Adhd workshop for paediatricians
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ADHD WORKSHOP FOR PAEDIATRICIANS. UCT Paediatric Refresher Course Feb 2010. The role of the Paediatrician in the treatment of ADHD. Diagnosis and management Increase in presentation More presentations to Paediatricians and reluctance to visit a Psychiatrist Families need from Paediatrician

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UCT Paediatric Refresher Course

Feb 2010

The role of the Paediatrician in the treatment of ADHD

  • Diagnosis and management

  • Increase in presentation

  • More presentations to Paediatricians and reluctance to visit a Psychiatrist

  • Families need from Paediatrician

  • Awareness of differential diagnosis

  • Awareness of co-morbidity

  • Medication cornerstone of treatment but holistic approach very NB

  • Paediatrician may be first professional to notice ADHD

General concepts of ADHD

  • Aetiological and symptomatic understanding

  • Predominantly a neurobiological condition

  • Strong family history

  • Constellation of symptoms (vs. signs)

  • Core symptoms: Inattention

  • Hyperactivity/Impulsivity

  • DSM IV criteria



  • Failure to give close attention to detail

  • Difficulty sustaining attention

  • Not listening when spoken to directly

  • Inability to finish work / follow through instructions

  • Difficulty organizing tasks or activities

  • Avoidance of tasks requiring sustained mental effort

  • Often looses things required for tasks

  • Easily distracted

  • Forgetful in daily activities

  • 6 symptoms required


  • Fidgety

  • Difficulty remaining in seat

  • Excessive running about / subjective feeling of restlessness

  • Difficulty engaging in leisure activity quietly

  • On the go / “driven by motor”

  • Excessive talking


  • Blurting out of answers

  • Difficulty waiting turn

  • Often interrupts or intrudes on others

  • 6 criteria required

  • ALSO

  • Symptoms present before age 7 years

  • Impairment in 2 or more settings

  • Impaired functioning

  • Symptoms not due to other causes

  • Spectrum of presentation i.e.. Below threshold presentation vs. mild/moderate presentation vs. severe and complicated presentation with several comorbid conditions

  • Up to 50% of children have co morbid disorder(s)

  • Impairment in social, family and academic functioning

  • Occurrence in at least 2 settings

  • Onset during childhood

  • Longitudinal course - 2/3 of patients progress into adulthood

  • Why are more children presenting now?

  • “Evolutionary” concept of ADHD

  • How/why do most patients/families present?

  • Disruption (in class) probably most common reason for referral

Has modern society created a disorder from a previous strength?

  • Genetic and adaptive factors in ADHD

  • Information overload

  • Stimulation overload

  • Academic overload

  • Outsourcing of care

  • Is it normal for a child to sit still at a desk for 6 – 8 hours

  • Societal issues vs mental health issues

Why NB to treat

  • Academic potential

  • Disruption

  • Self esteem

  • Impaired functioning (academic, social, family )

  • co morbidity

Evaluation of/Clinical approach to the child presenting with ADHD

  • May depend on referral source e.g.. Psychologist, school, parents etc

  • N.B. to take ones time, i.e. extended consult, 2-3 consultations

  • Differential diagnosis and co morbidity always need to be born in mind

  • Interview with parents (may need to start off without the child)

  • Child interview

  • Family observation

  • Physical information/evaluation of the child

  • Additional information/investigation

Interview with parents

  • May initially be necessary to exclude the child

  • Presenting complaint

  • History of presenting complaint

  • DSM IV checklist

  • Context of symptoms

  • Resulting impairments

  • Differential diagnosis i.e. may the child’s symptoms be due to another cause other than ADHD

  • Co morbidity i.e. are there additional emotional symptoms that the child is displaying e.g.. Mood, anxiety, conduct, defiance, intellectual impairment etc.

