ADHD 

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder and is estimated to affect approximately 10% of children and 5% of adults.

Males 5-10X in clinic referrals 

2-3X in community settings 

Mean age at diagnosis 9 yrs (boys < girls)

Heritability > 70%

• 1st degree relatives – 4-8 X increased risk
• MZ twins >50% concordance; sibs 33%

Aetiology 

• Toxins
  • Embryopathic: tobacco (Thapar 2003), alcohol (FASD) (Talge 2007, Peadon 2010)
  • Childhood neurotoxins : lead (Goodlad 2013)
• Diet (food sensitivities) – colourings, preservatives, salicylates, amines
• Premature birth (van Baar 2009, Lindstrom 2011),
  • low birth weight (OR 2- 2.5) (Galera 2011)
  • decr grey matter, white matter injuries
  • disruption of cortical development / connectivity
  • contribution of sensory stress, sleep deprivation, repetitive pain, disrupted parent-child interaction?
• Brain injury – raumatic (Herskivitz 1999), CVA – putamen (Max 2002), infective
• Family dysfunction, parental stress
  • common in ADHD (Johnson & Mash 2001)
• Parental psychopathology, family conflict more strongly assoc with ODD / CD than ADHD (Deault 2010)
  • Early maternal “scaffolding behaviour” (supportive, assisting risk-taking / growth) protects against ADHD in children with dev delays (Baker 2010)

 

Diagnostic journey of the vulnerable child – Stage/Diagnosis

• • Infancy –> Infant distress / sleep dysregulation
  • Toddlerhood –>  Language delay
  • Pre-school  –> Aggression / social-emotional delay
  • Start of school –> ADHD / ODD
  • Mid-primary school –>  Learning disorder
  • Mid-primary school –> Autism spectrum disorder

Long-term outcome: Increased risk

1. ADHD – persistence / partial remission ~65% (Greydanus 2007)
2. Academic failure / school drop-out (Barbaresi 2007, Barkley 2006)
3. Smoking, alcohol, substance abuse
4. Mental health problems eg. mood, ASPD (Biederman, 1997; Elkins 2007; Farone, 2006; Secnik,, 2005)
5. Unemployment / low occupational status / job retention (Barkley 2006; Manuzza, 1993)
6. Injuries eg MCA (Barkley 1996)
7. Delinquency / crime & incarceration
8. Relationship difficulties
9. Early parenthood / problems with parenting

 

Famous People with ADHD

• Albert Einstein
• Jim Carrey
• Vincent Van Gogh
• Stevie Wonder
• Michael Phelps

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The main signs and symptoms of ADHD include:

Inattention

• difficulty concentrating
• forgetting instructions
• moving from one task to another without completion
• Being easily distracted  
• Making careless mistakes 
• Having a hard time following instructions 
• Often forgetting or losing things 
• Having trouble staying organized  
• Appearing not to listen when someone speaks to them  
• Avoiding things that involve a lot of thinking or effort 
• Seeming unaware of what’s going on around them

impulsivity

• acting without thinking
• talking over the top of others
• losing control of emotions easily
• being accident prone

overactivity

• constant fidgeting
• restlessness
• Often running around and climbing on things  
• Constantly talking or interrupting others

ADHD may show the full range of features 

• (combined-type ADHD) or 
• may just have inattention (inattentive ADHD)

need to have functional impairment

• ADHD cannot be diagnosed simply in terms of fulfilling a certain number of listed criteria. 
• The key to diagnosis is that the symptoms are associated with functional impairment
• Functional impairment may be defined as a person being unable to meet the expectations of their roles or commitments.
• Modalities of functional impairment
  • Is considered capable of higher achievement – could/should do better
  • Behaviour presents unreasonable stress or disruption in school/work
  • Behaviour presents unreasonable stress or disruption in the family
  • Behaviour significantly affects peer relationships
  • Person is aware of having difficulties and has low self-esteem

