ADHD in Kids

PsychiatryPaediatrics
Written By Maladywise

Overview

  • 2.5% to 7.5% of kids

  • Twice as common in boys

  • Runs in families

  • Co-mordbit conditions are common

    • ODD

    • Conduct disorders

    • Tics

    • Anxiety and depression

    • Learning and language problems

    • Risk factors for academic underachievement, relationship and employment difficulties

    • Medication is one part of treatment

Main characteristics are

  • Inattention

  • Hyperactivity

  • Impulsivity

These are persistent, developmentally excessive and pervasive, and disrupt learning and socialisation

Subtypes

  • Predominately inattentive = 25 to 35%

  • Predominantely hyperactive only = Uncommon

  • Combination = 50 to 70%

Assessment

Symptoms

Hyperactivity

  • Climb out of pram or car restraint

  • Running off and getting lost in supermarkets

  • Refusing to hold hand or be restrained for safety

  • Climbing furniture, trees, fences in unsafe manner despite being asked not to

  • Not remaining seated at table or in classroom

  • Constant chatter, talking loud, talking at wrong times

  • Interupting others

  • Difficulty getting to bed, staying in ned, getting to sleep at night

  • Throwing things in the house

Impulsivity

  • Disruptive in class, sometimes to entertain others

  • Starting an activity without thinking through consequences (bake a cake at bedtime, cutting expensive clothing to alter it’s apperance, painting on the dinner table without something under it)

  • Rushing tasks without doing them properly (brushing teeth, homework, music practice)

  • Impulsive speaking without realising it might be inappropriate

  • Difficulty keeping secrets

  • Difficulty tolerating boredom

  • Getting excited about something new then loosing interest quickly

  • Overeating and making poor food choices

  • Smoking, drinking, or impulsive sex in teenage years

  • Careless spending

  • Difficulty resisting social media, internet, TV, gaming

  • Risky impulsve activities )train-surfing, shopping trolley riding, skateboard behind car, shoplifting)

Inattentive

  • Does not seem to hear you when you ask them to do something (asking multiple times to get a response)

  • Not following through on agreements

  • Easily distracted by noises or own thoughts

  • Daydreaming in class

  • No following safety instruction

  • Losing important belongings (jumper, books, lunchbox, travel pass, phones)

  • Forgetting to bring homework books home

  • Forgetting to do homework

  • Leaving lid off glue, drawers open, clean and dirty clothes together, rotten food in lunchbox, dirty plates in room)

  • Regularly running late, poor sense of time

These symptoms

  • Start < 7 years

  • Persist > 6 months

  • Cause functional impact

  • Not accounted for by another disorder

Family history

  • Mental health problems, anxiety, depression, ADHD

Social History

  • ACE

    • Physical, emotiona, sexual abuse

    • Neglect

    • Parent substance use or mental health issues

    • Intrauterine drug exposure

    • One or no parents, separation, divorce, incarceration, foster care

    • Traumatic exposure e.g. fire

Diagnosis

Exam:

  • Height and weight

  • Developmental milestones

  • Behaviour (unsual play, social engagement, sensory intolerance)

  • Dysmorphic features re: FASD

  • Parent or carer mental state and interaction

  • Non-accidental injury

Contributing conditions

  • Vision or hearing impairment

  • Poor nutrition

  • Iron deficiency

  • Constipation

  • Poor dentition

  • Eczema

  • OSA

  • Absence seizures

  • Thyroid

  • Medication side effects

Investigations

  • Hearing test

  • Visual testing

  • Sleep study

Differential or Comorbid

  • Normal behaviour

  • Anxiety / Depression

  • Attachment Disorders

  • ASD

  • ID

  • Learning difficulties

  • ODD, CD

  • Substance use

Management

Suspected ADHD

  • Diagnostic assessment by psychologist

  • Request parent and teacher behavioural scale e.g. Achenbach / Conner’s Behavioural Scale

  • Paediatrician or Psychiatrist

  • Behaviour management strategies

    • Acknowledge and reward achievements and positive behaviour often.

    • Attend to learning difficulties as soon as possible.

    • Create a quiet place without clutter for homework.

    • Talk with the child about the consequences of their actions.

    • Use a positive behaviour system at home to help increase desirable behaviours.

    • Ignore smaller negative behaviours, and use logical, immediate consequences for poor behaviours.

  • Advise parents:

    • that warm, consistent parenting with clear boundaries is optimal for a child’s development. Behavioural intervention outcomes are determined by the child's perception of their parents' or carer's motivation e.g., if intervention is perceived only as punishment, it is likely to be ineffective.

    • to reward desirable behaviour, and set clear consequences for undesirable behaviour.

  • Reassure parents and help set realistic expectations

    In most cases, behavioural difficulties are temporary, and occur as children strive to achieve normal developmental milestones. It can be helpful to see the child’s behaviour as a method for communicating their internal world:

    • Explain that interventions for behavioural concerns in children take time to work and should aim to:

      • respond to the identified contributing factors.

      • support, empower, and build skills in the important adults in the child’s life (e.g., parents or carers, teachers) and the child.

    • Provide psychoeducation where appropriate e.g., if long-term impact of prematurity on learning and attention is expected when the child starts school, or unsettled behaviour might be expected to follow access visits to biological family for children in out-of-home care.

  • Recommend useful resources:

    • The Raising Children Network website for education and advice on normal development.

    • Community Family Health Nurse for advice on normal development in children aged under 5 years, or where parenting support is required.

    • Parenting support providers (check locations covered) e.g., First Steps parenting for extra support with parenting challenges in children aged < 5 years if concerns about sleep, settling and feeding, parental postnatal depression or anxiety, adjusting to parenting, play, development and attachment intervention, behaviour management, parent/child relationship challenges, young parents, or vulnerable families, and toileting issues.

    • Resourcing Parents website for locally available parenting courses to help better equip parents e.g., Parents Under Pressure, Family Transitions, Triple P Parenting.

  • Recommend healthy eating, physical activity, getting enough sleep, and less time spent using media.

  • Encourage caregivers to spend quality one-on-one time with their child, engaging in fun activities which assist with bonding. See Raising Children Network – Enjoying Time With Your Child: Tips for Building Your Relationship.

  • provide parental education and training in behaviour management.

  • Allied health support

    • Arrange referral to:

      • a psychologist for

        • formal behavioural and/or educational assessment.

        • behavioural therapy, social skills training, or management of co-existing anxiety or depression.

      • an occupational therapist for strategies on how to cope with symptoms of inattention and/or hyperactivity.

      • a speech therapist for language delay or literacy issues.

      Request a report. A referral to public paediatric services requires report from allied health where relevant and available.

    • Therapy can be expensive, and public services wait lists are long and criteria restrictive. Where possible, consider:

  • National Disability Insurance Scheme Early Childhood Early Intervention

    • Note:

      • for patients aged 0 to 6 years who require intervention over time (e.g., those with complex psychosocial situations or a possible underlying developmental disorder e.g., ASD), parents need to self-refer.

      • no diagnosis is required initially.

      • if eligible, the service will facilitate referral to appropriate supports including ASD-specific.

      • the process can take 6 months.

    • Recommend parents self-refer to assess for eligibility for funding.

    • See Early Childhood Early Intervention (ECEI).

  • If the patient is attending school or preschool: encourage parents to seek support from the school.

  • Address co-morbidities

  • Address medical conditions

Confirmed ADHD

Resources

Maladywise https://www.maladywise.org
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