Managing ADHD in primary care

There is often no more satisfying or rewarding condition for a family practitioner to treat than child and adult attention deficit hyperactivity disorder (ADHD). Unfortunately, it is still a somewhat controversial condition. It does not need to be controversial. The prevalence of ADHD is about 5%, which makes it a very common disorder in general practice.

It is a neurodevelopmental condition with neurobiological and genetic underpinnings as strong as schizophrenia or bipolar disorder. Some of the clinical features can occur in the normal population, but in no way to the same degree.  

Definition of ADHD

The American Psychiatric Association DSM V defines a person with ADHD as someone who:

• Often fails to give close attention to details
• Has difficulty sustaining attention in tasks
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and finish work
• Often has difficulty organising tasks and activities
• Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
• Often loses things necessary for tasks or activities
•  Is often easily distracted
• Is often forgetful.

To get a diagnosis of childhood ADD (inattentive type) you need six or more of these symptoms. This condition is particularly missed in females.

In relation to the hyperactive impulsive type of ADHD, one needs at least six of the following symptoms, or for adolescents or adults aged 17 or older at least five symptoms are required from the following:

• Often fidgets or taps hands or feet
• Often leaves the seat in situations where remaining seated is expected
• Often runs about or climbs excessively
• Often unable to play or engage in leisure activities quietly
• Often on the go
• Often talks excessively
• Often blurts out answers before questions have been completed
• Often difficulty awaiting turn
• Often interrupts or intrudes into others.

In addition, several of these inattentive or hyperactive impulsive symptoms have to be present before the age of 12 years and there has to be functional impairment in two or more areas, eg. home, school, work or other activities.  There is also a severity coding in the new DSM V that is mild, moderate or severe. This is not a difficult diagnosis to make.

Possible misdiagnosis

In adults the condition is often confused with bipolar disorder or borderline personality disorder. Adults often present to their family practitioner with ADHD, with a history of problems from primary school onwards such as:

• Early drop-out from school
• Underperforming academically in relation to their IQ
• Attendance at many different post-school courses with drop out
• Having long lists of jobs, often up to 20 or more 
• Being easily bored
• Being impulsive, forgetful, easily distracted, restless
• Having difficulties remaining seated
• Being very disorganised
• Having poor time management
• Being extremely forgetful and/or not completing cognitive or other tasks. 

They often dabble in self-medication, for example cannabis, and indeed can go on to use cocaine as a form of self-medication, with tragic consequences.

They often have a tendency to get in trouble with the law and indeed, rates in prisons are higher than in the average population. Persons in trouble with the law should always be assessed for undiagnosed and untreated ADHD. They tend to have very high rates of marital breakdown and relationship breakdown. They also tend to experience a lot of accidents and are what is called ‘accident prone’. They use up extra health resources because of accidents, substance misuse and engagement in risky behaviour. They are sensation-seeking or novelty-seeking and can do well in occupations where there is a lot of novelty. This condition is not rare in artists and creative people.

Up to 50% of children and adolescents referred to child and adolescent mental health services will meet the criteria for ADHD. When children are in difficulties at school it is always necessary to assess and rule out ADHD. This would be one of the most common reasons for referral to child and adolescent mental health. Children and adolescents with inattentive type of ADHD are often missed for years and indeed it is very common for me to see them for the first time in their Leaving Certificate year when they are underperforming and it is clear that they have underperformed throughout their school career. It is a condition that is particularly easily missed in girls.

Those with severe hyperactive impulsive type of ADHD are on the other hand often quite obvious in pre-school play groups and one will often hear in the history that they have been in a number of pre-school groups because of their difficulties. These children will often require extra resource teaching in school, access to special needs assistants and during their Leaving Cert year it is necessary to complete the DARE form, which is part of the CAO form for people with this disability. They may need extra exam accommodations for their public examinations.

In terms of treatment, one starts with behavioural interventions, for example sitting in front of the class, sitting beside children with good concentration, sitting away from distraction. Depending on the age of the child, they are given stars or points for sitting on their seat, keeping their desk tidy, taking down material from the blackboard, etc.  If behavioural interventions are unsuccessful then medications should be considered. In Ireland, these medications are licensed up to the age of 18, after which they are prescribed off label. The exception medication is Concerta, a long-acting stimulant, which when prescribed before 18 can be continued on into adulthood. 

There is one medication licensed for adults in this country and this is called Strattera, which is not a stimulant. The medications used for children and adolescents include Ritalin, Equasym, Medikinet and Tyvense, the latter of which is a new medication licensed in this country as a second-line drug containing lisdexamfetamine dimesylate.  

Concerta lasts approximately 12 hours, the other medications last the schoolday, for example Medikinet MR, Ritalin LA, and Equasym XL.

The short-acting medications like Ritalin and dexamphetamine have to be given approximately three times a day. Ritalin has been on the market for about 50 years.  Strattera, which is not a stimulant and licensed for adults, lasts for 24 hours and is somewhat slower in being active initially. It is useful particularly for those who need 24-hour cover or who need very early morning cover or late at night cover. It can be given once a day or twice a day. 

Common side-effects include appetite suppression, stomach aches, headaches, irritability, weight loss, mild increase in blood pressure and heart rate. It is traditional to check height, weight, blood pressure and pulse before starting medication, and to do a full blood count yearly, but more frequently in very small children where the appetite suppression can have much more significant effects.

Elite athletes need to inform the TUE (Irish Sports Council’s Therapeutic Use Exemption) if they are on stimulants like Ritalin etc.

Persons with ADHD will often have comorbid conditions which should also be looked for and these will include oppositional defiant disorder, conduct disorder, Asperger’s syndrome, autism, anxiety, depression, specific learning difficulties, etc. These conditions will require treatment in their own right.

It is not uncommon for persons with ADHD to have talents in areas like sports, eg. Olympic athletes Michael Phelps and Ashley McKenzie. In the pop music world, Kurt Cobain, who was prescribed Ritalin, and persons with ADHD in the past have often been major explorers, novelists etc. 

It is important for families not to be pessimistic about ADHD, but to move forward hopefully, and it is important for families to know that there are effective treatments for this condition. It is often an enormous relief for the patient and the family to know that there is a diagnosis and a treatment for their condition. Sadly, people with ADHD are often labelled as lazy. 

People often ask if this is a new condition, but the truth is it is not new and indeed the ancient Greeks described the core features. Later, Hoffman described it in 1845 and George Still in England in 1902. In 1947 it was described as minimal brain damage and later as minimal brain dysfunction. Later still, in the 1960s it was described as hyperactive child syndrome, as attention deficit disorder in the 1970s and finally as attention deficit hyperactivity disorder in the 1980s. It is important to remember that behavioural interventions are used as a first-line treatment. 

References

1. Fitzgerald M, Belgrove M, Gill M. (2007) Handbook of Attention Deficit Hyper Activity Disorder. John Wiley & Sons: Chichester
2. Fitzgerald M. (2008) Attention Deficit Hyper Activity Disorder: Creativity, Novelty Seeking and Risk. Nova Science Publishers: New York