Oppositional defiant disorder (ODD) is commonly associated with ADHD

• 40% of primary school children with ADHD also have diagnosable ODD,
• Therefore, ODD may be considered as part of the presentation of ADHD in a large proportion of affected children and adolescents
• ODD behaviour tends to be most prominent in the preschool age group (‘terrible twos’) and in adolescence
  • Negative attitude, hostile, aggressive – temper outbursts, bullying
  • Baseline mood appears lower than normal

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BY Age Group

• Preschool children
  • At danger of overdiagnosing ADHD the are usually
    • are often active and impulsive
    • may not sit and concentrate for long
    • but  they can concentrate sufficiently to develop age-appropriate skills 
    • behavioural functioning improves substantially as they approach school age.
  • Consider ADHD when 
    • behaviour is extreme
      • impulsive, unpredictable behaviour associated with anger and aggression may make them unmanageable in preschool
      • safety issues, such as running out onto a road
      • unmanageable when shopping
    • features of ODD
      • have frequent, severe temper outbursts
      • Parents (or other carers) may be stressed because of a child’s frequent, unpredictable and violent temper outbursts
    • Functioning effected in two different settings – home and daycare

 

• Primary school children
  • peak age of diagnosis of ADHD is in primary school children aged 5–10 years.
  • Present with
    • with poor concentration that affects their learning
    • A child who is unable to concentrate for long may become bored and disruptive. 
    • Teachers are usually very good at identifying ADHD in primary school children
    • affect peer relationships:
      • may appear bossy and controlling
      • may develop a reputation for being aggressive or may be targeted by others and provoked into losing their temper. 
      • may therefore be either the victim or perpetrator of bullying. 
      • children progress through school, they expect more from their friends, and a child who does not listen and respond appropriately may be excluded.
    • ODD can mask ADHD: 
      • habitually refuses to attempt any schoolwork
      • ODD is unusual without ADHD, and a pattern of behavioural escalation to avoid work may point towards underlying difficulty concentrating.
    • Functional impairment at home 
      • disorganisation 
      • needing numerous reminders for getting dressed and ready. 
      • homework takes far longer and requires more parental input 
      • may have difficulty persisting with activities that involve mental effort
      • complaining of boredom unless they have electronic devices that provide constant stimulation and reward.

 

• High school children
  • typical disruptive behaviour and poor concentration
  • inattention and impulsivity persist
  • declining grades in high school
    • may lead to abandoning goals in life 
    • because of a perception that they are not achievable, and even dropping out of school.
  • Hyperactivity 
    • decline with age
    • hyperactive young child may develop into an underactive adolescent
  • motivation for socialising and sport 
    • decline as it involves too much effort
  • oppositional behaviour increase
  • experiment with drugs or start smoking
  • nicotine has a calming effect on the mood

 

• Adults
  • As the demands of life increase, so does the scope for dysfunction. 
    • struggle to cope with the complexities of holding a job
    • raising children and running a household
  • lifetime of underachievement
    • Failing or dropping out of courses
    • Family/relationship dysfunction
    • Being dismissed from work
  • Driving accidents/driving offences
  • Substance use/other addictions
  • Criminal activity
  • disorganisation and impulsive behaviour
  • poor self-esteem
  • anxiety
  • depression

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Differential diagnosis 

Normal 

Specific learning disorder 

Intellectual disability 

Learning/cognitive disabilities

• Formal assessment of learning difficulties may be necessary
• ADHD compounds the problems

Trauma

• Emotional trauma can be associated with difficulty concentrating and ‘acting out’
• Children from families with transgenerational ADHD/ODD may have a combination of genetic and environmental causes
• ADHD is common in children and adults who have experienced trauma and should not be overlooked

Autism

• characterized by challenges in 
  • social interaction
    • understanding social cues
    • forming relationships
    • In social settings, poor concentration (ADHD) may resemble inability to comprehend (autism)
  • communication
    • nonverbal communication
  • repetitive or restricted patterns of behaviour.
    • engage in repetitive behaviours
    • have specific interests
    • show resistance to changes in routines
    • Negativity and controlling behaviour (ODD) may resemble rigidity
  • Sensory sensitivities and difficulties with sensory processing

