The Management of ADHD in Children and Young People [1 ed.] 9781909962750, 9781909962729

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The Management of ADHD in Children and Young People

Edited by

Val Harpin A practical guide from Mac Keith Press

The Management of ADHD in Children and Young People

The Management of ADHD in Children and Young People Edited by Val Harpin

2017 Mac Keith Press

© 2017 Mac Keith Press Managing Director: Ann-Marie Halligan Production Manager/Commissioning Editor: Udoka Ohuonu Project Management: Riverside Publishing Solutions Ltd The views and opinions expressed herein are those of the author and do not necessarily represent those of the publisher. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written consent of the copyright holder or the publisher. First published in this edition in 2016 by Mac Keith Press 6 Market Road, London, N7 9PW British Library Cataloguing-in-Publication data A catalogue record for this book is available from the British Library Cover design: Hannah Rogers ISBN: 978-1-909962-72-9 Typeset by Riverside Publishing Solutions Ltd Printed by Hobbs the Printers Ltd, Totton, Hampshire, UK Mac Keith Press is supported by Scope.

Contents

Author Appointmentsvii Foreword ix Prefacexi Prologue: ADHD and proudxiii 1 ADHD: background and introduction Val Harpin

1

2 Referral: how to inform, educate and support referrers Val Harpin

15

3 Diagnostic assessment: a step-by-step approach Val Harpin

23

4 Coexisting difficulties Val Harpin

45

5 Psychoeducation and behavioural management David Daley

63

6 Medication: the drugs available to treat ADHD Peter Hill

83

7 Using, monitoring and optimising medication Peter Hill

103

8 Monitoring growth Val Harpin

131

9 Cardiac issues: initial assessment and monitoring of medication Eric Rosenthal

137

v

Contents

10 School and classroom strategies for the teaching and management of children with ADHD Fintan O’Regan

149

11 How coexisting difficulties may affect the management of ADHD Val Harpin and Shatha Shibib

161

12 The role of the ADHD nurse specialist Julie Warburton and Mel Seymour

175

13 Young people and ADHD Caroline Bleakley

185

14 Girls and young women with ADHD Nicholas Myttas

201

15 ADHD and substance misuse in young people KAH Mirza, Sudeshni Mirza and Roshin M Sudesh

215

16 Transition to adult services in ADHD Helen Crimlisk

239

Appendices255 Index267

vi

Author Appointments

Caroline Bleakley Associate Specialist in Paediatric Neurodisability, Ryegate Children’s Centre, Sheffield, UK Helen Crimlisk Consultant, General Adult Psychiatry, Sheffield Health and Social Care Foundation NHS Trust, Sheffield, UK David Daley Professor of Psychological Intervention and Behaviour Change, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham; Co-director, Centre for ADHD and Neurodevelopmental Disorders, Institute of Mental Health, University of Nottingham, UK Val Harpin Consultant Neurodevelopmental Paediatrician, Ryegate Children’s Centre, Sheffield, UK Peter Hill Consultant Child and Adolescent Psychiatrist, 127 Harley Street, London, UK KAH Mirza Consultant Psychiatrist, Department of Child Psychiatry, Hertfordshire Partnership University NHS Trust, Hertfordshire; Honorary Senior Lecturer, Institute of Psychiatry, King’s College London, UK vii

Author Appointments

Sudeshni Mirza Professor of Forensic Medicine, DM Wayanad Institute of Medical Sciences, Naseera Nagar, Kerlala, India Nikos Myttas Consultant Child and Adolescent Psychiatrist, 127 Harley Street, London, UK Fintan O’Regan Learning and Behaviour Trainer and Consultant; former Head Teacher of the Centre Academy School, London, UK Eric Rosenthal Consultant Paediatric & Adult Congenital Cardiologist, Evelina London Children’s Hospital, St Thomas’ Hospital, London, UK Mel Seymour ADHD Nurse Specialist, Sheffield Children’s NHS Foundation Trust, UK Shatha Shibib Consultant Child and Adolescent Psychiatrist, Sheffield Children’s NHS Foundation Trust, UK Roshin M. Sudesh Speciality Trainee in Emergency Medicine, Medway Maritime Hospital, Gillingham, UK Julie Warburton ADHD Nurse Specialist, Sheffield Children’s NHS Foundation Trust, UK

viii

Foreword

As a training psychiatrist in the early 1990s, then as a Consultant child and adolescent psychiatrist and finally a Clinical Director in a Child and Adolescent Mental Health Service, I have seen how the recognition, diagnosis and treatment of ADHD has been changing the shape of child mental health and paediatric services over the last 20 years. It has challenged clinicians’ understanding of behavioural difficulties and their perception of neurodevelopmental disorders. It has required education services to rethink how they manage children and young people with ADHD who are struggling in school. ADHD is a disorder surrounded in controversy and debate, in both the clinical setting and the wider community. Medicines are viewed as transforming by some, but as chemical restraint by others. Despite extensive research into the condition the world appears to be no closer to an agreement on the nature of the disorder and how best to treat it. While the arguments persist the children, young people and, more recently, adults continue to seek help for the problems that develop from the disorder, such as remaining focused or regulating their behavior. There is a wide range of books associated with the science or clinical management of ADHD. Some are purely neuroscience and focus on the current state of knowledge. But in this field the science is moving on so rapidly that by the time of publication these books are always slightly behind the cutting-edge research in on the subject. Others are self-help books for assisting families or individuals who are affected by the condition. The Management of ADHD in Children and Young People is written by clinicians and for clinicians and as a consequence it reflects the knowledge and needs of those providing care for those with ADHD. The authors have taken a practical approach to the disorder. They have not only referenced the most up-to-date literature but have also used their extensive clinical experience to describe what ADHD is, how to recognise it, what to ix

