Hyperkinesis: F From Symptom to Syndrome S t t S d Dr. Ama S - PowerPoint PPT Presentation

Hyperkinesis: F From Symptom to Syndrome S t t S d Dr. Ama S Addo, Consultant, Child & Adolescent and Intellectual Disability Psychiatry, LD-CAMHS, NHS Greater Glasgow & Clyde Dr Susie Gibbs, Consultant in Intellectual Disability Psychiatry, CAMHS- LD, NHS Lanarkshire , S a a s e ASA & SG ADHD Sept 2013 1

From Symptom to Syndrome From Symptom to Syndrome What would you like? Diagnosis Interventions Diagnostic Quandaries Clinical case examples ASA & SG ADHD Sept 2013 2

Introduction

Hyperkinetic Disorders yp Hyperkinetic disorders ICD 10  Disturbance of activity and attention  Hyperkinetic conduct disorder yp  Other Hyperkinetic disorders  Hyperkinetic disorder, unspecified  Hyperkinetic disorder, unspecified Male : Female = 4 : 1 Male : Female = 4 : 1 P Peak presentation age 3 – 7 k t ti 3 7 1.5 - 5% child – adolescent population ASA & SG ADHD Sept 2013 4

ICD-10 ADHD *Lack of persistence in activities requiring concentration Lack of persistence in activities requiring concentration Tendency to move from 1 activity/task to another y y without completion *Excessive Activity  disorganized  ill-regulated Impulsivity Impulsivity Poor awareness of danger Poor awareness of danger Social disinhibition P Poor peer relationships l ti hi ASA & SG ADHD Sept 2013 5 Emotional dysregulation

ICD-10 ADHD Clinical features must be:-  Apparent before the child is age 5 years  Excessive for the child’s age & development  Pervasive & evident in more than 1 environment  Not caused by others disorders e.g. Anxiety or ASD o caused by o e s d so de s e g e y o S  Associated with functional impairment  Associated with functional impairment ASA & SG ADHD Sept 2013 6

Associated disorders in childhood  Sleep disorders (up to 50%)  Behavioural difficulties ODD / CD (25-50%)  Specific Learning Disabilities 25% S ifi L i Di biliti 25%  Developmental Co-ordination Disorders  Social communication difficulties (~25%)  Anxiety symptoms (~25%)  Tics (~ 20%)  Mood difficulties (~20%)  Mood difficulties (~20%) ASA & SG ADHD Sept 2013 7  Increased psychosocial factors

Associations:-  Learning Disabilities  Learning Disabilities  Fragile X Syndrome g y  Tourette Syndrome  Neurofibromatosis I  William Syndrome  Willi S d  Prenatal exposure to:-  Prenatal exposure to:  Lead  Alcohol  Alcohol  Anti-Epileptics  Cocaine  Cocaine  Opiates ASA & SG ADHD Sept 2013 8

Adult ADHD

Adult ADHD  Emotional lability  Difficulty completing tasks  Difficulty completing tasks  Difficulty making decisions  Forgetfulness  Inefficiently busy  Over-talkative  Difficulty sitting still  Difficulty sitting still  Blurting out / interrupting others  Impatience I i  Acting without thinking. ASA & SG ADHD Sept 2013 10

ADHD in Adulthood M:F = 1:1 Up to 60% will have problems in adulthood  There is a x4  There is a x4 – x5 risk of dying in a Road Traffic Accident x5 risk of dying in a Road Traffic Accident  There is a x3 risk of having an illegitimate child  10% of prisoners have ADHD  10% of prisoners have ADHD Adult comorbid disorders include:-  Mood disorders (30%)  Substance abuse (14%) ( )  Anxiety Disorder (50%)  Dissocial / Borderline Personality disorders y Treatment for ADHD associated with 32% reduction in risk of criminality in men 32% reduction in risk of criminality in men ASA & SG ADHD Sept 2013 11 41% reduction in risk of criminality in women

Assessment

Assessment - History F From reliable informants li bl i f t  Current & past behaviours  Activity levels, impulsivity, emotional reactivity  Ability to sustain interest / attention (with and without adult involvement) adult involvement)  Responses to & interactions with others  Responses to & interactions with others  Eating & sleep habits g p  Systematic enquiry for other emotional & behaviour problems ASA & SG ADHD Sept 2013 13

Assessment - History Also  Antenatal alcohol &/or illicit drugs or medication  Patterns of feeding, sleeping and play  Developmental history  Developmental history  Sensory issues  Impact on patient / family / carers / peers  Interests / activities  Personal / parental management strategies  Personal / parental management strategies ASA & SG ADHD Sept 2013 14

