ADHD: History, Assessment, and Treatment Insights

M

R

C

P

s

y

c

h

C

h

i

l

d

a

n

d

A

d

o

l

e

s

c

e

n

t

P

s

y

c

h

i

a

t

r

y

M

o

d

u

l

e

A

t

t

e

n

t

i

o

n

D

e

f

i

c

i

t

H

y

p

e

r

a

c

t

i

v

i

t

y

S

y

n

d

r

o

m

e

(

A

D

H

D

)

C

A

M

H

S

M

o

d

u

l

e

:

A

D

H

D

A

i

m

s

a

n

d

O

b

j

e

c

t

i

v

e

s

•

The overall aim is for the trainee to gain an overview of ADHD

•

By the end of the session trainees should:

–

Describe signs, symptoms and differential diagnosis of

Attention Deficit Hyperactivity Disorder, and treatment options

C

A

M

H

S

M

o

d

u

l

e

:

A

D

H

D

T

o

a

c

h

i

e

v

e

t

h

i

s

•

Case Presentation

•

Journal Club

•

555 Presentation

•

Expert-Led Session

•

MCQs

•

Please sign the register and complete the feedback

C

A

M

H

S

M

o

d

u

l

e

:

A

D

H

D

Consider aspects of assessment, formulation, evidence

base, NICE guidelines of assessment and intervention,

differential diagnosis, co-morbidities, consequences of

non-treatment and impact on substance misuse.

•

History

•

Definition

•

ICD10 & DSM V

•

Prevalence

•

Clinical features

•

Differential diagnosis

•

Co-morbidities

•

Aetiology

•

Treatment

•

Prognosis: consequence of non treatment & impact on

substance misuse

A

D

H

D

•

N

o

t

a

n

e

w

c

o

n

c

e

p

t

–

1

8

6

5

H

e

i

n

r

i

c

h

H

o

f

f

m

a

n

,

G

e

r

m

a

n

P

h

y

s

i

c

i

a

n

•

described ‘Fidgety Philip’ – ‘won’t sit still, wriggles, giggles,

swings backwards, tilts his chair …growing rude and wild’

–

1

9

0

2

:

G

e

o

r

g

e

S

t

i

l

l

•

3 lectures to the Royal College of Physicians, described 43

impulsive children with significant behaviour problems – often

aggressive, defiant, resistant to discipline ……

–

1

9

0

8

:

T

r

e

d

g

o

l

d

•

also described similar children who would now have a

diagnosis of ADHD with Oppositional Defiant Disorder or

Conduct Disorder

H

i

s

t

o

r

y

o

f

A

D

H

D

H

i

s

t

o

r

y

o

f

A

D

H

D

–

1

9

1

7

-

1

8

E

n

c

e

p

h

a

l

i

t

i

s

e

p

i

d

e

m

i

c

i

n

N

o

r

t

h

A

m

e

r

i

c

a

•

Sequelae similar to concept of ADHD

–

1

9

3

7

C

h

a

r

l

e

s

B

r

a

d

l

e

y

•

Amphetamine in  children with EBD improvement in

over-activity & classroom behaviour

–

1

9

4

0

M

e

t

h

y

l

p

h

e

n

i

d

a

t

e

(

R

i

t

a

l

i

n

)

s

y

n

t

h

e

s

i

s

e

d

•

1

9

9

1

-

1

9

9

5

U

S

A

5

0

0

%

i

n

c

r

e

a

s

e

d

i

n

p

r

o

d

u

c

t

i

o

n

.

H

a

s

c

o

n

t

i

n

u

e

d

t

o

i

n

c

r

e

a

s

e

•

1996-2006 UK - 50,000 -500,000 prescriptions.

•

1990s Adult ADHD

•

Clearly defined clinical condition

•

Common

•

Tends to run in Families

–

probably results from a combination of factors

•

Children with ADHD have other problems

A

D

H

D

•

I

C

D

1

0

:

H

y

p

e

r

k

i

n

e

t

i

c

D

i

s

o

r

d

e

r

–

‘a persistent and severe impairment of psychological

development, characterised by ‘a combination of overactive,

poorly modulated behaviour with marked inattention and lack of

persistent task involvement; and pervasiveness, over situations

and persistence over time of these behavioural characteristics’

D

i

a

g

n

o

s

t

i

c

c

l

a

s

s

i

f

i

c

a

t

i

o

n

D

i

g

n

o

s

t

i

c

C

l

a

s

s

i

f

i

c

a

t

i

o

n

•

D

S

M

V

:

A

D

H

D

•

ADHD is described as “a persistent pattern of

inattention and/or hyperactivity-impulsivity that

interferes with development, has symptoms

presenting in two or more settings (e.g. at home,

school, or work), and negatively impacts directly

on social, academic or occupational functioning” -

symptoms present before age 12

•

F

9

0

H

y

p

e

r

k

i

n

e

t

i

c

d

i

s

o

r

d

e

r

–

 F90.0 Disturbance of activity and attention

–

 F90.1 Hyperkinetic conduct disorder

–

 F90.8 Other hyperkinetic disorders

–

 F90.9 Hyperkinetic disorder,

–

Age specific

I

C

D

1

0

:

