Before clinical contact: children and school-age teenagers

Parent- or teacher-completed rating scales can be used to identify individuals for a specialist clinic and to focus questioning at an initial appointment. It is possible to screen using the parent-scored Strengths and Difficulties Questionnaire (SDQ) (Reference GoodmanGoodman 1997). Although a score of 7 from the sum of items 2, 10, 15, 21 and 25 has been used to identify probable cases of ADHD in epidemiological studies, there may be advantages in using a lower score (5 or 6), since a false positive will matter less when selecting individuals for clinical assessment.

Questionnaires specifically focused on ADHD, such as the Conners 3 (Reference ConnersConners 2008) or the CADDRA ADHD Checklist (effectively an extension of the SNAP-IV or ADHD-RS scales with items for oppositional defiant disorder; Canadian ADHD Resource Alliance 2011), are best used in clinic (for pretreatment baseline measures), when wording can be clarified at interview. Rating scale scores alone are insufficient for diagnosis.

A school report or questionnaire collected before a first appointment can save time with primary school children, but with secondary school children it is wise to wait until the child is seen to clarify which teacher is best placed to be approached.

Assessment process at a first appointment

Assessment is a clinical procedure. There is no need for routine investigations such as brain scans, electroencephalograms (EEGs) or electrocardiograms (ECGs). A few centres use computerised tools such as the QbTest (Reference Vogt and WilliamsVogt 2011) or a qualitative EEG, but as things stand these cannot substitute for clinical judgement.

Observation and physical examination of the child

A child with ADHD may be attentive and self-contained during a very brief individual interview. Observing the child during an interview with the parents as well as seeing the child alone provides a total of at least an hour’s worth of sustained observation and much can be learnt from this.

Constructional toys are useful: give an instruction to build something and then look for completion and persistence, as well as coordination. Any clues from the parental account that might indicate dyspraxia should lead to a brief physical examination (Box 2).

BOX 2 Movement coordination screen

• Static tremor (outstretched arms and fingers)

• Static balance (standing on one leg for 20 seconds)

• Normal walking and running

• Heel–toe (tight-rope) walk

• Modified Fog’s test (walking on the medial sides of the feet with knees apart, then on the lateral sides with knees together): check for dystonic wrist and arm movements

• Finger–nose test

• Thumb to each fingertip in rapid sequence

• Rapid alternating rotation at wrists (‘polish a round doorknob’) with outstretched arm

• Joint mobility in fingers, thumbs, elbows and knees, and check for flat feet

• Writing their own name and address

• Drawing a man

Check hearing by speaking a number softly but with just a little resonance at 1 metre distance on each side. Listening to speech and assessing compliance with instructions screens for speech and language problems. A husky voice can indicate vocal abuse from excessive talkativeness.

It is wise to check for weak auditory short-term and working memory, since this is a common associated impairment and may be the only factor in purely inattentive ADHD. This can be done quickly using a digit span test (a random sequence of numbers spoken at a rate of one per second). Norms are given in Table 1.

TABLE 1 Norms for digit span recall

Because stimulants can (rarely) slow growth, it is important to record and chart baseline height and weight. Stimulants, and occasionally atomoxetine, can produce an elevation of blood pressure and tachycardia. It is therefore necessary to carry out a clinical examination of the cardiovascular system.

A detailed neurological examination is not likely to yield much of significance, but it can reassure parents, particularly if they raise the topic of brain damage. Watch the child as he leaves the room, since this is the time when tics are likely to be most evident, having been voluntarily suppressed during the assessment.

Further information

It is crucial to obtain a school report and rating scale to confirm pervasiveness of symptoms. The Conners 3-T (Reference ConnersConners 2008) offers broad scope for an initial assessment and includes the 10-item Conners ADHD Index (Conners 3AI), which is convenient for follow-up by teachers or parents. Some clinicians like to use the SKAMP (items 81– 90 of the 90-item SNAP-IV-C; Reference SwansonSwanson 2007) for teacher follow-up because of its face validity. Some estimation of academic achievement is needed to evaluate impairment, detect possible comorbid dyslexia, and provide a baseline for assessing treatment impact.

Simple misbehaviour

Marked, but age- (or mental age-) appropriate boisterousness, disobedience or cheekiness is the most common differential. The central issue is whether this is excessive for the child’s age or developmental level. Teachers are in an excellent position to make this comparison through daily experience of observing the child in a group of children his own age. Explosive temper or excitability are often referred to by parents or peers as ‘being a bit hyper’. Rating scales will help clarification.

