Attention-deficit / hyperactivity disorder (ADHD)

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Welcome to our ADHD Guide.  Use the headings below to reveal the sections of the Guide, or scroll down for latest ACAMH events, blogs, journal articles, videos and podcasts in ADHD.

 

  • Overview

    ADHD is a behavioural disorder with three key aspects, inattention, hyperactivity, and impulsivity. It affects home life and school, and can have a significant impact on a child’s academic success and their relationships. It’s a full-time, often challenging, disorder which can go beyond bad behaviour and problems at school, and may have an impact on every aspect of life.

    It is very common for ADHD in children to present together with other developmental and/or mental health problems, such as oppositional and attachment disorders, Tourette’s syndrome, autism spectrum disorders and anxiety disorders.

    No single risk factor explains ADHD, but a mix of genetic and environmental factors working together that looks likely to be the cause.

    Parent training programmes are currently recommended by NICE as the first line treatment for mild to moderate cases, although recent evidence questions their effects on ADHD core symptoms. The other main treatments are psychological treatments and medications. However, it’s unclear which treatment works better for children and young people with

    Support in school is important for children and young people with ADHD but the evidence on the efficacy/effectiveness of school interventions is mixed. However, any intervention should be tailored to individual children, classrooms and schools.

  • Introduction

    ADHD is a behavioural disorder with three key aspects, inattention, hyperactivity, and impulsivity, (APA 2013) which interfere with a child or young person’s functioning or development. It’s a long-term condition with symptoms that start in young children (under 12 years old) but often persist into adult life. ADHD is defined at a behavioural level, and those children who have it won’t necessarily have any neurological disease (NICE 2016).  Hyperkinetic disorder (HKD) is a term sometimes used when a child or young person has more severe symptoms (particularly hyperactivity), although HKD is characterised by the combination of the three symptom domains.

    Because it affects home life and school (as well as other activities, e.g. leisure), ADHD can have a significant impact on a child’s academic success and their relationships. This can mean that children with ADHD may have few friends, be socially isolated and do little in the way of constructive activities; all of which can lead to a poor quality of life.  Young people who are severely affected are more likely to develop antisocial behaviour, personality dysfunction or substance misuse in later adolescence and adult life (NICE 2016).

    The symptoms of ADHD fall into two types of behavioural problems; inattentiveness and hyperactivity/impulsiveness. Most children with ADHD have problems that fall into both these categories, but this isn’t always the case; some children may have problems with inattentiveness, but not with hyperactivity or impulsiveness. Over time, inattentive symptoms tend to continue and hyperactive-impulsive symptoms tend to reduce (Spencer, 2007).

    Common problems that characterise ADHD are (NICE CKS 2015, NICE 2016):

    • Inattention – wandering off task, lacking persistence, problems sustaining focus and being disorganised.
    • Hyperactivity – constantly ‘on the go’ when it is not appropriate, excessive fidgeting, tapping or talkativeness.
    • Impulsivity – hasty and potentially risky actions that happen without thinking about the consequences, social intrusiveness, such as interrupting.

    Common problems linked to ADHD are (NICE CKS 2015, NICE 2016):

    • Non-compliant behaviour, mood swings, aggression and temper tantrums.
    • Motor tics and clumsiness.
    • Poor sleep.
    • Literacy and other learning problems and immature language.
    • Conduct and oppositional disorders.
    • Tourette’s syndrome.
    • Attachment and post-traumatic disorders.
    • Autism spectrum disorders.
    • Anxiety disorders.

    The problems associated with ADHD appear in different ways at different ages. As children grow up and develop, their environment changes and the need for more self-control increases (Taylor & Sonuga-Barke, 2008). So, a pre-school child may have non-stop demanding extremes of activity; an older child may need to get up and move around when everyone else is being calm and an adolescent may fidget with their hands.

    ADHD is one of the most common disorders of childhood. Globally, it’s estimated that prevalence is around five per cent (Polanczyk, 2007). More boys than girls are diagnosed and treated for ADHD, possibly because boys are more likely to have disruptive behaviour, whereas girls more likely to have the inattentive type and less likely to have other conditions (Spencer, 2007). ADHD has also been linked with poverty, lower family income, and lower social class in the UK (Langley, 2007).

