ADHD

The GP’s role in the management of ADHD

It helps to remind patients that ADHD is not all bad. ADHD is associated with positive attributes
such as being more spontaneous and adventurous. Some studies have indicated that people
with ADHD may be better equipped for lateral thinking. It has been suggested that explorers or
entrepreneurs are more likely to have ADHD.

In addition, GPs can reinforce the importance of developing healthy sleep-wake behaviours,
obtaining adequate exercise and good nutrition. These are the building blocks on which other
treatment is based. For patients who are taking stimulant medication, it is helpful if the GP
continues to monitor their blood pressure, given that stimulant medication may cause elevation.
Once a patient has been stabilised on medication for ADHD, the psychiatrist may refer the
patient back to the GP for ongoing prescribing in line with state-based guidelines. However, in
most states and territories, the GP is not granted permission to alter the dose.

Text B

ADHD: Overview

Contrary to common belief, ADHD is not just a disorder of childhood. At least 40 to 50% of
children with ADHD will continue to meet criteria in adulthood, with ADHD affecting about one in
20 adults. ADHD can be masked by many comorbid disorders that GPs are typically good at
recognising such as depression, anxiety and substance use. In patients with underlying ADHD,
the attentional, hyperactive or organisational problems pre-date the comorbid disorders and are
not episodic as the comorbid disorders may be. GPs are encouraged to ask whether the
complaints are of recent onset or longstanding. Collateral history can be helpful for developing a
timeline of symptoms (e.g. parent or partner interview). Diagnosis of underlying ADHD in these
patients will significantly improve their treatment outcomes, general health and quality of life.
Text C

TABLE 2 . MEDICATIONS FOR ATTENTION D EFICIT HYPERACTIVITY DISORDER AND

TYPICAL DOSING

Medication Initiation Dose

Im m ediate- 5 to 10 mg in the m orning the firs t Total dose typically varies

release day; add a second dose of 5 to between 10 m g /day and
m ethylphenidate lO m g at lunch tim e for a week; then 60 m g /day
add fu rth e r increm ents weekly Doses o f more than
8 0 m g /d a y are uncommon
(m aximum recom m ended
dose in the NICE guidelines
is 1 0 0 m g /d a y)11
Transition to longer-acting
form ula tions can occur a fte r
a month

Extended-release 18 or 3 6 m g /d a y taken once daily in Increase in 18 mg

m ethylphenidate the m orning increm ents to a maximum of
72 m g /d a y
Adjust dosage a t weekly
intervals

Long-acting 2 0 m g /day taken once daily in the Adjust dose weekly in

m ethylphenidate m orning 10 mg increm ents
Dose usually would not
exceed 6 0 m g /d a y

D exam fetam ine 2.5 to 5 .0 mg in the m orning the Total dose typically varies
firs t day; add a second dose of 2.5 between 5 m g /d a y and
to 5 .0 mg a t lunch tim e for a week; 30 m g /d a y
then add fu rth e r increm ents weekly Doses over 40 m g /d a y
are uncom m on (m aximum
recom m ended dose in
the NICE guidelines is
60 m g /d a y )11

Lisdexam fetam ine 3 0 mg in the m orning the firs t day; Dose range typically 3 0 to
increase up to 70 mg according to 70 m g /d a y
response

Atom oxetine For tho se weighing less than 70 kg, Target dose 8 0 m g /day
s ta rt at 0 .5 m g /k g taken once daily Maximum dose 1 0 0 mg3
fo r three days then increase to
1 .2 m g /k g once daily in the morning
or as evenly divided doses in the
m orning and late a fte rn o o n /e a rly
evening. For those w eighing more
than 70 kg, s ta rt at 4 0 m g /d a y taken
once daily fo r three days then
increase to ta rg e t dose of 8 0 mg3
Text D

T reatm en t of ADHD

It is very im p o rtan t th a t the dosage of m edication is individually optim ised. An analogy m ay be m ade
w ith getting the right pair of glasses - you need th e rig h t prescription for your particular
p resen tatio n w ith n o t too m uch correction and n o t too little. The optim al dose typically requires
careful titratio n by a psychiatrist w ith ADHD expertise. Multiple follow-up appointm ents are usually
req u ired to m axim ise the tre a tm e n t outcome. It is essential th a t the benefits of tre a tm e n t outw eigh
any negative effects. Common side effects of stim u lan t m edication m ay include:
• ap petite suppression
• insom nia
• palpitations and increased h e a rt rate
• feelings of anxiety
• dry m outh and sw eating

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

Page 272
 • Look at the four texts, A-D, in the (printable) Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.

