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Q1: Definition, classification and epidemiology (3 min)
- Define ADHD and classify by DSM-5-TR presentation (predominantly inattentive, predominantly hyperactive-impulsive, combined). Why is "ADD" no longer used?
- State the DSM-5-TR symptom thresholds (6+ children, 5+ adults 17+), the duration (at least 6 months), the age-of-onset change from DSM-IV (before 7) to DSM-5-TR (before 12), and the requirement for 2+ settings and impairment.
- Give the prevalence (~5 percent children, 2.5 percent adults), the M:F ratio (3:1 clinic, 2:1 community — why are girls under-diagnosed?), and the heritability (74-88 percent — top tier in psychiatry; name susceptibility genes DAT1, DRD4, SNAP25).
Q2: Pathophysiology and mechanism (3 min)
- Explain the catecholamine / inverted-U hypothesis. Why can a stimulant "calm" hyperactivity?
- Name the brain regions implicated (dorsolateral PFC, anterior cingulate, striatum, cerebellar vermis, corpus callosum) and the cortical maturation lag (~2-3 years, Shaw).
- Describe the four dopamine pathways and how each maps to ADHD symptoms (mesocortical = inattention; mesolimbic = delay aversion/reward; nigrostriatal = hyperactivity; tuberoinfundibular = spared).
- Contrast the mechanisms of methylphenidate (blocks DAT/NET), amphetamines/lisdexamfetamine (promote release + reverse transporter), atomoxetine (selective NA reuptake inhibitor), and guanfacine/clonidine (alpha-2A agonist). Why is lisdexamfetamine preferred in adults (prodrug, less abuse/diversion)?
Q3: Differential diagnosis (2 min)
- List the medical mimics (hyperthyroidism, sleep disorders/OSA, hearing/vision impairment, iron deficiency, lead poisoning, absence seizures, fragile X, fetal alcohol spectrum disorder, TBI).
- Distinguish ADHD from anxiety, depression, bipolar disorder (episodic mood elevation — stabilise mood FIRST), autism (social-communication deficits), ODD (wilful defiance), and substance intoxication.
- State the rule: ADHD is highly comorbid (~60-70 percent have a comorbidity). Diagnose both, treat both.
Q4: Investigations and rating scales (2 min)
- Confirm ADHD is a CLINICAL diagnosis — no blood test, genetic test, or scan.
- Reproduce the DSM-5-TR criteria A-E verbatim.
- Name the rating scales: SNAP-IV, Conners-3, Vanderbilt (children); ASRS-v1.1 (adults — 4 of 6 shaded boxes positive).
- State baseline investigations before a stimulant: height/weight on centile chart, BP, HR; ECG only if cardiac history/symptoms/family history of sudden death under 40.
- State what MUST be excluded before diagnosing adult ADHD (active SUD, mania, psychosis).
Q5: Management — definitive and stepwise (3 min)
- Reproduce the NICE NG87 stepped approach: under 6 = group parent-training FIRST; 6+ = methylphenidate first-line after specialist diagnosis; adults = lisdexamfetamine first-line.
- Give methylphenidate, lisdexamfetamine, atomoxetine and guanfacine starting and typical effective doses and max doses.
- State the MTA Cooperative Group 14-month RCT result (combined stimulant + behavioural best short-term; advantage attenuates long-term).
- Describe monitoring on stimulants: height/weight 6-monthly on centile chart, BP/HR, appetite, sleep, mood, tics; drug holidays; diversion control.
- List contraindications to stimulants (symptomatic cardiac disease, structural heart defects, severe anxiety/psychosis, hyperthyroidism, glaucoma, MAOI) and the comorbidities that favour atomoxetine or alpha-2 agonists (tics, SUD, anxiety).
Q6: Complications, prognosis and special populations (3 min)
- List stimulant adverse effects (appetite, growth, insomnia, irritability, tics, cardiovascular, psychosis, bruxism).
- List atomoxetine black-box warnings (hepatotoxicity, suicidal ideation in children/adolescents).
- State that ADHD persists into adulthood in ~60 percent (full ~15 percent, partial ~45 percent); hyperactivity declines most, inattention persists.
- List the long-term risks of untreated ADHD (school drop-out, motor-vehicle crashes, SUD, incarceration, suicide) and the predictors of good/poor outcome.
- Address special populations: pre-school (behavioural first), girls/women (under-diagnosed, hormonal), pregnancy/breastfeeding (specialist MDT), adults (lisdexamfetamine first-line), SUD (atomoxetine/lisdexamfetamine prodrug), autism/intellectual disability (lower doses).
Q7: High-yield exam pearls (1 min)
- DSM-5-TR thresholds: 6+ children, 5+ adults; onset before 12 (was 7); 2+ settings; impairment; not better explained.
- Stimulants first-line (70-80 percent response); methylphenidate blocks DAT/NET; lisdexamfetamine = prodrug.
- Atomoxetine = SNRI, slower, non-addictive; two black-box warnings (hepatotoxicity, suicidal ideation).
- Behavioural therapy first under 6; combined for moderate-severe; lisdexamfetamine first-line in adults (NICE).
- ASRS-v1.1: 4 of 6 in shaded boxes = positive.
- Heritability 74-88 percent; persists in ~60 percent of adults.