Dr Fiona Forbes discusses the role of the GP in the identification of suspected attention deficit hyperactivity disorder and hyperkinetic disorder in children

Children with attention deficit hyperactivity disorder (ADHD) have persistent and disabling levels of restlessness and impulsiveness and/or inattention beyond developmental norms. The Diagnostic and statistical manual (DSM-IV) classifies ADHD into three categories:1

  • hyperactive-impulsive (restlessness and impulsiveness)
  • inattentive
  • combined (all of the above).

The International Classification of Diseases (ICD) system (version 10),2 uses the term hyperkinetic disorder (HKD), and its diagnostic criteria are more strict: the core symptoms of HKD—impaired attention and overactivity—need to be evident in more than one situation and onset must be before the age of 6 years. Symptoms need to be ‘of long duration’ (while DSM-IV stipulates of at least 6 months’ duration). Hyperkinetic disorder equates best with the ‘combined’ type of ADHD. However, the term ‘ADHD’ has become common parlance, even among UK specialists, despite the likelihood that it is a group or spectrum of disorders. The SIGN guideline uses the term ‘attention deficit and hyperkinetic disorders’ and the abbreviation ‘ADHD/HKD’, and this will be the term and the abbreviation used in this article.3

Prevalence of ADHD/HKD

Attention deficit and hyperkinetic disorders are common, chronic neurodevelopmental conditions affecting many areas of a child’s life, with a high rate of secondary problems and associated disorders. At least two-thirds of children with the condition continue to have problems in adolescence and many of them in turn continue to be symptomatic into adulthood.3

The prevalence rate of HKD (the most severe type of ADHD) is approximately 1.5% of schoolchildren; 5% is a conservative estimate for the prevalence of the less severe forms. However a study of children’s services (mental health and paediatrics) in Scotland found that only 0.6% of children were receiving input for ADHD/HKD.4

Updated guideline

The 2009 SIGN guideline on the Management of attention deficit and hyperkinetic disorders in children and young people (SIGN 112) updates SIGN 52, which was published in 2001.5 This update focuses on treatment and interventions, and concentrated on studies in which improvement in core ADHD/HKD symptoms was the primary outcome.3 A comprehensive NICE guideline on ADHD/HKD was published in 2008, which covered all age groups,6 and its evidence tables were examined and updated for the 2009 SIGN guideline as appropriate. An information leaflet for parents/carers, which is plain English approved by a Crystal Mark, is also available on the SIGN website (see www.sign.ac.uk/pdf/pat112.pdf).

Role of GP

The GP has three main responsibilities in the assessment and management of ADHD/HKD:3

  • Identification of possible ADHD/HKD and referral to appropriate service
  • Awareness of the range of disorders commonly associated with ADHD/HKD and of difficulties often experienced secondary to ADHD/HKD
  • Involvement in shared care, post-diagnosis, principally with respect to drug treatment.

Identification of suspected ADHD/HKD

Parents and/or teachers may suspect a child has ADHD/HKD or there may be concern about general behaviour difficulties. It is important to ask about the core features of ADHD/HKD, namely:3

  • poor concentration
  • overactivity and restlessness, and impulsiveness
  • duration (more than 6 months is necessary for diagnosis)
  • age of onset—before the age of 6 years (ICD-10 criterion for HKD); before the age of 7 years (DSM-IV criterion for ADHD)
  • if they occur in more than one situation (e.g. school and home)
  • the extent to which they are impairing the child’s day-to-day functioning.

If there is a strong suspicion of ADHD/HKD, the child should be referred for specialist assessment. Most commonly, it is the local child and adolescent mental health service (CAMHS), which manages possible ADHD/HKD, but sometimes it is the local paediatric service.3

Specialist assessment

Specialist assessment should involve a clinical interview with the child and their parents/carers covering the presenting difficulties and interventions to date, pre-natal and developmental history, family history, and family functioning. In addition, older children may require an individual assessment.3

Clinical examination of children and young people should include a systems enquiry (history taking of different bodily systems, e.g. cardiovascular, respiratory), details of previous health problems, current drug treatment, and physical examination. Vision and hearing should be assessed and formally tested if indicated.3

Parental consent should be sought to obtain information from the child’s school regarding the child’s presentation, as well as attainment level, and whether the child is achieving relative to age and ability.3

Questionnaires/rating scales, completed by parents and teachers (and adolescent patients) can be helpful. However, there is no laboratory or psychological diagnostic test.3

