Evidence-Based Recommendations for Evaluation, Diagnosis, and Treatment Ofattention Deficit

Evidence-Based Recommendations for Evaluation, Diagnosis, and Treatment ofattention deficit hyperactivity disorder (ADHD) in children and young people

Objectives:

• To provide an information summary on the clinical characteristics, diagnosis criteria and comorbidities in attention deficit hyperactivity disorder in children and adolescents.
• Increased understanding of the treatment options and to provide guidelines on prescribing and monitoring of stimulant and non-stimulant medications.

1. Background

The syndrome of restless, inattentive, and impulsive child behaviour known as Attention Deficit Hyperactivity Disorder (ADHD) in North America and Hyperkinetic Disorder (HKD) in Europe is a common neurodevelopmental problem. Persons affected by this disorder in childhood are at risk for learning, behavioural, and social problems and also for the development of serious impairments such as academic failure, substance abuse, and criminality in adolescence and adulthood. Consequently, the disorder places a substantial demand on mental health, educational, and judicial services.

2. Perspectives

Knowledge and views about ADHD may vary between professionals. In order for different disciplines to work effectively together, it is important to be aware of the issues raised by a diagnosis of ADHD. There is no one right way of thinking and a willingness to understand and accommodate different perspectives is essential to collaborative working.

2.1 Medical Perspective

Paediatricians in the UK are increasingly being asked to assess children in mainstream school who are not performing as well as their peers.1 Differential diagnoses in these children include developmental coordination disorder, general or specific learning disability, and behaviour problems such as ADHD. ADHD is a reflection of an underlying deficit that may have several ultimate causes such as genetic predisposition, psycho-physiological factors and psychological dysfunction, but a common pathway at the behavioural level.2 The problem with the ADHD label is that difficult decisions about individual children can be oversimplified as they come to be seen as a group requiring treatment. By labelling children with difficult behaviour as suffering from a disorder, we make it easier to treat the child and this carries with it the danger of over-diagnosis 3and over-prescription as an expedient way of dealing with complex problems. An over stretched National Health Service is particularly at risk of seeking quick and easy solutions, which may be compounded by poor monitoring. On the other hand, under-diagnosis and sub-optimal treatment of children with ADHD is also a well-documented public health issue.4

In many cases careful management of behaviour and advice to parents and teachers working with the child to control impulsiveness and maintain concentration may be sufficient to manage the problems.5 Where these are not deemed to be sufficient, however, medication may be required to assist the process. This is a matter to be decided by the clinical judgement of the professional, responsible for managing ADHD in consultation with those who have day to day care of the child.

2.2 Educational Perspective

Although the preschool years of a child with ADHD are stressful for the parents, the problem become salient when the children enter school and are suddenly expected to sit in their seats for longer periods of time, concentrate on lessons and interact with peers in play ground. Many ADHD children need additional help in school to obtain their full educational potential. Schools follow their procedures for the assessment and identification of Special Educational Needs with their SEN policy. After consulting parents they may propose the involvement of other services such as the Educational Psychology or Behavioural Support Services. Children develop at different rates and in different ways because of the complex interplay of biology and environment. Therefore it is important to adopt different teaching approaches to meet individual needs.

2.3 Parents’ Perspective

All parents worry about their children’s future. Concern about the future quality of life is heightened when parents observe their children struggling behaviourally at home, academically in school and socially on the playground. When told that a child has ADHD, parents may experience a period of grieving. Relief at finding a reason for their child’s difficulties over the years is superseded by feelings of guilt for the negative way they have been feeling towards the child’s behaviour and a sense of failure as a parent. Parents may be blamed for their child’s behaviour and the ADHD diagnosis confirms that it is not simply their fault. Parents are frequently being called into the school because of problems there and yet it is hard enough for them to deal with things at home. Home life is often stressful, with strained marriages, breakdown of family relationship and conflict with siblings. After diagnosis parents often feel ‘out on a limb’ and efforts to liaise with a range of professionals are often left to parents. Already demoralised and feeling overwhelmed by issues such as medication especially at lunch time in school and the need to obtain special educational support, parents can be left with a sense of being faced by layers of bureaucracy which seems insurmountable. This view reinforces the necessity for a co-ordinated approach between agencies.

2.4 Cultural Perspective

Some people argue that problems with inattention, hyperactivity and impulsivity are the results of cultural phenomena.6Yet this point of view appears to be changing with the acceptance of ADHD as a cross-cultural disorder.7 Some children are inherently more inclined to be inattentive, impulsive and hyperactive than others. Such traits may run in families and there seems to be a genetic predisposition to them. Mental traits can be inherited just as height and weight. What we are dealing with are normal human variations that are only understood as being disorders when they are in conflict with cultural expectations and norms.

2.5. Social Services’ Perspective

There is a variation of views and acceptance of a formal diagnosis of ADHD as a disability across the nation. However, in most places ADHD is considered in terms of criteria governing “children in need”, thus enabling those with the diagnosis, to access services, according to assessed needs. Framework for the Assessment of Children in Need and their Families, 8 issued jointly by the Department of Health, Department of Education and Employment and Home Office provides a valuable foundation for policy and practice for all those who manage and provide services to children in need and their families.

