Psychiatry: Neurodevelopment Flashcards
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What is ADHD?
Attention deficit hyperactivity disorder is a common neurodevelopmental disorder.
What causes ADHD?
aetiology of ADHD is complex and involves genetic, environmental and social factors
- high heritability (70-80%) but specific genes have not been identified
- Poverty
- low birthweight
- prematurity
- maternal smoking
- chemical exposure to manganese and lead
all increase the risk of ADHD.
- people born pre-term
- looked-after children and young people
- children and young people diagnosed with oppositional defiant disorder and conduct disorder
- children and young people with mood disorders (depression and anxiety)
- people with a close relative with ADHD
- people with epilepsy, autistic spectrum disorder, tic disorders, learning disability and specific learning difficulties
- adults with a mental health condition
- people with a history of substance misuse
- people known to the youth or adult criminal justice systems
- people with acquired brain injury.
If a child or young person presents with problems suggestive of ADHD, what are the next steps?
- severity of the problems
- how they affect the child and family
- extent they pervade different settings
If there is an adverse effect on development or family life - watchful waiting for up to 10 weeks, with referral to an ADHD support group.
If symptoms persist - refer to secondary care
If symptoms cause severe impairment- refer immediately (no watchful waiting)
When should ADHD be suspected?
Symptoms should meet the diagnostic criteria in DSM-5 or ICD-10.
-suspect ADHD if there are 6 inattention symptoms and/or 6 hyperactivity-impulsivity symptoms (5 for both in adults).
-symptoms must have:
* started before age 12
* occur in at least two important settings (social, familial, educational or occupational)
* cause at least moderate impairment.
* not exclusively during a psychotic disorder or better explained by another disorder eg. ODD, CD
What are the inattention symptoms of ADHD?
- Failing to give close attention to detail/making careless mistakes in schoolwork, work, or other activities.
- Difficulty in maintaining concentration when performing tasks or play activities.
- Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction.
- Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand).
- Difficulty in organizing tasks and activities.
- Reluctance, dislike, or avoidance of tasks that require sustained mental effort.
- Losing items necessary for tasks or activities such as pencils, mobile phones, or wallets.
- Easy distraction by extraneous stimuli.
- Forgetfulness with regard to daily activities.
What are the hyperactivity-impulsivity symptoms of ADHD?
- Fidgeting with or tapping hands or feet, or squirming when seated.
- Leaving the seat where remaining seated is expected, such as in a classroom.
- Running about or climbing in situations where inappropriate. In adolescents or adults, this may be limited to a feeling of restlessness.
- An inability to play or engage in leisure activities quietly.
- Being ‘on the go’ or acting as if ‘driven by a motor’. Others may experience the person to be restless or difficult to keep up with.
- Talking excessively.
- Blurting out an answer before a question has been completed.
- Difficulty waiting his or her turn.
- Interrupting or intruding on others.
ADHD can co-exist with other disorders, what are these common co-existing disorders in children and adults?
- Children: ODD, CD, Depression, anxiety, tourettes, learning difficulties
- Adults: personality disorder, mood disorders, depression, anxiety, bipolar disorder, substance abuse, CD.
Diagnosis is made by specialist service. They should discuss the diagnosis with the patient/family. Which areas should be discussed?
- the positive impacts of receiving a diagnosis (improving understanding of symptoms, identifying strengths, improving access to services)
- the negative impacts of receiving a diagnosis (including stigma and labelling)
- issues around education, training and occupation
- the importance of the environment in managing symptoms.
Adults may also need discussion on:
* issues in the workplace and social relationships
* substance misuse and self-medication
* effects on driving: ADHD and it’s medication can impair driving.
* Patients with ADHD must declare their diagnosis to the DVLA if their ADHD symptoms or medication affect their driving.
What should be done if there appears to be a link between certain foods and ADHD symptoms?
- keep a food and drink diary with assoc behaviour
- refer to dietician if diary supports a link
What is the first line management for children and young people with ADHD diagnosed in 2ry care?
ADHD-focused group parent training programme
Which is first line medication for ADHD?
- Methylphenidate is usually offered first-line
- lisdexamfetamine, dexamfetamine, and atomoxetine are alternatives if methylphenidate is contraindicated, not tolerated, or ineffective
Melatonin may be prescribed for children and adolescents aged 6-17 years with ADHD who have insomnia, where sleep hygiene measures have been insufficient.
What treatment may be offered to young people who have significant impairment despite medication?
- CBT
When is medication initiated in secondary care (what are the indications)?
Aged 5 years and over only if:
* ADHD symptoms are still causing a persistent significant impairment in at least one domain after environmental modifications have been implemented
* They and their parents and carers have discussed information about ADHD.
* baseline assessment done: review of ADHD symptoms, mental health and social circumstances, physical health (medical history, current medication, height, weight, pulse, BP, cardiovascular assessment and an ECG if the treatment may affect the QT interval).
What drug monitoring is required for ADHD medications?
- Weight - every 3 months age <10. Every 6 months in age >10 and adults.
- Height - every 6 months in children
- BP and heart rate - before and after each dose change, and every 6 months.
- Specialist review annually
Monitor for other side effects: tics, sexual dysfunction (especially erectile and ejaculatory dysfunction), seizures, insomnia, worsening behaviour, psychosis, concerns about diversion and problems with adherence.
