- Runs or climbs in inappropriate situations
- Unable to play quietly
- Talks excessively
- Frequently interrupts
- Difficulty waiting for their turn
Diagnostic criteria
A diagnosis of ADHD can be made if the symptoms:
- Meet the diagnostic criteria of DSM-5 or ICD-11
- Cause at least moderate psychological, social, educational or occupational impairment
- Should be pervasive across 2 or more important settings , such as social, family, school or occupation
Investigators
- Clinical assessment: a thorough history (including developmental, educational, behavioural, and family history) and physical examination to rule out other conditions.
- Behavioural rating scales: e.g. Conners’ rating scales or ADHD rating scale-IV for severity and frequency of symptoms
- School reports and observations: information from teachers about the child’s behaviour, academic performance, and social interactions can be invaluable
Initial management (NICE Guidelines)
Child’s behaviour suggestive of ADHD and impacting on their development or family life:
- A period of watchful waiting of up to 10 weeks, to establish if the behaviour is persistent
- Refer parents, or carers, to group-based ADHD-focused support
- Neither of these options require formal ADHD diagnosis
If a child’s behaviour is severe, or persists beyond 10 weeks:
- Referral to secondary care is indicated (CAHMS or paediatrician)
- Diagnosis or management should not be initiated in the primary care setting
Definitive management (children aged < 5 years)
- ADHD-focused group parent-training programme: this is the first-line option and is offered to all parents, or carers, of children under 5
- Medication : this should not be offered without a second specialist opinion from an ADHD service with expertise in managing ADHD in young children
Definitive management (children +5 and young people)
- Psycho education
- Environmental interventions:
= adjustments in school + home environmental to support learning - Dietary advice
- Medications
FIRST LINE = Methylphenidate
SECOND LINE = LISDEXAMFETAMINE
If above CI: ATOMOXETINE - CBT therapy
Definitive treatment adults
FIRST LINE: Methylphenidate: noradrenaline and dopamine reuptake inhibitor in the synaptic cleft, producing a stimulant effect in the CNS (prefrontal cortex)
Lisdexamfetamine: poorly understood mechanism, is a pro-drug
SECOND LINE pharmacological management:
Atomoxetine: noradrenaline reuptake inhibitor in the synaptic cleft
Non-pharmacological management: structured supportive psychological intervention focused on ADHD, regular follow-up and CBT
Complications
- Academic difficulties
- Social difficulties and peer rejection
- Increased risk of accidents: due to impulsivity
- Co-occurring mental health disorders: depression, anxiety disorders, conduct disorder)
- Medication complications: impacts on normal weight and height development, which may require breaks from drugs during the school holidays
How does methylphenidate work
noradrenaline and dopamine reuptake inhibitor in the synaptic cleft, producing a stimulant effect in the CNS (prefrontal cortex)
It is used to reduce symptoms of inattention, impulsivity, and hyperactivity by increasing the levels of certain chemicals in the brain. Brand name ‘ritalin’
How does atomoxetine work
this non-stimulant option is used when response to methylphenidate/lisdexafetamine is inadequate or if its use is contraindicated
