What is Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD is the continuous pattern of inattention and/or hyperactivity/impulsivity which disrupts overall functioning or development.

What causes ADHD?

Evidence from several studies in pharmacology, neuroimaging and genetics have reported that dopamine and noradrenaline play a vital role in the development of ADHD. With regards to family, adoption and twin studies, the role of genetic factors, such as the D4 receptor gene and the DAT1 systems, for instance, creates a heritability estimate for ADHD to approximately 75%. It can be characterised by a number of genes through different gene-environment-gene pathways, such as exposure to lead or other types of neurotoxins.

How is ADHD diagnosed?

Conner’s Rating Scale, which is a diagnostic tool,  is completed by parents and teachers to assess ADHD in children who are between 6 years old to 18 years old. DSM-5 guidelines suggest that the symptoms need to be present before the age of 12 years old and portrayed  in multiple settings, such as home and school for instance. In addition to the former, six out of nine symptoms of inattention and six out of nine hyperactivity and impulsivity symptoms must be present.

Gender Differences in ADHD

The ratio between males and females diagnosed with ADHD is 3:1

Females may be constantly overlooked, leaving them underdiagnosed due to the differences in how symptoms of the disorder are expressed amongst males and females. Females with ADHD are reported to possess fewer hyperactive-impulsive symptoms and more inattentive symptoms as compared to males with ADHD, and are most commonly diagnosed with the inattentive subtype as compared to males.

Referral bias may occur due to fewer disruptive behaviours in females diagnosed with ADHD, causing the condition to be overlooked. This then leads to lack of treatment for females with ADHD. Females may also possess co-occurring symptoms which may be a main contributing factor to late or missed diagnoses in females as the presence of co-occurring symptoms could often put a veil on the depiction of the diagnosis.

Brain development in males being slower as compared to girls, as well as larger male susceptibility to a multitude of prenatal and perinatal issues, like preterm birth for instance, makes males more susceptible to developing ADHD as compared to females.

Treatments Available

Pharmacological:

The psychostimulant medications, like methylphenidate are generally considered safe provided they are taken with medical supervision. Even though some children have reported feeling different or odd, psychostimulants do not lead to a child feeling a sense of “High”. These changes experienced are very minor and up to date; there has not been any evidence of psychostimulant medications leading to drug abuse or drug dependence. As reported from a number of long-term studies on psychostimulant medications and substance abuse, youth who continued consuming their ADHD medication regularly during their teenage years were less prone to getting into substance use or substance abuse, as opposed to other adolescents with ADHD who did not take medications . 

Methylphenidate was the first-line choice of pharmacological treatment for approximately half of school-aged children diagnosed with ADHD. In addition to the former, school-aged children taking amphetamine had a percentage of 21.9% and those taking dexmethylphenidate had a percentage of 16.2%. Methylphenidate or mixed amphetamine, as well as some non-psychostimulant treatments, like atomoxetine for instance, significantly provide a higher level of efficacy as opposed to that of a placebo, especially in the short term, when one is evaluating on the main ADHD symptoms as main outcome.

With regards to children and adolescents, studies reported from RCTs that amphetamines produced a  significantly greater change in ADHD symptoms as compared to other drugs like modafinil, atomoxetine, and methylphenidate. Furthermore, in children and adolescents, amphetamines brought about more change as compared to guanfacine while methylphenidate was greater as compared to atomoxetine. 

With regards to tolerability to the medication,  only amphetamines and guanfacine were less tolerable as compared to the placebo in children. Approximately half of the patients who received methylphenidate as treatment had a clinically-significant reaction which had made up for a 43% of  the total increase in improvements of ADHD symptoms over normal care.

Comparing methylphenidate to atomoxetine, no serious adverse effects were recognized. It was reported through clinical studies that there were no clinical differences in efficacy between these two medicines for quality of life, as well as parent-rated inattentive and hyperactivity ADHD symptoms or behavioural  consequences. 

Guanfacine is normally only used for ADHD when stimulants like methylphenidate are unsuitable, unendurable, or ineffective. Guanfacine seems to be the most effective in children aged 12 years old or younger.

