Broadly ADHD can be divided into 3 types
- Inattentive (more common in females)
- Hyperactive-impulsive
- Combined hyperactivity and inattentiveness
Diagnostic criteria:
- Persistent pattern of inattention and or hyperactivity/impulsivity that interferes with functioning or development
- Number of symptoms required vary across lifespan
- 6 or more in each catagory up to age 16
- 5 or more in each catagory from age 17
- Present for at least 6 months
- Inappropriate for age (eg its okay for a kid to be scatterbrained but a 40 yr old adult doesnt tend to be)
Inattentive criteria
- Fails to pay attention to details or makes careless mistakes
- Difficulty sustaining attention in tasks or play
- Often doesn’t seem to be listening when spoken to
- Doesn’t follow through with instructions and fails to finish school work or duties
- Has difficulty organising tasks or activities
- Avoids or dislikes sustained mental effort
- Often loses things
- Easily distracted by irrelevant stimuli
- Often forgetful
Hyperactivity and impulsivity
- Often fidgets, squirms in seat
- Leaves seat in classroom
- Runs about, climbs excessively
- On the go, acts as if driven by motor
- Unable to play… quietly
- Often talks excessively
- Blurts out answers, difficulty waiting turn
- Interrupts Longitudinal criteria
- need to be causing impariment before 12 Cross situational criteria
- Impairment is present in 2 or more settings Pervasiveness and severity criterion
- Clear evidence of significant impairment in social, academic, or occupational functioning Exclusion Cannot be attributed to anything else
Risk factors
- Genetic
- If a parent has ADHD = 60% risk the child will also have it
- 3x as likely to have ADHD if a biological parent has it versus an adoptive parent
- Dopamine regulation genes
- Pregnancy, birth and early development
- Birth complications, maternal stress and exposure to toxins can create a general risk for the child developing later problems
- Family influences
- Family interactions may exacerbate symptoms
- Family problems may result from the difficulty of dealing with ADHD symptoms
- Family conflict is related to the presence of oppositional problems
Associated problems
- Tourette’s disorder. ADHD precedes TS
- Autism spectrum disorder
- Trauma/maltreatment
- Nonsuicidal self injury
- Suicide attempts
- Substance misuse
- Challanging behaviour (Conduct Disorder, Oppositional Defiant Disorder, Intermittent Explosive Disorder)
- Cognitive problems
- Academic underachievement, school failure, unemployment
- substantially poorer language skill across expressive, receptive, and pragmatic language
- application of intellegance
- executive functions
- Emotional and social problems
- Problems reading others emotional cues, modulating responses
- reduced emotional regulation
- peer rejection
- Family stress and discord
- More likely to become hyperaroused in presence of reward and may become frustrated in absence of reward
Sleep
- Up to 70% of children with ADHD/Aroreretini experience sleep/Moe problems (cf 20-30% in the general population)
- Associated with worse ADHD symptoms, poorer quality of life and other mental health problems.
- Up to 20% of adolescents with ADHD report sleep problems (< 7 hours/night), daytime sleepiness, falling asleep in class (cf 10% without ADHD)
- Unclear whether treating sleep improves symptoms.
Physical problems
- Motor coordination and development
- risk of accidental injury is increase as well as heightened presence of risk taking behaviour
- Other health problems
- smoking
- obesity
- hypertension
Assessment for ADHD
- Specialist assessment
- Consider strengths and difficulties, fit with environment and expectations
- CBDS approach
- Consider common comorbidities and assess/screen for those
- May be involved with significant cost
- Specific problem descriptions, we need the parent to give specific descriptions
- functional analysis what precipitate difficulties
- family styles understand dynamics to see where can we help
- Cognitive Behavioural developmental approach to child characteristics CBDS
- Cognitive Behavioural developmental approach to caregivers characteristics
- environemntal contextual factors
- comorbidities
Treatment
- Medication + behavioural intervention is best.
- Medication can be difficult to figure out the correct dose and drug
- compliance can be poor
- Behavioural intervention - building skills to manage with ADHD and some strategies to cope. this can be elevated well with medication
Effects of medication
Compliance with stimulant medication quite poor, especially in adolescence
- Fewer than 10% of children persist with long term medication
- Parents tend to prefer non-medication approaches Side effects
- irritability, loss of appetite, insomnia
- longer term: social withdrawal, blunting, reduced weight and height gain, increased blood pressure and heart rate
- longer term reduced height with medication