Attention deficit hyperactivity disorder

Pre-referral guidelines for primary care providers

Referrals
Prereferral guidelines A-Z index
Attention deficit hyperactivity disorder

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice points

Management

Referral pathways

Attention deficit hyperactivity disorder (ADHD) is a common, sometimes controversial neuro-developmental disorder characterised by inattentiveness, hyperactivity and impulsivity. 3-5% of children are reportedly affected, with males more commonly diagnosed than females.

Diagnosis

ADHD is a clinical diagnosis made with the assistance of various questionnaires from both parents and teachers. There are no routine blood tests or imaging studies to assist with diagnosis.

The preschool age group are generally not diagnosed with ADHD given many of the diagnostic behaviours are normal in children of this age, thus a wait and watch approach is preferred.

Various screening tools exist for ADHD and other externalising disorders, such as the Vanderbilt questionnaire, Child Behavioural Checklist (CBCL or Achenbach questionnaire), Connor's questionnaire, SNAP IV questionnaire, etc.

DSM-V criteria:

Symptoms must have been present prior to 12 years of age, in amounts that clearly interfere with or reduce the quality of social, academic or occupational functioning. Symptoms must be present in one or two settings, not be explained by another mental disorder and include at least 6 out of 9 of the following:

  • Inattentive subtype
    • fails to give close attention to detail or makes careless mistakes
    • often has difficulty sustaining attention in tasks or play
    • often does not listen when spoken to directly
    • often does not follow through on instructions and fails to finish tasks
    • often has difficulty organizing tasks and activities
    • often avoids or is reluctant to engage in tasks that require sustained mental effort
    • often loses things necessary for tasks or activities
    • is often easily distracted by extraneous stimuli
    • is often forgetful in daily activities
  • Hyperactive subtype
    • often fidgets or taps hands or squirms in seat
    • often leaves seat in situations when remaining seated is expected
    • often runs about of climbs in situations where it is inappropriate
    • often unable to play or engage in activities quietly
    • is often ‘on the go’ acting as if ‘driven by a motor’
    • often talks excessively
    • often blurts out answers before questions have been completed
    • often has difficulty awaiting turn
    • often interrupts or intrudes on others

Practice points

  • Children display many features of ADHD as part of their normal development in their preschool years, thus we generally do not diagnose or treat children with ADHD in preschool years.
  • Consider developmental delay, intellectual disability, learning disorders or autism spectrum disorders manifesting as ADHD symptoms.
  • It is always important to gather information on the child’s behaviour from the school and other services involved.
  • Sleep impacts significantly on childhood behaviour, thus tackling any sleep difficulties is paramount to managing behaviour and ADHD symptoms.
  • Ensure hearing difficulties have been excluded prior to diagnosing ADHD
  • Always remember the role of the family and the child's environment as a contributing/ confounding factor in the presentation of possible ADHD.

Management

If there are concerns surrounding a child’s behaviour in the preschool age we advise behavior modification strategies, consideration of psychology services to help parents /careers, along with a monitoring approach.

The management of ADHD involves a combination of parental education, training and support, behavioural psychology and, when there is significant functional impairment not responsive to other management strategies, medication via a paediatrician. Children with ADHD are best managed via a multidisciplinary team.

Medication

  • Stimulants
    • methylphenidate (Ritalin®, Concerta®)
    • dexamphetamine (dexamphatemine, Vyvanse®).
  • Non-stimulants
    • atomoxetine (Strattera®)
    • guanfacine (not currently licensed for use in Australia).
  • other medications as required e.g. melatonin, clonidine.
  • Stimulant medications and atomoxetine can only be initiated by, or in consultation with, a paediatrician or psychiatrist.
  • All prescriptions require authority and expire in 6 months, regardless of amounts prescribed or repeats filled.
  • General practitioners may re-prescribe ADHD medications after consultation with a paediatrician or psychiatrist.
  • Common side effects include (but are not limited to): headache and gastro-intestinal upset (generally transient); appetite suppression and sleep disturbance; hypertension and tachycardia (rare).

Referral pathways

  • Paediatrician
    • generally a non-urgent referral to paediatric outpatient services to i) confirm diagnosis, ii) discuss management strategies and iii) consider appropriateness of medication.
    • Information to bring to any appointments:
      • recent school reports and any written reports from teachers
      • any testing (cognitive, learning, etc)
      • behavioural questionnaires (if done)
  • Psychologists
    • Psychology services can offer specific behavioural therapy to asset with symptom control in ADHD prior to the consideration of medication
    • Refer families for psychology whilst awaiting paediatric review if parenting strategies have been unsuccessful.
  • School support services
    • For school who are having significant difficulties with a child's behaviour, there are various options for assistance, including both school support services and psychology services.
  • Parent support groups
    • Pinarc ADHD support group 53291361