Dr Diane Mullins, RCSI Tutor in Psychiatry, St Ita’s Hospital, Portrane

Attention deficit hyperactivity disorder (ADHD) / diagnosis and management of ADHD
Diagnostic criteria (DSM-IV)
 Inattention
o Failure to give close attention to detail or makes careless mistakes in schoolwork,
work or other activities
o Difficulty sustaining attention in tasks or play
o Does not seem to listen when spoken to directly
o Does not follow through on instructions and failure to finish schoolwork or chores
o Difficulty organising tasks and activities
o Avoids, dislikes or reluctant to engage in tasks that require sustained mental effort
(i.e. schoolwork or homework)
o Looses things needed for tasks or activities (i.e. toys, school assignments, pencils,
books)
o Easily distracted by extraneous stimuli
o Forgetful in daily activities
 Hyperactivity
o Fidgets with hands or feet or squirms in seat
o Leaves seat in classroom or other situations in which remaining seated expected
o Runs about or climbs excessively in situations in which it is inappropriate
o Difficulty playing or engaging quietly in leisure activities
o Often “ on the go” or acts as if “driven by a motor”
o Talks excessively
 Impulsivity
o Blurts out answers before questions have been completed
o Difficulty awaiting turn
o Interrupts or intrudes on others (i.e. butts into conversations or games)
 Other criteria
o Symptoms present before age 7 years
o Symptoms present in two or more settings (e.g. school and at home)
o Impairment in social, academic or occupational functioning
o Symptoms do not occur exclusively during the course of a pervasive developmental
disorder, schizophrenia, or other psychotic disorder and are not better accounted for
by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder
or a personality disorder)
Epidemiology
 Incidence in USA is 2-5%, while in the UK it is reported as 1%
 Male > females
Aetiology
 Genetics
o Both parents and siblings of a child with ADHD are more likely to have ADHD than
the general population
o ↑ conduct disorder and substance misuse in parents
 Environmental
o Low birth weight, tobacco, alcohol and cocaine misuse during pregnancy
 Neurological
o Functional imaging shows frontal metabolism & frontal lobe hypoperfusion
 Neurotransmitters
o DA and NA dysregulation in prefrontal cortex
 Psychosocial stress & family dysfunction
Comorbidity
 Specific learning disorders (60%)

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e. intermediate and long-acting stimulants exist  Side effects of Methylphenidate  Growth retardation  ↓ appetite & ↓ weight  ↓ sleep  BP & pulse changes (both ↑ or ↓). RCSI Tutor in Psychiatry. A school visit to observe behaviour in the classroom may be useful  Connor’s Assessment Scale given to parents & teacher (= rating scale for ADHD) Treatment  Biological o CNS stimulants i. BP. fever. angina. medical and family history and assess family functioning  Interview with child: evaluate for physical or comorbid psychiatric disorder and assessment attachment style and level of activity  Collateral information from school. child & school)  Interview with parents: full developmental history. height  The use of ‘Drug Holidays’ is recommended i. weight. Portrane            Conduct disorder and oppositional defiant disorder (40%) Substance misuse Depression Anxiety disorder PTSD OCD Bipolar disorder Tics Tourette’s syndrome Bulimia Dyslexia Outcome  Approx 20% develop dissocial personality traits  15-20% develop substance misuse  High rates of suicidality  Poor self-esteem  Unemployment  ADHD symptoms may persist into adulthood  Inattention is often the last remitting symptom Assessment (involve parent. St Ita’s Hospital. arthralgia)  Rebound behaviour (when the effects of the medication begin to ↓)  Tics / Tourette’s syndrome  Depression  Irritability  Psychosis  Monitor for side effects of stimulants at each review.Dr Diane Mullins.e. i.e. cardiac arrhythmias  Chest pain  Confusion  Headaches  Hypersensitivity (rash. withholding the drug on weekends and during school holidays o Atomoxetine (norepinephrine receptor inhibitor) 2 . Methylphenidate (‘Ritalin®’) and Dextroamphetamine  Short. pulse.

e.Dr Diane Mullins. behavioural intervention. individual psychotherapy.e. St Ita’s Hospital. bupropion and venlafaxine) and α-adrenergic receptor agnosist (i. clonidine) Psychotherapy o Social skills training. family therapy and special education when indicated o  3 . Portrane Second line agents: antidepressants (i. RCSI Tutor in Psychiatry.