    ADHD is an often challenging disorder that can go beyond bad behaviour and problems at school, and may have an impact on every aspect of life. It can be exhausting and stressful to care for a child with impulsive, fearless and chaotic behaviours typical of ADHD. Children with ADHD can become stigmatised for their behaviour, and may be bullied, seen in a negative way and treated differently by their peers.

    Both teachers and parents can find it hard to deal with or live with a hyperactive child, but their tolerance and ability to cope may be the factor that determines whether their hyperactivity is seen as a problem or not.  Although ADHD symptoms often continue into adult life, many young people with ADHD adjust very well to life with the condition and have no ongoing mental health problems.

  • What we know already

    Causes

    In the last few decades, there has been an enormous amount of research into the causes of ADHD. The exact cause is as yet unknown, but we do know that no single risk factor explains ADHD (Thapar, 2012). Instead, it’s a mix of genetic and environmental factors working together that looks likely to be the cause. (Thapar 2012).

    ADHD runs in families and is heritable. Research into the genetics of ADHD suggests an overlap with other neurodevelopmental problems, notably, autism spectrum disorders (Thapar 2012).

    There are some additional identified risk factors for developing ADHD, including (Thapar 2012):

    • having a biological relative with ADHD
    • extreme early life adversity
    • pre and postnatal exposure to lead
    • low birth weight/prematurity

    Diagnosis

    The diagnosis of ADHD itself remains a contentious one. There has been criticism about the existence of ADHD as a formal diagnosis at all, and some researchers and health professionals don’t believe it is a condition in its own right (NICE 2016). Others have challenged the diagnostic criteria, including their language and specificity and the difficulty of accurately differentiating ADHD from other conditions (NICE 2016).  Finally, there has been discussion about the impact of overstated reporting by the media and stereotyping, plus the effects of social pressure on parents to find a diagnosis for their child’s behaviour (NICE 2016).

    There is no single definitive psychological or biological test for ADHD (NICE 2016). Making a diagnosis can be complex and needs to be done by a specialist with the input of a range of professionals using different techniques. Diagnosis is established by exploring the extent, severity and characteristics of symptoms, how and when symptoms developed, and whether other physical, mental health and/or learning disorders are present. There are reliable (semi) structured interviews that can be used to improve the accuracy of the diagnosis.

    Treatment

    Parent training and education

    Parenting interventions may lead to a positive impact on behaviour (Coates 2015). Parent training programmes, which teach parents to use behaviour therapy, are a first line treatment for children and young people with mild to moderate ADHD.  Programmes are mainly delivered in groups and follow a structured curriculum over several weeks.

    Parent training programmes are currently recommended by NICE as the first line treatment for mild to moderate cases, although recent evidence questions their effects on ADHD core symptoms.

    There is also some evidence that giving parents of school-age children written information about strategies to manage behaviour at home can bring about improvement. (NICE 2016).

    School based behavioural intervention

    Universal screening and general advice for teachers of children with ADHD has no effect on the core symptoms of ADHD or behaviour problems (NICE 2016).

    The evidence for whether school interventions improve ADHD symptoms or academic outcomes is mixed (Richardson 2015). This includes approaches such as contingency management, cognitive-behavioural self-regulation, academic and study skills training, social and emotional skills training. Interventions should be tailored to individual children, classrooms and schools (Richardson 2015).

    Medication

    Psychostimulants (Methylphenidate and Amphetamine derivatives) are effective at reducing the severity of ADHD core symptoms (i.e., inattention, hyperactivity, and impulsivity) (Banaschewski 2016). NICE recommends that medications be prescribed for children and young people only when the symptoms and impact of ADHD is severe, or for those whose symptoms are moderate but who haven’t responded to other treatments. Psychostimulants are amongst the most efficacious treatments, at least in the short term, not only in psychiatry, but also in medicine in general (Leucht 2012).

    Evidence supports the use of extended-release medications to improve symptoms of ADHD in adolescents (Chan 2016).

