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.

• 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

• 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)

• 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

• 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

• 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.

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