E-learning module in psychiatry on Attention Deficit Hyperactivity Disorder (ADHD)

Virtual PatientKirsty Jump

Name: Kirsty JumpCondition: Attention Deficit Hyperactivity Disorder (ADHD)

Age: 5Marital Status: N/AEthnicity: N/AOccupation: School child

Attention Deficit Hyperactivity Disorder (ADHD)

Oliver Mumby, 5th Year Medical StudentDept of Neurology and Psychiatry, UHW

Virtual Patient

Virtual PatientADHD

Although ADHD is a relatively uncommon disorder, about a third of children are described as overactive by their parents and up to a fifth of children by their school teachers.

Obviously not all of these children have ADHD, but it is important to recognise that these children range from normal high spirits to a severe disruptive and persistent disorder, which in severe cases is accompanied by inattention... so called Attention-Deficit Hyperactivity Disorder (ADHD).

This virtual patient will be especially useful for 4th year students who are doing their child health and psychological medicine blocks.

Virtual PatientLearning OutcomesBy the end of this Virtual Patient, it is hoped that you will have achieved the

following learning objectives: 4th year Psychological Medicine (Child Psychiatry):• Explain the characteristic presenting features and effective methods of

treatment for the following disorders:– Attention deficit hyperactivity disorder– Autism – Conduct disorder– Depression and anxiety– Tic disorders

• Describe the aetiological factors in the development of these disorders. • Describe the basic principles of assessment and treatment in childhood.• Summarise the components of the multidisciplinary team.

Virtual PatientInformation BoxADHD in a nutshell...

• Also called ‘Hyperkinetic Disorder’– alternative term for the disorder used by ICD-10

• Neurodevelopmental disorder• More common in boys• UK prevalence 1-2%• Typically appears in children between 3-7 years of age• Characterised by hyperactivity, inattention and impulsivity• Pervasive: present in all situations e.g. home, school• Behaviour present for more than 6 months• Results in significant psychological, social and educational problems

Name: Kirsty JumpCondition: Attention Deficit Hyperactivity Disorder (ADHD)

Age: 5Marital Status: N/AEthnicity: N/AOccupation: School child

Virtual PatientKirsty Jump

Virtual PatientConsultation: Visit 1

Consultation: Visit 1You are a GP in a local surgery...

Mrs Jump brings in her 5 year old girl, Kirsty, to see you.

She has been struggling to cope with Kirsty’s behaviour at home for a long time, but it was not until her first parents’ evening at school that she decided to seek medical advice, when Kirsty’s teacher raised some concerns about her behaviour at school.

Mrs Jump also tells you that she recently read about ‘ADHD’ in a magazine, and wondered whether her daughter could have a similar problem.

You take a history, with ADHD in mind…

Virtual PatientQuestion Box

Question: Which of the following symptoms would make you suspect ADHD in a child?

Easily distracted (correct)Fidgety (correct)PyrexiaInterrupts conversations (correct)Restlessness (correct)Clubbing

A fidgety, restless child who interrupts conversations and is easily distracted would raise your suspicions about ADHD. They represent features of all three characteristic symptoms of ADHD; hyperactivity, inattention and impulsivity.

Virtual PatientInformation BoxSymptoms of ADHD

Remember to say “HII!”Hyperactivity

Inattention

Impulsivity

Hyperactivity Inattention ImpulsivityFidgeting Difficulty in sustaining

concentrationBoisterous

Restlessness Problems with following instructions

Blurts out answers

Unduly noisy Careless mistakes in school work

Difficulty in waiting in lines

Excessive motor activity Loses things Interrupting conversations

Easily distracted Talks excessively

Virtual PatientPatient History (1 of 3)

History of Presenting Complaint

Mrs Jump says that Kirsty has always been ‘hyperactive’. When you ask her to elaborate on this she describes her daughter as an extremely restless and noisy child, who finds it difficult engaging in anything quietly.