Disruptive behaviour disorders

Oppositional-defiant disorder and conduct disorder may be differential diagnoses as well as comorbid conditions, since restlessness and inattention are common among disruptive children generally. The similarity and common coexistence of these disorders has led to a view in the general population of ADHD as essentially an antisocial, angry condition. The diagnosis of conduct disorder requires repetitive, persistent and serious antisocial, aggressive or defiant behaviour. In practice, the distinction between ADHD and disruptive behaviour disorders can be difficult to make because of comorbidity.

Disinhibited attachment disorder

Disinhibited attachment disorder can develop in children who have not had the opportunity to form selected secure emotional attachments because of the lack of sensitive or consistent parental care. Such children may present as distractible or restless, with attentional problems and social disinhibition. In some clinics, heated discussions arise as to whether inattentive restlessness is fundamentally ADHD or represents an attachment disorder. This is usually futile, as the National Institute for Health and Care Excellence (NICE) recommends treating ADHD symptoms when these are present, irrespective of putative aetiology (NICE 2008), and in any case both conditions may well be comorbid.

Generalised anxiety disorder

Generalised anxiety disorder can yield inattentiveness and restlessness, but social disinhibition and impulsiveness are less likely to be present.

Autism spectrum conditions

Mild autism spectrum conditions can present with inattentiveness and it can be difficult to separate inattention arising from a lack of interest in complying with another person’s instructions from inattention as a component of ADHD.

Bipolar disorder

Juvenile bipolar disorder has historically been invoked as a differential diagnosis, but there should be no confusion if the requirement for a sustained period of elevated mood with associated grandiosity in bipolar disorder is maintained.

Psychoeducation

It is apparent from the VOICES study (Reference Singh, Baker and ThomasSingh 2012) that many children with diagnosed ADHD do not understand what it is. It also seems likely that parents, some teachers and some primary healthcare professionals are less well informed than would be desirable. Newspaper journalism and the internet are not always helpful. Discussion with both parents and child, and letters to or discussions with schools and primary healthcare, can make the following points.

• ADHD is at the extreme end of a spectrum of difficulties with attention, activity and impulse control in the general population.

• ADHD rarely exists on its own. Most children with ADHD will have other problems, such as difficulties with anger, socialisation, physical coordination, short-term memory or learning. What is seen as ADHD is often actually an associated oppositional-defiant or conduct disorder.

• ADHD is based on known neurological dysfunction that can be demonstrated in research even if this is not yet defined sufficiently to be useful in clinical practice. Pictures from fMRI studies are helpful in making this point.

• The brains of children with ADHD show about 2 years’ delay in growth and development of the frontoparietal cortex.

• Research shows that a child with ADHD has particular problems with motivation (‘allocating mental effort’) and learning from experience.

• Medication can partially compensate for these shortcomings in brain development and motivational learning.

• It is helpful to see the ADHD as something that gets in the way of success (‘His ADHD stops you being the sort of parent you want to be’, ‘The ADHD gets in the way of learning at school and he can’t just turn it off’).

Parental handling

Clinics may simply refer parents to parenting classes. This is broadly in line with NICE recommendations (NICE 2008) but needs some thought. Parents who have brought up their child’s older siblings successfully may feel (and be) patronised. It may be better to discuss two simple points with parents:

• a child with ADHD requires more than standard parenting if he is to learn and prosper

• it is particularly hard to be an effective parent of a child with ADHD, as the ADHD works against the child’s ability to learn and the parent’s sense of competence.

And recommend that they:

• set a small number of household rules, couched in language that is specific and understandable by all (‘Schoolbag always packed before going to bed’)

• get beyond simply trying to control disobedience, overexcitement or hyperactivity and set out to have opportunities for a good time with their child, showing him love and appreciation

• keep verbal instructions short and clear

• include positive comments, praise and encouragement, linked with a points incentive system where appropriate

• consider deals (‘Get your homework done and OK’d by me, then you can go out’), but ensure that the child’s action precedes the reward or the parent’s half of the deal

• use a simple disciplinary system such as ‘1-2-3 Magic’ (www.123magic.com)

• avoid harsh punishment, harsh judgements and condemnations

• keep the child’s social life alive, but arrange brief play dates with structured activities to avoid overexcited mayhem or fights

• keep as calm as possible

• plan ahead to avoid trouble.

Families containing a child with ADHD need support from a local network if available or from the National Attention Deficit Disorder Information and Support Service (ADDISS). The strain on families is extensive, with parental depression, strained marital relationships and family break-up all common. Bear in mind that a child with ADHD is likely to have siblings and one or both parents who also have ADHD.