Substance abuse

• Can impair concentration and cognition
• Can be associated with aggression and hostility
• ADHD increases susceptibility to substance abuse

Emotional disturbance

• adjustment reaction 
• attachment disorder / PTSD
• anxiety/depression 

Personality disorders (adolescents / adults) 

• Borderline
• narcissistic (disorganised, dysregulated)

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Initial work-up

• Consider other causes of attention problems 
  • Anxiety
  • family dysfunction
  • communication disorder
  • hearing loss.
• Consider possibility of co-morbidities
  • disruptive disorders
  • emotional disorders
  • learning disabilities
  • developmental disorders.
• Consider administration of PEDS Screening Tool
• Consider assessing the child’s behaviour:

• • at childhood vaccination encounters.
  • opportunistically during unplanned visits.
  • to address concerns raised by parents or carers.
• Take a history and ask about:
  • concerning behaviour, and consider whether it is abnormal.

1.  

Abnormal behaviour

1. The behaviour is likely to be abnormal if it is:
   1. prolonged.
   2. extreme.
   3. potentially harmful or dangerous.
   4. occurring in at least 2 different settings e.g., home, preschool or school, social situations.

Concerning behaviour

1. Common behavioural problems in children aged < 6 years include:
   1. whining.
   2. tantrums.
   3. bedtime resistance.
   4. fighting e.g., with parents or carers, other children, siblings.
   5. biting.
   6. kicking.
   7. swearing.
2. Check:
   1. when the behaviour started.
   2. for a precipitating event (if any) e.g., entering daycare or kindergarten, birth of sibling, parental or carer separation, death of grandparent.
   3. where the behaviour occurs – home, educational, or social setting.
   4. mood (e.g., anxious, happy, sad), self-esteem.
   5. attention in general, not just towards interests.
   6. truthfulness.
   7. compliance or opposition.
   8. for episodes of anger (disruptive, destructive, violent).

medical history, including perinatal history

1. Check for symptoms of underlying medical problems:
   1. Malnutrition or specific nutritional deficiencies e.g., iron deficiency
2. Sleep disturbances e.g., obstructive sleep apnoea (OSA)
3. Problems with vision or hearing
4. Chronic constipation
5. Dysmorphic syndrome
6. family history
7. Developmental or behavioural problems in parents or carers and siblings
8. Mental health
9. Developmental Milestones

Assessing the child’s environment

• Seek collateral history whenever possible e.g., letter from childcare or kindergarten detailing behaviour and learning history.
• Assess behaviour in all environments (e.g., home, childcare, kindergarten, prep, with grandparents or babysitter), as children with intrinsic behavioural disorders will have problems in more than one setting.

Patient-specific factors

1. Temperament
2. History of trauma
3. Sleeping patterns e.g., adequate sleep, snoring
4. Eating habits and nutrition
5. Underlying medical problems e.g., constipation, eczema, glue ear, absence seizures
6. Developmental delay
7. Mood or anxiety disorder

Familial risk factors:

1. Family or parental disharmony
2. Domestic violence
3. Physical and sexual abuse
4. Low-level parental or carer supervision
5. Lack of routine
6. Children on access arrangements
7. parental or carer mental illness (linked with poorer attendance at behaviour management courses) – consider whether parent or carer’s mental state needs to be assessed.
8. drug or alcohol abuse.
9. large family size.
10. aggressive behaviour of parents or carers and siblings.
11. poor quality and quantity of maternal social contacts with relatives or friends outside the home (influences mother-child interaction within home).

Cultural factors 

1. Differences in parenting styles
2. Acceptance of behaviour
3. Cultural beliefs and traditions
4. Exposure to trauma

Social factors

1. Socio-economic disadvantage is a risk factor for behavioural disorders.
2. Check for:
   1. parental or carer unemployment.
   2. financial stress.
   3. lack of stable housing.
   4. lack of support from friends or extended family.
3. Consider whether support services are, or have been, involved with the family, and how they engaged with these services.

