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

1. Diagnosis and management of ADHD in children. Felt BT¹, Biermann B¹, Christner JG², Kochhar P¹, Harrison RV^{1 Am Fam Physician. 2014 Oct 1;90(7):456-64}.
2. East & North Hertfordshire NHS Trust ADHD Pathway  Guidance Notes for Health Professionals Oct 2011
3. BMJ Best Practice Attention deficit hyperactivity disorder in children https://bestpractice.bmj.com/topics/en-gb/142
4. CKS NHS Attention deficit hyperactivity disorder Last revised May 2018 https://cks.nice.org.uk/attention-deficit-hyperactivity-disorder
5. Attention deficit hyperactivity disorder : diagnosis and management NICE guideline 87 March 2018 https://www.nice.org.uk/guidance/NG87
6. Attention-deficit hyperactivity disorder. Biederman J, Faraone SV – Lancet – July 1, 2005; 366 (9481); 237-48
( abstract )
7. Management of ADHD in children and adolescents Jackie Pickett – Prescribing in children Prescriber February 2016 ❚ 17 https://www.prescriber.co.uk/wp-content/uploads/sites/23/2016/02/Management-of-ADHD-in-children-and-adolescents.pdf
8. Attention deficit hyperactivity disorder BNF Treatment summaries March 2019
9. DSM 5 ADHD criteria from https://images.pearsonclinical.com/images/assets/basc-3/basc3resources
/DSM5_DiagnosticCriteria_ADHD.pdf
10. NICE Bites ADHD North West Medicines Information Service April 2018 No 106