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Attention deficit hyperactivity disorder ( ADHD ) in children and young adults

Attention deficit hyperactivity disorder ( ADHD ) -A persistent pattern of inattention and/ or hyperactivity-impulsivity 
that interferes with functioning or development 
( American Psychiatric Association )

Known as hyperkinetic disorder in Europe and other nations that use the WHO classification system

How common – Most common behavioral disorder in childhood Neurodevelopmental disorder -childhood onset of symptoms and impairment Affects 8-12 % children worldwide
This may also vary depending upon criteria used for diagnosis Symptoms typically appear in children aged 3-7 yrs Rate of ADHD falls with age Prevalence increased Affects all sexes but is more common in boys
More commonly diagnosed in males Also affects adults Associated with poverty , lower family income and lower social class in the US , UK and other countries

Aetiology- Aetiology not fully understood Neurobiological underpinnings inconclusive Possibly mutifactorial and composed of genetic and environmental factors Response to stimulants suggest role of neurotransmitters

Why important – May continue into adulthood or undergo partial remission Inattentive symptoms tend to persist while hyperactive-impulsive symptoms tend to recede Problems at school ( ↓↓ academic performance ) , school dropout Increased risk of having another psychiatric condition Adolescents with ADHD ↑↑ ed risk of substance misuse , RTAs

Risk factors- Preterm Looked after and young people Children and young people with a diagnosis of oppositional defiant disorder or conduct disorder Children and young people with mood disorder
eg anxiety and depression People with close family members diagnosed with ADHD
two to 4 times more common Epileptics Underlying neurodevelopmentl disorders eg
◘ autism spectrum disorder ◘ tic disorders ◘ learning disability and specific learning adults with mental health condition h/o substance misuse people known to the Youth justice system or Adult criminal justice system people with acquired brain injury

DSM 5 diagnostic criteria – Persistent pattern of inattention and/ or hyperactivity-impulsivity that interferes with functioning or development. Six or more symptoms have persisted for atleast 6 months to a degree that is inconsistent with developmental levels and that negatively impacts directly on social and academic / occupational activities

Inattention – Failing to give close attention to details or makes careless mistakes in schoolwork , at work or during other activities Has problems staying focused on tasks or activities such as during lectures , conversations or long reading Often does not seem to listen when spoken to directly 
( seems to be elsewhere ) Failing to follow through on instructions and fails to finish schoolwork , chores , or duties in the workplace Difficulty organizing tasks and activities Often avoids , dislikes or is reluctant to engage in tasks that require sustained mental effort Often looses things needed for tasks or activities such as pencils , mobile phones or wallets Easily distracted Often forgetful with regards to daily activities

Hyperactive impulsive type – Fidgety or taps hands or feet or squirms in seat Unable to stay seated ( eg in classroom , workplace ) Runs about or climbs in situations where it is inappropriate Inability to play or engage in leisure activities quietly Always “on the go” as if driven by a motor Talks excessively Blurting out an answer before a question has been finished Difficult waiting for his/her turn Interrupting or intruding others

Several inattentive or hyperactive-impulsive symptoms were present before age 12. Present in two or more settings eg at home school or work , with friends or relatives , in other activities. Clear evidence that this interferes with or reduces the quality of social , academic or occupational functioning.Symptoms are not due to schizophrenia or another psychotic disorder & are not better explained by another mental disorder

NICE guidance summary ADHD – GPs should not make the initial diagnosis or start medication in young people with suspected ADHD ( NICE here recognises the frustration that GPs may face due to the long CAMHS waiting lists nationwide and the pressure that GPs face from parents )
 Referral to secondary care may involve professionals from
◘ health ◘ education ◘ social care professionals eg
GP, paediatrician , educational psychologists , SENCOs ( special education needs coordinator )
 When a child / young person presents with possible ADHD presentation -find out
○ the severity of problems
○ how these affect the child / young person and their parents / carers
○ extent to which they pervade different domains and settings
 If ADHD is causing an adverse impact on their development or family life – consider
○ period of watchful waiting for 10 weeks
○ offer parents / carers a referral to group based ADHD focused support ( without waiting for a formal diagnosis )
○ if behavioral /attention problem persists with atleast moderate impairment -refer the child/ young person to Child psychiatrist/paediatrician or specialist ADHD / CaMHS for assessment
 If severe impairment -refer directly to secondary care ie a child psychiatrist , paediatrician , or specialist ADHD CAMHS for assessment

Adults with ADHD – Adults without a childhood diagnosis of ADHD- should be referred for assessment by a mental health specialist trained in the diagnosis and Rx of ADHD
 Adults who were previously treated for ADHD as children / young people and present with symptoms suggestive of continuing ADHD should be referred to general adults psychiatry for assessment ( symptoms should be associated with at least moderate or severe psychological and / or social educational or occupational impairment )

Aim of treatment –Reduce hyperactive behaviour Detect and treat any co-existing disorder Promote academic , social functioning and learning Improve emotional adjustment , self esteem Relieve family stress

Pharmacological – Stimulants and non-stimulants
Stimulants include methylphenidate and amphetamines Non-stimulants include atomoxetine
( SNRI ) and guanfacine Medications aim to improve the core symptoms of overactivity , inattention and impulsivity Monitoring – each agent will have specific requirements 
( refer to shared care protocol )

Methylphenidate ( ritalin )-Usual first line Available as immediate and MR , oral , solid dosage forms eg of MR
Concerta XL , Delmosart XL , Equasym XL , Medikinet XL
All MR methylphenidate preparations also include an immediate release component ie biphasic action. The biphasic release profile varies between brands- so to avoid confusion prescriber should inform the brand to be dispensed Schedule 2 control drug Licensed for ADHD in children over 6 and adolescents Also used off-label sometimes for excessive somnolence eg narcolepsy , idiopathic insomnia Once stabilized ( usually slowly over 4-6 weeks ) – a supply of 4 weeks is normally issued before passing the care to primary care Mild SEs as headache , nausea , abdominal pain and emotional lability are common on initiation- but tend to resolve

Monitoring – Height Weight Cardiovascular effects – monitor HR / Bp and compare 
with the normal range for age and before and after each
 dose change
◘ If sustained tachycardia > 120 bpm or
◘ arrhythmia or
◘ rise in BP 
systolic BP > the 95 th percantile or
clinically significant increase on 2 occasions


Behavioural- Behavioral therapy Teaching social skills Parent/ child education School programming Balanced diet and exercise

References –References Diagnosis and Management of ADHD in Children Barbara T Felt MD MS et al AAFP 2014 East & North Hertfordshire NHS Trust ADHD Pathway Guidance Notes for Health Professionals Oct 2011 BMJ Best Practice Attention deficit hyperactivity disorder in children CKS NHS Attention deficit hyperactivity disorder Last revised May 2018 Attention deficit hyperactivity disorder : diagnosis and management NICE guideline 87 March 2018 Attention-deficit hyperactivity disorder. Biederman J, Faraone SV – Lancet – July 1, 2005; 366 (9481); 237-48
( abstract ) Management of ADHD in children and adolescents Jackie Pickett – Prescribing in children Attention deficit hyperactivity disorder BNF Treatment summaries March 2019 DSM 5 ADHD criteria from https://images.pearsonclinical.com/images/assets/basc-3/basc3resources
/DSM5_DiagnosticCriteria_ADHD.pdf NICE Bites ADHD North West Medicines Information Service April 2018 No 106 NICE Guideline 87 Attention deficit hyperactivity disorder : diagnosis and management March 2018

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