ADHD in Children & Adolescents – A Good Practice Guidance

This guideline has been developed on behalf of the Executive Committee of the George Still Forum, the National Paediatric ADHD Network Group in the UK. It can be used by paediatricians, child & adolescent psychiatrists,clinical psychologists, nurses and other healthcare professionals working in the field of ADHD in the UK.

Issue Date: 5 April 2011

Review Date: 4 April 2013

Contents

  1. Introduction3
  1. Objectives of GSF3
  1. Incidence4
  1. Symptoms4
  1. Assessment and monitoring4
  1. Management6
  1. Other management options12
  1. Adolescents 12
  1. Comorbidities13
  1. Cardiac risks of ADHD medications 15
  1. Interventions16
  1. Treatment options 16
  1. Management of some common problems17
  1. References20
  1. Appendix 1 Side effect questionnaire22
  1. Appendix 2 Care pathway23
  1. Appendix 3 Shared Care24
  1. GSF Executive Committee26
  1. INTRODUCTION

George Still Forum is an apex organisation of the paediatricians, involved in assessment and monitoring of ADHD in children and adolescents. The group is recognised by the Royal College of Paediatrics and Child Health as a special interest group. The aims of the forum are to exchange ideas, to increase professional awareness, to liaise with other professional groups, to influence public policy decisions where appropriate, to share information in relation to current issues in providing services to individuals and their families and to improve care for children and adolescents with ADHD.

There is an increase in number of ADHD patients countrywide, highlighting the shortfall in resources and extended waiting times for the new assessments. This situation is posing an extra burden and is a threat to burn out amongst ADHD clinicians. George Still Forum aims to bring these issues to the notice of the commissioners in the National Health Service.

  1. OBJECTIVES OF THE GSF
  • To take a leadership role in managing ADHD in children and adolescents.
  • To develop the ADHD guidelines for the Paediatricians in the UK.
  • To facilitate development of training standards.
  • To share information with the stakeholders.
  • To advocate to NHS commissioners about ADHD.

3. INCIDENCE
Estimates of the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) indicate that around 3 to 9% of school-aged children and adolescents would meet the Diagnostic and Statistical Manuel-IV (DSM-IV) of American Psychiatric Association’s diagnostic criteria for ADHD1.Follow-up studies of childrenwith ADHD find that 15% still have the full diagnosis at 25years, and a further 50% are in partial remission, with somesymptoms associated with clinical and psychosocial impairmentspersisting2.

  1. SYMPTOMS
    The three core symptom domains of ADHD are inattention, hyperactivity and impulsivity. Subtypes of ADHD are diagnosed based on meeting the symptom thresholds according to the Diagnostic and Statistical Manual of American Psychiatric Association3. The International Classification of Diseases of World Health Organization described this condition as hyperkinetic disorder4. The symptoms and subtypes of ADHD and associated comorbid disorders change throughout the lifecycle. Hyperactivity and impulsivity may decrease as patients get older but the demands on their attention may increase. The Predominantly Inattentive Subtype may be more obvious by adulthood.
  1. ASSESSMENT AND MONITORING

ADHD is a chronic medical condition and needs a long term management plan5.ADHD patients deserve every opportunity to attain their full potential by having timely assessments to identify their impairments and to access the best management. Like other medical conditions in Child Psychiatry, ADHD is a clinical diagnosis for which there are no specific signs. It is diagnosed when parents/carers and school report overactivity, impulsivity and/or short attention span. It is therefore important to gather the information from parents/carers and school before arriving at the diagnosis. The observation of the child in a clinic setting is unlikely to rule out the diagnosis. ADHD can be provisionally diagnosed in preschool children but it should be confirmed after the child has started school.The initial assessment for ADHD should include:

5.1Presenting Complaint

  1. Review with the parents oftheir concerns, the reason for referral, and the parents’ expectations from the assessment. Most often, a parent will come to discuss about hyperactivity, impulse control, inattentiveness or educational concerns. Parents should be asked about the pervasiveness of the symptoms.
  2. Review with the child/adolescent and parents/carers the completed rating scales.
  3. Interview with the child and parents/carers.
  4. Medical history and physical examination to ensure that there are no other medical causes for the symptoms of ADHD and to ensure that there are no medical contraindications to the possible use of medications.

