Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas 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%)

Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas Hospital, Portrane

Conduct disorder and oppositional defiant disorder (40%)

Substance misuse
Depression
Anxiety disorder
PTSD
OCD
Bipolar disorder
Tics
Tourettes 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, child & school)
Interview with parents: full developmental history, 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. A school visit to observe behaviour in the classroom
may be useful
Connors Assessment Scale given to parents & teacher (= rating scale for ADHD)
Treatment
Biological
o CNS stimulants i.e. Methylphenidate (Ritalin) and Dextroamphetamine
Short, intermediate and long-acting stimulants exist
Side effects of Methylphenidate
Growth retardation
appetite & weight
sleep
BP & pulse changes (both or ), angina, cardiac arrhythmias
Chest pain
Confusion
Headaches
Hypersensitivity (rash, fever, arthralgia)
Rebound behaviour (when the effects of the medication begin to )
Tics / Tourettes syndrome
Depression
Irritability
Psychosis
Monitor for side effects of stimulants at each review, i.e. pulse, BP, weight,
height
The use of Drug Holidays is recommended i.e. withholding the drug on
weekends and during school holidays
o Atomoxetine (norepinephrine receptor inhibitor)

Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas Hospital, Portrane

Second line agents: antidepressants (i.e. bupropion and venlafaxine) and -adrenergic
receptor agnosist (i.e. clonidine)
Psychotherapy
o Social skills training, behavioural intervention, individual psychotherapy, family
therapy and special education when indicated
o