  • Past psychiatric history including ADHD and treatment, past alternative treatments

  • Developmental history

  • Areas of strength

  • Medical history including medications

Family history

  • History of ADHD or co morbid disorder

  • Learning difficulty

  • Family coping style, level of organisation and resources

  • Family stressors

  • Signs of abuse and neglect (especially in younger children)

Child Interview

  • Note symptoms of ADHD (may however be absent during one on one consultation)

  • Note and explore:

  • Defiance

  • Aggression

  • Anxiety

  • Obsessions and compulsions

  • Form, content and logic of thinking and perception

  • Fine and gross motor coordination

  • Tics and movement disorders

  • Speech and language ability

  • Clinical estimate of intellect

Family observation

  • Patients behaviour with siblings and parents

  • Parental responses to child’s behaviour

  • Parental level of agreement around child rearing principles and discipline

Physical evaluation

  • Past medical history and medication

  • Medical record over past 12 months

  • Stability of any illnesses e.g. asthma, allergies etc (may tip the balance)

  • Visual acuity

  • Hearing

  • Height, weight and growth chart

  • Other evaluation as indicated e.g. neurological, cardiology, developmental assessment

Additional information/investigations

  • Forms/rating scales completed by parents, teachers and significant others

  • Conner’s forms: basic and extended, also important to complete once patient being treated

  • School reports (especially the comments)

  • Collateral information from teacher and others (aftercare, other carers)

  • Depending on presentation child may need:

  • Psychometric assessment

  • Speech and language assessment

  • OT assessment

  • No “special tests” available

  • Differential and co morbid scan

  • Diagnostic formulation

  • Treatment plan

The younger and older child

  • Young child: rule out neglect, abuse and other environmental factors, mother/parent: child relationship difficulties may be important contributor

  • Older child: NB. To make patient an active participant in treatment


  • Non pharmacological

  • Pharmacological (cornerstone of treatment)

Non pharmacological interventions

  • Psycho education: parents, child, others

  • Collaboration with/ interventions at school

  • Additional school/ remedial resources

  • Support group for parents

  • Books and other materials

  • Behavioural interventions

Behavioural interventions

  • Should be part of overall intervention

  • May be used on own if symptoms mild or parents refusing meds

  • Attend to child’s misbehaviours and complaints (target symptoms)

  • Token systems (target symptoms)

  • Time out

  • Manage non compliant behaviour in public places PTO

  • Daily school report and other school interventions

  • Anticipate future misconduct

  • Structure, routine, boundaries, predictability

  • *** may all be impossible if family stressors or if parent(s) have ADHD

  • Play therapy, CBT and social skills training not helpful in children who only have ADHD/ADD

  • May be useful for co morbid disorders

  • No empirical evidence for dietary intervention unless proven food intolerance

  • ? Food colorants in the very young

Pharmacological interventions

  • Methylphenidate: Ritalin IR

  • Ritalin LA

  • Concerta

  • Atomoxetine: Strattera

  • Other: Imipramine

  • Clonidine

Side effects and their management:Methylphenidate

  • Loss of appetite (daily quantity N.B.)

  • Weight loss (monitor)

  • Headache, abdominal pain

  • Rebound phenomena

  • Anxiety

  • Tics

  • Depression

  • Affective blunting/ emotional lability

  • insomnia

Management of stimulant S/E

  • loa

  • loss of wt

  • early insomnia

  • blunted affect

  • tic

  • stereotypic movement

  • growth delay

l o a

decrease dosage

increase breakfast + supper

if early - dev of tolerance

monitor wt and ht

if symptoms severe -- change to 2nd line meds

loss of wt

decrease dose

increase caloric intake (breakfast and supper)

no meds over w/e and holidays

monitor wt, growth curve

hope for tolerance

early insomnia

if IR - no meds after 3pm

if LA - lower dosage,

give dose earlier, give before breakfast for faster absorption

ensure bedtime routine eg reading

Clonidine, anntihisamine,melatonin

blunted affect

decrease dosage

change preparation


discontinue, if tic disappears restart

if tic recurs - change meds

  • stereotypic movement

    decrease dosage

  • growth delay

    decrease dosage

    drug holidays

    bone age monitoring on radiograph


  • Gastrointestinal disturbances

  • Sedation

  • Decreased appetite

  • Hepatic disorder

  • Black box warning: suicidality

  • “feeling ill” but unable to verbalize

  • Severe acting out behaviour

  • N.B. to discuss side effects before commencing treatment

  • Monitor for side effects

  • Use of different methylphenidate preparations i.e. which one to use

  • Advantages and disadvantage

  • Ritalin vs. Strattera

  • Ritalin generally considered 1st line

  • Consider Strattera if: tics, anxiety, Ritalin intolerance, patient preference

Introducing medication

  • Dosage

  • Start over weekend (parents feel in control)