F

9

0

B

e

h

a

v

i

o

u

r

a

l

a

n

d

e

m

o

t

i

o

n

a

l

d

i

s

o

r

d

e

r

s

w

i

t

h

o

n

s

e

t

u

s

u

a

l

l

y

o

c

c

u

r

r

i

n

g

i

n

c

h

i

l

d

h

o

o

d

a

n

d

a

d

o

l

e

s

c

e

n

c

e

•

Simultaneous hyperactivity, impulsivity and

inattentiveness

•

Symptoms prior to 6 years of age

•

Impairment present in ≥2 settings

•

Exclude diagnosis of mania, depression, anxiety

disorders and/or pervasive developmental disorde

r

I

C

D

1

0

m

e

d

i

c

a

l

c

l

a

s

s

i

f

i

c

a

t

i

o

n

s

y

s

t

e

m

f

o

r

H

K

D

•

Describes that the characteristic behaviour problems

associated with HKD should be of early onset (age <6

years) and of long duration

•

Caution is recommended in children of pre-school age

and 

only extreme levels of hyperactivity

 should lead to a

diagnosis in these individuals

•

Diagnosis of HKD may also be made in adult life using

the same criteria, however, attention and activity must be

judged with reference to developmentally appropriate

norms

I

C

D

1

0

m

e

d

i

c

a

l

c

l

a

s

s

i

f

i

c

a

t

i

o

n

s

y

s

t

e

m

f

o

r

H

K

D

•

C

h

i

l

d

r

e

n

–

≥6 symptoms of inattention and/or ≥6 symptoms of hyperactivity-

impulsivity, for 6 months prior to assessment

•

A

d

u

l

t

s

–

≥5 symptoms of inattention and/or ≥5 symptoms of hyperactivity-

impulsivity, for 6 months prior to assessment

•

Hyperactive-impulsive or inattentive symptoms prior to 12 years of age

Impairment present in ≥2 settings

•

Clinically significant impairment in social, academic or occupational

environments

•

Symptoms do not occur exclusively during the course of schizophrenia or

another psychotic disorder, or are not better accounted for by another

mental disorder

D

S

M

V

m

e

d

i

c

a

l

c

l

a

s

s

i

f

i

c

a

t

i

o

n

s

y

s

t

e

m

f

o

r

A

D

H

D

•

Inattention

•

Impulsivity

•

Hyperactivity

•

Executive Functions

A

t

t

e

n

t

i

o

n

D

e

f

i

c

i

t

H

y

p

e

r

a

c

t

i

v

i

t

y

D

i

s

o

r

d

e

r

•

B

u

t

t

h

e

r

e

a

r

e

a

t

l

e

a

s

t

6

t

y

p

e

s

o

f

a

t

t

e

n

t

i

o

n

–

Arousal, alertness, selective, divided, span of

attention, & persistence

•

N

o

t

a

l

l

a

r

e

i

m

p

a

i

r

e

d

-

W

h

a

t

i

s

?

–

Poor persistence toward goals or tasks

–

Impaired resistance to responding to distractions

–

Deficient task re-engagement following

disruptions

–

Impaired working memory (remembering so as to

do) in 80% of children with ADHD

I

n

a

t

t

e

n

t

i

o

n

•

Often fidgets with or taps hands or feet, or squirms in seat.

•

Often leaves seat in situations when remaining seated is expected.

•

Often runs about or climbs in situations where it is not appropriate

(adolescents or adults may be limited to feeling restless).

•

Often unable to play or take part in leisure activities quietly.

•

Is often "on the go" acting as if "driven by a motor".

•

Often talks excessively.

•

Often blurts out an answer before a question has been completed.

•

Often has trouble waiting his/her turn.

•

Often interrupts or intrudes on others (e.g., butts into conversations or

games)

H

y

p

e

r

a

c

t

i

v

i

t

y

a

n

d

I

m

p

u

l

s

i

v

i

t

y

•

ADHD disrupts the 

5

 levels EF but especially the tactical

and strategic levels thereby creating a disorder of self-

regulation across time

•

ADHD can be considered as “Time Blindness” or a

“Temporal Neglect Syndrome” (Myopia to the Future)

•

It adversely affects the capacity to hierarchically

organize behavior across time to anticipate the future

and to pursue one’s long-term goals and self-interests

(welfare and happiness)

•

It’s not an Attention Deficit but an 

Intention

 Deficit

(Inattention to mental events & the future)

(From Professor Russell Barkley)

E

x

e

c

u

t

i

v

e

F

u

n

c

t

i

o

n

i

n

g

•

Several inattentive or hyperactive-impulsive symptoms were

present before age 12 years

•

Several symptoms are present in two or more settings:

–

home, school or work; with friends or relatives; in other activities

•

There is clear evidence that the symptoms interfere with, or

reduce the quality of, social, school, or work functioning

•

The symptoms do not happen only during the course of

schizophrenia or another psychotic disorder.

•

The symptoms are not better explained by another mental

disorder

–

e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a

Personality Disorder

P

L

U

S

t

h

e

f

o

l

l

o

w

i

n

g

c

o

n

d

i

t

i

o

n

s

m

u

s

t

b

e

m

e

t

…

•

P

r

e

v

a

l

e

n

c

e

–

3-5% of UK children have ADHD

–

Gender ratio: M: F 4:1

•

Mental Health clinics  6:1 – 9:1

–

Many girls do not get diagnosed

•

Predominantly inattentive and diagnostic construct based in

male behaviour

–

Hyperkinetic Disorder

•

UK: 1% of school aged children, UK

•

~69,000 6-16 yrs olds in England (NICE)

•

4,200 in Wales (NICE)

•

LAC: 9% (BMJ 2007)

A

D

H

D

•

O

v

e

r

5

0

%

w

i

l

l

h

a

v

e

o

n

e

o

r

m

o

r

e

o

f

t

h

e

f

o

l

l

o

w

i

n

g

c

o

n

d

i

t

i

o

n

s

.