• Write your answers on the spaces provided in the ANSW ER SHEET.

• Answer all the questions within the 15-minute time limit.

ADHD

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from. You may
use any letter more than once.

In which text can you find information about...

1 different types of ADHD m edication?__________

2 possible side effects of m edication?____________

3 conditions which may be present alongside A D H D ?______________

4 a doctor’s control over a patient’s m edication?_____________

5 positive perspectives on having A D H D ?____________

6 when patients should take their ADHD m edicine?________________

7 figuring out a patient’s optimal dosage of m edication?_________________

Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both. Your answers should be correctly spelled.

8 W hat is the maximum recommended dose of Dexamfetamine?

9 W hat is typically needed to get the best results from ADHD treatment?

10 How can GP’s collect information about their patient’s collateral history?

11 W hat causes symptoms such as palpitations and anxiety in some patients?

12 W hat proportion of children with ADHD will carry symptoms into adulthood?

13 W hat positive personality traits are sometimes associated with ADHD?

14 Which medication has dose recommendations related to patient weight?

Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer
may include words, numbers or both. Your answers should be correctly spelled.

Sleep, exercise and nutrition comprise the (15)_________________________ of further ADHD treatment.

When diagnosing ADHD, it is important to ask if the issues arose recently or are (16)

It is possible to move to (1 7 )__________________ after one month of immediate-release

methylphenidate.

Signs of ADHD can be disguised by (1 8 )___________________which GPs are more likely to recognise.

GPs should regularly check the (1 9 )__________________ of patients prescribed stimulant medication.

Establishing the ideal dose of ADHD medication needs (2 0 )__________________ by an expert

psychiatrist.
 1. According to the extract, to prevent the spread of infection, emergency department isolation
rooms

a)
r should be placed away from the main entry doors,
r are more numerous than those of other departments,
b)
r
c) ought to be situated near where people enter the unit.

DESIGN PRINCIPLES FOR ISOLATION ROOMS

The aim of environmental control in an isolation room is to control the airflow, thereby reducing the number of airborne
infectious particles that may infect others within the enviromnent.
This is achieved by:

• controlling the quality and quantity of intake and exhaust air;

• diluting infectious particles in large volumes of air;
• maintaining differential air pressures between adjacent areas; and
• designing patterns of airflow for particular clinical purposes.

The location and design of isolation rooms within a particular department or inpatient unit should ideally enable their
separation from the rest of the unit. Multiple isolation rooms should be clustered and located away from the main entrance of
the unit. An exception is an emergency department where it is recommended that designated isolation rooms be located near
the entry to prevent spread of possible airborne infection throughout the unit.

2. What do staff need to be conscious of when working in Anterooms?

a) Keeping used and unused medical clothing apart.

b) Ensuring the ambient pressure in the room is a minimum 15 Pascal.

c) Keeping the door closed at all times.

ANTEROOMS

Anterooms allow staff and visitors to change into, and dispose of, personal protective equipment used on entering and
leaving rooms when caring for infectious patients. Clean and dirty workflows within this space should be considered so that
separation is possible. Anterooms increase the effectiveness of isolation rooms by minimising the potential escape of
airborne nuclei into a corridor area when the door is opened.

For Class N isolation rooms the pressure in the anteroom is lower than the adjacent ambient (corridor) pressure, and positive
with respect to the isolation room. The pressure differential between rooms should be not less than 15 Pascal.

Anterooms are provided for Class N isolation rooms in intensive care units, emergency departments, birthing units,
infectious diseases units, and for an agreed number of patient bedrooms within inpatient units accommodating patients
with respiratory conditions.
 3. What is the basic principle of flexible design?

C
a) Creating systems which match current policy and can adjust to other possible
guidelines.
C
b) Designing healthcare facilities which strictly adhere to current policy.
C
c) Changing healthcare policies regularly to match changes in the marketplace.

FLEXIBLE DESIGN

In healthcare, operational policies change frequently. The average cycle may be as little as five years.
This may be the result of management change, government policy, and turnover of key staff or change
in the marketplace. By contrast, major healthcare facilities are typically designed for 30 years, but may
remain in use for more than 50 years. If a major hospital is designed very tightly around the operational
policies of the day, or the opinion of a few individuals, who may leave at any time, then a significant
investment may be at risk of early obsolescence. Flexible design refers to planning models that can not
only adequately respond to contemporary operational policies but also have the inherent flexibility to
adapt to a range of alternative, proven and forward-looking policies.

4. When prescribing antibiotics for a human bite, what should the medical professional remember?

C
a) Not all patients should be given antibiotics given the nominal infection risk.
C
b) The bacterium Streptococcus spp. is the most common in bite patients.
C
c) Eikenellacorrodens is not susceptible to several antibiotics often used for skin
infections.

