Attention Deficit/Hyperactivity Disorder (ADHD) - Paediatrics

Mental Health

Attention Deficit/Hyperactivity Disorder (ADHD)

·        Background:

o  Estimates range from 2 – 5%

o  Boys > girls 

o  60% take some symptoms into adulthood (eg restless, disorganised, poor attention, impulse control) 

o  Was first described 100 years ago – only recently received appropriate recognition

o  Could be better described as „behaviour inhibition disorder‟

o  Is strongly genetic and is biological

·        Diagnosis:

o  Behaviour: 

§  Inattention: easily distracted, doesn‟t finish tasks, works best with supervision, poor short-term memory. “How does he get on with daily tasks like dressing/eating breakfast/doing homework” “Do you ever have to stand over him to make sure he finishes” 

§  Impulsiveness: acts without thinking, short fuse, aggressive, little self-control. “How often does he get into trouble for not thinking before he does something” 

§       Overactivity: restless, fidgets.  “How easy is it for him to sit still”

§  Insatiability: rarely satisfied, interrogates, over-intrudes in others space

§  Also poor co-ordination, disorganisation, fluctuation, and specific learning disabilities

§  Older child: low self esteem, mood swings, aggression, underachievement

o   Inappropriate for age and development

o   Pervasive across at least 2 settings

o   Onset < 7 years

o   Impairs social and academic functioning 

o   Hard to diagnose pre-school – tantrums and ¯attention common. Issue is whether they mature on transition to school. Gap widens as they get older. A 6 year old should be able to complete tasks, concentrate, etc 

o   Usually normal to high IQ

o   Diagnostic boundary is disputed – this falls on a continuum (like everything else!)

·        Differential: 

o   Learning disability ® not coping at school, frustrated ® acting out

o   Gifted child whose bored

o   Psychosocial stress: disruption at home, abuse

o   Anxiety

o   Psychiatric disorders (mood, anxiety or personality)

o   Problems with parenting – no boundaries or inconsistent boundaries

·        Associated factors:

o   Lower socio-economic status: poverty, poor housing, unemployment, illness, family breakdown 

o   Childhood depression/anxiety ®¯concentration

o   Auditory/visual perceptual difficulties ® inattention, loose interest

o   Reading problems: visual sequencing, letter-word orientation ® appears inattentive

·        Assessment:

o   Onset of behaviours

o   Situation specific or pervasive

o   Other learning difficulties

o   Context: parents management style, life events, teacher, etc

o   Use parent questionnaire

o   What are child‟s strengths – basis of self esteem 

o   Get information from school: general behaviour, problems in specific situations (transitions between lessons, unstructured time eg playground, changes to routines eg outings, academic problems 

o   Thorough developmental history (ABFWIMPS), especially:

§  Head injury

§  Perinatal problems

§  Attachment problems in first 2 years (eg PND, stresses, violence, drugs) 

o   Exam: dysmorphic features, tics (more common in ADHD and also side effect of ADHD medication), observation during interview

·        Classifications: 

o   Primary: early onset, feeding/sleeping problems from early on, overactive/unmanageable toddler, parents exhausted

o   Secondary:

§  Psychosocial causes: family disruption, demands of school, etc 

§  Specific learning disability (®­stress once school starts)

o   Mixed: an adolescent presenting with all of the above, plus ¯self-esteem

·        Management:

o   Multidisciplinary assessment

o   Behaviour strategies:

§  Clear, firm, consistent guidelines

§  Check understanding of instructions

§  Anticipate problems and have planned responses ready ® ¯parental stress and ­consistency

§  Avoid triggers (eg crowds)

§  Predictable routines (eg at bedtime)

§  Managed use of time out, withdrawal of privileges

o   At school:

§  Structured approach – plan day

§  Sit near teacher, between quieter kids

§  Brief, clear instructions

§  Supervision during transition times (coming in from breaks, etc)

o   At home:

§  Force leads to confrontation, resentment, broken relationships

§  Behavioural techniques work poorly – it‟s a biological problem 

§  Ignore all but the important misbehaviours. Have a few clear rules, with clear consequences, if broken act without argument. Don‟t debate or escalate 

o   Esteem: Encourage. Find something they are good at. Swimming, bike riding, cooking, judo and computers may be better than team sports. Encourage friendships – take a friend on outings 

·        Diet: < 10% sensitive to synthetic food colouring

·        Many dodgy therapies: avoid unless proven

·        Stimulant medication: 

o   ® Concentrate for longer (stimulates inhibition) ® complete tasks ® less disruptive and ­ self-esteem 

o   First: education for child and parents.

§  “Have you heard about medication – what?” 

§  Address myths: they‟re addictive, they sedate the child, child at ­risk of substance abuse later in life 

§  Side effects: sleep disturbance, appetite suppression (small effect, if marked ® growth suppression), moodiness, rebound, tics 

o   First line options are Methylphenidate (Ritalin) or Dexamphetamine. Both require specialist endorsement. Introduce slowly. Short T½ Þ need to fine tune dose times. Eg give before school ® Ok at school but difficult by the time they get home. Not in evening otherwise ¯sleep. Review – should have noticeable improvement, if not re-evaluate

·        Referral if:

o   Diagnosis/differential in doubt

o   Assistance with management of challenging behaviour

o   Assessment of role of family relationships in perpetuating the problems