–

Learning disabilities

•

20-30% have ADHD but can also mimic ADHD in situations

–

Tic & Tourette’s Syndrome

•

7% have Tic disorder

•

60% TS have ADHD

–

Oppositional Defiant Disorder (ODD)

•

1/3 of ADHD children mainly boys have ODD

–

Conduct Disorder (CD)

•

20-40% of ADHD children have CD

–

ASD

•

1/3 have ADHD

–

Anxiety 34%

–

Depression, Substance abuse, Developmental language delay

C

o

-

m

o

r

b

i

d

i

t

y

•

Easily distracted

•

Disorganized and “messy”

•

Friendship troubles

•

Forgetful/day dreamy

•

Difficulty completing tasks

•

Slow to process information and directions (It may even appear that

they aren’t hearing you)

•

Careless

•

Often late (poor time management)

•

Hyper-talkative

•

Verbally impulsive (blurts out, interrupts others)

•

Easily upset, over-reactive

A

D

H

D

i

n

g

i

r

l

s

•

Disinhibited attachment disorder;

•

Over-activity associated with autistic spectrum disorders

–

including Asperger's syndrome

•

Conduct disorder

•

Anxious in-attentiveness secondary to stress and trauma

•

Agitated depression;

•

past closed head injury

•

Attention deficit without over-activity

•

Gilles de la Tourette syndrome

•

Chromosomal disorders e.g. Fragile X syndrome

•

Lack of consistent parenting

•

Specific learning difficulties

•

Physical or sexual abuse or neglect

D

i

f

f

e

r

e

n

t

i

a

l

d

i

a

g

n

o

s

i

s

E

x

a

c

t

c

a

u

s

e

s

u

n

k

n

o

w

n

•

Substantial evidence:

–

Neurobiology and Genetics

•

Very little evidence for purely social factors or

child-rearing methods

•

Environment can play a part to influence severity

of ADHD but it is not the cause

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

•

Reduced Dopamine and Noradrenaline  in the

synaptic cleft

–

this is thought to be due to: faster reuptake of

NA/DA, not enough is produced

•

Medication for ADHD reduces the re-uptake of

DA and NA back in to the neurones

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

N

e

u

r

o

b

i

o

l

o

g

y

•

Some studies have shown association between:

–

use of Cocaine, Benzodiazepine abuse, Alcohol and

Cigarettes in pregnancy and risk of ADHD in the child

–

Low birth weight

–

Higher levels of lead in children with ADHD

–

Prenatal stress

–

Pesticides

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

E

n

v

i

r

o

n

m

e

n

t

a

l

a

g

e

n

t

s

•

Only a small percentage of children with

ADHD have suffered a traumatic brain

injury

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

B

r

a

i

n

I

n

j

u

r

y

•

1

9

8

2

s

c

i

e

n

t

i

f

i

c

c

o

n

s

e

n

s

u

s

–

about 5% of children with ADHD had food allergies, mostly

young children

•

1

9

8

5

&

1

9

9

4

s

t

u

d

i

e

s

–

no evidence

–

1985: alternate days of sugar /sugar substitute.

Parents/staff/children did not know

–

1994: Given sugar substitute (Aspartame). 50 % told they

were given sugar and other half told given Aspartame.

Parents who thought children had sugar rated more

hyperactivity and more critical

W

h

a

t

c

a

u

s

e

s

A

D

H

D

F

o

o

d

a

d

d

i

t

i

v

e

s

a

n

d

S

u

g

a

r

•

Often run in families

•

Studies have shown

–

25% close relatives in the families of ADHD children have ADHD

compared to 5% in the general population

–

1/3 of ADHD children have at least one parent who has ADHD

–

Twin studies:75% concordance in identical twins

•

ADHD molecular Genetics Network established in 1999

to help researchers to share the findings

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

G

e

n

e

t

i

c

s

•

Epilepsy and other brain disorders (minority) & Low

birth weight/prematurity

•

Major disruptions of attachments

•

Excessive drinking and smoking in pregnancy

•

Prenatal exposure to benzodiazepines and

anticonvulsants also predict later hyperactive

behaviour

•

Exposure to lead in utero and childhood.

9/28/2024

P

o

s

s

i

b

l

e

c

a

u

s

e

s

…

•

These are imaging studies of the brain

–

2002: studied 152 (boys and girls) with ADHD vs. 139 age

and gender matched controls:

•

ADHD children showed 3-4 % smaller brain volumes in

all regions

•

The ones on medication: white matter was similar to

normal

•

The ones who never had medication: had smaller white

matter

W

h

a

t

c

a

u

s

e

s

A

D

H

D

?