At Kirsty’s recent parents’ evening, her teacher had also noticed her hyperactive behaviour, adding that although she was more ‘fidgety’ than her peers, it was her boisterous nature which caused the most problems in the classroom; with Kirsty struggling to wait her turn during games and constantly interrupting others. He also raised his concerns with Kirsty’s school work, explaining how she rarely finishes her work and often makes careless mistakes.


Past Medical History• Premature baby• Nil else

Drug History• No known drug allergies• Uses 1% Hydrocortisone for Eczema

Family History• Both parents alive and well• Mother: smoker (smoked during her pregnancy)• Father: hypertensive, nil else


Social History• First year of school• Mother unemployed• Father works as a lorry driver• No other children• Lives in council house with her parents


Question: Which features of the history are recognised pre-disposing factors for ADHD?

EczemaLow socio-economic class (correct)Prematurity (correct)Hypertensive parentMaternal tobacco consumption (correct)

Prematurity, a low socio-economic class and maternal tobacco consumption (plus alcohol or illicit drugs) are all thought to contribute to ADHD.

Virtual PatientInformation Box (1 of 3)

Aetiology of ADHD• The exact cause of ADHD is unknown • It is thought to be multi-factorial; with multiple genetic and

environmental factors combining to produce the disorder

Remember: GENETIC FACTORS ENVIRONMENTAL FACTORS

- Pre-natal - Post-natal


Genetic Factors• ADHD is one of the psychological disorders most strongly

influenced by genetic inheritance• Highly heritable:

– A third of children with ADHD have at least 1 parent with similar symptoms

– Half of parents with ADHD have a child with the condition• Thought to be inherited by a pool of related genes related to

dopaminergic neurotransmission


Environmental Factors

• Pre-natal: – Prematurity– Obstetric complications– Prenatal exposure to nicotine and alcohol

• Post-natal:– Social adversity– Extreme early deprivation– Multiple foster placements

Virtual PatientConsultation: Visit 2 (1 of 5)

Consultation: Visit 2You are a specialist paediatrician working with the Child and Adolescent Mental

Health Services (CAMHS)...

Kirsty Jump is the next patient in your afternoon clinic. She is a 5 year old girl referred by her GP with suspected ADHD.

You read the GP’s letter and recognise some characteristic features in the history:• extremely restless child• problems with school work• struggles to wait her turn• interrupts others• maternal smoking during pregnancy• prematurity

Hyperactivity

Inattention

Impulsivity

Pre-disposing factors

Specialist Assessment• Neither the diagnosis or treatment of ADHD is

carried out in primary care. • Specialist referral is needed to confirm the

diagnosis and start management.• Referral may be to:– a specialist paediatrician– a child psychiatrist– Child and Adolescent Mental Health Services (CAMHS)

Virtual PatientInformation Box


Question: Which form part of the diagnostic criteria for ADHD?

Symptoms of hyperactivity, inattention and impulsivity (correct)

Family history of ADHD Symptoms for at least 6 months (correct) Onset before 7 years old (correct) Symptoms present in more than one setting (correct)

Although the DSM-IV and ICD-10 criteria require ADHD symptoms to be present before 7 years of age, the National Institute of Clinical Excellence (NICE) states that ADHD can be diagnosed in some children when the onset is after 7.


Diagnostic criteria for ADHDHyperactivity

Inattention

Impulsivity

Symptoms: Onset ≤ 7 years old ≥ 6 months ‘Pervasive’ ≥ 2 settings e.g. school, home Cause significant impairment of functioning

Remember to say “HII!”


Consultation: Visit 2

Kirsty Jump sprints into the consultation room and immediately heads towards the box in the corner, where she starts rummaging through the selection of toys. Her mother and father begin to tell you about their daughter’s problematic behaviour at home and at school.

When you have finished taking a thorough history from Mr and Mrs Jump, you ask them to each fill out a form.

When asked what the forms are for, you explain that they are questionnaires which will help you gain a greater understanding of Kirsty’s behaviour, and the impact it is having at home.


