How would you manage a 5-year-old child who presented to you with a history of inattention and hyperactivity?
Introduction
- Hyperactivity is a common complaint of parents who are presenting to a child and adolescent psychiatrist. However, it is an ambiguous term which does not seem to have a clear definition among mental health professionals.
- For some, it is merely a synonym for overactivity, whilst for others it indicates a style of behaviour that includes restlessness, inattentiveness, disorganization, and impulsivity. The definitions vary between Europe and the USA, with Americans drawing a clear difference between hyperactivity and inattention, and Europeans tending to use the term 'hyperkinesis' which is a composite term including both inattention and overactive behaviour.
- In the last few years, there has been a greater rapprochement across the Atlantic, with the diagnostic criteria for Attention Deficit/ Hyperactivity Disorder (DSM-IV) and Hyperkinetic Disorder (ICD-10) being virtually the same.
- Overactivity is common, with up to a third of parents describing their child as such, and around 5-20% of children being described as overactive by their teacher
Differential Diagnosis
- It may be helpful to look first at the differential diagnosis of a hyperactive child before we look at assessment, and the management of hyperkinetic disorder. A number of different disorders (and non-psychiatric conditions) may explain hyperactivity, including:
- Normal variation — activity is normal for children, and it varies between children. There is as yet, no clear dividing line between normal activity and abnormal activity levels. Teachers, with their experience of many children, are often quite good at being able to draw boundaries around children's behaviours, and key differences such as pervasiveness and impairment are good at differentiating normal from abnormal behaviour.
- General learning disability — children with learning disability may have activity levels that are appropriate for their developmental, but not chronological age. The issue is clouded by the fact that primary hyperactivity disorders are more common in children with mild low levels of intelligence.
- Situational Variation — children react in many different ways to their environment, and able children may become bored or restless in class, or behave chaotically because their home environment is chaos. The latter children often become more organized in a structured environment
- General antisocial behaviour — opposition-defiant disorder and conduct disorder both include impulsive and disinhibited actions, and these children may be disruptive in class, being unable to accept the presence of rules of conduct. Frequently, antisocial behaviour, and primary hyperkinetic disorder coexist — ICD has a separate category for this, termed hyperkinetic conduct disorder.
- Other mental health problems — anxiety can account for a child's restlessness and inattention.
- Developmental problems — impaired verbal skills or communication difficulties may result in children not being able to attend in class, or acting the clown in order to distract themselves and others. Dyspraxic children are often disorganized and clumsy, giving the impression of poorly modulated activity.
- Medication — anticonvulsants can cause an excited irritability that can mimic hyperactivity, and some people suggest that bronchodilators can cause hyperactivity.
Assessment of the hyperactive child
- A good history is essential to any psychiatric assessment. The child's developmental history, family history, and current functioning are all vital to understanding what is going on for the child. At least 50% of children with primary hyperactivity disorders will have other mental health problems, so the assessment should not just focus on elements of hyperactivity.
- Often, a more detailed analysis of behaviours is useful, in terms of time of onset, and situational variation. Antecedents, Behaviours, and Consequences can help to differentiate conduct problems from hyperkinetic disorders. The pervasiveness of behaviours is crucial in determining whether or not hyperkinetic disorder is present. A child who misbehaves and doesn't pay attention only at home is unlikely to be hyperactive in the psychiatric sense.
- Parental approaches to their child in terms of their management of the behaviours helps not only to establish whether the problems are purely behavioural, but also gives the clinician an insight into how the parents might cope with behavioural approaches to treatment.
- Pervasiveness is one of the key features of primary hyperkinetic disorder, so discussion or liaison with teachers and schools is vital. It is often in the classroom, being such a structured environment, that hyperactivity disorders become so evident.
- Observation of the child is another part of a comprehensive assessment. Some of this can be done informally during the interview, but setting the child tasks that require settled attention can help to bring out distractible, restless behaviour. Completing a Lego model, or cancelling out all occurrence of the letter 'e' in a text may be helpful. Direct measures of inattention (for example, using computer programs) are of no diagnostic use in the clinic.
