Adult ADHD for GPs Maria Mazfari Associate Nurse Consultant Adult ADHD Tina Profitt Clinical Nurse Specialist Adult ADHD
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What is ADHD? ADHD is a valid clinical condition defined in the DSM-IV and ICD-10 (hyperkinetic disorder) by high levels of; Hyperactive, Impulsive and Inattentive behaviours beginning in early childhood, persistent over time, pervasive across situations leading to clinically significant impairments.
ADHD: Is a common neurodevelopmental disorder Is associated with significant adult psychopathology Symptoms are present in childhood and often persist Results in significant impairment Is often associated with comorbidity Is often confused with other disorders Is a valid diagnosis Is a highly treatable condition, with evidencebased guidelines
So what does the ICD-10 Criteria say? Criteria for Hyperkinetic Disorder: All three of A, B, and C Onset of the disorder is no later than the age of 7 years. The criteria should be met for more than a single situation, for example, the combination of inattention and hyperactivity should be present both at home and at school (work), or at both school (work) and another setting where the person is observed, such as a clinic. (Evidence for cross-situationality will ordinarily require information from more than one source; parental reports about classroom behaviour, for instance, are unlikely to be sufficient.) The symptoms in A and C cause clinically significant distress or impairment in social, academic or occupational functioning.
Inattention A. At least six symptoms of attention have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with the level of development. Often fails to give close attention to details, or makes careless errors in school work, work or other activities Often fails to sustain attention in tasks or play activities Often appears not to listen to what is being said to him or her Often fails to follow through on instructions or to finish school work, chores or duties in the workplace (not because of oppositional behaviour or failure to understand instructions) Is often impaired in organising tasks and activities Often avoids or strongly dislikes tasks, such as homework, that require sustained mental effort Often loses things necessary for certain tasks and activities, such as school assignments, pencils, books, toys or tools Is often easily distracted by external stimuli Is often forgetful in the course of daily activities
Hyperactivity B. At least three symptoms of hyperactivity have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with the level of development. Often fidgets with hands or feet or squirms on seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, only feelings of restlessness may be present) Is often unduly noisy in playing or has difficulty in engaging quietly in leisure activities Often exhibits a persistent pattern of excessive motor activity that is not substantially modified by social context or demands
C. At least one of the following symptoms of impulsivity has persisted for at least 6 months, to a degree that is maladaptive and inconsistent with the level of development Impulsivity Often blurts out answers before questions have been completed Often fails to wait in lines or await turns in games or group situations Often interrupts or intrudes on others (for example, butts into others conversations or games) Often talks excessively without appropriate response to social constraints Sources National Collaborating Centre for Mental Health, National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. British Psychological Society. ICD-10 Version: 2010
How do these translate? - Adult ADHD symptoms Carelessness, lack of attention to detail Continually starting new tasks before finishing old ones Poor organisational skills, Inability to focus, or prioritise Continually losing or misplacing things Restlessness and edginess Difficulty keeping quiet and speaking out of turn Blurting responses, poor social timing when talking to others Interrupting people Mood swings (emotional dysregulation as opposed to pervasive mood states) Irritability and a quick temper Coping poorly with stress Extreme impatience Taking risks in activities, often with little, or no, regard for personal safety or safety of others Reference: NHS Choices ADHD/Symptoms in Adults) cited in AADD-UK 2012 (http://aadduk.org/)
For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should: meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder), [2] and be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings. As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. NICE CG 72 (2008, 2013) NG 87 (2018)
What ADHD is NOT!: Common Co-morbid Diagnoses; Learning Disability Oppositional Defiant Disorder Conduct Disorder Depression Anxiety Personality Disorders Substance misuse