  • Warn re side effects

  • Ritalin : fast onset

  • Strattera : 4-6 weeks onset (may start in holidays)

  • Drug holidays ; depends on side effects and level of functioning off meds

  • Follow up regularly including Connors form and collateral (see later)

  • A 9 year old girl is on Concerta 36mg daily. Reports from school indicate that her concentration remains poor until 1st break. What would your approach be?

  • Establish at what time meds are taken

  • Consider adding 5 - 10mg Ritalin mane

  • An 8 year old girl refuses to take Ritalin LA 20mg as she feels she cannot swallow it. What would you advise?

  • An 8 year old boy commenced on Strattera complains of persistent midday nausea. How would you manage him?

  • A single mother presents with her four year old son who presents with symptoms of ADHD. What would your approach to management be?

  • An 11 year old boy with ADHD and co morbid oppositional disorder stops responding to Ritalin LA 20 mg. you increase the dosage to 30mg without much success. How would you approach this presentation

  • A matriculant presents to you whom you had last seen 4 years ago and treated for ADD. He decided to stop meds then but now realises he requires them to get a decent matric result. How would you approach this problem?

Role play : the difficult parents

  • Meds around for over 30 years- no major lawsuits in USA

  • “drug” dependency issues – the opposite is true, never come across a child addicted to Ritalin, drug dealers don’t stock Ritalin…Why not

  • Self esteem issues and marginalisation

  • Co morbidity

  • Sitting on the other side

  • Why withhold something that works e.g. other meds (asthma), spectacles

  • Consideration of trial of meds

  • In and out of system….like coffee

  • If side effects… at least you can say you tried

  • Empirical evidence of other interventions lacking, i.e. diet, multivitamin loading, specialized programmes etc

  • If there were a proven intervention programme say over 10-15 sessions I would certainly administer it. It would be far more remunerative for me

  • If you know of a programme show me the evidence

  • Internet myths--- you can find anything on the internet

Patient follow up

  • What would your follow up strategy and protocol be for a patient that you have commenced on medication?

  • What specific features would you be looking out for?

  • Frequency of follow up (scripts may act as a good gatekeeper)

  • Weight, height, pulse and blood pressure

  • Co morbidity check, other disorders may creep in over time

  • Assess level of functioning in all spheres

  • Repeat Connor’s form

  • Side effects

  • Dosage

  • When to discontinue?

Differential diagnosis of ADHD/ADD and co morbidity

  • ADD may often go undetected until later. Why?

  • Symptoms of ADHD may often mimic other psychiatric conditions

  • In addition about 50% of individuals with ADHD meet criteria for one or more other psychiatric disorder(s)

  • The list is long and the treatment may be complex

Differential diagnosis and Co morbid conditions

  • Oppositional Defiant Disorder

  • Anxiety Disorders (incl OCD)

  • Mood Disorders (incl BMD)

  • Conduct Disorder

  • Learning Disorder

  • Tourette’s Disorder, Motor Tic Disorder

  • Substance Abuse Disorder

  • Pervasive Developmental Disorder

  • Sleep Difficulties/Disorders

  • Accidental Injuries

  • “Personality Difficulties”, Cluster B traits

  • Family dysfunction

  • Medical illnesses/ medication

  • Actively exclude co morbidity

  • Consider when ADHD “refractory”

  • ,

Joseph Biederman and Stephen Faraone 1996

Differential diagnosis

  • How would you differentiate a child suffering from ADHD/ADD from the following condition(s):Note that these patients may be referred to you with a request to treat their “ADHD/ADD”

  • Anxiety disorder( all types)