Associated disorders

Attention deficit and hyperkinetic disorders are associated with an increased rate of other conditions, including depression, anxiety, other behavioural disorders, autism spectrum disorders, tic disorders, specific learning difficulties, and developmental coordination disorder.3,7 Sleep problems are common, but not a criterion for diagnosis.3

Problems secondary to ADHD/HKD

Children with ADHD/HKD are at increased risk of a wide range of adverse sequelae, including low self-esteem, academic underachievement, poor peer relationships, disrupted family relationships, accidents, and anti-social behaviour. They may also be at increased risk of future substance misuse.3

Treatment of ADHD/HKD

Attention deficit and hyperkinetic disorders can impact on many areas of a child’s life. This results in the need for provision of a comprehensive package of care for children with these conditions. The SIGN guideline continues to underline the importance of a multi-agency approach to management of ADHD/HKD, particularly between health and education services.3

The Guideline Development Group (GDG) while updating the treatment section of SIGN 52, reviewed evidence for the effectiveness of a range of interventions, including psychological, pharmacological, and ‘alternative’ treatments.3 The main recommendations with respect to specific treatment approaches are summarised in Figure 1.

It is likely that the GP’s main role in treatment of ADHD/HKD will be in the prescribing of medication, usually on a shared-care basis with specialist services.3 A small number of GPs conduct ADHD/HKD medication review clinics for children who are well stabilised on medication, while maintaining links with specialist services.

Figure 1: Summary of recommended treatment approaches 3
ADHD=attention deficit hyperactivity disorder; HKD=hyperkinetic disorder; ODD=oppositional defiant disorder Scottish Intercollegiate Guidelines Network. Management of attention deficit and hyperkinetic disorders in children and young people. A national clinical guideline. SIGN 112. Edinburgh: SIGN, 2009. Reproduced with kind permission of the Scottish Intercollegiate Guidelines Network

Psychological interventions

Parents
The SIGN guideline recommends behavioural parent training for parents of pre-school children with symptoms of ADHD/HKD. This training should be delivered by trained facilitators.

Equipping parents with behavioural management techniques can be useful, particularly for oppositional behaviour problems often associated with ADHD/HKD. A behavioural analysis (‘ABC’ ‘Antecedents Behaviour Consequences’) allows problem behaviours to be targeted by trying to avert them, and by instituting immediate consequences if they occur.3 Parents should be encouraged to identify and positively reinforce good behaviours—a process that has often been lost amid heightened family tension and arguments—in parallel with tackling problem behaviours.3

Behavioural parent-training programmes should be considered in the first instance for parents of school-aged children with mild symptoms of ADHD/HKD. In pre-adolescent children with more severe symptoms, this intervention is recommended for the treatment of associated behavioural and/or anxiety disorders, which commonly co-exist with ADHD/HKD.3

Child
Individual cognitive, self-regulatory training (particularly targeting impulsive behaviours) for children with ADHD/HKD has not been proven to be very successful. Psychosocial treatment approaches with children are best reserved for associated problems, such as anxiety, low self-esteem, problems with peer relationships.

School
Individualised school-intervention programmes, including behavioural and educational interventions are recommended for children with ADHD/HKD.

Pharmacological interventions

Medication is recommended as treatment for core symptoms of severe ADHD (equivalent to HKD), and in general, results in superior outcomes compared with behavioural interventions. Only a specialist in either child and adolescent psychiatry or paediatrics who has training in the use and monitoring of psychotropic medications should initiate pharmacological treatment. Pharmacological treatment is not recommended as first-line therapy for children of pre-school age.

The use of medication, and in particular stimulants such as methylphenidate, has sparked controversy, at least in the media. Yet these are relatively safe drugs, which have been used for decades, and have been shown in numerous studies to be effective in treating the core symptoms of ADHD/HKD, at least in the short-to-medium term (24 months).

There are three licensed medicines in the UK for the treatment of ADHD/HKD:

  • psychostimulants:
    • methylphenidate hydrochloride
    • dexamfetamine sulphate
  • non-psychostimulant—atomoxetine.

Methylphenidate and atomoxetine are licensed for use in children aged 6 years and above, and dexamfetamine is licensed for use in children aged 3 years and above.