Human bites

Human bite injuries comprise clenched-fist injuries, sustained when a closed fist strikes the teeth of
another person, and occlusive bites, resulting from direct closure of teeth on tissue. Clenched-fist
injuries are more common than occlusive bites, particularly in men, with most human bites occurring on
the hands. Human bites result in a greater infection and complication rate than animal bites. Cultures of
human bites are typically polymicrobial. Mixed aerobic and anaerobic organisms are common, with the
most common isolates including Streptococcus spp. and Eikenellacorrodens, which occurs in up to one-
third of isolates.

Some authors suggest that all patients with human bites should be commenced on antibiotic
prophylaxis, given the high risk of infection. The choice of antibiotic therapy should cover E. corrodens,
which is resistant to first-generation cephalosporins (such as cefalexin), flucloxacillin and clindamycin,
antibiotics that are often used for skin and soft tissue infections.
 5. The extract informs us that a model of care

a) is only implemented at certain times and places.

C
b) should include its own application and assessment.
C
c) involves the development of a project management tool.

What is a MoC?

A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care
and services for a person, population group or patient cohort as they progress through the stages of a
condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team
and in the right place.

When designing a new MoC, the aim is to bring about improvements in service delivery through
effecting change. As such creating a MoC must be considered as a change management process.
Development of a new MoC does not finish when the model is defined, it must also encompass
implementation and evaluation of the model and the change management needed to make that happen.
Developing a MoC is a project and as such should follow a project management methodology.

6. What is the basic difference between delegation, referral, and handover?

How many practitioners are involved in each part of the process.

How much authority is attributed to each practitioner.
How long each of the processes take a practitioner to complete.

4.3 Delegation, referral and handover

Delegation involves one practitioner asking another person or member of staff to provide care on behalf of the
delegating practitioner while that practitioner retains overall responsibility for the care of the patient or client.
Referral involves one practitioner sending a patient or client to obtain an opinion or treatment from another
practitioner. Referral usually involves the transfer in part of responsibility for the care of the patient or client,
usually for a defined time and a particular purpose, such as care that is outside the referring practitioner's
expertise or scope of practice.
Handover is the process of transferring all responsibility to another practitioner.
Text 1: Personal devices and hearing loss
M ost o f us have experienced walking past someone and being able to hear every sound coming
from their headphones. If y o u ’ve ever wondered w hether this could be damaging their hearing, the
answer is yes. In the past, noise-induced hearing loss typically affected industrial workers, due to
prolonged exposure to excessive levels o f noise with limited or non-existent protective equipment.
There are now strict limits on occupational noise exposure and many medico-legal claims have
been filed as a result o f regulation. The ubiquitous use o f personal m usic players has, however,
radically increased our recreational noise exposure, and research suggests there may be some cause
for concern.

The problem is not ju st limited to children and teenagers either; adults listen to loud m usic too.
According to the W orld Health Organization, hearing loss is already one o f the leading causes o f
disability in adults globally, and noise-induced hearing loss is its second-largest cause. In Australia,
hearing loss is a big public health issue, affecting one in six people and costing taxpayers over
A$12 billion annually for diagnosis, treatm ent, and rehabilitation.

W hen sounds enter our ear, they set in motion tiny frequency-specific hair cells w ithin the cochlea,
our hearing organ, which initiate the neural impulses which are perceived by us as sounds.
Exposure to high levels o f noise causes excessive w ear and tear, leading to their damage or
destruction. The process is usually gradual and progressive; as our cochlea struggles to pick up
sounds from the damaged frequencies we begin to notice poorer hearing. Unfortunately, once the
hair cells are gone, they don’t grow back.

A num ber o f US studies have shown the prevalence o f noise-induced hearing loss in teenagers is
increasing, and reports from Australia have suggested th ere’s an increased prevalence o f noise-
induced hearing loss in young adults who use personal music players. This is a w orrying trend
considering the w idespread usage o f these devices. Even a slight hearing loss can negatively affect
a child’s language developm ent and academic achievement. This is o f significant concern
considering some studies have reported a 70% increased risk o f hearing loss associated with use o f
personal m usic players in primary school-aged children.

Some smartphones and personal music players can reach up to 115 decibels, which is roughly
equivalent to the sound o f a chainsaw. Generally, 85 decibels and above is considered the level
where noise exposure can cause perm anent damage. Listening at this level for approximately eight
hours is likely to result in perm anent hearing loss. W hat’s more, as the volum e increases, the
amount o f tim e needed to cause perm anent damage decreases. At 115 decibels, it can take less than
a minute before perm anent damage is done to your hearing.

