ADHD Flashcards
What is the epidemiology of ADHD?
Have to manifest manifest symptoms before 12yrs
4-7% of school age children i.e. one in every class in Sheffield
M>F at 4:1
Mostly comorbid - ASD, ODD, developmental coordination disorder, reading and writing disorders, developmental delay, tics, mood and anxiety disorders, substance misuse
What is the aetiology and pathophysiology of ADHD?
Nearly as hereditary as height so FHx is important
Environmental factors affecting epigenetics - brain injury, prematurity, alcohol + smoking in pregnancy
Something to do with DA and NAd
Cortical maturation occurs 5yrs later in those with ADHD - so secondary school age children will still struggle crossing roads and later, with driving (have to tell DVLA)
What is the prognosis for people with ADHD?
Carries twice the mortality rate of those without - mostly due to impulsive accidents
If not picked up and treated - will perform worse in pretty much all measures of achievement (academic and social); will also snowball - acquiring more and more comorbidity
Because of sexual disinhibition - are particularly vulnerable to sexual exploitation, including online + teen pregnancy is 10x more common in those with ADHD
What is required for a diagnoses of ADHD?
6/9 inattentive symptoms:
Can’t focus on school or home tasks, disruptive, lose things, don’t listen, easily distracted, dislikes sustained mental effort; mind wandering (older children/teens)
+
6/9 hyperactive-impulsive symptoms:
Squirms or fidgets, cannot sit still, runs/climbs always, cannot perform leisure activities quietly; talks excessively + small movements (girls); sexually disinhibited (including online)
+
For at least 6 months
+
Must present before 12 years old (typically aged 3-7)
+
Developmentally inappropriate
+
Pervasive (i.e. multiple settings - at school and home)
+
Clear negative impact on functioning/reduced QoL
+
Not due to other pathology e.g. specific LD, anxiety/depression, trauma
What symptoms are more common in children aged 6-12?
Distractability
Motor restlessness
Impulsive and disruptive behaviour
Specific LD, aggression, low self-esteem, repetition of years, rejection, impaired family relationships
What symptoms are more common in adolescents (13-17)?
Difficulty planning/organising
Persistent inattention
Reduction of motor restlessness
Aggression/antisocial behaviour, drug/alcohol use, emotional problems, accidents
What symptoms are more common in adults (18+)?
Residual symptoms e.g. lower levels of what were experienced before + more severe sequalae
Mental disorders e.g. depression
Antisocial behaviour +/- criminal records
Lack of achievement in academic and professional career
How is ADHD assessed?
Clinical interview with a CAMHS doctor - Hx (pregnancy, birth, development, illness, social)
ADHD nurse covert classroom observation (lucky to have this in Sheffield)
May not be observable:
In some highly structured or novel settings
When patient is engaged in interesting activities, rewarded frequently, or getting one-to-one support
Symptoms worsen when:
Unstructured or boring situations or repetitive activity
When minimally supervised
When sustained metal effort is required at own pace
Questionnaires - can’t be used alone as c.25% false positives, but useful adjunct to other methods - these assess symptoms
Quantitative Behaviour (QB) testing - objective testing of motion tracking whilst doing a performance test of matching shapes - will assess concentration and impulsive errors - results are plotted on graph-like plots which visually represent the number of errors that the child makes (shocking to see the improvements following medication)
How do you manage ADHD?
1st line - Education/training - parental and child - focusing on what skills and talents the child has and what resources the parent can use
School support
Medications - stimulants are the first line, then other types of non-stimulants; other drugs can be used as adjuncts - all patients will respond differently, likely due to differing genetics
What stimulants are used in ADHD?
Indicated in:
Children over 5 who are still experiencing persistent and significant difficulties in one domain after environmental modification has been implemented
Medical screening required:
Ensure nothing underlying, also important to rule out any cardiac disease as medications increase risk of cardiac events
Methylphenidate:
First line
Short or long acting
Switch to lisdexamfetamine if 6wk trial of methyphenidate at an adequate dose proves ineffective
If on stimulants, should have 6monthly height and weight (also BP) monitoring because suppresses appetite
What are some side effects of the stimulants used in ADHD? What are some contraindications?
Nervousness, agitation, anxiety
Sleep problems, dizziness, headache
Dry mouth, appetite suppression, weight loss
Not used in:
Anorexia, arrhythmias, CV disease, HTN etc
What are some non-stimulant drugs used in ADHD?
Used after failed response to amphetamines
Atomoxetine (noradrenaline/dopamine reuptake inhibitor)
Guanfacine (alpha adrenergic receptor agonist)
Atypical antipsychotics (specialist advice, used with concomitant aggression, rages or irritability)