Rating ScalesCommonly used in the assessment of ADHD

Measure:– hyperactivity– problem behaviour– attention– academic performance

Examples include:• Conners’ Teacher Rating Scale• Conners’ Parent Rating Scale



You then look at the Conners’ Teacher Rating Scale, which you asked Kirsty’s teacher to fill out prior to the consultation, as well as several reports from members of staff who observed Kirsty during some recent lessons. An extract from one of the reports reads as follows...

‘Throughout the lesson Kirsty appeared restless and left her seat on a number of occasions. She had considerable difficulty following simple instructions from the teacher and lost interest in the maths test soon after it had begun. The little work she did manage to produce was disorganised and contained many careless errors.’



With Mrs Jump’s help, you carry out a thorough assessment of Kirsty in your consultation room.

She is fidgety, easily distracted, and interrupts you repeatedly during the assessment, and you are able to witness a number of other features of ADHD in Kirsty which were documented by the school and described earlier in the consultation by the mother and father.

Furthermore, you are unable to find evidence to suggest any remediable causes for her symptoms and there is no evidence to suggest any co-morbid conditions.

Virtual PatientQuestion Box (1 of 2)

You suspect a diagnosis of ADHD.Question: Which of the following may represent

remediable causes of ADHD-like symptoms?

Neurological conditions (correct) Hearing difficulties (correct) Vision problems (correct)

Neurological conditions, hearing difficulties and visual problems can all manifest in ADHD-like symptoms.


Question: Which of the following form part of the assessment of a child with suspected ADHD?

Physical and psychosocial assessment of the child (correct)

Blood tests Conners’ Teacher/ Parent Rating Scales (correct) CT head scan Observer reports from the school (correct) Interviews with the parents (correct)

The diagnosis of ADHD is made by specialists on the basis of a wealth of gathered information about the child’s behaviour and development. This comes from parents, teachers and assessment of the child.


Specialist assessment• considers a weight of gathered information about the child’s behaviour

and development.

This information is formed from:1) A full physical and psychosocial assessment of the child2) A clinical interview with the parents, covering

• Family history• Pregnancy and birth history• Child’s developmental and medical history• Family functioning• Rating Scales

3) Information from the school• Observer reports• Rating Scales

Remember:ADHD is ‘pervasive’ (present in all situations) therefore the assessment process needs to gather information from at least two settings: classically at home and at school!


Specialist assessment

Specialist assessment also aims to:• distinguish ADHD from related disorders• Consider remediable causes

– Vision problems– Hearing problems– Neurological causes

• seek evidence for any co-morbidities– Conduct disorder, Tic disorders, autism



After careful consideration of the information gathered from Kirsty’s parents, school and your individual assessment of the child, you decide Kirsty is likely to have ADHD.

You explain the diagnosis to Kirsty and her parents and tell Kirsty that you would like her to meet one of your colleagues, who will help her learn some strategies to manage her behaviour better. You also ask Mr and Mrs Jump whether they would be willing to try something called a Parent Training Programme, which may help improve Kirsty’s behaviour at home without the need for medication. They agree to the programme and arrange to meet with you in 6 months time to assess Kirsty’s progress.

Finally, you inform the family that in the meantime you will contact Kirsty’s school to inform them of her diagnosis, and see whether they are able to make any arrangements to improve Kirsty’s educational support in the classroom.


Question: Which of the following form part of the management of a child with ADHD?

Family education (correct) School support (correct) Medication (correct) Individual support (correct) Behavioural therapies (correct)

ADHD management is ‘multi-modal’, and is not limited to the child themselves. Parental support as well as school liaison both form vital aspects of the management of the disorder.

Principles of treatmentMust provide a “package of care”:• Individual support– Psychotherapy– Medication

• Family support• School support

Any co-morbid problems, such as dyslexia, must also be addressed in the management of an ADHD child.


WARNING:Although the influence of dietary factors (such as food additives and sugar) in ADHD has attracted much public attention, there is little evidence to support elimination diets or supplementation in reducing symptoms!

Child Support• The child needs to know that their problem is

understood and that treatments are available.