School factors

• Friendship problems
• Bullying – as either victim or perpetrator
• Learning difficulties
• Sometimes a child is anxious at school because they are worried about their parents or carers at home.

Determine severity.

Consider severe behavioural problem if:

1. developmental regression or significant delay.
2. significant child distress.
3. social impairment e.g., school refusal.
4. severe aggression towards others e.g., classmates, siblings.
5. self-harming behaviours e.g., head banging, hair pulling, punching self.
6. sexualised behaviours.
7. parental or carer mental illness, drug or alcohol use, or severe distress.

Family’s goals and expectations

1. Consider whether:
   1. this is a low-risk family and social environment where the parents or carers simply want reassurance their child is normal.
   2. the parents or carers are looking for specific behavioural management strategies.
   3. there is a particular concern about a disorder such as autism spectrum disorder or ADHD.

 

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Examination

1. Height, weight, and head circumference, and plot in the appropriate growth chart – available in most patient record software
2. Nutritional status e.g., pallor, dentition
3. Response to visual and auditory stimuli
4. Communication – verbal and non-verbal (pointing, showing, eye contact)
5. Skin, including under arms, torso, limbs, and base of spine – look for:
6. skin manifestations of neurological conditions e.g., neurofibromas, café-au-lait spots (can occur under the armpit in middle childhood), hypopigmentation.
7. chronic skin conditions e.g., eczema.
8. Head and neck:
9. Tympanic membrane e.g., glue ear
10. Eyes e.g., range of movement, squint
11. Mouth – look for submucous cleft palate
12. Face e.g., dysmorphic features
13. Central nervous system – face symmetry, reflexes, power, tone, plantar response, and gait, looking for evidence of neurological conditions, e.g. spina bifida and cerebral palsy
14. Abdomen e.g., organomegaly, faecal loading
15. Muscles – look for atrophy, hypertrophy, asymmetry
16. Signs of injury or trauma (inflicted or accidental) e.g., bruises, burns

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Investigations

Arrange formal hearing or vision testing, if indicated.

Decide whether the behaviour is primarily:

reactionary with no underlying medical problem (i.e., a neurodevelopmentally normal child in an abnormal environment), or

due to an intrinsic medical problem or neurodevelopmental or mental health disorder.

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Management

Always engage family support services

1. If suspected child neglect or abuse, ensure the child’s safety.

Behaviour management advice

1. Advise parents or carers:
2. that warm, consistent parenting with clear rules is optimal for a child’s development.
3. to stay calm and use strategies appropriate for the child’s developmental stage.
4. to reward desirable behaviour and set clear consequences for undesirable behaviour.
5. The Raising Children Network website provides excellent parenting advice, including tips for encouraging good behaviour.
6. strengthen parental and carer support.

Parental and carer support

1. Recommend the Raising Children Network for excellent parenting support and advice.
2. Identify and manage any parental or carer mental illness. Consider a GP mental health treatment plan where eligible.
3. Help parents or carers access appropriate community support services.
4. Consider requesting parenting training to assist parents or carers with managing behavioural problems.

address school-related issues.

1. arrange regular follow-up and reassess behaviour, parental or carer engagement with support services, and response to interventions.

If the child is in out-of-home care supervised by the Department of Child Safety, and there is imminent threat of breakdown of the current foster placement due to behaviour, request child development assessment.