R

e

c

e

n

t

E

v

i

d

e

n

c

e

•

N

o

e

v

i

d

e

n

c

e

e

x

i

s

t

s

t

o

s

u

g

g

e

s

t

t

h

a

t

A

D

H

D

i

s

c

a

u

s

e

d

b

y

a

n

y

t

h

i

n

g

o

t

h

e

r

t

h

a

n

n

e

u

r

o

b

i

o

l

o

g

i

c

a

l

m

a

l

f

u

n

c

t

i

o

n

i

n

g

i

n

c

l

u

d

i

n

g

d

e

f

i

c

i

t

s

i

n

•

dopamine-decarboxylase in the anterior frontal cortex, leading to

reduced dopamine availability and diminished focusing and attention;

more symmetrical brains; smaller-sized brains in the area of the

prefrontal cortex (caudate, globus pallidus); duplication polymorphism

in the DRD4 and DAT genes

•

A

D

H

D

s

u

f

f

e

r

e

r

s

h

a

v

e

d

i

f

f

i

c

u

l

t

y

i

n

s

u

p

p

r

e

s

s

i

n

g

i

m

p

u

l

s

e

•

respond to all impulses, being unable to exclude those that are

unnecessary for the situation

•

rather than failing to pay attention, they pay more attention to more

cues than the average person, and are unable to stop the relentless

flow of information

•

fail to pause, to consider the situation, options and consequences - act

without thinking

S

u

m

m

a

r

y

•

Children do not grow out of it

–

70-80% carry the condition into their adult life

•

Early identification and multi-modal treatment reduces

the risk of developing future difficulties including

–

Antisocial behaviour

–

Abuse of alcohol & Tobacco & illicit substance

–

Poor academic & social functioning

–

Poor self esteem

–

Other psychiatric difficulties

–

Pressure on families

A

D

H

D

a

c

r

o

s

s

l

i

f

e

s

p

a

n

•

A

s

s

e

s

s

m

e

n

t

a

n

d

d

i

a

g

n

o

s

i

s

b

y

C

A

M

H

S

/

C

o

m

m

u

n

i

t

y

P

a

e

d

i

a

t

r

i

c

s

•

Assessment

–

Information from parents/carers and other professionals who know

the child (school teachers etc.)

–

Observations in clinic and at school

–

QbTest

–

Rule out other causes for the behaviour

•

Diagnosis

–

Inattention, impulsivity, hyperactivity, present before the age 7 and

pervasive

•

Regular monitoring as per NICE guidelines

•

Regular audit of practice against NICE Guidelines

A

s

s

e

s

s

m

e

n

t

a

n

d

D

i

a

g

n

o

s

i

s

•

Multi-modal:

–

social, psychological and behavioural intervention – child,

parents, teachers

•

Behaviour Management

•

Parenting strategies (WS groups, Parent Child Game)

•

Individual work with Children and Families

•

Medication

•

Address co-morbidities Liaison with school and other

agencies

Central Manchester PCT

Central Manchester and Manchester

Children’s Hospital NHS Trust

A

D

H

D

T

r

e

a

t

m

e

n

t

a

n

d

I

n

t

e

r

v

e

n

t

i

o

n

S

t

i

m

u

l

a

n

t

s

•

S

h

o

r

t

a

c

t

i

n

g

–

Methylphenidate (Ritalin, Equasym), Dexamfetamine.

•

L

o

n

g

a

c

t

i

n

g

–

Matoride/Concerta XL (20/80 – 12 hrs)

–

Equasym XL 30/70 – 8 hrs)

–

Medikinet XL (50/50 – 8 hrs)

–

Elvanse (pro-drug of Dexamfetamine) lasts for 12 hrs

Central Manchester PCT

Central Manchester and Manchester

Children’s Hospital NHS Trust

M

e

d

i

c

a

t

i

o

n

N

o

n

-

s

t

i

m

u

l

a

n

t

s

•

Atomoxetine

–

noerepinephrine reuptake inhibitor-long acting up to

24 hrs

•

Guanfacine

–

central alpha 2A-adrenergic receptor agonist

M

e

d

i

c

a

t

i

o

n

•

Reduced appetite

•

Sleep disturbance

•

Tics

•

Headache

•

Nausea & Vomiting

•

Abdominal Pain

•

Emotional

•

Listlessness

•

Increase in suicidal thoughts (Atomoxetine)

9/28/2024

M

e

d

i

c

a

t

i

o

n

S

i

d

e

-

e

f

f

e

c

t

s

•

Response of parents

•

Response of teachers

•

Peer influences

9/28/2024

M

a

i

n

t

a

i

n

i

n

g

f

a

c

t

o

r

s

•

Methylphenidate (MTP) is recommended as part of a

comprehensive treatment programme

–

not licensed for children <6

•

Assessment  and treatment by Child Psychiatrists or  Paediatricians

with special expertise in ADHD

•

Should involve children, parents, carers, school,

•

Consider cultural factors and environmental factors

•

Comprehensive treatment programme desirable

•

Regular monitoring and drug holidays

Central Manchester PCT

Central Manchester and Manchester

Children’s Hospital NHS Trust

N

I

C

E

g

u

i

d

e

l

i

n

e

s

f

o

r

A

D

H

D

•

Raising Awareness and training of front line

professionals who can refer or direct referrals to CAMHS

–

resource implications

•

Desire to treat Children with ADHD and impairment 

vs.

how can we manage if all these children are referred?

–

Need for multiagency integrated pathways)

•

Multi-modal therapies are the treatment of choice

–

This needs skilled practitioners and closer working relationship

with other children services colleagues

•

Implications for ADHD graduates from CAMHS to

adulthood

•

Addressing myths about ADHD/Treatments

Central Manchester PCT

Central Manchester and Manchester

Children’s Hospital NHS Trust

C

h

a

l

l

e

n

g

e

s

f

o

r

H

e

a

l

t

h

S

e

r

v

i

c

e

s

•

C

h

i

l

d

r

e

n

w

i

t

h

A

D

H

D

d

o

n

o

t

g

r

o

w

o

u

t

o

f

i

t

−

Between 70-80% carry the condition into their adult life to a

varying degree (Klein and Mannuzza, 1991)

•

E

a

r

l

y

i

d

e

n

t

i

f

i

c

a

t

i

o

n

a

n

d

m

u

l

t

i

m

o

d

a

l

t

r

e

a

t

m

e

n

t

r

e

d

u

c

e

s

t

h

e

r

i

s

k

o

f

d

e

v

e

l

o

p

i

n

g

f

u

r

t

h

e

r

c

o

m

p

l

i

c

a

t

i

o

n

s

−

Antisocial behaviour

−

Abuse of alcohol, tobacco and illicit substances

−

Poor academic and social functioning,

−

Further psychiatric morbidity

P

r

o

g

n

o

s

i

s

H

o

w

i

m

p

o

r

t

a

n

t

i

s

i

t

t

o

t

r

e

a

t

?

