Communication Skills: Explaining Attention Deficit Hyperactivity Disorder (ADHD)

Example OSCE station: you are a junior doctor on placement in a Child and Adolescent Mental Health Services (CAMHS) clinic. You have been asked to see Mrs. Jones, who is concerned about her hyperactive son, Connor. Take a brief history focusing on attention deficit hyperactivity disorder, and then outline the treatment options and respond to her concerns.

  • Wash hands
  • Introduce yourself
  • Establish mother's agenda for the consultation
  • Establish own agenda for the consultation
  • Remind her that she can ask questions throughout the consultation

Important points in the history:
  • When did their symptoms start? (<7?)
  • Impulsive? Inattentive? Hyperactive? (Elicit examples)
  • Does these issues present at school, at home, and when he tries to socialise?
  • Explore possible causes of the behaviour
  • Ask about family history of ADHD
  • Ask the mother about her ideas, concerns and expectations with regards to his behaviour

What is ADHD?
  • ADHD stands for Attention Deficit Hyperactivity Disorder
  • It is a behavioural disorder
  • It affects more males than females (ratio of 3:1)
  • 2% of children are affected in the UK
  • It normally occurs in childhood by age 7
  • Symptoms should have lasted for over 6 months in order to make the diagnosis
  • Symptoms include:
    • Impulsivity
    • Inattention
    • Hyperactivity
    • Impaired functioning
      • I.e.: may affect a child's schooling and relationships with family and friends
    • And should affect the child in more than one domain in their life (e.g. at home and at school)

What is the cause of ADHD?
  • A mixture of factors are suspected to contribute to ADHD formation. This includes;
    • Genes - a family history of ADHD may be present
    • Environmental
      • Social deprivation and neglect in childhood
      • Neurodevelopmental abnormalities
      • Includes mother drinking alcohol and taking drugs such as heroin during pregnancy (BEWARE: don't make this sound like you are accusing or judging the mother if you say this)
      • Includes obstetric complications
      • Includes a low birth weight of the child

What is the treatment for ADHD?
  • Family education and support
    • Parent training programme
  • school education and support
    • teachers may meet with parents and psychiatrist to discuss support in school
  • Family and individual therapy
    • Family therapy
    • CBT
    • Social awareness therapy
  • Behavioural treatment
    • Rewarding good behaviour and discouraging bad behaviour
  • Medication
    • Only in children over 6 years old
    • Methylphenidate, i.e.: Ritalin is most commonly used
      • This increases dopamine in the brain, which is thought to improve concentration and reduce hyperactivity
      • Titrate medication up over time
      • Drug given 3 times a day at first. The short acting methylphenidate begins working within about 20 minutes and lasts for 3-4 hours.Once at a therapeutic dose, a longer acting version of the drug may be used, taken once per day
      • Child is monitored for side effectS
      • Side effects include: headaches, insomnia, appetite decrease, poor weight gain if taken long term
      • Child should be reviewed every 6 months. It is recommended that the doctor also check your child's height, weight and blood pressure.
      • Most children will need to continue medication through high school. Once children become teenagers, some doctors will recommend a trial off the medication each year. This is to make sure that medication is still necessary.
      • If methylphenidate does not work, other drugs are available, e.g.: Modafenil, which can be discussed more in the future if needed.
      • It is shown that 1/3 children resolve with treatment

Is he ever going to get better?
  • Prognosis is variable
  • Gradual improvement occurs in adolescence, but up to 8 in 10 children with ADHD will continue to experience some symptoms into their teenage years e.g.: restlessness and inattention
  • However, early and consistent treatment improves this prognosis.

written by: celine_lakra, first posted on: 19/03/12, 21:29

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