Adult ADHD for GPs

Maria Mazfari – Associate Nurse Consultant Adult ADHD

Tina Profitt – Clinical Nurse Specialist Adult ADHD

I’m a Believer….. Are You?

What is ADHD?

ADHD is a valid clinical condition defined in the

DSM-IV and ICD-10 (hyperkinetic disorder) by high

levels of;

Hyperactive, Impulsive and Inattentive

behaviours beginning in early childhood,

persistent over time, pervasive across

situations leading to clinically significant

impairments.

ADHD:

• Is a common neurodevelopmental disorder

• Is associated with significant adult

psychopathology

• Symptoms are present in childhood and

often persist

• Results in significant impairment

• Is often associated with comorbidity

• Is often confused with other disorders

• Is a valid diagnosis

• Is a highly treatable condition, with evidence-

based guidelines

So what does the ICD-10 Criteria say?

Criteria for Hyperkinetic Disorder:

All three of A, B, and C

Onset of the disorder is no later than the age of 7 years.

The criteria should be met for more than a single situation, for

example, the combination of inattention and hyperactivity should be

present both at home and at school (work), or at both school (work)

and another setting where the person is observed, such as a clinic.

(Evidence for cross-situationality will ordinarily require information

from more than one source; parental reports about classroom

behaviour, for instance, are unlikely to be sufficient.)

The symptoms in A and C cause clinically significant distress or

impairment in social, academic or occupational functioning.

A. At least six symptoms of attention have persisted for at least 6

months, to a degree that is maladaptive and inconsistent with the level

of development.

Often fails to give close attention to details, or makes careless errors in school

work, work or other activities

Often fails to sustain attention in tasks or play activities

Often appears not to listen to what is being said to him or her

Often fails to follow through on instructions or to finish school work, chores or

duties in the workplace (not because of oppositional behaviour or failure to

understand instructions)

Is often impaired in organising tasks and activities

Often avoids or strongly dislikes tasks, such as homework, that require sustained

mental effort

Often loses things necessary for certain tasks and activities, such as school

assignments, pencils, books, toys or tools

Is often easily distracted by external stimuli Is often forgetful in the course of daily

activities

Inattention

B. At least three symptoms of

hyperactivity have persisted for at least 6

months, to a degree that is maladaptive and

inconsistent with the level of development.

Often fidgets with hands or feet or squirms on seat

Often leaves seat in classroom or in other situations in which remaining seated is expected

Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, only feelings of restlessness may be present)

Is often unduly noisy in playing or has difficulty in engaging quietly in leisure activities

Often exhibits a persistent pattern of excessive motor activity that is not substantially modified by social context or demands

Hyperactivity

Sources

National Collaborating Centre for Mental Health, National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. British Psychological Society.

ICD-10 Version: 2010

C. At least one of the following symptoms of

impulsivity has persisted for at least 6 months, to a

degree that is maladaptive and inconsistent with the

level of development

Impulsivity

Often blurts out answers before questions have been completed

Often fails to wait in lines or await turns in games or group situations

Often interrupts or intrudes on others (for example, butts into others’ conversations or games)

Often talks excessively without appropriate response to social constraints

How do these translate? - Adult ADHD symptoms

Carelessness, lack of attention to detail

Continually starting new tasks before finishing old ones

Poor organisational skills, Inability to focus, or prioritise

Continually losing or misplacing things

Restlessness and edginess

Difficulty keeping quiet and speaking out of turn

Blurting responses, poor social timing when talking to others

Interrupting people

Mood swings (emotional dysregulation as opposed to pervasive mood states)

Irritability and a quick temper

Coping poorly with stress

Extreme impatience

Taking risks in activities, often with little, or no, regard for personal safety or safety

of others

Reference: NHS Choices ADHD/Symptoms in Adults) cited in

AADD-UK 2012 (http://aadduk.org/)

For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:

meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder),[2] and

be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and

be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.

As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health.

NICE CG 72 (2008, 2013) NG 87 (2018)

What ADHD is NOT!:

Common Co-morbid Diagnoses;

Learning Disability

Oppositional Defiant Disorder

Conduct Disorder

Anxiety

Depression

Personality Disorders

Substance misuse

ADHD is a highly heritable disorder, with twin studies suggesting a heritability

estimate of .76 (Faraone et al., 2005).