• Psychological approaches can be useful, such as cognitive behavioural therapy (CBT), and aim to:– Improve the child’s understanding of their condition– Achieve increased self-control


Family Support• Improves the family’s understanding of the condition

Parent Training Programmes e.g. The Webster-Stratton Programme, Triple PThese are behavioural therapy techniques taught to the child’s parents to

help them manage their child’s behaviour– Structured programmes over several weeks– Usually conducted in groups

The main objectives are:• teach the principles of child behaviour management• increase parental confidence in raising children• improve the relationship between the parent and child


School SupportInvolves liaising with the school and training the teachers

1) Liaise with the school– Advise them on the severity of the problem and the nature of the help that

may be required

2) ‘Teach the teachers’– teachers can access similar programmes to parent-training groups

• Improve their understanding of the condition• Teach them skills in behavioural modification



Consultation: Visit 3You are a specialist paediatrician working with the Child and Adolescent Mental

Health Services (CAMHS)...

3 months later Kirsty returns to your clinic with her parents. You were not expecting to see her for several months but agreed to see the family earlier after receiving a call from Kirsty’s GP, who was concerned that her symptoms were showing no signs of improvement since her last visit to you. The school have also reported a deterioration in her behaviour leading to concerns about her academic progress.

Mr and Mrs Jump explain that following your last meeting, they attended the Webster-Stratton Programme you recommended, and learnt a number of behavioural therapy skills they had hoped would help manage their daughter’s behaviour more effectively. However, these techniques had failed to achieve any significant improvement, and both parents were keen to consider further therapy.


The multi-disciplinary team approach to ADHD

The role of the specialist:• Confirming the diagnosis• Initiating and co-ordinating the management

The role of primary care:• Detecting the symptoms of ADHD and referring appropriately• Working alongside specialist care to

– Oversee drug treatment– Monitor for adverse effects

• Supporting the families of affected children• Liaises with the specialist for advice if there are concerns regarding drug

treatments, or if there is unexpectedly poor progress in the child

Shared care between primary care and the specialist


Question: When should medication be considered in the management of ADHD?

School-age children with severe ADHD (correct) Pre-school children with ADHD Young children with severe ADHD (correct) When parent-training or psychological approaches have

failed (correct)

Drug treatment is usually not recommended in the management of pre-school children with ADHD. However it should be considered when parent-training and/or psychological approaches have failed, and in children with severe impairment from their ADHD symptoms.

Drug treatment of ADHD• Controlled drugs which must be prescribed by a specialist• Usually not recommended in pre-school children

Indications:1) School-age children and young people with moderate

ADHD when parent-training or psychological approaches have failed or have been refused

2) School-age children and young people with severe ADHD, used in combination with parent-training and psychological approaches


NICE Guidance on the drug management of ADHD:

1st line:– Methylphenidate (Ritalin)

If Methylphenidate is:– Ineffective at the maximum tolerated dose– Causing adverse effects→ consider 2nd line drugs…

2nd line: – Dexamphetamine– Atomoxetine




You explain to Mr and Mrs Jump that current NICE guidelines on ADHD recommend the use of medication when parent-training and psychological approaches have failed, specifically a drug called Methylphenidate, which you would like to try with Kirsty.

You reassure the parents that the drug is not addictive, and has been shown to be very effective in reducing the symptoms of ADHD, producing a global improvement in behaviour.

Mr and Mrs Jump want to know more about Methylphenidate...


Question: What percentage of children with ADHD respond to Methylphenidate?

30-50% 50-70% 70-90% (correct)

70-90% of children started on Methylphenidate show a significant improvement in their symptoms.


Question: Which of the following are recognised side effects of Methylphenidate?

Headaches (correct) Rash Sleep problems (correct) Poor appetite (correct)

Headaches, sleepiness (insomnia) and poor appetite have all been reported in children on Methylphenidate and as a result patient’s height and weight are measured every 6 months.


Question: Which of the following drugs should be considered in a child showing no improvement with Methylphenidate?