3.Epidemiology:

The National Institute for Health and Clinical Excellence (NICE) estimates the prevalence of ADHD to be about 3 to 9% for school age children and young people, using the DSM-IV criteria and 1 to 2% in the same age group using the ICD-10 criteria.9

The ratio of boys to girls with ADHD/HKD is between 3:1 and 9:1 but this may decrease with age.10, 11 Part of the difference between sexes may be referral bias12 as boys are more hyperactive / impulsive and have more oppositional and conduct symptoms.

4. Aetiology:

No genetic marker has been consistently identified. In children with ADHD, neuroimaging studies confirm abnormalities in those regions of the brain that are implicated in executive function. These studies report significantly smaller asymmetrical prefrontal and basal ganglia structures, particularly on the right side, in children with ADHD.Correlations of magnetic resonance imaging-based anatomical measures and specific-task performance in children with a diagnosis of ADHD suggest that the right prefrontal cortex is involved in inhibiting attentional and behavioural responses, whereas the basal ganglia seem to be involved in the execution of these responses. Executive functioning broadly includes the ability to self-monitor, stay focused in the face of interference, think flexibly, and organize oneself.

One third of affected individuals have at least one parent who suffers from similar symptoms. ADHD is associated with: low birth weight (<1500g); environmental toxins; tobacco, alcohol and cocaine abuse during pregnancy.13

5. Symptoms:

The cardinal features of ADHD are excessive and impairing levels of activity, inattention, and impulsiveness. Children have great difficulty remaining seated when required in structured situations such as in the classroom or at the dinner table. They are more active than their peers in unstructured situations such as in the playground. They fail to pay attention to instructions in academic and social situations. They have serious difficulty withholding a response of any kind, interrupting an inappropriate course of action once initiated, and adjusting incorrect or maladaptive responses.

The difference between ADHD and normal behaviour is the degree of impairment, and mainly how it affects the child at home, school and socially. The alarming signals may be a child who is academically under-achieving because of his behaviour, despite having a normal intellect with no specific learning difficulties or a child exhibiting behaviour problems both at home and in school, which are considerably worse than would be expected for the standard of parenting and home environment.

6. Assessment and diagnosis

6. 1. Assessment

In the absence of an identified underlying biologic mechanism or aetiology for ADHD that would support a diagnostic test, clinicians are asked to use criteria and rating scales. It is also recommended that the child should have a physical examination. The assessment process often involves a multidisciplinary team approach.

The sources of information are typically parents and teachers, who provide information about the child’s functioning at home and in school. The behaviour checklist or rating scales are an essential tool to obtain such information. These tools are an aid to the assessment of a child with behavioural difficulty and not a substitute for diagnosis of ADHD.Diagnosis should never be based on a rating scale alone but should utilize data from rating scales to complement other information.There are many behaviour checklists available, many of which have been developed in the USA.

The usual psychological profile of children with ADHD is that their verbal skills are better than their nonverbal skills.

A multidisciplinary approachis essential to any model of good practice. Whilst acknowledging the differing perspective presented above, there are clear areas of agreement, which should enable the various disciplines, involved to develop ways of working together in the interests of the children and their families. There are national and European guidelines addressing waysto develop joint working arrangements between the various professional groups working with children who present the problems associated with ADHD. There are some organisational differences covering different parts of UK, which necessitate some variation in the procedures.

6.1.1 Identification

Children presenting with indications of ADHD may be identified in a range of settings and by various carers and professionals:

• Parents / Carers
• General Practitioners (GPs)
• School nurses
• School and Educational Professionals
• Social Workers

Not all children and young people presenting with difficult behaviour will warrant a specialist referral. This depends on the severity of child’s difficulties and their responses to initial interventions. Given the range of situations in which ADHD may be presented, professionals at all tiers should have access to common understandings of what does and what does not constitute a potential ADHD presentation.

6.1.2 Referral

The ideal central screening point should consist of multi-discipline professionals, who will screen referrals for behaviour-based difficulties and collects information from relevant agencies. The group then will consider one of the following three options:-

• Child and Adolescent Mental Health Service – if there is no indication of developmental delay.
• Community Paediatric Service – if there is indication of developmental delay.
• Divert the referral to another service considered to be more appropriate.

The screening group will inform the referring professional, indicating the outcome.

6.1.3 Assessment and diagnosis

A medical practitioner, either a child psychiatrist or a paediatrician with expertise in ADHD should make the formal diagnosis. The assessment process should involve a multi-disciplinary approach and an appropriately trained mental health worker may undertake the initial assessment. The professional concerned would normally seek parental permission to request and obtain relevant information.The assessment should have five principle components:

A.Interview with the child and the parents or carers to gather information about:

• Presenting difficulties;

• Family and social history;
• Child’s developmental history;
• Child’s medical history;
• Anxiety levels and self-esteem of the child;
• The wider systems such as educational progress and social services involvement.

B. Information gathering

Parents and teachers should be asked to complete a rating scale. Information should be obtained from school’s SENCO about peer relationship and the child’s academic progress.