Foreword

do when you see it, and how to treat it and its coexisting difficulties. They give insights into the history of the condition and then using the UK as an example they have built a profile of how ADHD presents in the modern world and the challenges it now presents to clinicians. ‘Every child with ADHD is different’ is a phrase used by clinicians to reassure parents that the understanding of their child and the treatment offered is being tailored to their individual needs. Although this is true, there is much that can be learnt from clinical examples that highlight the frequently occurring problems associated with the condition and its treatment. This is reflected in this volume. The authors’ use of clinical vignettes throughout the chapters brings a reality to the condition that makes the book relevant to clinicians working with individuals with ADHD. It provides practical suggestions on how to approach the condition or how to develop services to meet the needs of the ever increasing number of people seeking help. The topics covered in this book reflect the questions clinicians working in the specialities of child and adolescent psychiatry or paediatrics frequently want answered and so would be ideal for training grade clinicians. The authors have used their experience of delivering teaching to ensure that their content is clear and understandable to all. This book is not a simple introduction to the subject; clinicians from all backgrounds in children’s services, and at all levels of seniority will find something of value or interest, whether it be seeking validation for their current clinical practice or new insights into how to approach clinical challenges. As the science basis expands, our understanding of the neurobiology of this condition will increase; however, the need for access to the experience of clinicians who have been delivering care to this group of children and young people will remain irreplaceable. This book thoroughly fulfills that need. Dr Duncan Manders Consultant Child and Adolescent Psychiatrist Royal Hospital for Sick Children Edinburgh, UK

x

Preface

I didn’t choose ADHD. It chose me. I am so pleased it did. I started to work with children and young people with ADHD and their families in the early 1990’s, just as awareness was increasing in the UK and the rest of Europe. We had little to offer at that time: some behavioural management and short acting methylphenidate as the only available medication, but at least ADHD was being recognised. So much has changed in the last 25 years. In that time, we have all realised how complex ADHD is and how important thorough assessment and optimal treatment is to improved outcomes. We also have many more treatment options. My fascination for the topic has grown and grown and I have been fortunate to learn so much from the children, young people and their families and from teachers and colleagues. The aim of this book is to share sound, practical management advice built on a strong evidence base and many years of practical experience. The management of ADHD needs input from a strong multidisciplinary team to offer children and young people and their families the services they need. Our book starts with the viewpoint of David Tompkinson, a young man who has grown up with ADHD. He describes some of his experiences and how he now celebrates his ADHD and succeeds. I am very grateful to David for sharing this with us. The chapter authors come from a variety of multidisciplinary backgrounds, with contributions from paediatrics, child and adolescent psychiatry, psychology, specialist nursing, teaching and adult psychiatry, each sharing their expertise and advice on a particular aspect of ADHD management. The result is a comprehensive overview xi

Preface

of issues we face as clinicians involved in the management of ADHD and its many comorbid conditions. Although the services described are based on UK school and health systems, the principles involved and the practical management advice offered are international: ADHD is universal. I would like to thank all of the authors for their excellent input, for freely giving their valuable time and for their ongoing support throughout the process. My thanks also to the team at Mac Keith, especially Udoka Ohuonu, who has been throughout a calm and positive guide and to Lisa Trueman for patience and thoroughness as the book became ‘real’. Thank you, of course, to all the children, young people and families I have had the pleasure of working with at the Ryegate Centre in Sheffield and to the fantastic staff Team I have been privileged to work with over the years. Lastly, special thanks to my wonderful family, Martin, Briony, Nick and Krystina. Val Harpin September 2016

xii

Prologue: ADHD and proud

When Doctor Harpin asked me to write this piece for this very important and much needed book, I jumped at the chance. Of course I did. Without thinking. No hesitation. I said yes. That’s what life with ADHD is like. But whilst so much of ADHD is given a bad reputation, I’m here to let you into a little secret: it can be used to a person’s advantage. I can 100% say, even when I stop for a moment and think (a rare occasion indeed), that I am so proud to have ADHD. Of course it can be a struggle, and my journey with ADHD has had an abundance of them. But with the right help and the right support it can be channelled into success. Before I digress further, and please do bare with me if I do this, I don’t always mean to it’s just that….. whoops. There I go again. Allow me to introduce myself, my name is David Tompkinson, and I have ADHD. I want to tell what I think is a very positive story about a condition that I have struggled with, wrestled with, grown up with and eventually tamed. I came to Dr Harpin when I was a 6-year-old. I was not fascinated with the lady who has now come very close to my heart, but instead with the Mr Potato toy in her office. (I never had the heart to tell her I once ‘liberated’ his left shoe). I was referred to Dr Harpin because essentially I was a problem; a problem for my parents, teachers, brother and pretty much anyone who I was with for a long period of time. I couldn’t sit still. I was very hyperactive. I was impulsive. I was so ADHD. xiii