    Psychological treatment

    The main psychological treatments used for children and young people with ADHD are Cognitive Behavioural Therapy (CBT) and social skills training. However, the effect of psychological treatments on ADHD symptoms may be inconsistent (Chan 2016). This type of treatment seems to lead to some improvements in emotional or behavioural symptoms and interpersonal functioning. The impact on academic and organizational skills, such as completing homework, is greater and more consistent (Chan 2016).

    For school-age children interventions offering mixed CBT and social skills training group sessions for children, along with parallel group sessions for parents, are beneficial (NICE 2016).

    Diet

    There is no evidence that Omega-3 polyunsaturated fatty acid compounds (fish oils), iron supplements or zinc supplements are effective in the treatment of ADHD (Stevenson, 2014.

    NICE recommends that healthcare professionals stress the value of a balanced diet, good nutrition and regular exercise for children, young people and adults with ADHD (NICE 2016). NICE also recommends that clinicians ask about foods or drinks that appear to influence hyperactive behaviour as part of the clinical assessment of ADHD in children and young people (NICE 2016).

  • Areas of uncertainty

    There is a theory that ADHD is related to a delay in brain maturity. In the first large scale study of its kind, researchers compared seven parts of the brain in people with and without ADHD (Hoogman 2017). They found some significant differences in brain size. Five of the seven brain regions were smaller in children and young people with ADHD, particularly the amygdala. This is the part of the brain linked to emotional and self-control. Areas linked to memory and learning were also smaller. These size differences didn’t exist in adults with ADHD.

    It’s unclear which treatment works better for children and young people with ADHD; psychological treatments or medication (NICE 2016). We also don’t know whether, once medication is stopped it continues to have any beneficial effects in the long term. Epidemiological studies from Sweden, might be cited to support a long-term effect of medications, despite the obvious lack of a long-term randomised controlled trial (Ginsberg 2015, Chen 2014, Zetterqvist 2013). Treatment decisions should be based on a range of factors as well as effectiveness, including possible side-effects of medication and the preferences of the child and/or parent (NICE 2016).

    As with any medication, the drugs used to treat ADHD have side-effects, some of which can significantly affect a child or young person’s quality of life, and some of which can be serious. These include loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, seizures, suicidal thoughts/behaviours and psychotic symptoms. Expert consensus is that most side effects can be managed by the clinician, so that medication won’t need to be stopped. However, more rigorous evidence for the management of side effects is needed (Cortese, 2013).

    There is quite a lot of research exploring the use of CBT in adults with ADHD but relatively little that focuses on children or adolescents.  What there is shows that CBT has some promise – for example, it may impact on the severity of symptoms in young people, when given in conjunction with medication (Sprich 2016). But we don’t know how effective it is in younger children and in those not taking medication.

    The delivery of psychological therapies, teaching support and parent training can be challenging, so it’s not clear how well these are supporting children and young people in practice. Parents and young people with ADHD drop out of treatment because of conflict and stress; in secondary school teachers expect students to function independently and can refuse to implement treatment; and adolescents have a tendency to minimise or deny the impact of the condition and may refuse some treatments (Sibley, 2014).

    When looking at the impact of school interventions on ADHD, there is a lack of good quality studies which look at similar interventions and outcomes. That means that it’s hard to tell what interventions work well and for whom (Richardson 2015).

    The jury is out on dietary changes, such as elimination or ‘few food’ diets and removing artificial colouring and additives and whether they have an impact on ADHD symptoms (Sonuga-Barke 2013, Stevenson 2014). The quality of research studies is generally poor and unclear on the long-term impact of making this kind of change.

  • What's in the pipeline?

    In terms of medications, several nonstimulant therapies are in development for treatment of ADHD. The first and farthest along in terms of clinical development is an extended-release formulation of guanfacine (already on the market in the UK as Intuniv®. This has been used for many years as a treatment for high blood pressure. Initial clinical trials show that it seems to be well tolerated and effective at reducing symptoms (Wilens, 2015)

  • Useful organisations and resources

    NICE Guideline: Attention Deficit Hyperactivity Disorder: Diagnosis and management of ADHD in children, young people and adults.  https://www.nice.org.uk/guidance/cg72/evidence/full-guideline-pdf-241963165

  • Sources

    NICE Clinical Knowledge Summaries. (2015). Attention deficit hyperactivity disorder [online]. Available at: https://cks.nice.org.uk/attention-deficit-hyperactivity-disorder [accessed 25 May 2017]