Medication

Stimulants (methylphenidate or dexamfetamine) are the mainstay of medication in ADHD, particularly following the initial findings of the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study (MTA Cooperative Group, 1999). They are highly effective (effect size 0.8–1.2) against all three symptom areas of ADHD, long-established (>50 years) and relatively safe. Methylphenidate is recommended by NICE as an initial agent (NICE 2008), although some individuals will respond better to dexamfetamine. Both competitively block the dopamine transporter which provides presynaptic reuptake of dopamine from the synapse.

A physical examination must be carried out before prescribing. Potential adverse effects on cardiovascular functioning (very mildly raised blood pressure and pulse rate) mean it is also necessary to check that there are no significant cardiac symptoms and no family history of sudden cardiac death in early adulthood.

Two single-dose trials of 5 and 10 mg of standard (immediate release) methylphenidate on separate days, each given 1 hour before an assigned task that involves simulated or actual schoolwork, with the effect observed by a parent, form a powerful and sensitive predictor of likely effect. Such trials can also identify the few children who become excited or irritable after taking the drug. The trial approach can subsequently be extended to school days, comparing morning and afternoon effects following a morning dose. The clinical duration of a single dose of methylphenidate is 3–4 hours.

There is no standard dose of methylphenidate or dexamfetamine, so it is necessary to titrate dose against effect. Simply obtaining a positive result is not good enough; one aims for an optimal result in terms of either general symptom relief or achievement against a specific goal.

An excessive dose produces a vacant expression and diminished social responsiveness. To avoid this it is important to obtain reports from school, since blood levels will be maximal there and have declined by return home.

Most children will move from immediate-release methylphenidate to extended-release preparations such as Equasym XL^®, Medikinet XL^® or Concerta XL^®. These each have differing pharmacokinetic properties with differing release patterns across the day. It is important to track symptoms or deficits across the school day and choose the appropriate preparation accordingly.

Although it has been conventional for drug marketing authorisations (‘licences’) to cite a 60 mg maximum daily dose of methylphenidate, this has no scientific backing and in practice it is often necessary to exceed this. NICE makes the same point (NICE 2008).

Dexamfetamine can be tried in a similar fashion, using doses approximately half those required for methylphenidate. There are no extended-release preparations of dexamfetamine available in the UK, but the prodrug lisdexamfetamine provides extended effect for 12–13 hours following a single dose. It is inert when taken, but is converted into dexamfetamine by red blood cells.

Stimulant medication commonly suppresses appetite during the day. This is occasionally associated with slowing of weight growth and, less commonly, with slowing of height growth. Existing follow-up studies are weak, but do not show an effect on ultimate adult height. Nevertheless, height and weight should be monitored 6 monthly and the dose adjusted accordingly.

If stimulants are given too late in the day, there is the risk that sleep onset will be delayed. This can be dealt with by simple sleep hygiene advice or, if necessary, melatonin. Other side-effects include abdominal pain, headache and very rarely a skin rash or Raynaud’s phenomenon. Some children feel socially constrained or suffer lowering of mood and, occasionally, irritability. Auditory hallucinations are rare and alarming but they do not endure once the medication is discontinued.

Children for whom school behaviour and achievement are the key problems do not necessarily need medication at weekends or holidays. In similar vein, the optimal dose regimen may differ from day to day. One treats for the day in question. There is no need to offer a ‘course’ of treatment or allow for accumulation, since stimulants are eliminated or metabolised on the day of administration. Occasionally it is necessary to increase the dose after a few months in order to maintain the effect, probably because of reactive upgrading of the dopamine transporter.

Stimulants are controlled drugs and not all general practitioners will prescribe them, in spite of NICE recommendations for shared care protocols between specialist clinics and primary care (NICE 2008). The introduction of specialist ADHD nurses, especially those who can prescribe, has been a major service development.

Children who are anxious, have tics or preexisting sleep problems, or who need treatment that covers early mornings and evenings will probably need atomoxetine. This is a noradrenaline reuptake inhibitor with similar effects to stimulants, but it does not affect sleep onset, so can be given at night or twice daily. Its side-effect profile includes occasional nausea, irritability and low mood that reverse promptly on discontinuation. Side-effects can be minimised by gradually increasing the dose (starting with 10 mg daily for 7 days and increasing the daily dose according to capsule size (18 mg, 25 mg, 40 mg, 60 mg, 80 mg, …) each week when initiating. Dose is conventionally 1.2–1.8 mg/kg/day. Atomoxetine is not a controlled drug.

Treatment of hyperactive, disorganised or aggressive behaviour in the early morning or evening is hard to achieve with stimulants alone, and either a switch to atomoxetine or supplementation with clonidine or guanfacine should be considered if behavioural management techniques fail.