5.2Medical Assessment

Medical assessment should include a perinatal anddevelopmental history and a physical examinationincluding neurological examination and for any contraindications for medication use, such as some cardiac dysrhythmias. Any abnormalities that arefound in the physical examination should be followed by more detailed and specific tests. A history of sleep pattern as well as any preference to a fixed routine in daily life should be obtained. Vital signs of height, weight, blood pressure, and pulse rate should be documented and plotted on centile charts as baseline and during each follow-up visits if medication is prescribed.The following points should be included in the history during the initial assessment:

5.2.1 Antenatal History:

  • Antenatal infections (e.g., TORCH).
  • Smoking cigarettes, cannabis etc (how many a day, How often and how long?)
  • Exposure to drugs
  • Exposure to alcohol
  • High-risk pregnancy (e. g. premature delivery, LBW).
  • History of birth asphyxia.

5.2.2 Behavioural / Developmental History:

  • Early developmental milestones.
  • High activity level and difficulty engaging in quiet play.
  • Problems with obeying commands and oppositional behaviour.

5.2.3 Family History:

  • Parent or sibling with school failure.
  • Parent and/or sibling history of ADHD.
  • Drug or alcohol abuse.
  • Psychiatric illnesses.
  • Problems with the law.
  • Cardiac arrhythmias or sudden death especially in 35 years or younger age.

5.2.4 Home Environment:

  • Key caregivers.
  • Frequent moves?
  • Frequent changes in school?
  • Chaotic home environment?
  • Poor or crowded housing?
  • Excess (>2 hours/day) TV, computer, video games?

5.2.5 Peer Relationships:

  • Plays alone as has no friends.
  • Problems in maintaining friendships.

5.2.6 School History:

  • Academic under-achievement.
  • Truancy.
  • Does the child enjoy school?
  • Ask the school age child if he/she thinks he/she has trouble concentrating.
  • Review current school report as well as those from earlier years.
  • Specific Learning Difficulty (SLD; Dyslexia) is part of the differential and/or is comorbid with ADHD. Educational evaluation contributes to identification of SLD, learning strengths, under achievement relative to potential, impact of ADHD on learning and identification of processing speed, working memory and peer relationship skills.

5.2.7 Eating History:

  • Appetite.
  • Any dietary restrictions.
  • Skipping meals regularly.
  • Joins family members for dinner?

5.2.8 Physical examination

It is important to document a baseline physical examination. Special attention should be paid to the following elements of the exam:

  • Growth parameters. Height and weight will need to be plotted on a centile chartas baseline and at each follow-up visit if the child is prescribed medication.
  • Blood pressure and pulserate are recorded and plotted on the centile chart.
  • Cardiac examination including auscultation for murmurs and femoral pulses.
  • Dysmorphic features suggestive of Fetal Alcohol Syndrome (FAS) or other genetic conditions.
  • Thyroid enlargement.
  • Cutaneous stigmata, such as café au lait spots.
  • Bruising or other evidence of injury (accidental or intentional).
  • Tonsillar hypertrophy, mouth breathing etc which may contribute to sleep apnea.
  • Neurologic exam and age-appropriate mental status exam.
  • Tics, either motor or vocal or both.
  • General behaviour: overall activity level, restlessness.
  • Observe the child/parent interaction.
  • Vision & Hearing screen (if indicated).

5.3Cognitive Assessment

The child should have a cognitive assessment in school preferably by an Education Psychologist for possibility of associated SLD. Academic achievements in key subjects are important as they may suggest the need for additional educational needs.

5.4Emotional/Behavioural Assessment

Assessment for any possible comorbid condition in the childis important. Input from the child’s teachers regarding his/her social, academic and emotional functioning is valuable as teacher/s can compare the child in the classroom setting compared to other pupils of same age range.