- Questionnaires are commonly used both in terms of assessment, and also in getting a baseline value of the child's behaviour. Probably the most commonly used scale in practice is the Connor's Rating Scales (CRS) which comes in versions for parents and teachers. It measures many different aspects of behaviour, but crucially includes a hyperactivity index which records things like impulsive behaviour, or inability to concentrate. They are not diagnostic scales, but are sensitive to change, and are appropriate for recording treatment responses.
- It may be appropriate, if the facilities exist, to conduct a double-blind placebo-controlled trial of stimulant medication should the diagnosis be uncertain. This involves a four week trial where each week is either placebo (two weeks in total), 5mg methylphenidate, or 10 mg methylphenidate. Parents and teachers complete CRS questionnaires for each week, and at the end of the month, the clinician is unblinded and any response of behaviour to active therapy can be assessed.
Hyperkinetic Disorder
- Hyperkinetic disorder is an increasingly common condition, and is probably the top of the list of differential diagnoses of the hyperactive child. This is partly due to the existence of an effective treatment for the condition, and perhaps also due to greater public awareness that their child's behaviour may be a medical problem amenable to treatment. Much of this kind of thinking is reaching us from the USA where some people are estimating a prevalence of 10% for ADHD, and some 20 million children are on stimulant medication.
- Hyperkinetic disorder, as classified in ICD-10, has a number of key features:
- impaired attention and hyperactivity
- these should be evident in more than one situation
- deficits in attention should only be diagnosed if they are excessive for the child's age
- the behavioural problems should be evident before the age of 6, and they should be longstanding
- Hyperkinetic disorder (HD) is three times more common in boys than in girls. In the UK, the prevalence of HD is around 0.1%.
- there is some evidence of a genetic basis, in that similar symptoms often run in families, and there is a greater concordance in MZ twins than in DZ twins. Neuroimaging has postulated that there is a dopaminergic abnormality mainly in frontal regions.
Management of HD
- The question that all parents want to know is “can you give my child Ritalin?”. Ritalin, or methylphenidate, is a stimulant drug whose mode of action is similar to amphetamines, in causing dopamine release in certain areas of the brain. It is suggested that increasing dopaminergic activity reverses the underlying problem in HD. It is licensed in the UK for HD in children. The other drug commonly used is dexamphetamine sulphate which has a similar mode of action.
- Neither dexamphetamine nor methylphenidate are recommended for children under 6 years, but the former tends to be used in children under 6 more frequently than methylphenidate. The Americans seem to be using both drugs from an early age.
- The rationale behind using these agents is to improve the attention, rather than making the child docile. By being able to attend to schoolwork and other tasks requiring sustained attention, it is hoped that the problems of poor schooling and inability to learn can be minimised to improve function in later life.
- The mainstays of first-line treatment in mild to moderate cases are behavioural therapies, special educational provision, and family advice.
Prescribing psychostimulants
- Stimulant drugs should perhaps be seen as a last-resort treatment for HD, and many people would suggest that they only be used after a suitable trial of non-drug treatments has failed.
- A sensible approach to prescribing involves starting the drug at a low dose (methylphenidate 10 mg per day), usually given in two 5 mg doses. Most children take it in the morning and at lunchtime to cover the school day in particular, although many take it at other times as well.
- Side-effects of methylphenidate include insomnia (some are reluctant to use it in the evening, mood changes, appetite suppression, and reduced growth rate. It is estimated that the average child treated with psychostimulants would lose perhaps 1-2 cm of his expected adult height.
Conclusions
- It is often observed that inattention and hyperactivity lessen with age, perhaps due to eventual learning of age-specific behaviours and social norms. Despite this, the emergence of the possibility of adult ADHD has arising firstly in the USA, and now in this country. Some psychiatrists are advocating the use of methylphenidate in adults, as well as lifelong treatment for some children.
- Hyperkinetic disorder is a disabling condition which can affect educational attainment significantly. Antisocial behaviour is seen in 25% of adults who had ADHD as children, and 20% meet the criteria for antisocial personality disorder in adult life. It is therefore a condition which is worth treating.
- Behavioural approaches should be used in the first instance and in mild cases, this may be all that is required. However, stimulants should not be overlooked since they are effective treatment for ADHD. Sensible approaches to assessment and treatment, with the support of the family and teachers at all stages can reduce the likelihood of pervasive disability from this condition.
