Therapeutic Focus

Attention Deficit Hyperactivity Disorder(ADHD)

Hyperkinetic (attention deficit) disorder Presenting complaints
Patients:

• can't sit still
• are always moving
• cannot wait for others
• will not listen to what others say
• have poor concentration.

Younger ones are likely to be failing in school work.

Diagnostic features

Usually there is:

• severe difficulty in maintaining attention (short attention span, frequent changes of activity)
• abnormal physical restlessness (most evident in classroom or at mealtimes)
• impulsiveness (the patient cannot wait his or her turn, or acts without thinking).

Sometimes there may be discipline problems, underachievement in school, proneness to accidents.
This pattern occurs in all situations (home, school, play).
Avoid premature diagnosis. High levels of physical activity are not necessarily abnormal.
Differential diagnosis
Also consider presence of:

• a specific physical disorder (e.g., epilepsy, fetal alcohol syndrome, thyroid disease)
• general emotional disorders (patient exhibits anxiety depression)
• autism (social/language impairment and sterotyped behaviours are present)
• conduct disorder (patient exhibits disruptive behaviour without inattentiveness, see Conduct disorder - F91)
• mild mental retardation or learning disability.

Hyperkinetic behaviour can either cause or result from parent-child problems. Assessment of family relationships may be important. Hyperkinetic (attention deficit) disorder - management guidelines Essential information for patient and family

• Hyperkinetic behaviour is not the child's fault, it is caused by an impairment of attention and self-control that is often inborn.
• The outcome is better if parents can be calm and accepting.
• Hyperactive children need extra help to remain calm and attentive at home and school.
• Some hyperactive children continue to have difficulties into adulthood, but most make a satisfactory adjustment.

Counselling of patient and family

• Encourage parents to give positive feedback or recognition when the child is able to pay attention.
• Avoid punishment. Disciplinary control must be immediate (within seconds) to be effective.
• Advise parents to discuss the problem with the child's schoolteacher (to explain that learning will be in short bursts, immediate rewards will encourage attention, and periods of individual attention in class may be beneficial).
• Stress the need to minimise distractions (e.g., have child sit at front of class).
• Sport or other physical activity may help release excess energy.
• Encourage parents to meet with the school psychologist or counsellor (if available).

Medication

For more severe cases, stimulant medication may improve attention and reduce overactivity (e.g., methylphenidate 15-45mg a day or dextroamphetamine 10-30mg a day). Pemoline 6-120mg a day is preferred if substance abuse is possible (adolescents) and clonidine 25-50mg a day is preferred if motor tics are also present.

Specialist consultation

If available, consider consultation before starting drug treatment or if the above measures are unsuccessful.

Referral for behavioural treatment, if available, can improve attention and self-control.