Attention Deficit Hyperactivity Disorder Flashcards
Define Attention Deficit Hyperactivity Disorder
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
Define inattention
wandering off task, lacking persistence, having difficulty in sustaining focus and being disorganised
Define hyperactivity
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)
Define impulsivity
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)
What are the three types of ADHD
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
What are the risk factors for ADHD
Epilepsy
Acquired brain injury
Perinatal:
- LBW
- Maternal smoking
- pre-term delivery
- Lead, iron, or alcohol exposure during pregnancy
- Adverse maternal mental health
What is the epidemiology of ADHD
global prevalence 5%, UK prevalence 3-4%
Boys > girls (2-5:1)
What are the symptoms of ADHD
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
What are the differentials for ADHD
Learning or language disorder
Autism Spectrum disorder
Intellectual disability
Oppositional defiant disorder, conduct disorder
Depression, anxiety
Bipolar affective disorder
Psychosis
iron deficiency anaemia
What investigations should be done for ADHD
Refer to specialist for diagnosis
Bedside: Conners rating scales, ADHD rating scale, Vanderbilt scale
What is the management for ADHD
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
Who may be in the MDT for ADHD
Paediatrician
Psychiatrist
ADHD Specialist nurses
Mental health and learning disability trusts
CAMHS,
Parent groups
Social care workers
School/college and school nurses
What monitoring should be done for methylphenidate
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
What alternative medications can be given for ADHD (excluding methylphenidate)
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
What are the side effects of methylphenidate
Growth restriction
Cardiac: palpitations, arrhythmias, HTN
GI: abdo pain, N&V, diarrhoea, dypepsia, decreased appetite
CNS: headache, insomnia, tics