Prologue: ADHD and proud

At the time (and do note when I say, at the time) this was a problem because I was trouble at school and simply didn’t engage with any of my learning or teachers. But also, school didn’t engage with me. I was labelled a ‘hopeless’ case and a drain on the teachers’ time and efforts. In Infant school and Junior school, I was outside of the class more times than I was in it. Thankfully, the days of making children wait in corridors has long gone. My parents used to have countless messages from my school on the answer phone when they got home; ‘David’s done this, David’s done that.’ My father being the diligent organiser he is (a trait I never picked up), kept all the letters and exchanges between the schools and reading them back now, I can see it was just a constant battle for them. I once shed a tear reading the ending to one of my Dad’s letters to school which read: ‘Whatever people think about our son, he is incredibly special to us and we will always look to see the beauty in a boy that my wife and I love endlessly’. My parents have been my rock throughout my journey with ADHD and have kept me on the straight path so many times. Without their support I wouldn’t be where I am today. That’s my first massive avocation, supportive parents. At times it must have been so hard for my parents to put on a brave face, but they believed in me and never lost hope. Unconditional love as my Mother always puts it. As I grew older I started to manage the condition a little better. I discovered a love of history, politics, thought and debate- much to my brother’s annoyance. But he was, and still, is an incredibly intelligent man. I started to engage with him and talk to him about all the things I was interested in. He developed my love of learning and ignited passions for things I never really thought I could bring to the surface. GCSE’s were a battle and a struggle. I had lost so much of my early years in learning, and the foundations were not there. Especially in mathematics and getting a C in maths is up there with my greatest achievements, gaining me entry to Sixth form where I could study the subjects I loved. Was University in sight for a boy who was deemed a failure and a ‘no hoper’? June 6th 2012 was one of the happiest days of my life. I sat stunned, looking at a computer screen that was telling me I had been accepted at the University of Durham. My Mother was in floods of tears, unable to speak for pride. That was their day; 21 years of sleepless nights, worry, phone calls, backhanded comments from other parents. That was their moment. On the day I graduated I handed Dad my robes to try on, and I said: ‘I wouldn’t be here today if it wasn’t for you Dad.’

xiv

Prologue: ADHD and proud

I am currently training to be a primary school teacher (ironic huh?) having just graduated from Durham University with a First Class Honours degree. This is the boy who couldn’t sit still (and still can’t really) for longer than 30 seconds. This is the boy who was told by a teacher he ‘would go nowhere in life’ because he’s ‘stupid’. Life with ADHD is truly a rollercoaster. I still can’t sit still. I still can’t really concentrate. But I have found a way to make life work for me. There is hope. Just believe in the ADHD child. Give them the right support in the right places and they will go so far. I have an abundance of people to thank in my journey with ADHD. My Mother who is my rock and still to this day puts me on the right path. My Father who taught me hard work and graft- and still does to this day; my brother who cultivated my very strange yet beautiful mind (sit still no, but boy, I am as sharp as a razor sometimes); my Grandparents and my Uncle Philip. But last and not least my wonderful partner in crime, Becky- who I need to thank for being brash enough to say yes to me all that time ago. For being foolish enough to stay with me, and for loving me in a way I never thought I could be loved. I hope you have enjoyed reading my story as much as I have writing it. I have no doubt this publication will be a massive success. Dr Harpin is a lady I have no superlatives for. Her advice is impeccable. Her understanding immense and her dedication to the field of ADHD, long before I was born, amazing. Remember, believe and have the faith that the light at the end of the tunnel is not just a silly phrase but an incredible possibility. David Tompkinson

xv

Chapter 1 ADHD: background and introduction Val Harpin

ADHD can be defined simply as ‘a developmentally inappropriate level of inattention and/or hyperactivity-impulsivity present before the age of 12 years that causes significant impairment’. Diagnosing ADHD is, of course, much more complex than that sounds. Attention deficit hyperactivity disorder (ADHD) is a chronic, highly comorbid, neurodevelopmental disorder (Biederman et al. 1991; Kadesjo & Gillberg 2001; Yoshimasum et al. 2012) that typically presents with symptoms of inattention, impulsivity and hyperactivity and may have a profound impact on the individual and their family (Pliszka 1998; Harpin 2005; Biederman & Faraone 2005; Faraone et al. 2006; Loe & Feldman 2007). This book will take a practical but evidence-based look at the diagnosis and management of ADHD in children and young people.

The evolution of the concept of ADHD The use of the diagnosis of ADHD has been the subject of considerable controversy and debate. Even now, ADHD is seen, by some, as a new and invented disorder used by parents to explain the bad behaviour of their children. The National Institute for Health and Care Excellence (NICE) Guideline Development Group reviewed, in depth, the evidence that ADHD is a valid diagnostic construct, going back to the earliest literature and following the emergence of the concept and the supporting evidence. Their review and critique of the evidence is well worth reading (NICE 2008). The Group concluded 1