C.Observation

Observation of the child in the clinic should take account of

• General level of activity and talkativeness;
• Distractibility;
• Interruptions;
• Attention span;
• Play skills – particularly problem solving and constructional toys.

D. Physical examination

A detail physical examination and developmental assessment including:

• Neurological examination;

• Tests for vision and hearing;
• Co-ordination tasks and handwriting;
• Fine and gross motor skills;
• Speech and language;
• Height, weight, and blood pressure;
• Information about child’s appetite and sleep;
• If deemed necessary, psychological assessment.

E.Differential diagnosis and other existing conditions

The assessment process should take account of the other conditions, which may better account for the behaviour causing concern. These might include:

Medical disorders-

Sleep apnoea
Seizure disorders
Developmental disorders (eg, learning disabilities and specific learning difficulties)
Brain injury

Use of other medications (e. g. phenobarbital)
Sensory impairments

Mental disorders-

Oppositional Defiant Disorder / Conduct disorder;

Anxiety / Depression

Adjustment disorder

Attachment disorder
Substance abuse
Others-

• Autism Spectrum Disorder
• The normal active preschool child
• Family dysfunction

One or more condition may exist along with ADHD. On completion of the assessment

clinician will then make the diagnosis using the ICD-1014 or DSM-IV15 diagnosis criteria. Following diagnosis, full reports should be provided to the parents, GP, school nurse, SENCO, and where necessary, the social services department. Information regarding medical terminology and treatment options should be provided.

6. 2 Diagnosis

The diagnosis of ADHD can be a complicated and challenging process, because the disorder manifests differently at various stages of development. In addition, its key features—inattention and hyperactivity/impulsivity—are symptoms of many other disorders. The clinician's role is further complicated by the absence of laboratory tests and imaging studies that can detect ADHD. It is not just the symptom clusters that characterize this condition, but also the fact that it is a chronic disorder characterized by the divergence from expected development in certain domains of functioning.

Another challenge may be, when reports from various observers of the children, particularly parents and teachersdo not agree on the types of behaviours. This may not mean they are necessarily inaccurate; it may be attributed to the fact that the parents and the teachers are seeing the children in different settings. To date, there are no clear guidelines on how clinicians should utilize and/or respond to parent-teacher discrepancies when they do occur. Another challenge seen is that many children fall right at the borderline of meeting the diagnostic criteria for ADHD. The exact cut off point is subjective and unclear in regard to the terms "significant" and "some impairment". The diagnosis is also environmentally dependent, which explains why clinicians will see differences in the child's behaviour between school and home settings. The other challenge to making adiagnosis is that there are no explicit criteria for defining what is "appropriate behaviour" for specific age groups.

Three groups of core signs of ADHD are Inattention, Hyperactivity and Impulsivity. Both major systems of classification for mental disorders; DSM –IV and ICD -10 identify identical sets of 18 symptoms (Table 1).

Table 1. Symptom domains for ADHD / HKD in DSM-IV and ICD-10

Inattention (IN) / Hyperactivity (H) / Impulsivity (IMP)
Fails to attend to details / Fidgets with hands or feet
Difficulty sustaining attention / Leaves seat in classroom
Does not seem to listen / Runs about or climbs
Fails to finish / Difficulty playing quietly
Difficulty organising tasks / Motor access (on the go, in DSM-IV)
Avoids sustained effort / Talks excessively (DSM-IV) / Talks excessively (ICD-10)
Loses things / Blurts out answers to questions
Distracted by extraneous stimuli / Difficulty waiting turn
Forgetful / Interrupts or intrudes on others

6.3Differences between the two major diagnostic manuals

There are some differences in the diagnosis criteria between the two manuals.

A.In the three symptom domain groups of Inattention, Hyperactivity, and Impulsivity; an ICD-10 diagnosis of HKD needs some symptoms from all three groups whereas DSM-IV ADHD does not, but instead specifies subtypes if symptoms are from only one domain. (Table 2). HKD is broadly similar to severe type of ADHD.

B. Because of the high rate of conduct disorder, ICD-10 uses the presence or absence of conduct disorder as the basis for the main subdivision of HKD. DSM-IV does not make any special provision for conduct disorder as a co-morbid condition but allows its diagnosis as it does other psychiatric disorders.

C. Another difference between the two classifications is the use of other co-morbid conditions as exclusion criteria (Table3). ICD-10 aims at a single diagnosis and does not recommend the HKD diagnosis in the presence of internalising disorders such as anxiety and depression. DSM-IV aims to recognize, as many diagnoses as there are symptom patterns.

Table 2.HKD diagnosis and ADHD diagnosis subtypes

HKD (ICD-10) / Six or Six or more from IN domain, three or more from H domain and one or more from IMP domain.
ADHD & subtypes (DSM-IV)
Combined type / Six or Six or more from IN domain and six or more from the H / IMP domain.
Inattentive type / Six or Six or more from IN domain and less than six from H / IMP domain+/- H / IMP less than 6
Hyperactive/Impulsive / Six or Six or more from H / IMP domain and less than six from IN domain.

IN: Inattention H: Hyperactivity IMP: Impulsivity