In A ustralia a num ber o f hearing education campaigns, such as Cheers for Ears, are teaching
children and young adults about the damaging effects o f excessive noise exposure from their
personal music players w ith some encouraging results. Hopefully, this will lead to more responsible
behaviour and prevent future cases o f noise-induced hearing loss in young adults.
Currently, there are no m aximum volum e limits for the manufacturers o f personal music players in
Australia. This is in stark contrast to Europe, where action has been taken after it was estimated that
50 and 100 million Europeans were at risk o f noise-induced hearing loss due to personal music
players. Since 2009, the European Union has provided guidance to limit both the output and usage
time o f these devices. Considering the impact o f hearing loss on individuals and its cost to society,
it’s unclear why Australia has not adopted similar guidelines. Some smartphones and music players
allow you to set your own m aximum volum e limits. Limiting the output to 85 decibels is a great
idea if y o u ’re a regular user and value preserving your hearing. Taking breaks to avoid continued
noise exposure will also help reduce your risk o f damaging your hearing.

Losing your hearing at any age will have a huge impact on your life, so you should do what you can to
preserve it. Hearing loss has often been referred to as a “silent epidemic”, but in this case it is definitely
avoidable.

1. The writer suggests that the risks from exposure to excessive industrial noise

C
a) Have become better regulated over time.
C
b) Have increased with the spread of new media devices.
C
c) Were limited or non-existent in the past.
C
d) Are something most people have experienced.

2. The word 'ubiquitous' in paragraph 1 suggests that use of personal media players is

C
a) Getting out of control.
C
b) Radically increasing.
C
c) Extremely common.
C
d) A serious health risk.

3. In the second paragraph, the writer aims to emphasise the

C
a) Impacts of hearing loss on young people.
C
b) Significant global effect of noise related hearing loss.
C
c) WHO's statistical information on hearing loss.
C
d) Huge cost of hearing loss treatment in Australia.
What does the word 'their' in paragraph 3 refer to?

a) Smart phones and music players

C
b) People with hearing loss
C
c) Neural impulses entering our ear
C
d) Tiny hair cells in the ear

What does the research mentioned in paragraph four show?

C
a) A higher prevalence of personal music devices in primary schools.
C
b) The negative impact of device related hearing loss on academic and linguistic skills.
C
c) An increasing number of teens and young adults suffering noise related hearing loss.
C
d) The widespread trend for increased use of personal music devices.

In paragraph 5, the writer suggests that

C
a) Chainsaws and smartphones are negatively impacting the public's hearing
C
b) Listening to music on a smartphone will damage your hearing.
C
c) Smartphones are designed to play music at dangerously high volumes.
C
d) More rules should be in place to control how loud smartphones can go.
e)
Why does the writer mention the Australian education programs in paragraph 6?

C
a) To encourage schools to adopt the Cheers for Ears program.
C
b) To suggest that education could lead to safer behaviour in young people
C
c) To criticise governments for not educating youths on the danger of excessive noise.
C
d) To highlight a successful solution to the issue of hearing loss in young people.

What is the writer's attitude to the lack of manufacturing guidelines for music devices in
Australia?

C
a) There is no clear reason why Australia has not created guidelines.
C
b) The implementation of guidelines in Australia is unnecessary.
C
c) Guidelines probably won't be created in Australia.
C
d) It will be difficult to create guidelines in Australia.
Text 2: What is herd immunity?
A recent outbreak of chickenpox is a reminder that even in countries where immunisation rates are high,
children and adults are still at risk of vaccine-preventable diseases. Outbreaks occur from time to time
for two main reasons. The first is that vaccines don’t always provide complete protection against
disease and, over time, vaccine protection tends to diminish. The second is that not everyone in the
population is vaccinated. This can be for medical reasons, by choice, or because of difficulty accessing
medical services. When enough unprotected people come together, infections can spread rapidly. This is
particularly the case in settings such as schools where large numbers of children spend long periods of
time together.

When a high proportion of a community is immune it becomes hard for diseases to spread from person
to person. This phenomenon is known as herd immunity. Herd immunity protects people indirectly by
reducing their chances of coming into contact with an infection. By decreasing the number of people
who are susceptible to infection, vaccination can starve an infectious disease outbreak in the same way
that firebreaks can starve a bushfire: by reducing the fuel it needs to keep spreading. If the immune
proportion is high enough, outbreaks can be prevented and a disease can even be eliminated from the
local environment. Protection of “the herd” is achieved when immunity reaches a value known as the
“critical vaccination threshold” . This value varies from disease to disease and takes into account how
contagious a disease is and how effective the vaccine against it is.