•

Barkley et al 2002 (Milwaukee) identified that

adults with ADHD compared to a control

group have:

−

2.4 times the rate of heart disease

−

11.4% higher BMI

−

2.2 times the rate of non-medical drug use

−

32% more medical/dental problems

−

2.5 times the rate of sleep problems

H

o

w

i

m

p

o

r

t

a

n

t

i

s

i

t

t

o

t

r

e

a

t

?

•

Barkley et al 2002 (Milwaukee) note that adults

with ADHD have:

−

increased use of the healthcare system

−

increased use of sick days from employment

−

higher rates of depression, anxiety and antisocial

personality disorder

−

higher risk sexual activity

−

higher rates of divorce and separation

H

o

w

i

m

p

o

r

t

a

n

t

i

s

i

t

t

o

t

r

e

a

t

?

•

Barkley et al 2002 (Milwaukee) notes that

adults with ADHD have:

−

more job terminations, disciplinary actions, job

changes, lower incomes and more problems

following instructions and carrying a workload

−

they have significant problems budgeting

−

they have greater rates of driving accidents

•

A

f

o

u

r

y

e

a

r

o

l

d

b

o

y

i

s

b

r

o

u

g

h

t

t

o

c

l

i

n

i

c

w

i

t

h

h

i

s

p

a

r

e

n

t

s

.

T

h

e

y

r

e

p

o

r

t

t

h

a

t

h

e

i

s

i

n

a

t

t

e

n

t

i

v

e

a

t

s

c

h

o

o

l

,

w

i

l

l

n

o

t

s

i

t

a

n

d

p

l

a

y

w

i

t

h

h

i

s

s

i

b

l

i

n

g

s

a

t

h

o

m

e

a

n

d

o

n

o

n

e

o

c

c

a

s

i

o

n

l

e

t

g

o

o

f

h

i

s

m

o

t

h

e

r

’

s

h

a

n

d

w

h

i

l

s

t

s

h

o

p

p

i

n

g

a

n

d

r

a

n

o

u

t

i

n

t

o

t

h

e

r

o

a

d

.

F

o

l

l

o

w

i

n

g

a

s

s

e

s

s

m

e

n

t

a

n

d

d

i

a

g

n

o

s

i

s

,

w

h

a

t

w

o

u

l

d

y

o

u

r

i

n

i

t

i

a

l

m

a

n

a

g

e

m

e

n

t

s

t

e

p

b

e

?

•

a) Refer patient for individualised CBT

•

b) Refer family for Family Therapy

•

c) Refer family to parent training and education sessions

•

d) Commence 5mg methylphenidate daily, titrating up weekly until

improvement is seen

•

e) None of the above

M

C

Q

:

1

•

A

n

s

w

e

r

:

c

:

r

e

f

e

r

t

o

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

s

e

s

s

i

o

n

s

.

N

I

C

E

g

u

i

d

e

l

i

n

e

s

a

d

v

i

s

e

t

h

a

t

f

i

r

s

t

s

t

e

p

s

i

n

m

a

n

a

g

e

m

e

n

t

o

f

p

r

e

-

s

c

h

o

o

l

a

g

e

d

c

h

i

l

d

r

e

n

w

i

t

h

a

d

i

a

g

n

o

s

i

s

o

f

A

D

H

D

s

h

o

u

l

d

b

e

a

r

e

f

e

r

r

a

l

f

o

r

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

.

M

e

d

i

c

a

t

i

o

n

i

s

n

o

t

f

i

r

s

t

l

i

n

e

f

o

r

p

r

e

-

s

c

h

o

o

l

c

h

i

l

d

r

e

n

o

r

t

h

o

s

e

w

i

t

h

m

i

l

d

-

m

o

d

e

r

a

t

e

i

l

l

n

e

s

s

.

A

n

s

w

e

r

•

W

h

i

l

s

t

t

a

k

i

n

g

a

h

i

s

t

o

r

y

f

r

o

m

a

f

a

t

h

e

r

o

f

a

6

y

e

a

r

o

l

d

b

o

y

w

i

t

h

s

u

s

p

e

c

t

e

d

A

D

H

D

,

h

e

t

e

l

l

s

y

o

u

t

h

a

t

h

i

s

s

o

n

d

r

i

n

k

s

a

l

o

t

o

f

o

r

a

n

g

e

s

q

u

a

s

h

w

h

e

n

h

e

v

i

s

i

t

s

h

i

s

g

r

a

n

d

p

a

r

e

n

t

s

a

n

d

h

i

s

i

m

p

u

l

s

i

v

e

a

n

d

i

n

a

t

t

e

n

t

i

v

e

b

e

h

a

v

i

o

u

r

s

e

e

m

s

t

o

b

e

w

o

r

s

e

a

f

t

e

r

w

a

r

d

s

.