Though medication does not rid one of ADHD completely, it can be an extremely efficient way to improve the symptoms associated with ADHD when it is consumed as per the prescription provided. It is essential to keep in mind that none of the available treatments will cure ADHD completely. Thus, it is highly vital for a child or adolescent with ADHD to go for continuous care and treatment monitoring in order to track the change in symptoms and evaluate the next course of action which is likely to change due to the child or adolescent’s activities and expectations as he/she gets older.

Treatment with medication allows the child or adolescent to function in a better manner and manage their ADHD symptoms. In addition to the former, they are able to seek help from academic and other related interventions proposed to improve their general performance in school, at home, as well as in other social settings. After a course of treatment and monitoring, a proportion of children may not need the support treatment to manage their ADHD symptoms as they grow into late adolescence and adulthood.

Non-Pharmacological:

In order to help ease frustration, blame and anger which both parents and children may have, specialized assistance is available in order to help the families to learn skills to manage challenging behaviours.

According to NICE guidelines, children and adolescents could receive Cognitive Behavioural Therapy (CBT) which is beneficial for children and adolescent who have benefited from taking medications. Through CBT, the mental health professional could counsel the individual in order to identify their strengths to manage their negative thoughts which would in turn allow them to manage their negative emotions of anger, blame and frustration. The individual with ADHD could also learn social skills with peers like waiting for a turn which could be modeled by the therapist, problem-solving skills, active listening skills controls, as well as managing emotions and expressing them in a more positive manner.

There are group parent-training programmes, such as Incredible Years, Triple P and New Forest Parenting Program which has approximately 10-12 sessions which are 2 hours each for parents and caregivers to manage their children’s challenging behaviours through behaviour modification with a token or point system and sticker charts for instance. The programs teaches parents how to use “time out” or isolation to a chair or bedroom when the child’s behaviour becomes completely out of control. During time outs, the child is taken out from the troubling situation and the child has to sit in silence for a short time in order to put some ease on his/her negative emotions. Parents would also learn how to give the child “quality time” each day, such as the parents and child sharing a satisfying or peaceful activity. During this time together, the parent keeps a lookout for chances to observe and let the child know which aspects he/she has done well by giving praise for his or her strengths and abilities.

There are also school-based interventions where teachers could practice consequence-based strategies and self-management skills, which includes using sticker charts and raising hands while waiting to speak instead of shouting out the answer. Teachers would also write daily report cards to send to parents in order to update them about the child’s level of attention, social skills with peers, as well as overall performance in school.

The diversity and range of non-pharmacological treatment can be attractive to to individuals with ADHD, as well as their families who may be reluctant to seek pharmacological treatment of ADHD due to its possible side-effects. 

The diversity of non-pharmacological treatments and styles produce substantial challenges when studying the evidence base and outlining any significant assumptions on which course of treatment could bring about the most benefits in the long-term. Adverse impacts of non-pharmacological treatment are much less frequently well-thought-out and very infrequently recorded in trials which makes it difficult to evaluate the efficacy of non-pharmacological treatments. Keeping other kinds of variables, such as internalising symptoms and self-efficacy, into consideration, there is insufficient evidence of the beneficial effects of non-pharmacological treatment. 

A number of recent studies support the efficacy of non-pharmacological treatment for school-age children. Based on a study that was done for 21 children who were aged between 7-10 years old, the effectiveness of a new 10-week intervention program called Family STARS was evaluated. This program combines behavioral stimulation which is a  type of behavioral therapy designed to treat anxiety and depression, combined with Parent Training. The results identified a decline in behavioral issues which was lower than clinical significance level. 

Another study based on 74 children was used to evaluate the efficacy of a program precisely designed for fathers called Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) which is a combination of Parent Training and sports skills for children and parents. This was intended to improve father-child interactions using the setting of a football match. In comparison with Parent Training on its own, there were no significant differences that were indicated with regards to ADHD symptoms. However, it was observed that parents became more involved in the the COACHES program which in turn led to an increase in their participation in the sessions, as well as commitment with tasks and contentment with treatment. In addition to the former, parent evaluations of their child’s developments were more positive. This could show that having parental commitment in helping children with ADHD produces positive emotions in both parents and children, leading to better parent-child relationship and  overall outlook with regard to ADHD, thus bringing about positive change in quality of lives.