The continuing benefit from, and need for medication should be assessed at least once per year.3

Psychostimulant medication

Psychostimulants are the first-choice medication for core symptoms of ADHD/HKD. The SIGN guideline recommends that if the first psychostimulant is ineffective the other should be used. In the UK, it is most commonly methylphenidate that is the psychostimulant of choice. If there is no response to methylphenidate or poor tolerance of side-effects, dexamfetamine can be considered. The effect of psychostimulants occurs very quickly—in approximately 20 minutes—and lasts for only 3 or 4 hours.

Healthcare professionals should note that psychostimulants are controlled drugs.

Adverse effects

The adverse effects of psychostimulants include insomnia, reduced appetite, abdominal pain, gastrointestinal disturbance, headache, nausea, dizziness; and less frequently, anxiety, irritability or tearfulness. Most of the short-term adverse effects are dose related and subject to differences between patients. They frequently diminish within 1–2 weeks of starting treatment, and usually disappear when treatment is discontinued, or the dose reduced.3

There is some evidence that growth may be affected in some children treated with psychostimulants and this should be monitored regularly. In addition, there remains debate about the association of tics with psychostimulant use, but it is likely to be a weaker relationship than previously thought.

Titration and monitoring

A trial of a psychostimulant is initiated with a small dose, gradually increasing, with response titrated against adverse effects. During this trial period, there should be close liaison with parents and with the school. Once an optimum response has been reached, arrangements for follow up and 6-monthly checks of height, weight, and blood pressure are necessary.3 Good practice entails continuing liaison with the school to help in decisions regarding possible dose adjustments. With regards to long-term prescribing of stimulant medication, shared-care protocols should be developed with GPs.3

It should be noted that there are three modified-release formulations of methylphenidate to facilitate medication cover throughout the day and these may also help improve compliance especially in adolescents. There is a very helpful table in the SIGN guideline that summarises the main characteristics of each of the methylphenidate formulations.3

Currently, there is no UK licensed modified-release preparation of dexamfetamine available.

Abuse potential of psychostimulants
Despite some media reports suggesting otherwise, methylphenidate has a much lower abuse potential than cocaine, but abuse does occur, mainly by intravenous injection. Although ADHD/HKD per se may increase the risk of later substance misuse, treatment with psychostimulants may confer a protective effect compared with no treatment.8

Non-psychostimulant medication

Atomoxetine
Atomoxetine is a relatively new drug. It is a noradrenaline reuptake inhibitor and is licensed for use in the UK for the treatment of ADHD/HKD in children aged 6 years and older. It is recommended for treating core symptoms of ADHD/HKD in children in whom psychostimulant medication is not appropriate, not tolerated, or is ineffective.

Adverse effects
Adverse effects of atomoxetine include nausea, appetite reduction, abdominal pain, dry mouth, insomnia, constipation and mood swings. These adverse effects are similar to those seen with psychostimulants and diminish over the first few months of treatment. Unlike psychostimulants, somnolence is commonly seen with atomoxetine. It has been suggested that this drug is less likely to cause sleep problems in comparison to psychostimulants, but there are no data delineating this from the somnolent adverse effect of the medication.3

Initiating medication
Prescribing of atomoxetine is based upon body weight for individuals under 70 kg.3,9

The effects of atomoxetine may not become apparent for 4 or more weeks. Anecdotal evidence has found that treatment at the highest dose for up to 12 weeks may be necessary before benefits are observed. Once treatment is established, efficacy is described as being present over the 24-hour period, with possibly greater effect over the 12 hours following administration. Short-term initial combination with psychostimulant medication may be necessary during the transition phase.3

Follow up
Prescribing of atomoxetine requires patient review every 6 months, which should include:3

  • assessment of ongoing efficacy and adverse effects
  • measurement of growth, pulse, and blood pressure.

Additional monitoring is advised for patients at increased cardiovascular, hepatobiliary, and seizure risk, and for potential suicidal ideation.3

Unlicensed medications

The SIGN guideline reviews several unlicensed treatments including tricyclic antidepressants and the
alpha-2-noradrenergic drug, clonidine. There is less evidence for the effectiveness of these medications in treating ADHD/HKD symptoms, and they should only be considered when licensed medications have been unsuccessful. Their use should only be considered by clinicians with considerable experience in the treatment of ADHD/HKD.3

Treatment duration

It is important to establish the necessity of continuing drug treatment in patients (e.g. by having annual drug-free periods in adolescence, and monitoring response).3 However, many children with ADHD/HKD will continue to require medication to treat the core symptoms of these disorders during their teenage years and indeed for some this requirement will continue into adulthood.