W

h

a

t

w

o

u

l

d

b

e

y

o

u

r

i

n

i

t

i

a

l

a

d

v

i

c

e

?

•

a) Instruct the grandparents not to give him orange squash

•

b) Refer to a dietician

•

c) Commence fatty acid supplements

•

d) Advise father to commence a food/behaviour diary

•

e) All of the above

M

C

Q

:

2

•

A

n

s

w

e

r

:

d

:

a

d

v

i

s

e

f

a

t

h

e

r

t

o

c

o

m

m

e

n

c

e

a

f

o

o

d

/

b

e

h

a

v

i

o

u

r

d

i

a

r

y

.

C

l

i

n

i

c

a

l

a

s

s

e

s

s

m

e

n

t

o

f

A

D

H

D

s

h

o

u

l

d

i

n

c

l

u

d

e

a

s

k

i

n

g

a

b

o

u

t

f

o

o

d

a

n

d

d

r

i

n

k

s

t

h

a

t

a

p

p

e

a

r

t

o

i

n

f

l

u

e

n

c

e

h

y

p

e

r

a

c

t

i

v

e

b

e

h

a

v

i

o

u

r

.

I

f

t

h

e

r

e

i

s

a

c

l

e

a

r

l

i

n

k

,

h

e

a

l

t

h

p

r

o

f

e

s

s

i

o

n

a

l

s

s

h

o

u

l

d

a

d

v

i

s

e

p

a

r

e

n

t

s

o

r

c

a

r

e

r

s

t

o

k

e

e

p

a

d

i

a

r

y

o

f

f

o

o

d

a

n

d

d

r

i

n

k

s

t

a

k

e

n

a

n

d

A

D

H

D

b

e

h

a

v

i

o

u

r

.

I

f

t

h

e

d

i

a

r

y

s

u

p

p

o

r

t

s

a

r

e

l

a

t

i

o

n

s

h

i

p

b

e

t

w

e

e

n

s

p

e

c

i

f

i

c

f

o

o

d

o

r

d

r

i

n

k

s

a

n

d

b

e

h

a

v

i

o

u

r

,

t

h

e

n

a

r

e

f

e

r

r

a

l

t

o

t

h

e

d

i

e

t

i

c

i

a

n

s

h

o

u

l

d

b

e

o

f

f

e

r

e

d

.

D

i

e

t

a

r

y

f

a

t

t

y

a

c

i

d

s

u

p

p

l

e

m

e

n

t

a

t

i

o

n

i

s

n

o

t

r

e

c

o

m

m

e

n

d

e

d

f

o

r

t

h

e

t

r

e

a

t

m

e

n

t

o

f

A

D

H

D

i

n

c

h

i

l

d

r

e

n

a

n

d

y

o

u

n

g

p

e

o

p

l

e

.

(

N

I

C

E

g

u

i

d

e

l

i

n

e

s

2

0

0

8

1

.

4

.

2

.

3

-

4

)

A

n

s

w

e

r

•

T

h

e

p

a

r

e

n

t

s

o

f

a

5

y

e

a

r

o

l

d

g

i

r

l

r

e

c

e

n

t

l

y

d

i

a

g

n

o

s

e

d

w

i

t

h

A

D

H

D

h

a

v

e

c

a

n

c

e

l

l

e

d

t

h

e

i

r

s

e

c

o

n

d

g

r

o

u

p

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

s

e

s

s

i

o

n

.

T

h

e

y

t

e

l

l

y

o

u

t

h

i

s

i

s

b

e

c

a

u

s

e

t

h

e

i

r

1

1

y

e

a

r

o

l

d

s

o

n

h

a

s

l

e

a

r

n

i

n

g

d

i

s

a

b

i

l

i

t

i

e

s

a

n

d

i

s

w

h

e

e

l

c

h

a

i

r

b

o

u

n

d

.

T

h

e

y

h

a

v

e

n

o

e

x

t

e

n

d

e

d

f

a

m

i

l

y

o

r

c

l

o

s

e

f

r

i

e

n

d

s

t

o

h

e

l

p

w

i

t

h

c

h

i

l

d

c

a

r

e

a

r

r

a

n

g

e

m

e

n

t

s

o

n

t

h

e

d

a

y

s

r

e

q

u

i

r

e

d

.

W

h

a

t

w

o

u

l

d

y

o

u

a

d

v

i

s

e

?

•

a) Offer to commence medication for the patient as they will not be able to attend the

parent training and education sessions

•

b) Offer to hold individualised parent training and education sessions on a day that

would better suit them

•

c) Discharge the family from your case load as they have missed two consecutive

appointments

•

d) None of the above

•

e) Ask them to contact children and family services to arrange child care whilst they

attend the training sessions

M

C

Q

:

3

•

A

n

s

w

e

r

:

b

:

o

f

f

e

r

t

o

h

o

l

d

i

n

d

i

v

i

d

u

a

l

i

s

e

d

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

o

n

a

d

a

y

t

h

a

t

w

o

u

l

d

b

e

t

t

e

r

s

u

i

t

t

h

e

m

.

I

n

d

i

v

i

d

u

a

l

-

b

a

s

e

d

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

p

r

o

g

r

a

m

m

e

s

a

r

e

r

e

c

o

m

m

e

n

d

e

d

w

h

e

n

•

A group programme is not possible due to low participant numbers

•

There are particular difficulties in attending group sessions such as

disability, needs related to diversity such as language

•

Family needs are too complex to be met by group based training

•

(NICE guidelines 2008 1.5.1.5)

A

n

s

w

e

r

•

Y

o

u

h

a

v

e

a

s

s

e

s

s

e

d

a

7

y

e

a

r

o

l

d

b

o

y

w

i

t

h

s

u

s

p

e

c

t

e

d

A

D

H

D

i

n

c

l

i

n

i

c

.