  • Depression

  • Bipolar mood disorder

  • Learning disorder

  • Oppositional defiant disorder

  • Substance use disorder

  • Pervasive developmental disorder

  • Similarities in presentation

  • vs

  • Differences in presentation

  • See flip chart

Co morbidity and ADHD/ADD

  • More complex than establishing whether another diagnosis/disorder may be responsible for an “ADHD/ADD” presentation is when one or more disorders are indeed present in addition to ADHD/ADD

  • Furthermore when these disorders present during treatment of ADHD we need to ask ourselves whether these symptoms could be as a result of medication

  • If co morbid condition(s) is mild, treatment of ADHD may significantly improve co morbid presentation

  • Caution in :

  • Anxiety disorders and stimulants (academic performance anxiety may however be improved)

  • Tourrette’s disorder

  • Bipolar mood disorder

  • Psychological intervention often necessary when co morbid conditions present

  • Polypharmacy may be unavoidable

  • Second opinions often useful

  • How would you treat a child with ADHD and the following comorbidities given the fact that the child/family is receiving psychological intervention?

  • Tourette’s syndrome

  • PDD

  • BMD

  • Substance abuse

  • Anxiety disorder

  • Depressive disorder

Tourette’s Syndrome

  • clonidine

  • atomoxetine

  • stimulants (not as problematic as initially thought)

Pervasive Development Disorder

  • meds not as effective 50% vs 70%

  • S/E less well tolerated

  • can be used but monitor

  • ? other agents eg Risperidone


  • OK to use once stable on mood stabilizer

    Substance abuse

  • avoid stimulants (however)

  • NB preventative role

Anxiety Disorder

  • Second line agents

  • add SSRI

Depressive disorder

  • Consider adding a SSRI (Fluoxetine)

  • Imipramine of limited value

Challenging cases over time

  • Imaad, 5 yrs old at end 2007

  • Met parents at ADHD Support Group

  • Recently diagnosed with ADHD and had been commenced on Ritalin 5mg mane

  • Now presents with mood swings and irritability in afternoons

  • Changed to Concerta 18mg with good effect

  • Mid 2009 – Psychometric assessment reveals some learning difficulties and significant ADHD “break through” symptoms

  • Increased dose to 36mg, initially symptoms controlled

  • Oct 2009 emergence of vocal tic (parents concerned +++)

  • changed to Atomoxetine, Clonidine and Risperidone (monotherapy)….. Mild reduction of tics but ADHD out of control

  • Recommenced on Concerta 18mg in Jan 2010, ADHD symptoms controlled, still minor vocal tics

  • Lara, grade 1, 2009, Referred with diagnosis of ADHD/anxiety…Aggression on Strattera, mood swings on Ritalin, dysinhibited on Fluoxetine

  • Found to have additional ODD when seen

  • Predominant symptom ADHD

  • Commenced on Concerta 18mg

  • Developed severe insomnia

  • Commenced on Risperidone 0,25- 0.5 mg nocte, Concerta stopped

  • Manageable

  • 2010- severe anxiety , not coping at school, psychometric assessment – discrepencies, weight gain

  • Commenced on 12.5mg Sertraline recently….. Awaiting response

  • Tristan, aged 8, 2009, ADHD, tics and temper outbursts. Started on Strattera….

  • Major “meltdown” requiring hospitalisation

  • Sensitive and hyperreactive

  • Co morbid ODD, anxiety and ? Depression

  • Strattera stopped

  • Commenced on Risperidone 0,5mg and Fluoxetine 10 mg

  • Reasonable response

  • Concentration difficulties at school Sept2009

  • Addition of Concerta 18mg

  • Good response

  • RSA karate champ end 2009

  • Mini “meltdown” beginning school year 2010

  • Parental tension

  • Couple counselling

  • Keeping fingers crossd……

  • Recent referral

  • Learning disorder and ADHD

  • PTO

  • Comment of the year 2009

  • A 17 year old boy diagnosed with ADHD in Grade 11 and commenced on Methylphenidate:

  • Marks initially improved by 20%

  • “For the first time in my life I realized that I am not STUPID!”

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