5.5Feedback and Expectations

Ensure that the patient and family have had an adequate opportunity to know about ADHD and various treatment options. Theyshould be provided written information about ADHD and available option of various management strategies, website addresses, and contact details of the local support groups. Do ask the family to find out more about ADHD. Instruct the family to do some research on ADHD. Only proceed to feedback and treatment if the child has well documented evidence of impairment and meets the thresholds for ADHD, shows no other medical problems that would contraindicate further treatment and has parent(s)/carer(s) who are motivated. They need to know the symptoms that are being treated (no medication effectively eliminates all the symptoms of ADHD). There must be a discussion of the risks and benefits of the prescribed treatment and the alternatives. There needs to be discussion regarding potential risks of no treatment.Describe the key findings obtained from the assessment. Include a clear statement about the diagnosis and the basis on which the diagnosis is made. Explain to the family that you will be sending them a report and a copy made for the school, GP and other relevant agencies involved.

  1. MANAGEMENT

ADHD is a clinical diagnosis based on a combination of a reliable history, reports from home and school and a physical examination to rule out any other underlying medical conditions. Therefore it is important that symptoms be recorded using valid, reliable and sensitive rating scales to evaluate symptom frequency and severity. Rating scales are not diagnostic; they give information about a child’s current functioning and difficulties. Rating scales can also be used to monitor treatment efficacy and side effects.

6.1Drugs

Medications are to facilitate a holistic approach and are not a stand alone intervention. Discuss the drug treatment options. There is no one drug that is suitable for everypatient.The guiding principle of drug intervention is to start in a low dosage and gradually increase it, though weight-based dosage may be used as a way of gauging adequate dosing. Parents should be informed that well controlled studies have shown medication to be safe and very effective in treating the symptoms of ADHD. In ADHD with comorbidity, multiple medications may be used. Start medication in low dosage and go slow but continue increasing the dose until maximum recommended dose level is reached or to where the target symptoms show improvement or the side effects appear. At the end of the visit, give the parent(s)/carer(s) the rating scale to be completed by parent(s)/carer(s), the rating scale to be completed by the class teacher and the side effect form that should be filled out by the parent(s)/carer(s) before medication is started and then every week.

After establishing the diagnosis of ADHD with comorbidities if medication is considered then try stimulant if immediate response needed. If there is evidence of tics then non-stimulant is recommended. Similarly if there is need for late evening and early morning cover then non-stimulant medication may be tried.

6.3Choice of medication

The choice of medication will depend on the following factors:

  1. Age
  2. Duration of effect
  3. The onset of action of the medication
  4. Comorbid disorders
  5. History of earlier medication use
  6. Attitudes towards medication use
  7. Presence of comorbid tics, anxiety
  8. Other associated medical problems
  9. Associated features similar to medication side effects
  10. Combining stimulants with other medications
  11. Drug diversion
  12. Clinicians’ attitude towards ADHD medications
  1. Agedexamfetamine (DEX) is licensed from 3 years of age and methylphenidate (MPH) and atomoxetine (Strattera) from 6 years of age. There is no maximum age to treat ADHD. A caution is needed to use drugs in women of childbearing age as effects of ADHD medications on the foetus and on breast-feeding are unknown.
  1. Duration of effect Tasks that require mental effort change over the years. In childhood there may only be a need to treat during daytime while in adolescents, the need to cover the evenings may be necessary. This may be critical for tasks such as driving.
  1. The onset of action of the medication When patients require rapid response,stimulants are the treatments of choice. Non stimulant may require two to six weeks to show a treatment response.
  1. Comorbid disorders When there is a comorbid disorder along with ADHD, it is generally advised that the ADHD should be treated first. However, major mood disorders like Depression, Bipolar Disorder, and Substance Abuse Disorder should be identified and treated prior to ADHD.If the relevant comorbidity puts the patient at risk for harm to others or to himself/herself, then this comorbidity takes precedence for treatment. It is important to review drug to drug interactions to ensure that there is no risk to the patient.
  1. History of earlier medication use If there is a lack of improvement or substantial side effects, another ADHD drug may be considered. If a patient is responding well to one medication, it is advised that another medication should not be tried to see if there is a better response. Patients who do not respond to one stimulant may very well respond to another (e.g., MPH vs. DEX). The same seems to be true for side effects; one may be better tolerated than the other.
  1. Attitudes towards medication use Patients and their families/carers need to be educated about ADHD and current management. The choice of medication should follow the informed consent. Biases against the use of ADHD medications are often due to misinformation regarding side effects and guilt about having caused the problem due to bad parenting. Alternatively, parents/carers may have excessive expectation from drug therapy and may lead to disappointment. Drugs are part of the holistic approach.
  1. Presence of comorbid tics, anxietyStimulants and non-stimulant may be used in presence of comorbid tics or anxiety.
  1. Other associated medical problemsIt is important for the clinician to do a thorough medical assessment including physical examination before prescribing medications. Many conditions look like ADHD (e.g., hyperthyroidism, hearing deficits, Autism Spectrum Disorder, Learning disability or Specific Learning Difficulty etc). It is important for clinicians to be aware of any other medical condition the patient may have that affects suitability for a medication.
  1. Side effects All drugs have side effects. Most side effects usually improve over one to two weeks of continuous use. One of the most common reasons for non-compliance is related to a lack of awareness or understanding of the side effects. Patients’ understanding of the side effect profile of each medication may afford a better compliance.
  1. Polypharmacy When a clinician feels that a second medication is needed, it is advised to begin with an ADHD medication that is known to combine safely with the second medication. For example, in the selection of an ADHD medication for a patient with severe conduct disorder and aggressive behaviour, a psychostimulant could be combined with an atypical antipsychotic6. Some of the side effects related to drug interaction occur because of competition for liver enzymes that metabolise the drug.
  1. Drug diversionPatients or parents/carers, who are at risk for substance abuse/drug-diversion should not be prescribed short-acting stimulants.
  1. Clinicians’ attitude towards ADHD medications Information on ADHD is rapidly evolving (i.e., understanding of comorbidity, adult ADHD, drugs, etc). It is imperative that clinicians have updated information to practice evidence based medicine.

