GP Dr Chris Barclay welcomes comprehensive guidance from SIGN on treating attention deficit and hyperkinetic disorders in children
The latest SIGN guideline addresses a subject that many will be aware of but few will be confident in handling – attention deficit hyperactivity disorder)(ADHD) and hyperkinetic disorders (HKD).1
These disorders appear to be excessive expression of otherwise normal childhood behaviours. The extensive literature relates to North American Caucasian males and may not be transferable to girls or to children in the UK.
ADHD is a sustained behavioural disorder beginning in early childhood and affecting life at home, school and in social spheres. It probably affects 2-5% of children in the UK, and is four time more common in boys than girls. It induces negative attitudes in parents, who are thus more likely to suffer depression and marital/relationship difficulties.
Although many children grow out of the problem, in some it continues into adolescence and adult life. Those who do grow out of it may find their education potential and social relationships with peers, family and teachers permanently blighted.
Not surprisingly, ADHD is strongly linked to substance abuse and antisocial and criminal activity later in life. Children with ADHD are also more likely to be involved in accidents.
One of the most useful parts of the guideline was the clear presentation of the nomenclature. I felt immediately empowered by being enabled to apply names to some of the behaviours I have come across.
- ADHD – developmentally inappropriate levels of impulsive behaviour, difficulty in concentrating, disorganised activity, excessive levels of activity; subdivided into a predominantly inattentive type, a predominantly hyperactive-impulsive type and a combined type
- HKD – part of the ADHD spectrum,abut requires more severe disturbance, with significant hyperactivity as a diagnostic criterion
- Conduct disorder and oppositional defiant disorder – although not defined, these self-explanatory and immediately recognisable disorders appear to be present in at least one quarter of children with ADHD.
ADHD is treatable. The SIGN guideline describes help that can be given to affected children and those around them, but stresses that a thorough assessment should be made by appropriately qualified practitioners. In general practice, this means being alert to ADHD, offering support to affected families and arranging for swift referral to a paediatrician with a particular interest in ADHD or a child/ adolescent psychiatrist. Significant levels of psychiatric co-morbidity exist in children with ADHD.
The initial assessment will be made from the history obtained from parents or carers. Children with ADHD may not behave typically when visiting the surgery. Parental reports must be taken seriously, although the children themselves are better at reporting their internal feelings. Psycho-educational reports are also of great assistance. Psychological and psychiatric assessments are more helpful than clinical and laboratory testing.
Therapies split into the pharmacological and non-pharmacological (which includes family and school interventions). The role of psychostimulants is discussed in detail. Methylphenidate and dexamphetamine are most commonly used and should be reserved for specialist use.
Specialist prescribers should be named and be rapidly accessible should problems arise with medication. "Clear lines of contact should be established between the family and the treating physician," say the guideline authors. When a stable and effective dose has been achieved it is permissible for GPs to prescribe, but a shared care protocol should be in place.
The gold standard now is a comprehensive specialist assessment of the child's psychosocial universe followed by specialist prescription and monitoring of therapy.
This guideline will be of immediate use to all concerned with child health and welfare (see Figure 1, below, for Quick Reference Guide). If implemented, it could have considerable benefits, not only for the children and their families, but also for society in general.
|Figure 1: Quick Refernce Guide to attention deficit and hyperkinetic disorders in children and young people (SIGN Guideline No. 52)|
- Attention Deficit and Hyperkinetic Disorders in Children and Young People. Edinburgh: SIGN, 2001.