The Management of ADHD in Children and Young People

that there was strong evidence for the clustering of inattentive and hyperactive-impulsive symptoms in both population and clinical samples and that ADHD should be viewed as one component of a group of neurodevelopmental problems that arises from shared aetiological influences. The data reviewed also evidenced that the cluster of symptoms consistent with ADHD persists over time and causes significant impairment. There have, in fact, been descriptions of children with ADHD throughout history. The first example of a medical description of a disorder that appears to be similar to ADHD was given by Scottish physician Sir Alexander Crichton in 1798, when he described ‘the incapacity of attending with a necessary degree of constancy to any one object’. Eminent British paediatrician Sir George Still published in the Lancet in 1902, describing children with a ‘defect of moral control’ (Still 1902). He stressed that inattention, impulsivity and hyperactivity played a major role and that the condition did not respond to punishment. Later, the idea of minimal brain damage was formed, although the symptoms were also seen in individuals with no apparent neurological damage. The evolution of the concept of ADHD is described in Box 1.1, and the diagnostic criteria from DSM-5 (American Psychiatric Association 2013) are discussed further in Chapter 3. The International Classification of Diseases (ICD-10) (WHO) coding has been used in the UK and Europe. These criteria require symptoms to be present before the age of 7 years and to be of at least 6 months duration. The term ‘hyperkinetic disorder’ is used. The ICD criteria are currently under revision. Currently, the DSM criteria are most commonly used in research and in clinical practice and will be used here.

Box 1.1:  Illustration of the evolution of the concept of ADHD from Still’s description to the current American Psychiatric Association Diagnostic and Statistical Manual Version 5 (DSM-5) 2014 DSM-5 criteria 1997: DSM-IV updated criteria for ADHD 1980: Attention deficit disorder + or – hyperactivity (DSM-III) 1966: Clements listed attention as a deficit in children 1960: Minimal brain dysfunction 1955: Methylphenidate created 1937: Bradley, Benzedrine reduces overactivity 1902: George still described ADHD symptoms

2

Chapter 1  ADHD: background and introduction

Box 1.2:  ADHD affects all domains of function

Before school

School

After school

Difficulty with

Difficulty with

Difficulty with

Difficulty with

 Waking up

 Lack of focus

 Sports/clubs

 Stopping activities

 Getting ready for school

 Lower grades

 Completing homework

 Sibling interactions

 Risky behaviour and injuries

 Settling down and falling asleep

 Struggling excessively with parents

 Disruptive behaviour  Difficulty with friendships

 Sitting through dinner

Bedtime

 Bedtime prep

 Staying asleep

Continuous symptoms throughout the day

ADHD affects all aspects of an individual’s life, as shown in Box 1.2.

Prevalence of ADHD One of the major issues of controversy in the UK setting is the very high and variable prevalence rates for ADHD reported in the literature. ADHD is a common disorder. In the UK, The British Child and Adolescent Mental Health Survey (1999) carefully assessed 10 438 children between the ages of 5 and 15 years. The survey also included impairment in the diagnosis. This documented that 3.62% of boys and 0.85% of girls had ADHD (Ford et al. 2003). A study in Newcastle in the UK that specifically addressed the role of impairment found that among 7- to 8-year-old children, 11.1% had the ADHD syndrome based on symptom count alone. When impairment was also taken into account, 6.7% had ADHD, with Children’s Global Assessment Scale (C-GAS, measuring impairment) scores of less than 71, and only 4.2% had C-GAS scores of less than 61. When pervasiveness included both parent- and teacher-reported ADHD symptoms and the presence of psychosocial impairment, the prevalence fell further to 1.4%.

3

The Management of ADHD in Children and Young People

The more restricted ICD-10 diagnosis of ‘hyperkinetic disorder’ is naturally less common, with prevalence estimates of around 1.5% for boys of primary school age (McArdle et al. 2004). In the international scientific literature, prevalence estimates for ADHD vary widely across studies. Polanczyk and colleagues (2007) undertook a systematic review of prevalence studies and concluded that the great majority of variability derived from the methods used, such as the way symptoms were measured and the exact definitions used. If this was taken into account there were relatively minor differences across the world, and the estimated ADHD worldwide, pooled prevalence was around 5.3%. The same authors published an update of this review in 2014 (Polanczyk et al. 2014). They concluded that the new meta-regression analyses confirmed that ‘variability in ADHD prevalence estimates is mostly explained by methodological characteristics of the studies. In the past three decades, there has been no evidence to suggest an increase in the number of children in the community who meet criteria for ADHD when standardised diagnostic procedures are followed’. Sometimes it is helpful to divide ADHD into three presentations: • combined (50–75%) • primarily inattentive (20–30%) • primarily hyperactive-impulsive (12h