ADHD is a highly heritable disorder, with twin studies suggesting a heritability estimate of.76 (Faraone et al., 2005). Therefore a parent or close relative of a child diagnosed with ADHD may present with higher risk of having the condition (and Vice Versa) A number of early developmental risk factors have also emerged as significant predictors of ADHD and its symptoms: Genetics/Heritability Smoking during pregnancy Prenatal exposures to other agents, such as alcohol, illicit drugs, and psychotropic medications Premature birth (before 37 weeks) and low birth weight Post-date delivery (40+) Maternal stress and psychosocial adversity during pregnancy Damage to the brain either whilst in womb or first few years of life (anoxia / seizures (including febrile seizures) increase risk profile) (J Can Acad Child Adolesc Psychiatry. 2013 Feb; 22(1): 47 54)
ADHD as an early developmental risk for the development of other mental health disorders Anxiety and Depression Antisocial PD Borderline PD Substance Use Disorders Environmental and Genetic Risks
The Assessment Tools used in TEWV Adult ADHD Service Adult ADHD Self Report Scale (ASRS-v1.1) An instrument consisting of 18 DSM-IV-TR criteria. ASRS-v1.1 is used as a screening tool. Insights gained through screening can suggest the need for a more in depth clinical assessment./interview. Takes approx. 5 minutes to complete. The Question content reflects the importance that DSM-IV places on; symptoms, impairments and history for a correct diagnosis. To save on resources this is one of the screening tools sent out prior initial appointment. Patients are asked to bring them to the initial appointment.
Defining Impairment (NICE) Impairment to a degree that most people would consider requires some form of medical, social or educational intervention Without a specialist professional or higher level of intervention to ameliorate the problems, there is likely to be long term, adverse implications to the person affected, as well as problems in the short and medium term Impairment should be pervasive, occur in multiple settings and be at least of moderate severity Significant impairment should not be considered where the impact of ADHD symptoms are restricted to academic work / performance alone, unless there are moderate to severe impact on other domains
Developmental Impact of ADHD Pre-School School age Adolescent College Adult Behavioural disturbance Behavioural disturbance Not reaching exam potential Academic Failure Mood instability Low selfesteem Not coping with ADLs Low selfesteem Feelings of parental Incompetence Academic Impairment Increasing lack of acceptance / tolerance from peers Occupational difficulties Relationship Problems Difficulty organising Difficulty in social interaction often tolerated by peers Smoking / SUDs Low selfesteem Diff. planning & task completion Motor accidents Anti-social Behaviour SUDs Injury / Accidents SUDs Parenting
Why bother treating ADHD? Life expectancy of individual with untreated ADHD is 15 years less than those without! The life trajectory of and outcomes of individuals with ADHD are significantly improved with medication / treatment ADHD is a highly treatable disorder Typical Improvements: Less restlessness & Fidgeting Sustained effort (especially for tedious tasks) Better at initiating and completing tasks More able to read (mind wanders less) Less ceaseless, unfocussed mental activity More able to wait (less boredom, impatience, irritability) Less mood instability
Assessment / Interventions Drug treatment should be: the first-line treatment unless the person prefers psychological treatment started only under the guidance of a psychiatrist, nurse prescriber specialising in ADHD or other clinical prescriber with training in ADHD diagnosis and management part of a comprehensive treatment programme addressing psychological, behavioural and educational or occupational needs. Carry out a pre-drug treatment assessment first Including; a full mental health and social assessment risk assessment for substance misuse and drug diversion.
Physical Health Screening NICE recommend regular physical screening prior to and during pharmacological treatment in Adult ADHD Initial assessment BP Pulse Weight/ Height (BMI) Explore any Personal/Family History of Cardiac Problems EGC
Key Points Important areas to cover when taking a history Presenting complaints Age of onset Pervasiveness of symptoms Screening for common co-morbidities Assessing for impairment Personal / Early Development / Developmental history Psychiatric History Family History Drug / Alcohol / Addiction History Risk assessment / Formulation
Having ADHD does not mean that a person can t have strengths and maximise these in order to achieve success The people seeking support from mental health services will ordinarily have functional difficulties / impairment and may not have found theirs
What ADHD Means to me? A Service User Perspective
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