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Attention Deficit Hyperactivity Disorder - Coggle Diagram
Attention Deficit Hyperactivity Disorder
Definitions
ADHD
Neurodevelopmental disorder characterised by inattention, hyperactivity and impulsivity
Inattention
Careless mistakes
Diffuculty sustining attention - tasks or play
Doesn't seem to listen
Fails to follow through instructions
Difficulty organising / prioritising
Avoids sustained mental efforts
Loses things necessary for tasks
Forgetful
Easy distracted - internal and external
Hyperactivity
Figiting
Leaves seat in situations in which sitting is expected / Inner restlessness in adults
Runs / climbs excessively / Feelings of restlessness
Difficulty playing in activities quietly
On the go / driven by a motor
Talks excessively
Impulsivity
Blurts out answers
Difficulty awaiting turn
Interrupts or intrudes on others
DSM 5 Diagnostic Criteria
Predominantly innattentiv (>6 inatt)
Predominantly Hyperactive-impulsive (>6 H/I)
Combined types (>6 in both)
Other Criteria
Onset <12y/o
6 months duration
Causing difficulties in at least 2 settings
Interfering with life
Epidemiology
3-5% prevalence - most common disorder in CAMHS
60% persists to adulthood
M:F 3-4:1
Highly heritable
Over 80% have at least 1 comorbidity
Approx 60% have 2 comorbidity
Co-Morbidities
Neurodevelopmental Disorders
Language
Learning
Motor (DCD)
ASD
Mental health disorders
Anxiety
Depression
Substance misuse
Behavioural disorders
ODD
Conduct disorder
Take home: If you diagnose a child with only ADHD you are probably missing a diagnosis - 80% comorbid
Aetiology
Genetics
60% genetic
Twin studies 74% heritability
Environmental Risk Factors
Prenatal / Perinatal
Prematurity
VLBW
In utero drug exposure - illicit, alcohol, paracetamol
Infections
Brain trauma
Environmental Toxins
Lead
Organophospahtes
Polychlorinated biphenyls
Psychosocial
Extreme early social deprivation (romanian orphanages)
Likely Gene-Environment interactions
Brain Dysfunction
Abnormal structure
Abnormal brain function
Abnormal brain networks
Assessment
Collect Information
School reports
Health documents
History
Structured assessment form
Go through criteria for ADHD
Screen for co-morbidities
Get understanding of level of functional impairement
Observation
In clinic
Hyperactivity
Attention
Impulsive features
MSE
Level of engagement
Rapport / mood
In School
Structured interview with class teacher (CHATTI)
School report form
QbTest
Test of sustained attention
Objective measure of hyperactivity
Diagnostic Aid only
Management
Psychoeducation
Explain what ADHD is
Explain medication role / effectiveness
Discuss underdiagnosis in IRE
Explain why pharmacological treatment is suitable
Teaching parenting skills
– Understanding parent-child relations
– Providing a consistent routine with structure to the environment
– Setting clear consistent boundaries
– Making simple and clear requests
– Breaking down complicated tasks into smaller steps
– Praising positive behaviour and effort
– Time out techniques for difficult behaviour
– Devising reward systems for good behaviour eg star charts
– Setting reasonable time limits for tasks
– Modelling appropriate behaviours
– Regular communication with teachers
Medication
Stimulants
Methlyphenidate (ritalin)
Dexafetamine
Non-Stimulants
Atomoxetine
Guanfacine
Medication
Types of Medication
Stimulants
Examples
Dexafetamine
Methylphenidate
MOA
Methylphenidate: Blocks reuptake of dopamine
Dexafetamine (amohetamine): Blocks reuptake of dopamine and increases production
Side Effects
Loss of appetite
- monitor growth in children
Irritability or sadness
Insomnia
Mid increased HR or BP
Rebound effect
Headache
Spaced out - less sociable
Efficacy
70% respond well
90% respond well to one or the other
Dosage
Methylphenidate
20-30mg (start from 5-10 and increase)
Max dose 60mg
Lisdexamphetamine
20-30mg (start dose 20mg)
Non-Stimulants
Atomoxetine
MOA
Selective Noradrenaline re-uptake inhibitor
Dose
Up to 1.2mg / kg
Side Effects
Suicidal ideation - monitor
Liver dysfunction - monitor LFTs
Advantage over Stimulants
24hr coverage
Not controlled substance
Less abuse potential than stimulants
Disadvantages
Takes several weeks to work
Guanfacine
Extended release Guandacine
Use
3rd line - If stimulants are not suitable / not tolerated / not effective
MOA
Alpha 2 agonist
Dosing
Start 1mg increase 1mg weekly
Max dose depending on weight (3-4mg)
Side effects
Hypotension at start of treatment
Risk of rebound hypertension
Drug interactions
NICE Guidelines
Children and Adolescents
1️⃣ Methylphenidate
2️⃣ Lisadexamphetamine
3️⃣ Atomoxetine / Guanfacine
Monitoring
Rate Symptoms (ADHD-RS)
With Each dose change
Every 3 months with parents
Every 6 months with school
Height / Weight
After 3 months
6 monthly
BP / HR
3 monthly
Complete side effect checklist
Each review
Assess other problems
No bloods / ECG unless clinical indication
Premedication Assessment
HR and BP
Plot on Age appropriate charts
Height and weight - growth chart
CVS exam
Conside ECG / cardiac screening if red flags (Phx / Fhx)
Risk assessment for substance misuse / diversion
Baseline side effect rating scale
Baseline SNAP from home AND school
Medication information sheets
Informed consent
Sleep rating scale (CSHQ) by parents
ABC completed by home and school
Inadequate Response to Medication
MPH
Optimise dose
Switch to Tyvense in most cases
Consider switch to Atomoxetine / Guanfacine (takes 3 month to determine efficacy)
Causes of Failure of Medication
Poor adherence
Wrong dose
Timing wrong
Adverse effects lim9t dose
Wrong diagnosis
Rarely - refractory
Untreated ADHD
Highly increased Risk of
Substance misuse
Lack of academic achievement
Unemployment
Teenage pregnancy
Injuries and trauma
Serious RTA
Antisocial behaviour / criminality
Relationship dysfunction
Mental illness in adulthood
Poor parenting
Treatment improves outcomes
Differential Diagnosis
Hearing impairment
Visual impairement
Epilepsy - TLE
Exhaustion / sleep disorder
Malnourishment
Post viral fatgiue
Hypothyroidism
Drugs
