Overview

• ADHD Criteria → persistent pattern (≥6 months in 2 settings) of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, not explained by other disorders.
  • Inattention → lack of persistent task involvement and quickly moving on from incomplete tasks.
  • Overactivity → characterised by restlessness, talkativeness, noisiness and fidgeting.
• Risk Factors → FH of ADHD, conduct disorder, learning disability, autism spectrum disorder, sepression/anxiety, obstetric (prematurity, low birth weight, fetal alcohol syndrome).

Making Diagnosis

Clinical Features

• Inattention ⇒
  • Struggles holding attention.
  • Struggles organising tasks/activities.
  • Does not listen when spoken to directly.
  • Does not follow through on instructions and fails to complete tasks.
  • Dislikes doing tasks that require mental effort over long period of time.
  • Easily distracted.
  • Forgetful and often loses things necessary for tasks and activities.
• Hyperactivity/Impulsivity ⇒
  • Unable to play quietly.
  • Talks excessively.
  • Does not wait their turn easily.
  • Will spontaneously leave their seat when expected to sit.
  • Is often ‘on the go’.
  • Often interruptive or intrusive to others.
  • Will answer prematurely, before a question has been finished.
  • Will run and climb in situations where it is not appropriate.

Investigations

• Collateral History (parents and teachers).

Management Plan

• MDT Approach → paediatrician, psychiatrist, ADHD nurses, mental health and learning disability trusts, CAMHS, parent groups, social care, school/college.
• Children <5 years:
  • If don’t yet meet full criteria → period of watchful waiting for up to 10 weeks (encourage self-help and simple behavioural management). IF PERSIST AFTER 10W W+W REFER TO SECONDARY CARE.
  • First Line (AFTER 10W WATCH AND WAIT) → offer ADHD-focused group parent-training programme to parents and carers.
    • 10-16 meetings in a group of 10-12 participants.
  • Second Line → if this fails, seek advice from a specialist ADHD service.
• Children >5 years:

  • First Line (AFTER 10W WATCH AND WAIT) → ADHD-focused group parent-training programme.

  • Second Line → if persisting, specialist services can offer medication.

    • First Line → 6 week trial of methylphenidate (Ritalin).
      • Sfx → abdo pain, nausea, dyspepsia, stunted growth (MONITOR WEIGHT AND HEIGHT EVERY 6 MONTHS).
        • Height: every 6m. Weight: every 3m if ≤10, every 6m if ≥10. HR and BP every 6m.
        • If interruptions to growth → referral and a planned break to allow catch-up growth.
      • Also do baseline ECG (MEDS ARE CARDIOTOXIC) and monitoring of heart rate and blood pressure. Measure HR and BP every 6 months.
    • Second Line → lisdexamphetamine.

    <aside> 💡 PHARMACOTHERAPY ONLY IN THOSE >5 YEARS OLD.

    </aside>

  • Third Line → CBT if significant impairment in social skills, self-control, active listening, dealing with expressing feelings.

Complications →

Prognosis → manifestation of ADHD will change as child gets older (hyperactivity tends to become less of a problem and inattention becomes more pronounced). Some may grow out of it, 90% get conduct disorder if untreated, 15% have ADHD as an adult.