Primary care plays a key role in the management of
ADHD
Making a provisional diagnosis and referring appropriately
It is estimated that at least 5% of children in New Zealand have ADHD; which equates to one or two children in every classroom.
ADHD tends to run in families. It is a complex genetic disorder with a range of environmental and other nongenetic factors involved in its expression. Family history, pregnancy and delivery complications, maternal smoking during pregnancy and adverse family environment variables are considered important risk factors for ADHD.1
The principle characteristics are inattention, hyperactivity and impulsivity that are excessive, longterm and pervasive
For some people with ADHD inattention is the predominant issue, for others hyperactivity and impulsivity predominate. Some people exhibit both inattention and hyperactivity/impulsivity.
These behaviours are, of course, not exclusive to people with ADHD. Everyone shows them at some time. Many parents for example, rate their under five-year olds as inattentive and hyperactive but most of these behaviours settle with time.
For a diagnosis of ADHD to be considered the behaviours must be excessive, longterm and pervasive. They must:
- appear before the age of seven years
- continue for at least six months and
- create a real handicap in at least two areas of a person’s life, usually home and school
ADHD-like behaviour may have other causes
When general practitioners are considering a diagnosis of ADHD they will first want to seek other causes for these behaviours such as:
- hearing or visual problems
- stressful or chaotic family situations
- undetected seizures
- adverse effects of medications, such as sympathomimetics for asthma management
Diagnosis and management usually requires specialist multidisciplinary approach
Diagnosis of ADHD, consideration of management options and evaluation of response to treatment, usually requires comprehensive assessments by specialist multidisciplinary teams. As well as gathering information on a child’s behaviour these assessments need to address specific cultural issues, which may impact on a child’s behaviour, the support that is available and the ability of carers to adhere to management strategies.
Specialist teams also consider other conditions, which may account for the behaviours, such as psychosis and autism. Comorbidities will be found in most children with ADHD. Some of these, such as oppositional defiant disorder, conduct or learning disorders, can mistakenly be assumed to be part of the ADHD but require their own management strategies. Oppositional defiant disorder, the commonest comorbidity, is characterised by persistent negativistic, hostile and defiant behaviour causing significant functional impairment.
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