Atomoxetine (correct) Fluoxetine Dexamphetamine (correct) Risperidone

Dexamphetamine and Atomoxetine are both 2nd line drugs used in the management of ADHD and should be considered in 2 circumstances:

1. When Methylphenidate is ineffective at the maximum tolerated dose

2. When a child experiences adverse effects from Methylphenidate

Methylphenidate• (Ritalin, Equasym, Concerta)• 70-90% response rate• Works by increasing levels of dopamine in the brain

Choice of preparation usually discussed with family and school: • Immediate-release: usually TDS

– Provides excellent control of symptoms• Extended-release: usually a single dose at breakfast

– Avoids stigma of taking medication at school– School doesn’t have to dispense a controlled medication

Adverse effects: Sleepiness (insomnia) Poor appetite Headaches


Consider 2nd line drug treatment if:1) Methylphenidate is ineffective at

the maximum tolerated dose2) Methylphenidate is causing adverse effects

Dexamfetamine• Alternative stimulant drug

Atomoxetine (Strattera)• Non-stimulant drug approved for treatment of ADHD• Acts via the noradrenergic pathway




After discussing the drug with you, Mr and Mrs Jump agree to Kirsty starting the Methylphenidate treatment. They decide to opt for the extended-release form of the medication; concerned that taking the shorter-acting drug at school could result in a substantial amount of stigma for Kirsty among her peers.

You arrange to see Kirsty and her parents again in 3 months, where you explain that you will assess the success of the medication, monitor Kirsty’s height and weight, and evaluate the need for any 2nd line drugs.


Consultation: Visit 4You are a specialist paediatrician working with the Child and Adolescent

Mental Health Services (CAMHS)...

You see Kirsty and her parents in clinic 3 months later.

Mr and Mrs Jump are delighted with the improvement they have witnessed in their daughter since she was started on Methylphenidate. They explain that her behaviour has improved significantly at home, resulting in less stress among the family, and an improved relationship with their daughter as a result. School have also informed them that Kirsty’s academic performance is improving and she is far less disruptive in class.



As part of your assessment, you take Kirsty’s height and weight and ask her parent’s if they have any concerns regarding her development since starting the stimulant medication. They are happy to report none of the sleeping difficulties, appetite changes or headaches they were warned about during your last meeting.

You end the consultation by arranging to see Kirsty and her parents in 3 months time, to continue to monitor her progress.

Virtual PatientSummary (1 of 2)Attention Deficit Hyperactivity Disorder (ADHD)Hyperactivity Inattention Impulsivity

Fidgeting Difficulty in sustaining concentration

Boisterous

Restlessness Problems with following instructions

Blurts out answers

Unduly noisy Careless mistakes in school work

Difficulty in waiting in lines

Excessive motor activity Loses things Interrupting conversations

Easily distracted Talks excessively

Remember to say “HII!”Hyperactivity

Inattention

Impulsivity

≥ 6 months ‘Pervasive’ ≥ 2 settings e.g. school, home Early onset ≤ 7 years oldCause significant impairment of functioning

Virtual PatientSummary (2 of 2)Attention Deficit Hyperactivity Disorder (ADHD)

• Neurodevelopmental disorder• Multi-factorial; multiple genetic and environmental factors combine to

produce the disorder• Diagnosis made by specialists on the basis of a wealth of gathered information

about the child’s behaviour and development.• Treatment options depend on the child's age and the degree of functional

impairment from their symptoms• Package of care:

– Individual support• Psychotherapy e.g. CBT• Medication e.g. Methylphenidate

– Family support e.g. Parent-training programmes– School support

Virtual PatientFurther readingUseful websites:www.addiss.co.ukwww.adders.orgwww.adhdandyou.co.ukwww.livingwithadhd.co.uk

Books:Understanding ADHD - Dr. Christopher Greene & Kit CheeTeenagers with ADHD – Chris A-Zeigler DendyADHD in Adulthood – Margaret Weiss

http://www.adddiss.co.uk/

http://www.adders.org/

http://www.adhdandyou.co.uk/

http://www.livingwithadhd.co.uk/

Documents

E-learning module in psychiatry on Attention Deficit Hyperactivity Disorder (ADHD)