Y

o

u

w

o

u

l

d

l

i

k

e

t

o

g

e

t

f

u

r

t

h

e

r

i

n

f

o

r

m

a

t

i

o

n

a

b

o

u

t

h

i

s

b

e

h

a

v

i

o

u

r

i

n

s

c

h

o

o

l

f

r

o

m

h

i

s

t

e

a

c

h

e

r

s

.

W

h

i

c

h

o

f

t

h

e

f

o

l

l

o

w

i

n

g

r

e

g

a

r

d

i

n

g

c

o

n

s

e

n

t

t

o

d

i

s

c

u

s

s

t

h

e

c

a

s

e

w

i

t

h

s

c

h

o

o

l

i

s

c

o

r

r

e

c

t

?

•

a) You will need to document that you have obtained consent from the

patient’s parents or carers before you contact the school for information

•

b) You will need to document that you have obtained consent from the

patient before you contact school for information

•

c) You don’t need consent to request information with school

•

d) You don’t need consent to request information from school as long as you

don’t discuss treatment with them

•

e) You will need verbal consent from the patient’s parents or carers before

you contact the school for information

MCQ:4

•

A

n

s

w

e

r

:

a

:

y

o

u

w

i

l

l

n

e

e

d

t

o

d

o

c

u

m

e

n

t

t

h

a

t

y

o

u

h

a

v

e

o

b

t

a

i

n

e

d

c

o

n

s

e

n

t

f

r

o

m

t

h

e

p

a

t

i

e

n

t

’

s

p

a

r

e

n

t

s

o

r

c

a

r

e

r

s

b

e

f

o

r

e

y

o

u

c

o

n

t

a

c

t

t

h

e

s

c

h

o

o

l

f

o

r

i

n

f

o

r

m

a

t

i

o

n

.

Y

o

u

m

u

s

t

a

l

w

a

y

s

o

b

t

a

i

n

c

o

n

s

e

n

t

f

r

o

m

p

a

r

e

n

t

s

o

r

c

a

r

e

r

s

b

e

f

o

r

e

c

o

n

t

a

c

t

i

n

g

o

u

t

s

i

d

e

a

g

e

n

c

i

e

s

a

b

o

u

t

a

p

a

t

i

e

n

t

,

i

n

c

l

u

d

i

n

g

s

c

h

o

o

l

,

p

a

e

d

i

a

t

r

i

c

i

a

n

s

e

t

c

.

T

h

i

s

s

h

o

u

l

d

b

e

d

o

c

u

m

e

n

t

e

d

i

n

t

h

e

n

o

t

e

s

(

h

i

s

t

o

r

i

c

a

l

l

y

,

l

e

g

a

l

c

a

s

e

l

a

w

s

u

g

g

e

s

t

s

t

h

a

t

i

f

s

o

m

e

t

h

i

n

g

i

s

n

’

t

w

r

i

t

t

e

n

d

o

w

n

,

i

t

n

e

v

e

r

h

a

p

p

e

n

e

d

!

)

.

O

c

c

a

s

i

o

n

a

l

l

y

,

i

n

c

a

s

e

s

w

h

e

r

e

t

h

e

r

e

a

r

e

c

h

i

l

d

p

r

o

t

e

c

t

i

o

n

c

o

n

c

e

r

n

s

a

n

d

c

o

n

s

e

n

t

i

s

r

e

f

u

s

e

d

;

t

h

i

s

r

e

f

u

s

a

l

c

a

n

b

e

o

v

e

r

r

i

d

d

e

n

i

f

y

o

u

f

e

e

l

t

h

e

r

i

s

k

t

o

t

h

e

c

h

i

l

d

i

s

h

i

g

h

e

n

o

u

g

h

t

o

w

a

r

r

a

n

t

i

t

.

A

n

s

w

e

r

•

F

o

l

l

o

w

i

n

g

a

s

s

e

s

s

m

e

n

t

o

f

a

n

8

y

e

a

r

o

l

d

b

o

y

,

y

o

u

d

i

a

g

n

o

s

e

s

e

v

e

r

e

A

D

H

D

w

i

t

h

s

e

v

e

r

e

i

m

p

a

i

r

m

e

n

t

o

f

f

u

n

c

t

i

o

n

i

n

g

i

n

b

o

t

h

s

o

c

i

a

l

a

n

d

a

c

a

d

e

m

i

c

d

o

m

a

i

n

s

.

W

h

a

t

w

o

u

l

d

b

e

y

o

u

r

i

n

i

t

i

a

l

s

t

e

p

i

n

m

a

n

a

g

e

m

e

n

t

?

•

a)Refer family to Family Therapy

•

b) Refer patient for CBT

•

c) Refer family to parent training and education

•

d) Commence the patient on medication

•

e) None of the above

M

C

Q

:

5

•

A

n

s

w

e

r

:

d

:

c

o

m

m

e

n

c

e

t

h

e

p

a

t

i

e

n

t

o

n

m

e

d

i

c

a

t

i

o

n

.

