Hyperkinesis: F From Symptom to Syndrome S t t S d Dr. Ama S - - PowerPoint PPT Presentation

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Hyperkinesis: F From Symptom to Syndrome S t t S d Dr. Ama S Addo, Consultant, Child & Adolescent and Intellectual Disability Psychiatry, LD-CAMHS, NHS Greater Glasgow & Clyde Dr Susie Gibbs, Consultant in Intellectual Disability

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Hyperkinesis: F S t t S d From Symptom to Syndrome

  • Dr. Ama S Addo, Consultant, Child & Adolescent and Intellectual Disability

Psychiatry, LD-CAMHS, NHS Greater Glasgow & Clyde Dr Susie Gibbs, Consultant in Intellectual Disability Psychiatry, CAMHS- LD, NHS Lanarkshire , S a a s e

1 ASA & SG ADHD Sept 2013

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From Symptom to Syndrome From Symptom to Syndrome

What would you like? Diagnosis Interventions Diagnostic Quandaries Clinical case examples

2 ASA & SG ADHD Sept 2013

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Introduction

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Hyperkinetic Disorders yp

Hyperkinetic disorders ICD 10  Disturbance of activity and attention  Hyperkinetic conduct disorder yp  Other Hyperkinetic disorders  Hyperkinetic disorder, unspecified  Hyperkinetic disorder, unspecified Male : Female = 4 : 1 Male : Female = 4 : 1 P k t ti 3 7 Peak presentation age 3 – 7 1.5 - 5% child – adolescent population

4 ASA & SG ADHD Sept 2013

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ICD-10 ADHD

*Lack of persistence in activities requiring concentration Lack of persistence in activities requiring concentration Tendency to move from 1 activity/task to another y y without completion *Excessive Activity

 disorganized  ill-regulated

Impulsivity Impulsivity Poor awareness of danger Poor awareness of danger Social disinhibition P l ti hi Poor peer relationships Emotional dysregulation

5 ASA & SG ADHD Sept 2013

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ICD-10 ADHD

Clinical features must be:-  Apparent before the child is age 5 years  Excessive for the child’s age & development  Pervasive & evident in more than 1 environment  Not caused by others disorders e.g. Anxiety or ASD

  • caused by o

e s d so de s e g e y o S  Associated with functional impairment  Associated with functional impairment

6 ASA & SG ADHD Sept 2013

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Associated disorders in childhood

 Sleep disorders (up to 50%)  Behavioural difficulties ODD / CD (25-50%) S ifi L i Di biliti 25%  Specific Learning Disabilities 25%  Developmental Co-ordination Disorders  Social communication difficulties (~25%)  Anxiety symptoms (~25%)  Tics (~ 20%)  Mood difficulties (~20%)  Mood difficulties (~20%)  Increased psychosocial factors

ASA & SG ADHD Sept 2013 7

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Associations:-

Learning Disabilities Learning Disabilities Fragile X Syndrome g y Tourette Syndrome Neurofibromatosis I Willi S d William Syndrome Prenatal exposure to:- Prenatal exposure to:

 Lead  Alcohol  Alcohol  Anti-Epileptics  Cocaine  Cocaine  Opiates

8 ASA & SG ADHD Sept 2013

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Adult ADHD

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Adult ADHD

 Emotional lability  Difficulty completing tasks  Difficulty completing tasks  Difficulty making decisions  Forgetfulness  Inefficiently busy  Over-talkative  Difficulty sitting still  Difficulty sitting still  Blurting out / interrupting others I i  Impatience  Acting without thinking.

ASA & SG ADHD Sept 2013 10

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ADHD in Adulthood

M:F = 1:1 Up to 60% will have problems in adulthood

 There is a x4 x5 risk of dying in a Road Traffic Accident  There is a x4 – x5 risk of dying in a Road Traffic Accident  There is a x3 risk of having an illegitimate child  10% of prisoners have ADHD  10% of prisoners have ADHD

Adult comorbid disorders include:-

 Mood disorders (30%)  Substance abuse (14%) ( )  Anxiety Disorder (50%)  Dissocial / Borderline Personality disorders y Treatment for ADHD associated with 32% reduction in risk of criminality in men 32% reduction in risk of criminality in men 41% reduction in risk of criminality in women

11 ASA & SG ADHD Sept 2013

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Assessment

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Assessment - History

F li bl i f t From reliable informants

 Current & past behaviours  Activity levels, impulsivity, emotional reactivity  Ability to sustain interest / attention (with and without adult involvement) adult involvement)  Responses to & interactions with others  Responses to & interactions with others  Eating & sleep habits g p  Systematic enquiry for other emotional & behaviour problems

13 ASA & SG ADHD Sept 2013

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Assessment - History

Also  Antenatal alcohol &/or illicit drugs or medication  Patterns of feeding, sleeping and play  Developmental history  Developmental history  Sensory issues  Impact on patient / family / carers / peers  Interests / activities  Personal / parental management strategies  Personal / parental management strategies