Therefore a parent or close relative of a child diagnosed with ADHD may

present with higher risk of having the condition (and Vice Versa)

A number of early developmental risk factors have also emerged as significant

predictors of ADHD and its symptoms: • Genetics/Heritability

• Smoking during pregnancy

• Prenatal exposures to other agents, such as alcohol, illicit drugs, and psychotropic

medications

• Premature birth (before 37 weeks) and low birth weight

• Post-date delivery (40+)

• Maternal stress and psychosocial adversity during pregnancy

• Damage to the brain either whilst in womb or first few years of life (anoxia / seizures

(including febrile seizures) increase risk profile)

(J Can Acad Child Adolesc Psychiatry. 2013 Feb; 22(1): 47–54)

Anxiety and Depression

Antisocial PD

Borderline PD

Substance Use Disorders

Environmental and Genetic Risks

ADHD as an early developmental

risk for the development of other

mental health disorders

The Assessment Tools used in TEWV Adult ADHD Service

Adult ADHD Self Report Scale (ASRS-v1.1)

An instrument consisting of 18 DSM-IV-TR criteria.

ASRS-v1.1 is used as a screening tool. Insights gained through screening can

suggest the need for a more in depth clinical assessment./interview.

Takes approx. 5 minutes to complete.

The Question content reflects the importance that DSM-IV places on; symptoms,

impairments and history for a correct diagnosis.

To save on resources this is one of the screening tools sent out prior initial

appointment. Patients are asked to bring them to the initial appointment.

Defining “Impairment” (NICE)

Impairment to a degree that most people would consider requires

some form of medical, social or educational intervention

Without a specialist professional or higher level of intervention to

ameliorate the problems, there is likely to be long term, adverse

implications to the person affected, as well as problems in the short

and medium term

Impairment should be pervasive, occur in multiple settings and be

at least of moderate severity

Significant impairment should not be considered where the impact of

ADHD symptoms are restricted to academic work / performance

alone, unless there are moderate to severe impact on other domains

Pre-School School age Adolescent College Adult

Behavioural

disturbance

Behavioural

disturbance

Not reaching

exam

potential

Academic

Failure

Mood instability

Low self-

esteem

Not coping

with ADLs

Low self-

esteem

Feelings of

parental

Incompetence

Academic

Impairment

Increasing

lack of

acceptance /

tolerance

from peers

Occupational

difficulties

Relationship

Problems

Difficulty

organising

Difficulty in

social

interaction

often

tolerated by

peers

Smoking /

SUDs

Low self-

esteem

Diff. planning &

task

completion

Motor accidents

Anti-social

Behaviour

SUDs

Injury /

Accidents

SUDs

Parenting

Developmental Impact of ADHD

Why bother treating ADHD?

Life expectancy of individual with untreated ADHD is 15 years less than those

without!

The life trajectory of and outcomes of individuals with ADHD are significantly

improved with medication / treatment

ADHD is a highly treatable disorder

Typical Improvements:

Less restlessness & Fidgeting

Sustained effort (especially for tedious tasks)

Better at initiating and completing tasks

More able to read (mind wanders less)

Less ceaseless, unfocussed mental activity

More able to wait (less boredom, impatience, irritability)

Less mood instability

Assessment / Interventions

Drug treatment should be:

– the first-line treatment unless the person prefers psychological treatment

– started only under the guidance of a psychiatrist, nurse prescriber

specialising in ADHD or other clinical prescriber with training in ADHD

diagnosis and management

– part of a comprehensive treatment programme addressing

psychological, behavioural and educational or occupational needs.

Carry out a pre-drug treatment assessment first –Including;

– a full mental health and social assessment

–risk assessment for substance misuse and drug diversion.

Physical Health Screening

NICE recommend regular physical screening prior to and during pharmacological

treatment in Adult ADHD

Initial assessment

BP

Pulse

Weight/ Height (BMI)

Explore any Personal/Family History

of Cardiac Problems

EGC

Key Points

Important areas to cover when taking a history

Presenting complaints

Age of onset

Pervasiveness of symptoms

Screening for common co-morbidities

Assessing for impairment

Personal / Early Development / Developmental history

Psychiatric History

Family History

Drug / Alcohol / Addiction History

Risk assessment / Formulation

Having ADHD does not mean that a person

can’t have strengths and maximise these in

order to achieve success…

The people seeking support from mental

health services will ordinarily have

functional difficulties / impairment and may

not have found theirs…

What ADHD Means to me?

A Service User Perspective

Any Questions