    Spencer TJ, Biederman J, Mick E et al. (2007). Attention-Deficit/Hyperactivity Disorder: Diagnosis, Lifespan, Comorbidities, and Neurobiology. J Pediatr Psychol (2007) 32 (6): 631-642. DOI: https://doi.org/10.1093/jpepsy/jsm005 Available at: https://academic.oup.com/jpepsy/article-lookup/doi/10.1093/jpepsy/jsm005 [accessed 25 May 2017]

    NICE. (2008/2016) Attention Deficit Hyperactivity Disorder: Diagnosis and management of ADHD in children, young people and adults. National Institute of Health and Care Excellence. Available at: https://www.nice.org.uk/guidance/cg72/evidence/full-guideline-pdf-241963165 [accessed 25 May 2017]

    Thapar, A., Cooper, M., Eyre, O. and Langley, K. (2013), Practitioner Review: What have we learnt about the causes of ADHD?. Journal of Child Psychology and Psychiatry, 54: 3–16. doi:10.1111/j.1469-7610.2012.02611.x Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02611.x/full [accessed 25 May 2017]

    Chan E, Fogler J M,  Hammerness P G. (2016) Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents A Systematic Review. JAMA. 2016;315(18):1997-2008. doi:10.1001/jama.2016.5453 Available at: https://www.researchgate.net/profile/Eugenia_Chan/publication/302910050_Treatment_of_Attention-DeficitHyperactivity_Disorder_in_Adolescents_A_Systematic_Review/links/5739c6d508ae9f741b2c89f9.pdf  [accessed 25 May 2017]

    American Psychiatric Association (APA). 2013. Diagnostic and statistical manual of mental disorders, 5th ed., (DSM-5). Washington, DC: American Psychiatric Publishing. Available at: http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 [accessed 26 May 2017]

    Taylor, E. & Sonuga-Barke, E. (2008) Disorders of attention and activity. In Rutter’s Child and Adolescent Psychiatry (5th edn) (eds M. Rutter, E. Taylor, J. S. Stevenson, et al.). London: Blackwell

    Polanczyk, G, Silva de Lima, M, Lessa Horta, B et al.  (2007) The Worldwide Prevalence of ADHD: A Systematic Review and Metaregression Analysis. The American Journal of Psychiatry. 164 (6) 942-948 Available at: http://ajp.psychiatryonline.org/doi/full/10.1176/ajp.2007.164.6.942 [accessed 26 May 2017]

    Langley, K., Holmans, P. A., van den Bree, M. B. et al (2007). Effects of low birth weight, maternal smoking in pregnancy and social class on the phenotypic manifestation of Attention Deficit Hyperactivity Disorder and associated antisocial behaviour: investigation in a clinical sample. BMC Psychiatry, 7, 26. http://doi.org/10.1186/1471-244X-7-26 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913513/ [accessed 26 May 2017]

    Coates J, Taylor JA, Sayal K. J (2015) Parenting Interventions for ADHD: A Systematic Literature Review and Meta-Analysis. Atten Disord. Oct;19(10):831-43. doi: 10.1177/1087054714535952. Epub 2014 Jun 10.  Available at: http://journals.sagepub.com/doi/abs/10.1177/1087054714535952 [accessed 26 May 2017]

    Sibley, M.H., Kuriyan, A.B., Evans, S.W. et al. (2014). Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature. Clinical Psychology Review, 34, 218–232. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24632046 [accessed 26 May 2017]

    Richardson M, Moore DA, Gwernan-Jones R et al. (2015) Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess 2015;19(45) Available at: https://www.journalslibrary.nihr.ac.uk/hta/hta19450#/abstract [accessed 28 May 2017]

    Punja S, Xu D, Schmid CH, Hartling L, Urichuk L, Nikles CJ, Vohra S (2016b) Amphetamines and methylphenidate for pediatric ADHD: a systematic review and meta-analysis of n-of-1 evidence. J Clin Epidemiol, in press. doi: 10.1016/j.jclinepi.2016.03.026 Available at: https://www.ncbi.nlm.nih.gov/pubmed/27107878  [accessed 28 May 2017]

