Neobook — clinical reference

ICD-10 codes: F90.0-F90.9

DESCRIPTION

Children with ADHD display developmentally inappropriate degrees of inattention, impulsiveness and hyperactivity that interfere with their functioning.

DIAGNOSTIC CRITERIA (DSM 5)

May be mild, moderate or severe:

predominantly inattentive,
predominantly hyperactive-impulsive, and
combined.
- Inattention: (9 symptoms)
  - Failing to give close attention to details or making careless mistakes.
  - Having difficulty sustaining attention in tasks or play.
  - Not listening when spoken to directly.
  - Failing to complete tasks or follow-through on instructions.
  - Often losing things for tasks or activities.
  - Often having difficulty organising tasks and activities.
  - Being forgetful in daily activities.
  - Being easily distracted by extraneous stimuli.
  - Avoiding or being reluctant to engage in tasks requiring sustained mental effort.
- Hyperactivity: (6 symptoms)
  - Often fidgeting, squirming or tapping.
  - Leaving his/her seat.
  - Running or climbing inappropriately.
  - Is “on the go”, or behaves as if “driven by a motor”.
  - Is unable to play quietly.
  - Talking excessively.
- Impulsivity: (3 symptoms)
  - Blurts out answers.
  - Has difficulty waiting his/her turn.
  - Interrupts or intrudes on others.

Onset of several symptoms before 12 years.
Requires 6 symptoms of inattention or hyperactivity/impulsivity.
Symptoms have persisted for 6 months to a degree inconsistent with their developmental level.
Symptoms present in two or more settings.
Interferes with or reduces the quality of social, academic or occupational functioning.
Exclude psychotic or other psychiatric disorders.

Note: Common co-morbid conditions include specific learning disabilities, oppositional defiant disorder, conduct disorder, depression (particularly in girls) and substance use disorders (SUDs), as well as epilepsy.

Certain conditions may mimic ADHD such as, developmental disorders, motor coordination problems, intellectual disability, post-traumatic and post infectious encephalopathy as well as anxiety and mood disorders.

Girls may more commonly present with inattentive-type ADHD. The diagnosis may, therefore, be missed.

GENERAL AND SUPPORTIVE MEASURES

Identify and treat co-morbidities such as depressive disorders early, as this may prevent the onset of substance misuse (to ‘self-medicate’) and other risk-taking behaviours during adolescence.

Parent counselling:
- Rules and limit-setting.
- Positive reinforcement of pro-social behaviour.
- Consistent routine.
- Restrictive diets and OTC medications are of no proven value.
Behaviour-based interventions:
- Reward positive behaviour.
- Improve social awareness and adjustment.
Social skills groups.
Identify learning difficulties and refer to educational support services.

MEDICATION TREATMENT

For children under the age of six years:

Refer for diagnostic assessment by a child and adolescent psychiatrist or paediatrician.

For children over the age of six years:

Initiate treatment using the short-acting methylphenidate formulation until effective dosage achieved. Reduce the dose or withdraw methylphenidate if a paradoxical increase in symptoms occurs.

Methylphenidate, short-acting, oral, 1 mg/kg/day.
- Initial dose: 5 mg, 2 - 3 times daily, at breakfast, lunch and no later than 14h30 (approximately every 3 to 3½ hours).
- Increase the dose at weekly intervals by 5 - 10 mg until symptoms are controlled. Use the lowest effective dose.
- Recommended maximum daily dose: 60 mg (adult dose)/maximum of 2 mg/kg/day. Any dose greater than 60 mg/day should be prescribed by a child psychiatrist or paediatrician.

LoE III¹

Contraindications to methylphenidate

Absolute:

Hyperthyroidism.
Glaucoma.
Concomitant mono-amine oxidase inhibitor therapy.
There is no absolute contraindication to the concomitant use of methylphenidate with antiepileptic drugs (AEDs) or antiretroviral therapy (ART). However, exercise caution with the prescribed dosages, be aware of potential drug-drug interactions and monitor for adverse effects.

Relative:

Hypertension.
Cardiac abnormality – needs ECG and cardiology assessment.
Anxiety.
Agitation.
Epilepsy.
Tics.

Discontinuation of treatment

If no objective improvement of symptoms has been observed, e.g. using an ADHD rating scale, after appropriate dosage adjustments over a two-month period, discontinue treatment and refer to a specialist.
To establish whether on-going treatment is indicated in a child on long-term stimulant therapy, trial periods off treatment should be part of the management plan.
Indications for a trial off treatment:
- treatment duration in excess of 2 - 3 years,
- adolescent age (particularly late adolescence), and
- a substantial reduction in core ADHD symptoms, evident in more than one setting.
Trials off treatment should be planned at times least disruptive to the child’s academic and social functioning, i.e. time the treatment withdrawal outside of major commitments such as examinations.
Duration of treatment withdrawal can be for one week to a month, depending on whether stability is maintained.
Treatment can be withdrawn abruptly, with no need to taper dosages.
Obtain feedback from teachers and parents (verbal feedback, completion of parent and teacher ADHD rating scales), before and during the trial off treatment.
Assess the child and document the mental state (symptoms of ADHD), before and during the trial off treatment.
Monitor 3-monthly for one year.
Re-initiate treatment (at last dosage prescribed), if:
- there is a significant re-emergence of symptoms after one week off treatment and/or during the month off medication, or
- after a longer trial off medication, e.g. at 3-monthly follow up visits, there is evidence of symptom re-emergence.

Note: Adolescents are more likely to present with poor concentration, inattentiveness or impulsivity, rather than hyperactivity.

» Hyperactivity symptoms usually decrease but inattention symptoms may persist during adolescence.

» Remission is achieved in 30% of patients during adolescence.

REFERRAL

No response to treatment after 8 weeks.
Presence of comorbid psychiatric conditions with severe functional impairment: oppositional defiant disorder, mood disorders, anxiety disorders, debilitating tics.
Presence of uncontrollable seizures.
HIV infected status.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 14: Child & Adolescent Psychiatry, 14.3 Attention Deficit Hyperactivity Disorder (ADHD)