Diagnosis and Management

of ADHD
 ADHD

“Attention deficit hyperactivity disorder (ADHD) is

a pattern of behaviour which is the most recent in
a series of American attempts to characterise
inattentive restlessness as a condition. It is
effectively a syndrome encompassing
hyperactivity, poor concentration and marked
impulsive, impatient, excitable behaviour. Most,
but not all, instances are predominantly genetic in
origin, with various inherited deficiencies of the
dopamine neurotransmitter system.”
Hill, P. Child & Adolescent Mental Health in Primary Care 2003; 1(1):2-4
 Symptoms of ADHD

Inattention Hyperactivity
Impulsivity
 Impact of ADHD on
School Performance
 Poor classroom behaviour
 Poor academic achievement
 Special education requirements (tutoring and
special educational programmes)
 School exclusion (either suspension or
expulsion)
 Repetition of grades
 Failure to gain external qualifications
Effects of ADHD on Behavioural
Development
 Problems with productivity and motivation
 Reduced ability to express ideas and emotions
 Decreased working memory
 Problems with social interaction
 Impairments in speech
 Problems with verbal reasoning
 Symptom Groups
Inattention Hyperactivity Impulsivity
Does not attend Fidgets Talks excessively †
Fails to finish tasks Leaves seat in class Blurts out answers
Can’t organise Runs/climbs Cannot await turn
excessively
Avoids sustained Interrupts others
effort Cannot play/work
quietly Intrudes on others
Loses things,
‘forgetful’ Always ‘on the go’
Easily distracted Talks excessively *

* ‘Talks excessively’ is one of the DSM-IV criteria for hyperactivity but not one of the ICD-10 criteria
†
‘Talks excessively’ is one of the ICD-10 criteria for impulsiveness but not one of the DSM-IV criteria

DSM-IV – Diagnostic and Statistical Manual, 4 th Edition (American Psychiatric Association, 1994)
ICD-10 – International Classification of Diseases, 10 th Edition (World Health Organisation, 1993)
DSM-IV ADHD Diagnostic Criteria

 List of symptoms must be present for past 6

months
 Must have six (or more) symptoms of inattention
and/or hyperactivity–impulsivity
 Some symptoms present before 7 years of age
 Some impairment from symptoms must be present
in two or more settings (e.g. school and home)
 Significant impairment: social, academic or
occupational
 Exclude other mental disorders
 DSM-IV Subtypes of ADHD

 Predominantly inattentive
 Predominantly hyperactive–impulsive
 Mixed/combined
 In partial remission
 Not otherwise specified (NOS)
 ICD-10 HKD Diagnostic Criteria

 Used to diagnose hyperkinetic disorder (HKD), a

more severe form of ADHD
 List of symptoms must be present for at least six
months
 Must have: at least six symptoms of inattention AND
at least three symptoms of hyperactivity AND at least one
symptom of impulsivity
 Onset of symptoms no later than 7 years of age
 Impairment of symptoms must be present in two or
more settings (e.g. school and home)
 Significant impairment: social, academic or
occupational
 Therapy Options as Part of a
Total Treatment Programme
 Behavioural treatment
 Medication management
 Combining medication/behavioural treatment
 Educating parents/patient about ADHD
 Educational support services
 Tools Used in Behavioural
Treatment
 Specific strategies
 Reward system  Group problem-solving
 Time out  Sports skills
 Social reinforcement  Social skills training
 Behaviour modelling
 Support for parents
 Family and patient education

Cunningham, Barkley. Child Dev 1979; 50: 217–224

 Behavioural Treatment in the
Home
 Identify problem situations and the precipitating
factors
 Enhance positive parent–child interactions
 Limit negative parent–child interactions
 Use cost systems to reduce problem behaviours
 Use time outs as punishment for serious
problem behaviours
 Behavioural Treatment in the
Classroom
 Behavioural treatment in school setting similar to
the approach used in home with parents
 Goal: Reduce inattention and disruptive
behaviour
 Specific school accommodations:
 Ensure structure and predictable routines
 Employ cost–response token economy systems
 Use daily report cards
 Teach organisational and work/study skills
Atkins, Pelham. 1992:69–88; Barkley, Cunningham. Arch Gen Psychiatry 1979; 36: 201–208
 Effectiveness of Behavioural
Therapy
 Parent training is generally regarded as the most
effective behavioural therapy
 Parent training combined with medication
management increases parent acceptability of
medication
 School-based treatment is more effective than
individual strategies, however benefits are only
seen during treatment programmes
 Individual treatment approaches have not been
shown to be effective
 Pharmacological Agents Used
in Treatment of ADHD*
Stimulants Methylphenidate
(Recommended Amphetamine compounds
first-line therapy) Dextroamphetamine
Pemoline

Antidepressants Tricyclic antidepressants

Bupropion

Antihypertensives Clonidine
Guanfacine
* Not all agents are available in some countries

Wilens T, et al. ADHD, In Annual Review of Medicine, 2002: 53

Greenhill L. Childhood attention deficit hyperactivity disorder: pharmacological treatments. In: Nathan PE, Gorman J, eds.
Treatments that Work. Philadelphia, PA: Saunders; 1998:42-64