1. ADHD: Attention Deficit
Hyperactivity Disorder
Epidemiology:
 Prevalence in School aged children:
o USA = 1-7%
o UK = 1% (Lower as ICD-10 classification narrow)
 More common in boys (Between 3-9 : 1)
Aetiology:
 The following factors have been implicated:
o Genetic factors – Siblings have a 2-3x ↑ risk and 79% Concordance in twins
o Developmental – LBW babies and Maternal use of Drugs / Alcohol / Tobacco
o Head Injury – Some evidence, but most children with ADHD haven’t had one.
o Dietary factors – Sugar is rarely implicated – only around 5% of children respond
positively to dietary restrictions. Food additives e.g. Sodium Benzoate, have some
studies supporting induction of hyperactivity.
 NB: ADHD is NOT caused by Psychological distress – though this can make it worse
There are TWO core Symptom Groups:
Impaired Attention (>6) Hyperactivity or Impulsivity (>6)
1. Poor attention to detail, involving
careless mistakes
2. Trouble keeping attention on
tasks or play activities
3. Doesn’t seem to listen when
spoken to directly
4. Fails to follow instructions and
fails to complete: Homework,
Chores, Work
5. Difficulty organising activities
6. Avoids or dislikes things requiring
lots of mental effort
7. Often loses things needed for
tasks and activities
8. Easily distracted
9. Forgetful in daily activities
1. Fidgets with hands or
squirms in seat
2. Gets up from seat, when
remaining in seat is
expected
3. Runs or climbs when
and where it is
inappropriate
4. Has trouble playing
quietly
5. ‘On the go’ – acting ‘As if
driven by a motor’
6. Talks excessively
1. Blurts out answers
before question finished
2. Has trouble waiting
one’s turn
3. Interrupts or Intrudes on
others
The symptoms should be:
 6 from Impaired Attention + 6 from Hyperactivity or Impulsivity
 Present in >1 situation – for example: School + Home
 Present for >6months
 Usually noticeable before the age of 7
 With clear evidence of significant impairment in Social; School
or Work functioning
If there are only symptoms in one of the two groups, diagnoses
include:
 Inattentive Subtype
 Hyper-active Impulsive subtype
NB: ICD-10 calls it ‘Hyperkinetic Disorder’ (Need all three core symptom groups to diagnose)

2. Complications:
Short Term Long Term
Biological  Sleep Problems
 Accidental Injury (4x more RTA’s)
 Psychiatric Co-morbidities e.g.
Anxiety / Depression and SA
Psychological  Low Self Esteem  Anti-social personality disorder
Social  Family / Peer Relationship issues
 Reduced Academic Achievements
 Reduced employment success
 Increased criminal activity (2x )
Assessment:
 History: Interview the child, their family and teachers if possible (or collect School Reports)
 Observation: Preferably in >1 situation e.g. Clinic + School
 Examination: General Observations and Neurological
 Rating Scales: Conner’s Rating Scale and Strengths and Difficulties Questionnaire (SDQ)
 Screen for Co-Morbidity – Anxiety and Depression
Management:
Non-Pharmacological:
 Behavioural Interventions:
o Positive reinforcement of desired behaviours
 Focussed Praise
 Star Charts
o Diminish negative behaviours
 1,2,3 Rule and Time-out
 Diversion – change task, rather than telling to ‘Stop’
o Consistent Contingency management
 Family education and support:
o Clear and Concise communication - Encouraging realistic
expectations, breaking down tasks and reducing distractions
 Personal Organisational Skills and Time Management
 Anger and Stress Management
 Voluntary Organisations:
o ADDISS (Attention Deficit Disorder Information and Support Service)
Pharmacological:
 CNS Stimulants
o Methylphenidate
 Immediate release (Lasts 4hrs) = Ritalin
 Modified release (Lasts 8-12hrs) = Equasym / Concerta /
Medikinet XL
 Advantageous as don’t have to be administered at
school
 S/E: Abdominal pain; N&V; dry mouth; anxiety; insomnia;
dysphoria; headaches and reduced weight gain.
 Growth monitoring is advised
o Dexamphetamine
 Used in those whose symptoms are refractory to other drugs
 Same S/E as Methylphenidate
o Have been shown to be ‘highly effective’ in up to ¾ of children
o Improve: Ability to sustain attention and academic sufficiency
 Non Stimulants
o Atomoxetine (Strattera)- Non-stimulant Noradrenaline Reuptake Inhibitor
 Taken once daily  effective 24hr cover, but takes up to 6wks to work
 S/E: Anorexia, dry mouth; N&V; headache; fatigue; dysphoria

3.  Side Effect Treatments:
o Insomnia  Administer drugs earlier in day; change to
shorter acting preparations; prescribe Melatonin /
Antihistamines to aid sleep. Atomoxetine may also be used
as an alternative – as it is a non-stimulant
o Loss of Appetite / Weight loss / Nausea  Administer with
meals and caloric supplements
Prognosis: Improvement usually occurs with development, remission
of symptoms typically occurs between 12-20 years of age. However,
15% have symptoms lasting into adulthood – a worse prognosis is
associated with: Coexisting conduct disorder (see Chloe’s PBL) and
unstable family dynamics.
On-going Controversy:
The concept of ADHD has been criticised for Over-medicalising a
‘Social problem’ and that it subsequently undermines the role of
parents. Nevertheless, it is recognised that not treating can lead to
poor outcomes, persisting into adulthood. Families who have
experienced good results with medications usually want to continue
– despite the long term uncertainty – See MTA study.
MTA Study:
 Multimodal Treatment Study of ADHD
 Better and greater response to Medication, compared to Behaviour Therapy initially
 However at 3 years this gap was significantly reduced, however this was likely to be because:
o No Medication follow up – non-compliance likely to be high and doses suboptimal
o Significant proportion of the Behaviour Therapy group was started on medication
o Sustained released CNS stimulants were not used e.g. Ritalin only
NICE subsequently recommends that Medication should be offered as 1st
line Rx for ADHD.
DDx:
 Age appropriate behaviours e.g. Playing ‘It’ / Chatty with friends
 Attachment Disorders – Ambivalent / Avoidant / Disorganised
 Behavioural Disorders – See Chloe’s PBL
 Children placed in academic settings inappropriate to intellectual ability:
o Intelligent children in an under stimulating environment
o Children with Learning Disabilities in a confusing environment
 Medication Side Effects e.g. Anti-Histamines ( Drowsiness, misinterpreted as Inattention)
 ALWAYS screen for symptoms of Anxiety and Depression – restlessness, Overactivity and
inattention can also be present in these diagnoses.
Key Points
 Diagnosis = 6x Inattention Symptoms + 6x Hyperactivity / Inattention Symptoms
o Present for >6months, in >2 situations – affecting everyday life
 Assessment = Conner’s Rating Scale or Strengths and Weaknesses Questionnaire
 Management = CNS Stimulants and Behavioural Interventions
References:
1. Geddes, J. Psychiatry: 4th
Edition Oxford University Press; 2012
2. Semple, D. Oxford Handbook of Psychiatry: 2nd
Edition. Oxford University Press; 2009
3. Bourke, Castle and Cameron. Crash Course Psychiatry. 3rd
Edition. Mosby Elsevier; 2008