For a disease outbreak to “grow”, each infected person needs to pass their disease on to more than one
other person, in the same way that we think about population growth more generally. If individuals
manage only to “reproduce” themselves once in the infectious process, a full-blown outbreak w on’t
occur. For example, on average someone with influenza infects up to two of the people they come into
contact with. If one of those individuals was already fully protected by vaccination, then only one of
them could catch the flu. By immunising half of the population, we could stop flu in its tracks.

On the other hand, a person with chickenpox might infect five to ten people if everyone were
susceptible. This effectively means that we need to vaccinate around nine out of every ten people (90%
of the population) to prevent outbreaks from occurring. As mentioned earlier, vaccines vary in their
ability to prevent infection completely, particularly with the passing of time. Many vaccines require
several “booster” doses for this reason. When vaccine protection is not guaranteed, the number of
people who need to be vaccinated to achieve herd immunity and prevent an outbreak is higher.
Chickenpox vaccine is one such example: infections can occur in people who have been vaccinated.
However, such cases are typically less severe than in unimmunised children, with fewer spots and a
milder symptom course.

In Australia, overall vaccine coverage rates are high enough to control the spread of many infectious
diseases. Coverage shows considerable geographic variation, though, with some communities recording
vaccination levels of less than 85%. In these communities, the conditions necessary for herd immunity
may not be met. That means localised outbreaks are possible among the unvaccinated and those for
whom vaccination did not provide full protection. In the Netherlands, for example, high national
measles vaccine uptake was not enough to prevent a very large measles outbreak (more than 2, 600
cases) in orthodox Protestant communities opposed to vaccination.

Australia’s National Immunisation Strategy specifically focuses on achieving high vaccine uptake
within small geographic areas, rather than just focusing on a national average. Although uptake of
chickenpox vaccine in Australia was lower than other infant vaccines, coverage is now comparable.

Media attention has emphasised those who choose not to vaccinate their children due to perceived risks
associated with vaccination. However, while the number of registered conscientious objectors to
vaccination has increased slightly over time, these account for only a small fraction of children. A
recent study found only 16% of incompletely immunised children had a mother who disagreed with
vaccination. Other factors associated with under vaccination included low levels of social contact, large
family size and not using formal childcare.

Tailoring services to meet the needs of all parents requires a better understanding of how families use
health services, and of the barriers that prevent them from immunising. To ensure herd immunity can
help protect all children from preventable disease, it’s vital to maintain community confidence in
vaccination. It’s equally important the other barriers that prevent children from being vaccinated are
identified, understood and addressed.

1. According to the writer what causes occasional outbreaks of preventable diseases?

C
a) A high prevalence of disease.
C
b) Limited access to vaccination.
C
c) A low prevalence of vaccination.
C
d) Attitudes towards vaccination.
e)
2. Why does the writer mention bushfires in paragraph 2?

C
a) To emphasise the effectiveness of herd immunity.
C
b) To describe a method for eliminating disease.
C
c) To warn of the risks of of vaccination.
C
d) To highlight the severity of the flu.
e)
3. The phrase "stop flu in its tracks" in paragraph 3 refers to the

a)
r Prevention of flu spreading.
r Eradication of the flu virus.
b)
r
c) Minimisation of flu victims.
r Reduction in severity of flu symptoms
d)
e)

4. Information in paragraph 4 implies that

a)
r The chickenpox vaccine is highly unreliable.
r Chickenpox is more contagious than the flu.
b)
r
c) Booster vaccines should be given in schools.
r Outbreaks of chickenpox are on the rise.
d)
5. In paragraph 5, the writer emphasises the importance of

a)
r How geographical variation contributes to outbreaks.
r Differences in global vaccination guidelines.
b)
r
c) The influence of religious beliefs on vaccination.
r Enforcing high vaccine coverage rates.
d)

6. Why does the writer mention Australia's National Immunisation Strategy?

C
a) To serve as a counter argument.
C
b) To engage Australian readers.
C
c) To reinforce a previous point.
C
d) To introduce a new topic.

7. The research quoted in paragraph 7 reinforces that

C
a) The media presents vaccination negatively.
C
b) Many factors contribute to under vaccination.
C
c) Parental objections account for most unvaccinated children.
C
d) The number of conscientious objectors has increased over time.

8. In the final paragraph, the writer focuses on

C
a) The importance of widespread faith in vaccination.
C
b) The difficulty of tailoring health services to all parents.
C
c) The identification of barriers to overcoming under vaccination.
C
d) The different kinds of preventable disease that need to be overcome.