Total release

Concerta XL 18

18mg

2mg

5mg

4mg

4mg

15mg

Equasym XL

10mg

3mg

4mg

2mg

1mg

10mg

5mg

3mg

2mg

–

–

5mg

Medikinet XL

10mg

3mg

4mg

2mg

1mg

10mg

Concerta XL 27

27mg

4mg

7mg

7mg

5mg

22.5mg

Concerta XL 36

36mg

5mg

9mg

9mg

7mg

30mg

Equasym XL

20mg

6mg

7mg

4mg

2mg

20mg

Concerta XL 45

45mg

6mg

11mg

11mg

9mg

37.5mg

Methylphenidate plain

10mg

6mg

4mg

–

–

10mg

Medikinet XL

20mg

7mg

8mg

4mg

2mg

20mg

Concerta XL 54

54mg

7mg

14mg

13mg

11mg

45mg

Concerta XL 63

63mg

9mg

16mg

16mg

12mg

52.5mg

Equasym XL

30mg

9mg

11mg

6mg

4mg

30mg

Methylphenidate plain

15mg

9mg

6mg

–

–

15mg

Concerta XL 72

72mg

10mg

18mg

18mg

14mg

60mg

Medikinet XL

30mg

10mg

12mg

6mg

3mg

30mg

Equasym XL

40mg

12mg

15mg

8mg

5mg

40mg

Methylphenidate plain

20mg

13mg

7mg

–

–

20mg

Medikinet XL

40mg

13mg

15mg

8mg

3mg

40mg

Equasym XL

50mg

15mg

19mg

10mg

6mg

50mg

Methylphenidate plain

25mg

16mg

9mg

–

–

25mg

Medikinet XL

50mg

17mg

19mg

10mg

4mg

50mg

Equasym XL

60mg

18mg

22mg

12mg

7mg

60mg

Methylphenidate plain

30mg

19mg

11mg

–

–

30mg

Methylphenidate plain

262

Appendices

Appendix 5a (Continued) Product

Stated content

0–4h

4–8h

8–12h

>12h

Total release

Medikinet XL

60mg

20mg

23mg

12mg

5mg

60mg

Equasym XL

70mg

21mg

26mg

14mg

8mg

70mg

Methylphenidate plain

35mg

22mg

13mg

–

–

35mg

Medikinet XL

70mg

23mg

27mg

14mg

6mg

70mg

Equasym XL

80mg

24mg

30mg

16mg

10mg

80mg

Methylphenidate plain

40mg

25mg

15mg

–

–

40mg

Medikinet XL

80mg

27mg

31mg

16mg

7mg

80mg

Equasym XL

90mg

27mg

33mg

18mg

11mg

90mg

Methylphenidate plain

45mg

28mg

17mg

–

–

45mg

Medikinet XL

90mg

30mg

35mg

18mg

8mg

90mg

Methylphenidate plain

50mg

32mg

18mg

–

–

50mg

Courtesy: Reproduced by Professor Steve Bazire Disclaimers: 1. Chart assumes dose(s) are taken at the correct time (e.g. before, with or after food; slower transit can increase absorption). 2.  Confidence intervals are not known so these assume a uniform release. 3. Concerta XL® is reported not to release its full content so the actual release may be around 15% less than the stated content. 4. Calculations are based on proportions of the AUC (Area Under the Curve). 5. It is presumed that Xenidate XL® and Matoride XL® are equivalent to Concerta XL®, although the available data is limited. 6. Different products can be mixed e.g. IR and XL, different XLs, and omitted on some days e.g. weekends. Thanks to Prof Peter Hill, Dr Val Harpin, Dr Chris Steer, Prof David Coghill and Dr Adrian Brooke for inspiration and for help with this. Reproduced courtesy of Prof. Stephen Bazire, Choice and MedicationTM 2016.

263

264

Strengths, size and what they look like

30%

50%

Equasym XL 10mg (wax pellets in 20mg a capsule) 30mg

Medikinet 5mg XL 10mg (wax pellets in 20mg a capsule) 30mg 40mg 50mg 60mg 50%

70%

78%

78%

22%

22%

78%

Later

22%

0-4h

Release

18mg 36mg 54mg

Matoride XL (2 chamber OROS tablet)

Methylphenidate Concerta XL 18mg (3 chamber 27mg OROS capsule) 36mg 54mg Xenidate XL 18mg (wax pellet 36mg tablets) 54mg

Product

0

0

0

3

3

3

6

6

6

9 Hours

9 Hours

9 Hours

12

12

12

15

15

15

How much there is in your blood after you take a dose

Non-stimulant medicines are also available e.g. atomoxetine and guanfacine

Appendix 5b  Comparison of stimulants for the symptoms of ADHD

sprinkle onto apple sauce and give straight away • Do not chew or crush

• Swallow whole, or open and

• Take with or after breakfast

contents onto apple sauce and give straightaway

• Swallow whole, or sprinkle

• Take before breakfast

• Swallow whole – do not chew

• Take before, with or after breakfast

• Can be halved

• Swallow whole

• Take with or after food

• Swallow whole – do not chew

• Take before, with or after breakfast

Practical advice

Appendices

5mg 10mg 20mg

Strengths, size and what they look like 0-4h 90%

Later 10%

Release

0

3

6 Hours

9

12

15

How much there is in your blood after you take a dose you have one dose then a second 4 hours later

• The graph shows what happens if

Practical advice

0

3

3

6

6

9 Hours

9 Hours

12

12

15

15

you have one dose then a second 4 hours later

• The graph shows what happens if

Thanks to Prof Peter Hill, Dr Val Harpin, Dr Chris Steer, Prof David Coghill and Dr Adrian Brooke for inspiration and for help with this. Reproduced courtesy of Prof. Stephen Bazire, Choice and MedicationTM 2016.