T

h

e

f

i

r

s

t

l

i

n

e

t

r

e

a

t

m

e

n

t

f

o

r

s

c

h

o

o

l

a

g

e

d

c

h

i

l

d

r

e

n

w

i

t

h

s

e

v

e

r

e

A

D

H

D

a

n

d

s

e

v

e

r

e

i

m

p

a

i

r

m

e

n

t

i

s

d

r

u

g

t

r

e

a

t

m

e

n

t

.

I

f

t

h

e

c

h

i

l

d

w

i

s

h

e

s

t

o

r

e

f

u

s

e

m

e

d

i

c

a

t

i

o

n

a

n

d

/

o

r

t

h

e

p

a

r

e

n

t

s

r

e

j

e

c

t

i

t

,

a

p

s

y

c

h

o

l

o

g

i

c

a

l

i

n

t

e

r

v

e

n

t

i

o

n

m

a

y

b

e

t

r

i

e

d

b

u

t

d

r

u

g

t

r

e

a

t

m

e

n

t

h

a

s

m

o

r

e

b

e

n

e

f

i

t

s

a

n

d

i

s

s

u

p

e

r

i

o

r

t

o

o

t

h

e

r

f

o

r

m

s

o

f

t

r

e

a

t

m

e

n

t

f

o

r

t

h

i

s

g

r

o

u

p

.

P

a

r

e

n

t

s

c

a

n

b

e

o

f

f

e

r

e

d

t

h

e

p

a

r

e

n

t

t

r

a

i

n

i

n

g

a

n

d

e

d

u

c

a

t

i

o

n

a

s

a

n

a

d

j

u

n

c

t

.

(

N

I

C

E

g

u

i

d

e

l

i

n

e

s

2

0

0

8

1

.

5

.

3

)

A

n

s

w

e

r

•

Y

o

u

w

i

s

h

t

o

c

o

m

p

l

e

t

e

a

p

r

e

-

d

r

u

g

t

r

e

a

t

m

e

n

t

a

s

s

e

s

s

m

e

n

t

o

n

a

7

y

e

a

r

o

l

d

g

i

r

l

w

i

t

h

d

i

a

g

n

o

s

e

d

s

e

v

e

r

e

A

D

H

D

.

W

h

i

c

h

o

f

t

h

e

f

o

l

l

o

w

i

n

g

i

s

N

O

T

r

o

u

t

i

n

e

l

y

r

e

q

u

i

r

e

d

?

•

a) Record of height and weight plotted on centile chart

•

b) ECG

•

c) Heat rate and blood pressure plotted on a centile chart

•

d)Mental health and social assessment

•

e) Assessment of cardiovascular symptoms

M

C

Q

:

6

•

A

n

s

w

e

r

:

b

:

E

C

G

.

A

n

E

C

G

i

s

n

o

t

p

a

r

t

o

f

t

h

e

r

o

u

t

i

n

e

a

s

s

e

s

s

m

e

n

t

a

n

d

i

s

o

n

l

y

r

e

q

u

i

r

e

d

i

f

t

h

e

r

e

i

s

a

p

a

s

t

m

e

d

i

c

a

l

o

r

f

a

m

i

l

y

h

i

s

t

o

r

y

o

f

s

e

r

i

o

u

s

c

a

r

d

i

a

c

d

i

s

e

a

s

e

,

a

h

i

s

t

o

r

y

o

f

s

u

d

d

e

n

d

e

a

t

h

i

n

y

o

u

n

g

f

a

m

i

l

y

m

e

m

b

e

r

s

o

r

a

b

n

o

r

m

a

l

f

i

n

d

i

n

g

s

o

n

c

a

r

d

i

a

c

e

x

a

m

i

n

a

t

i

o

n

.

(

N

I

C

E

g

u

i

d

l

e

i

n

e

s

2

0

0

8

1

.

5

.

4

.

1

)

A

n

s

w

e

r

•

Y

o

u

h

a

v

e

b

e

e

n

s

e

e

i

n

g

a

1

2

y

e

a

r

o

l

d

b

o

y

w

i

t

h

A

D

H

D

.

P

a

r

e

n

t

t

r

a

i

n

i

n

g

/

e

d

u

c

a

t

i

o

n

s

e

s

s

i

o

n

s

p

r

o

v

e

d

i

n

e

f

f

e

c

t

i

v

e

.

W

i

t

h

t

h

e

p

a

r

e

n

t

s

’

c

o

n

s

e

n

t

y

o

u

c

o

m

m

e

n

c

e

d

t

h

e

p

a

t

i

e

n

t

o

n

l

o

w

d

o

s

e

m

e

t

h

y

l

p

h

e

n

i

d

a

t

e

,

5

m

g

d

a

i

l

y

.

A

t

t

h

e

f

o

l

l

o

w

i

n

g

r

e

v

i

e

w

t

h

e

m

e

t

h

y

l

p

h

e

n

i

d

a

t

e

i

s

n

o

t

w

o

r

k

i

n

g

a

n

d

t

h

e

p

a

t

i

e

n

t

’

s

b

e

h

a

v

i

o

u

r

c

o

n

t

i

n

u

e

s

t

o

b

e

i

m

p

a

i

r

i

n

g

h

i

s

s

o

c

i

a

l

a

n

d

a

c

a

d

e

m

i

c

f

u

n

c

t

i

o

n

i

n

g

.

Y

o

u

a

r

e

h

a

p

p

y

t

h

a

t

y

o

u

r

d

i

a

g

n

o

s

i

s

r

e

m

a

i

n

s

c

o

r

r

e

c

t

.

H

e

d

o

e

s

n

o

t

d

e

s

c

r

i

b

e

a

n

y

s

i

d

e

e

f