Arabic clinical guidelines for ADHD
ADHD is a persistent and severe impairment of psychosocial development resulting from a high level of inattentive, hyperactivity and impulsive behavior, its onset in early childhood, below age of 7- it often persists into adolescence and adult life and puts its sufferers at risk for a range of abnormalities in personality development.
(European clinical guidelines)
ICD 10 criteria: -
-All three problems of attention, hyperactivity and impulsiveness should be present.
-More stringent criteria for pervasiveness a cross situation are met.
-The presence of another disorder of another disorder such as anxiety state is in itself an exclusion criterion.
-Most cases will have a single diagnosis.
-Clinically significant impairment in social, academic or occupational functioning.
Broadly defined and so commoners diagnosis: -
Majority of practicing psychiatrists find criteria of DSM 4 to be more useful in their clinical uses.
For impairment: -
-Children Global assessment scale (CGAS) > 60.
-Multi-axial classification of child and adolescent psychiatry disorder (WHO) axis 6 (range 0-8).
-Conduct & oppositional defiant disorder.
-Emotional disorders (anxiety & depression).
-Specific learning disorders.
-Developmental coordination disorder.
-Mental retardation not better accounted.
Workup primary care level: -
-Hearing & vision tests, CBC, TFT, & sugar as indicated by history.
-If there is evidence of impairment then child to be referred to mental health developmental pediatrics.
-List of differential diagnosis to be included.
Clinical interview: -
-With the child (observation).
-With the parents.
-Obtaining information from kindergarten, school.
-AD/HD symptoms must be evaluated according to child developmental level.
Secondary care level-
-Any significant co-morbidity.
-Intelligent testing if indicated by history.
-Stimulus should only be prescribed after a full assessment has been made.
-Assessment should be comprehensive, multidisciplinary.
-Speech and language as indicated by history.
-Attention and impulsivity tests.
-These tests are not standardized for individual diagnosis.
-Investigation should not be done routinely but guided by history and physical examination.
-Treatment should be tittered to meet individual needs.
-Treatment should be multimodal.
-Methylphenidate (up to one year to monitor efficacy, up to 60 mg).
-Dexamphetamine, atomoxetine, chlonidine, imipramine, desipramine, long acting methylphenidate.
-Initial medication should be as a trial and.
-Methylphenidate is usually the 1st choice and given twice daily doses (0.2mg per Kg dose).
-If these medications failed dexamethasone can be used.
-Long acting methylphenidate can be used as 1st choice. Advantage is that it is given once daily and so increase compliance.
Stimulants are contraindicated in schizophrenia, hyperthyroidism, cardiac arrhythmias, angina pectoris and glaucoma.
Caution is needed in depression. Tics, severe mental retardation and drug dependence or alcoholism.
Monitoring At each visit check: -
Psychological interventions: -
-Psycho education to child, family and teachers.
-Parent training and behavioral interventions in the family which include
-Analysis of positive and negative consequences and contingencies of appropriate and problem behaviors together with parents.
-Teach parent effective methods communicating commands and setting rules.
-Use of token systems in order to reinforce positive behavior in specific situations.
-Develop with parent appropriate negative consequences for problem behavior.
-Response cost system, timeout.
Educational intervention: -
-Teacher training and behavioral intervention similar principles adopted for parents.
-Social skill training.
-Apply self-instruction to the child, school and home.
-Smaller number of children in each class.
-Teacher assistant should be available.
-ADHD children should sit in front of the class, close to the teacher.
-Avoid distraction as much as possible.
-Increase time allocated for class work and class examination.
-Frequent reminder of the time and exam progress.
-Clarify what each question exactly mean.
-Doing exam in a separate quite room if necessary.
Dietary Treatment :-
-Food & Food colorings and preservatives as a main cause of hyperactivity is a false concept.
-Reduce sugar, evening primrose oil- little value.
-There is no enough evidence to establish guidelines for dietary treatment.