1mg/ml solution

Dexamfetamine Amfexa 5mg 

0

If switching from one product to another talk to your prescriber if your symptoms are not as well managed Lisdexamfetamine Elvanse 30mg • Swallow whole or empty into a liquid and swallow straightaway 50mg 70mg

Immediate release tablets

Product

Non-stimulant medicines are also available e.g. atomoxetine and guanfacine

Appendix 5b  (Continued)

Appendices

265

Index

Notes: b = boxed text. t = table/diagram. App = Appendix. Page numbers in bold denote extended/ detailed treatment. Active Literacy Kit 154 ADDISS (Attention Deficit Disorder Information and Support Service) 105 ADHD (Attention Deficit Hyperactivity Disorder) adolescents see young people with ADHD advice on management 251b2 and brain chemistry 83 definition 1, 215 and diet 76–7, 134–5 effects on functionality 3b effects on quality of life 40 evolution of concept 1–3, 2b gender statistics 4 heritability 32 prevalence 3–4, 15 prognosis 4–6 societal cost 11–12 see also adult ADHD; aetiologies; comorbidity; diagnosis; growth and ADHD; parenting and ADHD; specialist nurses; symptoms; treatments

adolescents see young people with ADHD adult ADHD 239–54 adult services vs. children’s 249–50 developmentally appropriate care 247–8 historical issues 240 lack of clinician flexibility 241 lack of health services 241 ‘lost to follow-up’ 241–2 symptoms 240 transition from adolescent services 197–8, 242–7, 242b; preparation 248–9 Transition Group Curriculum 251b1 transition process 246b aetiologies 6–11, 6b, 8t, 69 brain anatomy 8t environmental 8t, 10 genetic 8t, 9 neurochemical 8t, 83, 84b1 neurophysiological 8t neurotransmitters 6 prenatal factors 10, 11b traumatic brain injury 10 affective disorder in female patients 209–10 rate of comorbidity with ADHD 46 alpha2-adrenoceptor agonists 108 and comorbidity 124

267

Index

dosing 113–14 see also medications American Academy of Child and Adolescent Psychiatry Work Group 118 American Academy of Pediatrics (AAP) 128 amfetamine 84b2 pharmacological studies 219 Anderton, Phillip 195 animal studies 218 anxiety 39, 48–9 and ADHD medication 93 in female ADHD patients 207, 210, 212 and management of ADHD 163–4 rate of comorbidity with ADHD 46 asthma 11 atomoxetine 84b2, 93–6, 108 and anxiety 164 and autism spectrum disorder (ASD) clinical effect 94–5 and comorbid substance abuse 230 dosing 94 indications 96 initiation 112–13, 113b pharmacology 94 side effects 95–6 vs. stimulants 93 attachment disorder 10, 57–8 autism spectrum disorder (ASD) 31, 52–4, 53b, 54b and ADHD medication 125 and anxiety 164 and education 169b and management of ADHD 168–70, 168b Behaviour Assessment System for Children (BASC) 40 behavioural management 63–81 anger management 75 cognitive training 76–7 dietary interventions 76–7 generic vs. specialised 76 group vs. individual intervention 74 neurofeedback 76–7 parenting interventions 66–7 preschool interventions 67b in school 72–4 schooling 156–7 self-help interventions 76

268

social skills training 75 blood pressure 34 recommended cuff bladders 260 App2c table of levels, boys 256–7 App2a table of levels, girls 258–9 App2b Bradley, Charles 83 Bradley Report (2009) 196, 196b British Child and Adolescent Mental Health Survey (1999) 3 bupropion 97–8 Canadian ADHD Resource Alliance (CADDRA) 105 carbamazepine 172 cardiovascular issues 137–48 and ADHD medications 139–40 case scenarios 137–9, 146–7 history taking 140–1 importance of monitoring: blood pressure 144; heart rate 144–5 normal heart rate by age 260 App3 physical examination 141–2, 142b possible warning signs 142 and stimulants 145 symptoms 141 Care Quality Commission 15 catechol-O-methyltransferase (COMT) 9 catecholamine reuptake inhibitors see specific medications causes (of ADHD) see aetiologies Child and Adolescent Mental Health Services (CAMHS) 161, 164, 241, 242 Child Behavior Checklist (CBCL) 40 Children and Adults with AttentionDeficit/Hyperactivity Disorder (CHADD) 105 cholinergic pathways 7 clonidine 84b2, 96–7 dosing 120 indications 97 side effects 97 and tic disorders 171 coexisting conditions see comorbidity cognitive behavioural therapy (CBT) 75 and substance abuse 227t communication disorders 52–5 and management of ADHD 167 comorbidity 9, 33, 42, 45–62, 215–16 in adolescents 196 in adults 240–1

Index

assessment of 60 behaviour 58 and behavioural intervention 73 causes 217b and choice of medication 124 diagnostic imaging 60 language and communication 59 and management of ADHD 161–74 mood 58 motor problems 59 prevalence 45–6 statistics 46 studies 216 see also specific disorders conduct disorder 47–8, 48b, 74 and management of ADHD 162–3 rate of comorbidity with ADHD 46 and substance abuse 220 Conners 3-Teacher (3-t) 117, 128 Conners Parent Rating Scale 38–9, 66 Crichton, Alexander, Sir 2 cyanotic congenital heart disease 11 depression 49–50 in female ADHD patients 207, 210, 212 and management of ADHD 164–5 developmental coordination disorder 55–6, 56b and management of ADHD 170 dexamfetamine 83, 85, 86–7, 118 and comorbid substance abuse 230 delivery systems 93 initiating 111b vs. methylphenidate 85 and preschool children 125 sustained-release 111–12 diagnosis (of ADHD) 23–44 assessment process 29b computerised testing 42–3 diagnostic criteria 2, 24 difficulty 24 family history 32 homelife and environmental factors 32 importance of timing 23 medical history 31 medication history 31 misdiagnosis 24 observation 36–8, 36b over-diagnosis 24 physical examination 33, 34b