ASA & SG ADHD Sept 2013 14

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Questionnaires

Do you usually feel restless? Yes / no Do you usually feel restless? Yes / no Do you usually act first and then think? Yes / no Do you usually have concentration problems? Yes / no Have you always had this? (as long as you can y y ( g y remember, or have you been like this most of your life) Yes / no life) Yes / no  Conners’ Rating Scales

  • P

t

  • Parent
  • Teacher
  • S lf

t

  • Self-report

 E l ti f E l M i & L t Aft /E i  Evaluation of Early Morning & Late Afternoon/Evening Behaviour

ASA & SG ADHD Sept 2013 15

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Assessment – Clinical Examination

 Appropriate to previous health problems  Hearing and vision screening checks  Height & Weight (growth chart / b.m.i)  blood pressure & heart sounds p  screening for neurological signs & physical  screening for neurological signs & physical anomalies  Role of Psychiatrist & when to refer on?

ASA & SG ADHD Sept 2013 16

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Assessment - Diagnosis

Direct Observations in ≥ 1 setting  Ability to attend to & understand others’  Ability to attend to & understand others communications  O i ti f k t k  Organisation for work tasks  Concentration on work tasks  Levels of activity  Signs of impulsivity  Signs of impulsivity  Follow environmental/social rules Adaptive Functioning Assessment e.g. VABS Adaptive Functioning Assessment e.g. VABS

ASA & SG ADHD Sept 2013 17

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Treatment

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Psychoeducation

Information sources  Royal College of Psychiatrists –  Royal College of Psychiatrists – http://www.rcpsych.ac.uk/mentalhealthinfo/  National Attention Deficit Disorder Information and S t S i htt // ddi k Support Service – http://www.addiss.co.uk  Pharmaceutical companies (use with caution)

ASA & SG ADHD Sept 2013 19

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Medication Best Practice

Medication is 1st line in adults with ADHD and moderate /severe levels of impairment Medication offered as a trial dependent on Target symptoms Pre-medication assessment  Mental health assessment to identify comorbidity  Mental health assessment to identify comorbidity  Exclude significant cardiovascular pathology F il CVS hi  Family CVS history  Social history (Substance misuse / drug diversion)

ASA & SG ADHD Sept 2013 20

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Pre-medication assessment

 Heart rate  Heart rate  Blood pressure  Weight  ECG / Cardiology opinion

ASA & SG ADHD Sept 2013 21

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Medication options in ADHD

1st line - Psychostimulants  Methylphenidate (blocks Dopamine re-uptake) y ( ) In BNF but not licensed in adults Standard & modified release preparations  Dexamfetamine (DEX) (releases dopamine stored in presynaptic vacuoles) In BNF but not licensed in adults S & f Standard & modified release preparations 2 d li N d li R U k I hibi 2nd line - Noradrenalin Re-Uptake Inhibitor  Atomoxetine* Li d i d l Licensed in adults

22 ASA & SG ADHD Sept 2013

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Methylphenidate / Dexamfetamine

Effective in 75% of ADHD cases  Improve attention span  Reduce hyperactivity R d i l i it  Reduce impulsivity  Improve academic productivity (50%)  Improve academic productivity (50%)  Improve parent-child interactions  Improve parent child interactions  Decrease aggression gg

23 ASA & SG ADHD Sept 2013

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Methylphenidate Side Effects Methylphenidate Side-Effects

ASA & SG ADHD Sept 2013 24

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Methylphenidate / Dexamfetamine

Use with caution in:-  ?Tics ?Tics  Hypertension  ?Epilepsy  ?Epilepsy  Known / Family history of cardiac arrhythmias  ?Hyperthyroidism (CI in BNF)  ?Hyperthyroidism (CI in BNF)  Glaucoma Absolute contra-indications:-  Moderate to severe hypertension  If convulsions occur

25 ASA & SG ADHD Sept 2013

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Psychostimulant monitoring Psychostimulant monitoring

St ti d ? Starting dose? Regularly after dose increases 3 – 6 monthly Monitor the patient’s:- Monitor the patient s:  Weight / b.m.i  Pulse / Blood Pressure  Pulse / Blood Pressure  Medication Efficacy  Medication Side effects  Medication Side-effects

ASA & SG ADHD Sept 2013 26

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Methylphenidate / Dexamfetamine

Drug Holidays (at weekends or during holidays)?  Allows for growth in children whose appetite loss h l d t d d th has led to reduced growth.  Allows for appetite improvement if significant weight loss g  Allow for parents / patient to observe functioning  Allow for parents / patient to observe functioning without medication.

27 ASA & SG ADHD Sept 2013

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Atomoxetine

N ti l t ti N d li R Non-stimulant pre-synaptic Noradrenalin Re- Uptake Inhibitor (blocks Noradrenaline b t t ) membrane transporter) Effective in 75% of cases  ADHD with comorbid Anxiety  Tic Disorders  Tic Disorders  Depression  Learning Disabilities  Pervasive Developmental Disorders. Pervasive Developmental Disorders.