When to refer

• Significant parent concern PEDS Screening Tool 
• Multidisciplinary assessment is required.
• Response to simple behavioural measures not effective.
• Medication may be considered.
• Has co-morbid symptoms that require special assessment or interventions

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Medications

Stimulant Medications:

• Indications: 
  • Stimulant medications are typically considered the first-line treatment for ADHD due to their effectiveness in reducing symptoms of inattention, hyperactivity, and impulsivity. 
  • They are often prescribed when symptoms significantly impact daily functioning and impair quality of life, Improved peer interactions / social standing
  • Stimulants are usually the initial choice for most individuals without contraindications.
• Considerations: 
  • Stimulant medications can be short-acting or long-acting, and the choice between them depends on the patient’s needs and lifestyle. 
  • Long-acting formulations provide extended symptom control and are preferred for sustained relief throughout the day.
• Examples: 
  • Methylphenidate (Ritalin, Concerta)
  • Amphetamine salts (Adderall)
  • Dexmethylphenidate (Focalin).
• Side effects: 
  • Loss of appetite, poor weight gain, emotional blunting, Anxiety, Tics trouble sleeping, increased heart rate, increased blood pressure, irritability, headache, stomach ache.

• Contraindications: 
  • Pre-existing heart conditions
  • high blood pressure
  • glaucoma
  • history of substance abuse
  • anxiety disorders
  • psychotic disorders.
• Follow-up: Regular monitoring of blood pressure, heart rate, and height/weight in children. Ongoing assessment of symptom control and potential side effects.

Non-Stimulant Medications:

• Indications: 
  • Non-stimulant medications are considered when stimulant medications are ineffective, not well-tolerated, or contraindicated. 
  • They may also be used as an initial treatment option for individuals who prefer non-stimulant options or have specific comorbidities, such as anxiety or substance abuse disorders.
• Considerations: 
  • work differently than stimulants, targeting different neurotransmitters. 
  • They may take longer to achieve the desired effect compared to stimulants. 
  • Non-stimulants may be particularly helpful for individuals with certain comorbid conditions or those who cannot tolerate stimulant side effects.
• Examples: 
  • Atomoxetine (Strattera)
  • Guanfacine (Intuniv)
  • Clonidine (Kapvay).
• Side effects: 
  • Upset stomach, drowsiness, dizziness, decreased appetite, mood changes, dry mouth.
• Contraindications: 
  • Severe heart disease, uncontrolled high blood pressure, narrow-angle glaucoma, concurrent use of monoamine oxidase inhibitors (MAOIs).
• Follow-up: 
  • Regular monitoring of blood pressure, heart rate, liver function (for Atomoxetine), and symptom assessment.

Alpha-2 Adrenergic Agonists:

• Indications: 
  • may be prescribed as an adjunct or alternative to stimulant medications
  • can be helpful for individuals who experience prominent symptoms of hyperactivity and impulsivity, as well as aggression or oppositional behavior. 
  • They are also sometimes used to manage ADHD symptoms in individuals with comorbid conditions, such as insomnia or tics.
• Considerations: 
  • can cause sedation or drowsiness, which may be desirable for individuals with ADHD who also struggle with sleep difficulties or anxiety
  • Examples: 
    • Clonidine (Catapres).
  • Side effects: 
    • Drowsiness, fatigue, dry mouth, dizziness, low blood pressure.
  • Contraindications: 
    • Severe heart disease, recent heart attack, current use of monoamine oxidase inhibitors (MAOIs).
  • Follow-up: 
    • Regular monitoring of blood pressure, heart rate, and symptom assessment.

Antidepressant Medications:

• • Indications: 
    • considered when stimulant or non-stimulant options have not provided sufficient symptom relief or have been poorly tolerated. 
    • They may be helpful for individuals who have comorbid depression or anxiety alongside ADHD.
  • Considerations:
    • should be used with caution in individuals with a history of seizures, bipolar disorder, or eating disorders. 
    • They may require several weeks to reach their full therapeutic effect
  • Example:
    • Bupropion, Tricyclics (amitriptyline, imipramine, desipramine)
  • Side effects: 
    • Insomnia, dry mouth, headache, nausea, increased heart rate, anxiety.
  • Contraindications: 
    • History of seizures, eating disorders, current or previous diagnosis of bipolar disorder.
  • Follow-up: 
    • Regular monitoring of symptoms and potential side effects. Caution regarding the risk of seizures.