psychological assessment 37–8 questionnaires 38–40 school and social life 32–3 in the United Kingdom 12 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 38 on autism spectrum disorders 53 changes to ADHD diagnostic criteria 202, 203b on comorbidity 46 and diagnosing ADHD 2 diagnostic criteria for ADHD 25–6b, 26–7b on neurodevelopmental disorders 50–1 questionnaires 115 Diagnostic and Statistical Manual of Mental Disorders (DSM-III) 45 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 202 diet and additives 134–5 dopamine 6, 9, 83, 87 and substance abuse 218–19 Dundee-Difficult Times of Day Scale (D-DTODS) 128 eating disorders 6, 124 electrocardiogram (ECG) 140, 142–3, 143b electroencephalogram (EEG) 34, 57, 60 epilepsy 11, 31, 34, 60 and ADHD 57, 171–2 European Academy of Childhood Disability (EACD) 56 European School Survey Project on Alcohol and Other Drugs (ESPAD) 215 fatty acid supplementation 135 female ADHD patients 201–14 adolescents 205–7 anxiety 207, 212 compared to male cases 202–3 depression 207, 212 diagnostic issues 203–5 external structures 210–11 hormonal factors 207–8, 211–12 key assessment points 209b1 key management points 209b2 lack of recognition 204b self-harm 207, 212 sexual activity 208, 212

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Index

social skills 207b and substance abuse 208 Food and Drug Administration (FDA) 83 Fragile X 10, 11 general practitioners (GPs) 16, 20 and nurse-led clinics 182 Great Ormond Street Hospital 56–7 growth and ADHD 131–6 causes of poor growth 134 effect of medications 131–2 monitoring 132–3 starting medication 133–4 guanfacine 84b2, 96–7 and comorbid substance abuse 230 and epilepsy 171–2 indications 97 prolonged-release 114, 114b side effects 97 hyperkinetic disorder 2, 4, 27 see also Attention Deficit Hyperactivity Disorder (ADHD) hyperthyroid 11, 209 Impairment continuum assessment of 28b as diagnostic tool 27–8 Incredible Years Parent Training Programme (IYPTP) 67, 68b duration 70 trials 70 International Classification of Diseases (ICD-10) 2, 4 on comorbidity 46 on hyperkinetic disorder 27 The Lancet (journal) 2 language disorders see communication disorders learning disabilities 51 and management of ADHD 167 see also specific learning difficulties (SpLD) medication, types of 83–102 active sites 84b1 anti-psychotics 163

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efficacy 218 modes of action 84b2 non-stimulant 84b2, 93–8; and ODD 162 stimulants see stimulants (main heading) see also names of medications medication, usage/monitoring 103–30 in adolescents 196–7 autonomy 126 choosing a medication 108 combining medications 124 continuing medication 125 delivery systems 125 failure to respond 121–2 follow-up clinic 123b2 gauging response 123b1 goals and targets 106–8 increasing dose process 119b introduction to patients and family 104–6, 107b managing side effects 119–21 measuring progress 115–18, 116b1, 116b2 non-stimulants: choice of 122 preschool children 124–5 prevention of substance abuse 231b2 progressive titration 112, 115, 118 and specialist nurses 182 stopping medication 125–6 switching medication 123–4 in women and girls 209 see also stimulants melatonin 167 methylphenidate 83, 84b2, 85, 86, 108 animal studies 218 delivery systems 92–3 vs. dexamfetamine 85 dosing 109 and growth 131 initiating 110b pharmacological studies 219 side effects 120 sustained-release 117–18, 262–3 App5a and young children 125 microdeletion syndrome 11 misdiagnosis see diagnosis (of ADHD); misdiagnosis Misuse of Drugs Act 1971 85 Misuse of Drugs Regulations 2001 85 modafinil 98

Index

Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) 46, 132 multisystemic therapy 163 National Autistic Society (NAS) 169 National Institute for Health and Care Excellence (NICE) 10 on ADHD as diagnostic construct 1 and adult ADHD 240, 241 and autism spectrum disorder 168 and depression 165 on impairment 27–8 on medication 118 on referrals 20 on transition to adult services 247b neurodevelopmental disorders 50–1 neurofibromatosis 10, 31 neuropsychological tests and stimulant medications 87–8 New Forest Parent Training Programme (NFPTP) 67, 67b duration 70 online version 77 and self-help 76 success treating ADHD 69 trials 70 noradrenaline 6, 83, 87 nurses see specialist nurses obsessive compulsive disorder (OCD) 39 oppositional defiant disorder (ODD) 46–7 and management of ADHD 162 rate of comorbidity with ADHD 46 parental training programmes 67–8 evidence supporting effectiveness 70–2 and specialist nurses 178–9 young children v. older children 71 see also names of specific programmes parenting and ADHD 64 communicating with adolescents 191–2 driving lessons/licensing 195 effect of negative parenting 73–4 fears of medication 105–6 girls and young women 208–9; hypercritical relationships 210 helpful techniques 69b homework 155b introducing medication 104–6, 107b

