A Guide to Attention Deficit Hyperactivity Disorder rebrand · What is Attention Deficit...

A Guide toAttention DeficitHyperactivityDisorder

ADHD is a common condition that mainlyaffects behaviour. Children with thiscondition show persistent restlessness,impulsiveness and/or inattention. It isusually diagnosed in children butcan be present in adults. The diagnosis ismade after a detailed assessment.

Treatment includes parent trainingprogrammes, and sometimes medication.

©EMIS 2010, as distributed on http://www.patient.co.uk/health/Attention-Deficit-Hyperactivity-Disorder.htmUsed with permission.

What is Attention DeficitHyperactivity Disorder?Attention Deficit Hyperactivity Disorder(ADHD) is also known as attention deficitdisorder (ADD) and hyperkinetic disorder.It is a common condition that mainlyaffects a child’s behaviour. There mayalso be problems with the child’sintellectual, social and psychologicaldevelopment as a result of the behaviour.

What are the symptoms of ADHD?Children with ADHD show persistentrestlessness, impulsiveness and/orinattention. These features are seen inmore than one setting, for example, atschool and at home.

They are also seen in more than oneactivity, for example in schoolwork and inrelationships. They occur at a levelgreater than expected for their age andcause significant disruption to the child’sdaily life.

A Guide to Attention Deficit HyperactivityDisorder

There are three sub-types of ADHD:

• Hyperactive-impulsive sub-type.Some features of this type of ADHDare that a child may fidget a lot, runaround in inappropriate situations, havedifficulty playing quietly, and may talkexcessively. They may interrupt othersand have trouble waiting in line.

• Inattention sub-type.In this subtype, a child may have troubleconcentrating and paying attention, maymake careless mistakes, may not listen orfollow through on instructions and maybe easily distracted. They may also beforgetful in daily activities, lose essentialitems such as school books or toys, andhave trouble organising activities.

• Combined sub-type.If a child has this sub-type, they havefeatures of both of the other sub-types.

Children with ADHD are also more likelythan average to have other problemssuch as anxiety and depression, conductdisorders and co-ordination difficulties.

What causes ADHD?The cause of ADHD is not known. It isthought that there may be subtle changesin parts of the brain which controlimpulses and concentration. Although themain cause of ADHD is not known,various factors are thought to increase therisk of a child developing ADHD.

These include:

• Genetics.Genes are passed ontoa child from each parent. Our genesdetermine how our body functions,what we look like and sometimes whatdiseases we will get.

Some studies have shown that certaingenes are related to ADHD. A child maytherefore be more likely to have ADHD ifthere is another family member such asmother, father, brother or sister withADHD.

• Antenatal problems.If a mother drinksalcohol, smokes or takes heroin whileshe is pregnant, this may increase therisk of the child developing ADHD.

• Obstetric problems.This means problems that occur when ababy is born such as a difficult labourcausing lack of oxygen to the brain.Babies with very low birth weight are alsomore likely to develop ADHD.

• Severe deprivation.If a child is severely neglected early inlife, this may make ADHD more likely.Factors in a child’s upbringing such aspoor parenting, watching a lot of TV orvideos, family stress, etc, do not causeADHD.

However, such factors may makethe behaviour of a child with ADHDworse.

How common is ADHD?ADHD affects at least 5 in 100 children inthe UK. Some studies suggest evenmore children than this are affected. It isthree to four times more common in boysthan in girls.


How is ADHD diagnosed?There is no simple test to diagnoseADHD.

If your child’s teacher or doctor suspectthat your child may have ADHD, they maysuggest that you and your child attend aprogramme to help improve your child’sbehaviour. If this is not effective or if thecondition is severe, they may refer yourchild to a specialist team for assessment.

The assessment may involve adiscussion with you and your child as wellas a physical examination. The specialistmay ask for a report from the school andmay even want to observe your childdoing certain tasks.

You and your child may also see a nurseor other health care professionals forfurther testing and Assessment.

There are a few aims of this assessment.

These include:

• To confirm whether your child definitelyhas ADHD.

• To make sure that there are no otherreasons that explain your child’sbehaviour such as a hearing difficulty,epilepsy or thyroid problems.

• To identify any other problems your childmay have such as anxiety, low selfesteem or a learning difficulty.

For a doctor to make a firm diagnosis ofADHD, there are strict criteria that need tobe fulfilled. For example, the symptomsof inattention and/or hyperactivity andimpulsivity need to be present for atleast six months.

They also need to be causing problems inyour child’s life as well as being differentfrom what would be expected for theirage. They also must have started to occurbefore age seven, and be present in morethan one setting (for example, at homeand at school).

What are the treatment options?The treatments recommended dependon how severe the condition is as wellas the age of the child. Ideally, treatmentshould involve a team of professionalswho are experienced and trainedspecifically in ADHD and may include adoctor, teacher, nurse, social worker,occupational therapist, mental health careprofessional or psychologist.

Treatments include drug and non-drugtreatments.


Non-drug treatments for ADHDGenerally, for pre-school children or forolder children with mild to moderateADHD, the first step is usually for you(parent or guardian) to be referred to aparent training programme.

Sometimes your child will also be referredfor a group treatment programme aimedat improving behaviour.

The parent programme may include suchthings as:

• Learning skills to manage and reduceproblem behaviour.

