ADHD

Diagnostic Criteria (DSM-5)

• Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

  • Children ≥ 6 symptoms for ≥ 6 months, inconsistent with developmental level and negatively impacts social, academic/occupational activities (not manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions)

    • Several symptoms present prior to age 12 years

    • Several symptoms present in ≥ 2 settings (home, school, work, friends/relatives, activities)

    • Clear evidence symptoms interfere with, reduce quality of social, academic, occupational functioning

    • Symptoms do not occur during psychotic disorder, not better explained by other psychiatric disorder (mood, personality, substance)

  • Note: Adults (≥17yo) ≥ 5 symptoms required

• Symptoms of inattention

  • Often fails to give close attention to detail or makes mistakes

  • Often has difficulty sustaining attention in tasks or activities

  • Often does not seem to listen when spoken to directly

  • Often does not follow through on instructions and fails to finish schoolwork or workplace duties

  • Often has difficulty organising tasks and activities

  • Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort

  • Often loses things necessary for tasks or activities

  • Is easily distracted by extraneous stimuli

  • Is often forgetful in daily activities

• Symptoms of hyperactivity and impulsivity

  • Often fidgets with or taps hands and feet, or squirms in seat

  • Often leaves seat in situations when remaining seated is expected

  • Often runs and climbs in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restless)

  • Often unable to play or engage in leisure activities quietly

  • Is often ‘on the go’, acting as if ‘driven by a motor’

  • Often talks excessively

  • Often blurts out answers before a question has been completed

  • Often has difficulty waiting their turn

  • Often interrupts or intrudes on others

Initial Visit

• Screen children 4 years and older who present with academic or behavioural problems and symptoms of ADHD (no evidence for under 4 years old, other than referral to PTBM)

  • Do you find it harder to focus, organize yourself, manage time and complete paperwork than most people?

  • Do you get into trouble for doing impulsive things you wish you had not?

  • Do you find you are always on the go, or that you are constantly restless or looking for something exciting to do?

  • Do you find it really difficult to get motivated by boring things, though it is easier to do the things you enjoy?

  • Do people complain that you are annoying or are easily annoyed, unreliable or difficult to deal with?

• If any suspicion of ADHD complete Assessment Form

• Ask for all documentation of past (school report cards, assessments)

• Give age-group specific toolkit

• Discuss courage and coping skills that patient/family have used to work with difficult circumstances and outline importance and value of these efforts

• Consider referral to parent training in behavior management [PTBM] which may be helpful at all ages and does not require a diagnosis

  • Help parents learn age-appropriate developmental expectations, heaviours tha strengthen parent-child relationship and specific management skills for problem behaviours

Medical History and Physical Exam

• Continue ADHD Assessment Form

  • Complete physical exam

  • Rule out other medical causes

  • Review any medical consequences (accidents, poor sleep/nutrition)

  • Ensure no medical contraindication

• Referral if needed

  • Occupational Therapy for coordination problem

  • Speech and Language Therapist for expressive/receptive language problems

ADHD Interview

• Review childhood developmental history

• Life events of emotional concern (abuse, deaths, major changes)

• Collateral information (parents, close relative)

• Review CAAT Rating Scales

• Referrals

  • Psychologist

  • Psychiatrist

  • Neurologist

Feedback and Treatment Recommendations

• Only proceed if

  • Well documented evidence of impairment

  • Meets thresholds for ADHD on assessment batteries

  • No medical problems that contraindicate treatment

  • Uncomplicated ADHD (no comorbid except oppositional defiant disorder)

  • Motivated to learn about ADHD (or has guardians that are motivated)

• If not, clarify problems, consider referral to ADHD specialist

• Explaining ADHD

  • Neurobiological condition (changes in brain development and function) with strong genetic predisposition

  • All symptoms of ADHD can be problems to everyone, but more severe and impairment in patients with ADHD (not willpower)

• Ask patient for feelings, questions, reactions

• Explain impact in school/vocational

Treatment and Advocacy

• "Encadrement" - collaboration with child, parents, school

  • Education of parents, families, teachers regarding diagnosis

  • Behavioural Interventions

    • Positive reinforcement

      • Token economy (a combination of positive reinforcement and response cost)

    • Calm discipline (eg. Time-out)

      • Response cost (withdrawing rewards or privileges when unwanted or problem behavior occurs)

    • Limit choices

    • Small reachable goals

    • Charts/checklists

    • Specific logical places for items

  • Time Management interventions

    • Daily schedule

  • School-based interventions

    • Tutoring

    • Resource room support

    • Accommodations (more time to complete tasks, less distracting environment)

  • Social Skills / Psychotherapy

  • Physical activity

  • Mindfulness

• Discuss medical treatment

  • Ensure no history of cardiac symptoms or family history of sudden death, WPW, HCM, long QT

    • ECG and consider referral to pediatric cardiology if not normal

  • Stimulants

    • Adverse effects

      • Short term: Appetite loss, abdominal pain, headaches, sleep disturbance

      • Long term: Decrease growth of about 1-2 cm from predicted adult height

      • Rarely: Hallucinations, psychotic symptoms

    • May increase HR and BP to clinically insignificant degree

  • Non-stimulant (atomextine, gunafacine, clonidine)

• Select initial medication and dosing strategy

  • Long-acting psychostimulants (Amphetamine or methylphenidate)

    • Consider combine with non-stimulant or short-acting

  • Failure: Trial of other long-acting psychostimulant

    • Combine with nonstimulant or add short-acting

  • Failure: Trial of nonstimulant monotherapy (Selective norepinephrine reuptake inhibitor, selective alpha-2a-receptor agonist)

    • If suboptimal, nonstimulant as adjuvant therapy

• Give ADHD Medication Form to follow symptoms

DDx ADHD

• Psychiatric

  • GAD

  • OCD

  • Major Depression

  • Bipolar I or II

  • Psychotic Disorder

  • Autism Spectrum Disorder

  • Oppositional Defiant Disorder

  • Conduct Disorder

  • Disruptive Mood Dysregulation disorder

  • Substance Use Disorder

  • Learning Disorder

  • Language Disorder

  • Tic Disorder/Tourette Syndrome

  • Borderline Personality Disorder

  • Antisocial Personality Disorder

  • Intellectual disabilities

• Medical

  • Head Trauma

  • Seizure

  • Hearing or Vision impairment

  • Thyroid dysfunction

  • Hypoglycemia

  • Anemia

  • Lead posioning

  • Sleep Disorder

  • Fragile X

  • FASD

  • Phenylketonuria

  • Neurofibromatosis

• Abuse/neglect

• Medication-related