6.4Follow-up visits

  • Monitor response by using rating scales.
  • Monitor side-effects.
  • Monitor the medication dosage.
  • Parent and teacher rating scales should be obtained for each follow up visit.
  • A telephone call may be beneficial to follow up the prescribed ADHD medication till the dose is optimised.
  • Once a stable optimal dose has been determined, the ideal medication follow-up is 6 months. Non-compliance to treatment may be related to lack of frequency of follow-up.

6.5Monitoring

  • A baseline rating of clinical symptoms is needed before considering medical treatment.
  • The patient may not be the best informant regarding efficacy as they often have poor self-awareness. Helping the adolescent to understand this is a key point in psychoeducation.
  • School performance is a useful indicator of treatment effect.
  • Get information from one teacher the adolescent likes and one they dislike so as to get the best range of teacher observation.
  • Side-effects may be assessed by the parent/carer through the use of a structured questionnaire (appendix I).

6.6Side-effects

If a change of medication is thought necessary because of side-effects, switch medication during school holidays to avoid possible side effects that may impair school performance. If a ‘trial off’ medication is required, it should preferably be done during school holidays to minimize impact on school performance.

6.7Available drugs in UK

ADHD drugs are indicated as part of a comprehensive treatment programme for ADHD. Treatment must be initiated by child and adolescent psychiatrists, paediatricians with expertise in ADHD, ADHD Specialist Nurse Prescribers or GPs with a special interest (GPSi) in ADHD.

Methylphenidate and Atomoxetine are not licensed for use in children less than six years of age or in adults. Dexamfetamine may be prescribed after 3 years of age. Stimulants are not licensed for children with marked anxiety, agitation or tension, symptoms or family history of tics or Tourette’s syndrome, hyperthyroidism, angina or cardiac arrhythmia, glaucoma or thyrotoxicosis. Stimulants are controlled by the Misuse of Drugs Act 1971 (Schedule 2 drug) and are subject to the regulations for Controlled Drugs. For details the practitioners are advised to consult the European treatment guideline12, 15.

6.7.1Presentations:

Methylphenidate immediate release (IR) is available as 5, 10 and 20mg tablets (5 and 20mg only available as Medikinet and methylphenidate tablets).

Medikinet® XL (methylphenidate) is available as 10, 20, 30, and 40mg sustained release capsules.