28 ASA & SG ADHD Sept 2013

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Atomoxetine

Action reportedly lasts:-  12 hours  12 hours Starting dose 0.5mg/kg/day but clinical practice? Therapeutic dose 1.2mg/kg/day with max. dose [120mg/day] [ g y] May take up to 6 weeks before clinical benefits May take up to 6 weeks before clinical benefits No drug holidays

29 ASA & SG ADHD Sept 2013

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Atomoxetine Side-effects:-

 Nausea / Vomiting*  Headaches  Appetite suppression  Weight loss g  Agitation

 Increased heart rate / blood pressure p

 Behavioural changes

  • Irritability
  • Mood swings / Rage Reactions
  • Suicidal thinking / Self-harming behaviours
  • Insomnia
  • Insomnia

 Disturbed hepatobiliary function

  • Abdominal pain / malaise/ darkened urine / jaundice
  • Abdominal pain / malaise/ darkened urine / jaundice

30 ASA & SG ADHD Sept 2013

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Unlicensed medications for ADHD Unlicensed medications for ADHD

Only by clinicians with ‘considerable experience’ Antihypertensives Antihypertensives  Clonidine Antipsychotics (Antidepressants)

ASA & SG ADHD Sept 2013 31

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Clonidine

Clonidine α 2 adrenergic receptor agonist Clonidine, α-2 adrenergic receptor agonist Children aged from 3 years Can be effective in:-

 ADHD with comorbid Tic Disorders  Hyperactivity with aggression

It t k t 6 k t t t t k It can take up to 6 weeks to start to work Onset of action Onset of action

 within 30 – 60 minutes

Action lasts Action lasts

 3 - 6 hours

Starting dose:- Therapeutic dose:-

 0.025 mg /day 0.1 – 0.6 mg / day in 2 – 3 divided doses

32 ASA & SG ADHD Sept 2013

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Clonidine

Should not be taken by people who have:- Should not be taken by people who have:

 Depression  Diabetes  Diabetes  Heart disease  Kidney disease  Kidney disease

Side-effects

 N / C ti ti  Nausea / Constipation  Hypotension / Dizziness S d ti  Sedation  Depression /  Dry eyes / Dry mouth  There is also a very slight risk of hallucinations Rebound effects on abrupt withdrawal ECG & Blood Pressure monitoring

33 ASA & SG ADHD Sept 2013

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Antipsychotics

 Not recommended for treatment of adult ADHD  May be effective in ADHD with comorbid y challenging behaviour

ASA & SG ADHD Sept 2013 34

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Monitoring response to medication

 Clinical assessment & observation  Clinical assessment & observation f  Reports from home, school, other environments  Repeat Conners’  ‘Symptom and side effect monitoring’

ASA & SG ADHD Sept 2013 35

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Psychological Interventions

Insufficient Evidence for Psychological interventions in adults with ADHD and moderate functional in adults with ADHD and moderate functional impairment C id CBT Consider CBT :- If medication is only partially effective There is no response to medication Adult would prefer a psychological approach to Adult would prefer a psychological approach to medication as 1st line Interventions for appropriate comorbid disorders Interventions for appropriate comorbid disorders Environmental Management

ASA & SG ADHD Sept 2013 36

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Prognosis

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Prognosis:-

Depends on co morbidity Depends on co-morbidity

 Organic disorders  Psychiatric disorders – ODD / CD  Psychiatric disorders – ODD / CD  Specific Learning difficulties  Which symptoms predominate Which symptoms predominate  In what environment symptoms predominate

Predictors of persistence into adulthood include:-

 Maternal depression  Maternal depression  Marital discord  Negative parent child interaction  Negative parent-child interaction  Family socio-economic disadvantage  F ili l ADHD  Familial ADHD

38 ASA & SG ADHD Sept 2013

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Complexities

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Differential diagnoses / Co morbidities Differential diagnoses / Co-morbidities

Anxiety/ASD transitions Early developmental stage Early developmental stage Sensory processing Organic causes

Medication side effects Medication side effects Obstructive sleep apnoea? H th idi ? Hyperthyroidism? Others….

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Treating the symptom

Diagnosis in severe ID or complex co-morbidity In these cases rule out other causes/try other In these cases rule out other causes/try other interventions:

Developmentally appropriate environments Developmentally appropriate environments Autism friendly environment y Sensory processing

Trial of medication – beware of sedation being seen as ‘treatment’

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References

 Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72 modified 2013  I t ti l Cl ifi ti f Di 10 WHO  International Classification for Diseases – 10 WHO  Adult ADHD J.J.S. Kooij Cutting Edge Psychiatry in Practice D El K C l Child P hi i N h Gl  Dr Eleanor Kerr, Consultant Child Psychiatrist, North Glasgow  Management of attention deficit and hyperkinetic disorders in hild & l S tti h I t ll i t G id li children & young people, Scottish Intercollegiate Guidelines Network 112 SIGN 112 at: http://www sign ac uk/guidelines/fulltext/112 http://www.sign.ac.uk/guidelines/fulltext/112  Case Study: Adverse Response to Clonidine Cantwell, D; Swanson,J; Connor, D Am. Acad. Child Adolesc. Psychiatry, , ; , y y, 1997, 36(4):539-544  Prof J Turk – Nature of mental health issues as experienced by children & young people with ID (overview)

ASA & SG ADHD Sept 2013 42