and specialist nursing 176 working with teachers 157–8 pathophysiology 7b personality disorders 39 pharmacological studies 218–19 phenylketonuria (PKU) 11 physical impairment hearing 31, 60 visual 31, 60 post-traumatic stress disorder (PTSD) 39 Preschool ADHD Treatment Study (PATS) 125 psychoeducation 63–81 definition 65 in schools 72–4 usefulness in ADHD cases 65–6 psychological assessment as diagnostic tool 37–8 psychosocial intervention 72b Quantified Behaviour Test (QBtest) 42 questionnaires Broadband rating scales 39–40 as diagnostic tool 38–40 and medication side effects 119–20 referral of ADHD patients to blood pressure specialist 143–4 to cardiologist 143 case studies 16–19 female patients 204b by GPs 16 information to include 19b Royal College of Psychiatry ADHD Network 241 schooling 149–60 and autism spectrum disorder (ASD) 169b behavioural intervention 72 behavioural management 156–7 examinations 156b and female ADHD patients 211 homework 155–6 impact of ADHD on 72, 149 impact of technology 153–4, 154b mainstream vs. specialist schools 149 and medication 112, 117 secondary education 159b, 187, 187b sex education 212

271

Index

and specialist nurses 176–7 specialist nurses and teacher training 180 study skills for ADHD children 154–5 teaching strategies for ADHD children 150–3 transitioning between schools 158–9 and treatment plans 159–60 working with parents 157–8 selective serotonin reuptake inhibitors (SSRIs) 164 self-harm/suicidal thoughts 207, 212 serotonergic pathways 7 sexuality 208, 212 SKAMP Rating Scale 39 sleep disorders 50 in adolescents 194–5 and diagnosis of ADHD 33 and management of ADHD 165–6 as side effect 120 treatment 167 SNAP-IV questionnaire 38, 39, 115, 128 social communication disorder 54–5, 55b specialist nurses 175–84 classroom observation 176–8, 177b clinics 181–2 general principles of nursing ADHD 175–6 and medication 181–2 parent training 178–9, 179b role in treatment 177b training teachers 180 working with families 178 specific learning difficulties (SpLD) 55 and management of ADHD 170 Still, George. Sir 2 stimulants 84b2, 85–93, 108–12 abuse of 221 clinical effects 88–9 comparison 264–5 App5b contraindications 145 and depression 165 effects on growth 131–2 effects on neuropsychological tests 87–8 and female patients 210 long term use 91–2 and ODD 162 recommended practice 109b side effects 85, 89–91, 120 (see also cardiovascular issues)

272

and sleep disorders 166 studies on abuse 218–19 usage guidelines 122b substance abuse 6 and ADHD medication 93; clinical implications 220–1 in adolescents with ADHD 193–4, 215–38; medical trials 227t assessment 221–2, 229b1 causes of comorbidity 217, 217b clinical studies 219 cocaine 226 in female ADHD patients 208 interactions with prescription medications 226–7 legal highs 226–7 opiates 226 pharmacological studies 218–19 prevalence in adolescence 215 reduction strategies 231 stages 224–5t studies on comorbidity 216 symptoms 222 treatment 222, 223–5, 227 suicide see self-harm/suicidal thoughts symptoms in adults 240, 241 age differences 5b in female cases 204 gender differences 202 and stimulant medications 264–5 App5b Teacher Report Form 40 Test of Everyday Attention of Children 38 Test of Variables of Attention (TOVA) 42–3 thyrotoxicosis 34 tic disorders 31, 56 and ADHD medication and management of ADHD 171 rate of comorbidity with ADHD 46 as side effect 120 Tourette syndrome 31, 39, 56–7 and ADHD medication 120–1 and management of ADHD 171 treatments anger management 75 care pathways: preschool children 260 App4a; school-age/young people 261 App4b

Index

and education 159–60 holistic approach 212 non-pharmacological 64–5, 72, 75b, 76–7, 164–5, 226; of female patients 210 social skills training 75 when comorbid with substance abuse 223–4 see also medication, types of; medication, using and monitoring; specific treatment plans tricyclic antidepressants 98 Triple P Positive Parenting Programme 67, 68b duration 70 trials 70 tuberous sclerosis 11 UK Adult ADHD Network (UKAAN) 241 Vanderbilt Assessment Scale 40, 115, 128 Wechsler Individual Achievement Tests (WIAT) 36 Wechsler Intelligence Scale for Children (WISC) 36 Williams syndrome 11 women and ADHD see female ADHD patients young people with ADHD 126, 185–200 adherence to medication 121, 125 adolescent-friendly services 248b

brain maturation 187–8 clinics 198, 198b comorbidity 196 criminal activity 195–6, 197b and depression 165 diagnostic profile 25–6b driving 195 education and employment 193 encouraging compliance with treatment plans 197 gender statistics 4 girls 205–7 hobbies and interests 193 medication choices 196–7 physical changes 186b predicted behaviours 189b relationships 194 side effects of medication 90–1, 92, 95 and sleep disorders 167, 194–5 social media 194 social skills 4, 194 substance abuse 193–4, 215–38; causes of comorbidity 217; choice of medication 228–31, 231 b1; studies 216 support for 188–9 symptom profile 5b in their own words 189–91, 190b transition to adult services 197–8, 242b transition to secondary education 187–8 youth services vs. adult 249–50

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