What is involved in ADHD diagnosis?
Full clinical and psychosocial assessment Full development and psychiatric history Observer reports and assessment of mental state
Diagnostic criteria for ADHD
Meet DSM-5/ICD criteria AND cause at least moderate psychological/social/educational impairment AND be pervasive, involving 2 or more important settings
When to consider prescribing medicines in ADHD?
- their ADHD symptoms are still causing a persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed - they and their parents and carers have discussed information about ADHD - a baseline assessment has been carried out
When to offer CBT?
Consider a course of cognitive behavioural therapy (CBT) for young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain, addressing the following areas:
social skills with peers
problem-solving
self-control
active listening skills
dealing with and expressing feelings
What does baseline assessment involve?
a review to confirm they continue to meet the criteria for ADHD and need treatment
a review of mental health and social circumstances, including: presence of coexisting mental health and neurodevelopmental conditions current educational or employment circumstances
risk assessment for substance misuse and drug diversion
care needs
a review of physical health, including:
a medical history, taking into account conditions that may be contraindications for specific medicines
current medication
height and weight (measured and recorded against the normal range for age, height and sex)
baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
a cardiovascular assessment an electrocardiogram (ECG) if the treatment may affect the QT interval.
When to obtain cardiology opinion?
Refer for a cardiology opinion before starting medication for ADHD if any of the following apply:
- history of congenital heart disease or previous cardiac surgery
- history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
- shortness of breath on exertion compared with peers
- fainting on exertion or in response to fright or noise
- palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
- chest pain suggesting cardiac origin
- signs of heart failure
- a murmur heard on cardiac examination
- Hypertension
Which is the first line drug?
Methylphenidate, either long or short acting
If there is little improvement after a 6 week trial, what next?
Consider switching to lisdexamfetamine
If lisdexamphetamine helps but longer acting profile is not acceptable, what is the alternative?
Dexamphetamine
If no response to methylphenidate or not tolerating lisdexamphetamine or dexamphetamine?
Offer atomoxetine or guanfacine