Questionnaires Do you usually feel restless? Yes / no Do you usually feel restless? Yes / no Do you usually act first and then think? Yes / no Do you usually have concentration problems? Yes / no Have you always had this? (as long as you can y y ( g y remember, or have you been like this most of your life) Yes / no life) Yes / no  Conners’ Rating Scales  P  Parent t  Teacher  S lf  Self-report t  Evaluation of Early Morning & Late Afternoon/Evening  E l ti f E l M i & L t Aft /E i Behaviour ASA & SG ADHD Sept 2013 15

Assessment – Clinical Examination  Appropriate to previous health problems  Hearing and vision screening checks  Height & Weight (growth chart / b.m.i)  blood pressure & heart sounds p  screening for neurological signs & physical  screening for neurological signs & physical anomalies ASA & SG ADHD Sept 2013 16  Role of Psychiatrist & when to refer on?

Assessment - Diagnosis Direct Observations in ≥ 1 setting  Ability to attend to & understand others’  Ability to attend to & understand others communications  Organisation for work tasks  O i ti f k t k  Concentration on work tasks  Levels of activity  Signs of impulsivity  Signs of impulsivity  Follow environmental/social rules Adaptive Functioning Assessment e.g. VABS Adaptive Functioning Assessment e.g. VABS ASA & SG ADHD Sept 2013 17

Treatment

Psychoeducation Information sources  Royal College of Psychiatrists –  Royal College of Psychiatrists – http://www.rcpsych.ac.uk/mentalhealthinfo/  National A ttention D eficit D isorder I nformation and S upport S ervice – http://www.addiss.co.uk t S i htt // ddi k S  Pharmaceutical companies (use with caution) ASA & SG ADHD Sept 2013 19

Medication Best Practice Medication is 1 st line in adults with ADHD and moderate /severe levels of impairment Medication offered as a trial dependent on Target symptoms Pre-medication assessment  Mental health assessment to identify comorbidity  Mental health assessment to identify comorbidity  Exclude significant cardiovascular pathology  Family CVS history F il CVS hi  Social history (Substance misuse / drug diversion) ASA & SG ADHD Sept 2013 20

Pre-medication assessment  Heart rate  Heart rate  Blood pressure  Weight  ECG / Cardiology opinion ASA & SG ADHD Sept 2013 21

Medication options in ADHD 1 st line - Psychostimulants  Methylphenidate (blocks Dopamine re-uptake) y ( ) In BNF but not licensed in adults Standard & modified release preparations  Dexamfetamine (DEX) (releases dopamine stored in presynaptic vacuoles) In BNF but not licensed in adults S Standard & modified release preparations & f 2 nd line - Noradrenalin Re-Uptake Inhibitor 2 d li N d li R U k I hibi  Atomoxetine* Li Licensed in adults d i d l ASA & SG ADHD Sept 2013 22

Methylphenidate / Dexamfetamine Effective in 75% of ADHD cases  Improve attention span  Reduce hyperactivity  Reduce impulsivity R d i l i it  Improve academic productivity (50%)  Improve academic productivity (50%)  Improve parent-child interactions  Improve parent child interactions  Decrease aggression gg ASA & SG ADHD Sept 2013 23

Methylphenidate Side Effects Methylphenidate Side-Effects ASA & SG ADHD Sept 2013 24

Methylphenidate / Dexamfetamine Use with caution in:-  ?Tics ?Tics  Hypertension  ?Epilepsy  ?Epilepsy  Known / Family history of cardiac arrhythmias  ?Hyperthyroidism (CI in BNF)  ?Hyperthyroidism (CI in BNF)  Glaucoma Absolute contra-indications:-  Moderate to severe hypertension  If convulsions occur ASA & SG ADHD Sept 2013 25

Psychostimulant monitoring Psychostimulant monitoring St Starting dose? ti d ? Regularly after dose increases 3 – 6 monthly Monitor the patient’s:- Monitor the patient s:  Weight / b.m.i  Pulse / Blood Pressure  Pulse / Blood Pressure  Medication Efficacy  Medication Side effects  Medication Side-effects ASA & SG ADHD Sept 2013 26

Methylphenidate / Dexamfetamine Drug Holidays (at weekends or during holidays)?  Allows for growth in children whose appetite loss has led to reduced growth. h l d t d d th  Allows for appetite improvement if significant weight loss g  Allow for parents / patient to observe functioning  Allow for parents / patient to observe functioning without medication. ASA & SG ADHD Sept 2013 27