An introduction to ADHD

1
An introduction to ADHD

• Contributor
• Dr C M Ni Bhrolchain
• Wirral
• (with thanks to Dr Morris Zwi for helpful
  comments)

2
HYPERACTIVITY

• George Still first described
• 1918 Encephalitis Lethargica Brain Damage
• 1960s Minimal Brain Dysfunction
  Hyperkinesis / Hyperactivity
• 1970s Feingold Exclusion Diet
• 1980s ADHD ADD included
  in DSM III)
• 1990s Disorders of attention, motor and
  perception
• (DAMP)

3
A problem is only a problem when it causes a
problem

• Core behaviours in ADHD
• Inattention easily distracted, fidgety, forgets
  instructions, flits from task to task, best in
  1-to-1 situations
• Impulsivity doesnt think
• Overactivity restless, fidgety

4
Other behaviours

• Nags constantly
• Sometimes physically clumsy
• Socially inept
• Disorganised
• Overlaps with learning difficulties d.g. dyslexia

5
Must also be

• Present for at least six months
• Inconsistent with childs developmental level
• Behaviour worse than you would expect from level
  of parenting
• Clinically significant social, academic or
  occupational impairment
• Present in 2 or more settings (school, work,
  home, surgery)

6
Common confusions (1)

• Normal toddler
• Look at parenting
• Hearing impairment
• Think about it and test
• Specific learning difficulties e.g. dyslexia or
  dyspraxia
• May co-exist. Consider psychometric testing
• Autism
• May be hyperactive but also other features

7
Common confusions (2)

• Learning disability
• Behaviour may be appropriate to
• developmental age
• Brain injury
• History of coma for 2 weeks
• Conduct disorder
• Basic rights or societal norms
• violated e.g. aggressive to
• people and animals, destroy
• property, deceit or theft

8
Does food cause ADHD?

• Not significantly so
• Usually parents can tell you which food
• Feingold diet helps in only 5 of children if
  challenged blind
• Diet itself may have placebo effect

9
National recommendations

• Both the Scottish Intercollegiate Guidelines
  Network (SIGN) and the National institute for
  Clinical Excellence (NICE) have examined ADHD
• www.sign.ac.uk
• www.nice.org.uk

10
Main findings

• Diagnosis and initial treatment should be
  provided by a psychiatrist or paediatrician with
  specialist knowledge of ADHD
• Stimulant medication is effective and underused
• Once dose is stable, joint care with GP

11
What will the specialist do? (1)

• Take a detailed history incl development and
  behaviour
• Consider alternatives and look for specific
  features of ADHD
• Consider parenting skills
• Collect information from school
• Formal assessment of behaviour by questionnaire
• Formal assessment of IQ if appropriate

12
What will the specialist do? (2)

• Behaviour management should usually be first
  option
• Consider medication (usually methylphenidate)
• If correct, effect is usually seen within weeks

13
Using medication in ADHD

• The purpose is to treat medically as adjunct to
  behavioural management
• Medication improves attention span, restlessness,
  distractibility
• Less effect on social skills etc

14
Medications used

• Methylphenidate
• (Ritalin, Concerta, Equasym)
• Dexamphetamine (Dexedrine)
• Impramine
• (Tofranil)
• Desipramine
• (Pertofran)
• Clonidine
• (Catapres)
• Atomoxetine

• Stimulants
• Other

15
Using stimulants

• Methylphenidate (in all its forms) and
  dexamphetamine are controlled drugs and
  prescription only medicines
• Introduced gradually over a few weeks
• Max dose approx 1mg/kg or 0.5 mg/kg respectively

16
Monitoring

• Monitor appetite and weight
• Measure height regularly
• Monitor BP
• Monitor for psychiatric diagnoses such as
  depression

17
Prognosis

• Symptoms were thought to resolve in adolescence
• Now thought that some continue to need treatment
  in adulthood
• This area needs further study