    Hoogman, M, Bralten J, Hibar DP et al. (2017) Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. The Lancet Psychiatry , Volume 4 , Issue 4 , 310 – 319 http://dx.doi.org/10.1016/S2215-0366(17)30049-4  Available at: http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30049-4/abstract  [accessed 28 May 2017]

    Keen D, Hadjikoumi I. (2015) Attention deficit hyperactivity disorder in children and adolescents. Systematic review 312. BMJ Clinical Evidence. Available at: http://clinicalevidence.bmj.com/x/systematic-review/0312/overview.html  [accessed 28 May 2017]

    Sonuga-Barke EJ, Brandeis D, Cortese, S. (2013) Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry; 170(3): 275-289. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0055097/ [accessed 28 May 2017]

    Stevenson, J., Buitelaar, J., Cortese, S. et al.(2014), Research Review: The role of diet in the treatment of attention-deficit/hyperactivity disorder – an appraisal of the evidence on efficacy and recommendations on the design of future studies. J Child Psychol Psychiatr, 55: 416–427. doi:10.1111/jcpp.12215 Available at: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12215/full [accessed 29 May 2017]

    Cortese, S., Holtmann, M., Banaschewski, T. et al. (2013), Practitioner Review: Current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. Journal of Child Psychology and Psychiatry, 54: 227–246. doi:10.1111/jcpp.12036 http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12036/full [accessed 29 May 2017]

    Wilens TE, Robertson B, Sikirica V, et al. (2015) A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. Nov;54(11):916-25.e2. doi: 10.1016/j.jaac.2015.08.016. Available at: http://www.jaacap.com/article/S0890-8567(15)00574-2/fulltext [accessed 29 May 2017]

    BMJ Best Practice (2017) Attention deficit hyperactivity disorder in children [online]. Available at: http://www.medscape.org/viewarticle/549974http://bestpractice.bmj.com/best-practice/monograph/142.html [accessed 29 May 2017]

    Banaschewski T, Buitelaar J, Chui CS, Coghill D, Cortese S, Simonoff E, Wong IC. (2016) Methylphenidate for ADHD in children and adolescents: throwing the baby out with the bathwater. Evid Based Ment Health. 2016 Nov;19(4):97-99. doi: 10.1136/eb-2016-102461. Epub 2016 Oct 6. https://www.ncbi.nlm.nih.gov/pubmed/27935807

    Leucht S, Hierl S, Kissling W, Dold M, Davis JM. (2012) Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. doi: 10.1192/bjp.bp.111.096594. https://www.ncbi.nlm.nih.gov/pubmed/22297588

    Stevenson J, Buitelaar J, Cortese S, Ferrin M, Konofal E, Lecendreux M, Simonoff E, Wong IC, Sonuga-Barke E. (2014) Research review: the role of diet in the treatment of attention-deficit/hyperactivity disorder–an appraisal of the evidence on efficacy and recommendations on the design of future studies. J Child Psychol Psychiatry. 2014 May;55(5):416-27. doi: 10.1111/jcpp.12215. Epub 2014 Feb 19. https://www.ncbi.nlm.nih.gov/pubmed/24552603

    Ginsberg Y, Långström N, Larsson H, Lindefors N. (2015) Long-Term Treatment Outcome in Adult Male Prisoners With Attention-Deficit/Hyperactivity Disorder: Three-Year Naturalistic Follow-Up of a 52-Week Methylphenidate Trial. J Clin Psychopharmacol. 2015 Oct;35(5):535-43. doi: 10.1097/JCP.0000000000000395. PMID: 26284932

    Chen Q, Sjölander A, Runeson B, D’Onofrio BM, Lichtenstein P, Larsson H. (2014) Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ. 2014 Jun 18;348:g3769. doi: 10.1136/bmj.g3769.

    Zetterqvist J, Asherson P, Halldner L, Långström N, Larsson H. (2013) Stimulant and non-stimulant attention deficit/hyperactivity disorder drug use: total population study of trends and discontinuation patterns 2006-2009. Acta Psychiatr Scand. 2013 Jul;128(1):70-7. doi: 10.1111/acps.12004. Epub 2012 Sep 4.

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