Nutrition and complementary and alternative therapies

The GP may also be asked about dietary and other approaches by the patient and/or parent/carer; the main findings and recommendations in the SIGN guideline are summarised below.

Nutrition
On reviewing the evidence, the SIGN GDG concluded that, as a good practice point, avoiding foods and drinks that contain certain artificial colours and/or preservatives may help some children with ADHD/HKD. Parents should be advised to take reasonable steps to limit the number and variety of these colours and preservatives in their children’s diet, excluding any item that seems to provoke an extreme physical or behavioural reaction.3

Supplementation
The SIGN guideline recommends, as a good practice point, that clinicians should consider iron status when taking a history, with measurement of serum iron and ferritin, and treatment where appropriate.3

There was insufficient evidence to recommend use of omega-3, omega-6, zinc, and antioxidant supplements.

Alternative and complementary therapies
There was insufficient evidence on which to base recommendations for the use of Bach flower remedies, homeopathy, massage therapy, and neurofeedback.3

Implementation

With respect to implementing the guideline recommendations on treatment of ADHD/HKD:

  • the provision of behavioural parent training should involve staff training and interagency service development across health, local authority, and voluntary sectors
  • the initiation and monitoring of pharmacological treatment by specialists in child and adolescent psychiatry or paediatrics will place an increasing burden on these specialists, especially as recognition of ADHD/HKD improves. In one Scottish Health Board area, two GPs have taken on an ‘ADHD/HKD review clinic’, linked to the local CAMHS. This may be a useful model to consider replicating elsewhere
  • the importance of a joint management approach between health and education services has been highlighted; this will entail training and a commitment to a coordinated approach to management.

Conclusion

Attention deficit and hyperkinetic disorders are common, chronic conditions that can adversely impact on many areas of a child and young person’s life and for which there are evidence-based treatment approaches. One national study in Scotland found that it is considerably under-recognised. The GP is well placed to identify possible ADHD/HKD and to contribute to their often long-term management.

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • The SIGN guideline emphasises the importance of multi-agency working to support patients with ADHD/HKD
  • Commissioners need to ensure they commission an effective care pathway for ADHD/HKD that captures all the specified elements
  • There should be clear shared-care guidelines for the prescribing of medications (including the use of unlicensed medicines) and monitoring of patients
  • There should be a clear referral pathway for patients with suspected
  • ADHD/HKD that is devised locally and understood by primary healthcare and educational services
  • Commissioners could look at the possibility of community GPwSIs or specialist nurse clinics to support patients along the pathway and ensure the necessary monitoring takes place
  • Commissioners should ensure an effective transfer process into adult services for those with persistent symptoms
  • Mental health services are currently outside the payment by results tariff system
  1. American Psychiatric Association. DSM–IV: Diagnostic and statistical manual of mental disorders, 4th edition. Washington DC: American Psychiatric Association, 1994.
  2. World Health Organization. The ICD–10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: WHO, 2007.
  3. Scottish Intercollegiate Guidelines Network. Management of attention deficit and hyperkinetic disorders in children and young people. SIGN 112. Edinburgh: SIGN, 2009. Available at: www.sign.ac.uk/guidelines/fulltext/112/index.html
  4. NHS Quality Improvement Scotland. Attention deficit and hyperkinetic disorders: services over Scotland. Report of the implementation review exercise. Edinburgh: NHS Quality Improvement Scotland, 2008. Available at: www.nhshealthquality.org/nhsqis/files/MentalHealth_ADHD_ImplementationReview_APR08.pdf
  5. Scottish Intercollegiate Guidelines Network. Attention deficit and hyperkinetic disorders in children and young people. SIGN 52. Edinburgh: SIGN, 2001.
  6. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG72
  7. Scottish Intercollegiate Guidelines Network. Assessment, diagnosis and clinical interventions for children and young people with autism spectrum disorders: a national clinical guideline SIGN 98. Edinburgh: SIGN, 2007. Available at: www.sign.ac.uk/guidelines/fulltext/98/index.html
  8. Wilens T, Faraone S, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Paediatrics 2003; 111 (1): 179–185.
  9. Joint Formulary Committee. British National Formulary—BNF 58. London: British Medical Association and Royal Pharmaceutical Society of Great Britain, 2009.G