• Learning more effective ways tocommunicate with your child.

• Helping you to understand your child’semotions and behaviours.

Your child’s school teacher may beinvited to be involved in the treatmentprocess.

They may be able to use certaintechniques in the classroom to help yourchild learn and function better. Familytherapy may also be helpful.

In more severe ADHD, or where theabove treatments have not succeeded,medication is usually recommended.

Drug treatments for ADHDThere are three main drugs licensedfor the treatment of ADHD in the UK.Methylphenidate (trade name of Ritalin®)is the most commonly used drug.Atomoxetine and dexamfetamine areother drugs that may also be used.

How effective is drug treatment?The drugs used for ADHD have beenused for many years and in manychildren with good effect.A number of studies have shown thatdrug treatment with or without intensivebehavioural training programs is moreeffective than behavioural trainingprograms alone.

How does the methylphenidate work?Methylphenidate is a type of stimulantdrug. It works by increasing the amountof a brain chemical called dopamine incertain parts of the brain.

The parts that it works on are responsiblefor self control and attention. Increasingthe amount of dopamine in these areas ofthe brain stimulates them to work better.This then helps to focus your child’sattention and improve concentration.


How do I give methylphenidate to mychild?Usually, your child will start on a low dosesuch as 5mg three times a day and willbe carefully monitored for side effects.This dose will be increased gradually toa maximum of 20 mg three times dailyaccording to how well it is working andwhether side effects occur.

The most common side effects to look outfor with methylphenidate are insomnia(difficulty with sleep), loss of appetiteand weight loss.

Once the total daily dose has beendetermined, it may be possible for yourchild to switch to a once daily long actingversion of methylphenidate.

When your child is on medication, theyshould be reviewed every six monthsto check that the dose is working andthat there are minimal side effects. It isrecommended that the doctor also checkyour child’s height, weight and bloodpressure.

It is good for this review to includefeedback from those who are in regularcontact with your child such as teachers,family members and other carers.

How quickly does methylphenidatework?The short acting methylphenidate beginsworking within about 20 minutes andlasts for 3-4 hours. The longer actingversion takes longer to start working butlasts for about 12 hours and gives amore stable level of drug in thebloodstream throughout the day. It maytake several weeks to see the full benefitof medication.

How long will my child be onmedication?Most children will need to continuemedication through high school. Oncechildren become teenagers, somedoctors will recommend a trial off themedication each year. This is to makesure that medication is still necessary.

If the use of methylphenidate causesunacceptable side effects or is noteffective, the two other drugs mentionedabove may be used.

Dexamfetamine is another stimulant andatomoxetine is a different type of drugthat works on a chemical callednoradrenaline in the brain.

There are other drugs that may be usedfor ADHD but these are usually onlyrecommended if the above drugs arenot effective.


Are the drugs safe?The use of drugs to treat ADHD iscontroversial. This is mostly becausesome people are worried about theireffectiveness as well as the possibility ofside effects.

Also, there is the possibility of the drugsbeing misused or abused. However, therecent guidelines from the NationalInstitute for Health and ClinicalExcellence (NICE) advise that they arestill useful and important in the treatmentof severe ADHD and in milder formswhen other treatments have not beeneffective.

The drugs do not seem to have anaddictive potential when used in children.There are reports of the drugs beingabused in teenagers and adults.However, it is likely that the risk ofsubstance abuse with street drugs suchas cocaine in someone with untreatedADHD is greater than the risk of abuse ofthe prescribed drugs.

The controversy is largely unfoundedbecause both scientific studies and yearsof experience have shown that thesedrugs are generally safe and effective.

What about diet?Dietary changes for the treatment ofADHD have been widely used for manyyears.

They take the form of:• Supplements with substances thoughtto be lacking. For example, fatty acidssuch as omega 3 and omega 6, and/or:

• Cutting out foods thought to be harmful.For example, foods containing artificialcolouring and other additives.

The subject of diet and its relationshipto behaviour, hyperactivity and ADHD iscontroversial. An editorial in the BritishMedical Journal by Kemp in 2008(reference at the end), and thesubsequent correspondence, gives aflavour of the issues and controversies.

It suggests that there is enough evidenceto recommend more research into diettreatments for ADHD.


However, the NICE guideline published in2008 came to the conclusion that there isno evidence that dietary changes canhelp children with ADHD, but that“assessment of ADHD should includeasking about foods or drinks that appearto influence their hyperactive behaviour.

If there is a clear link, healthcareprofessionals should advise parents orcarers to keep a diary of food and drinkstaken and ADHD behaviour. If the diarysupports a relationship between specificfoods and drinks and behaviour, thenreferral to a dietitian should be offered.”

So, in short, diet probably does not causeADHD and a change in diet may not helpin many cases. However, there may besome cases where children do respond toa change in diet or are negativelyaffected by certain foods or additives.

If you notice that a particular ingredient orfood makes your child’s behaviour worse,then take a note of it and discuss thisfurther with your doctor or a dietician. Seethe ‘further help and information’ sectionfor support groups that can provide moreinformation on diet.

Is there anything else availablefor older children or adults?In older children, there may be somebenefit gained from psychologicaltreatment such as cognitive behaviouraltherapy (CBT) or social skills training.

These techniques aim to teach your childmore about why they act and react theway that they do. They also give themstrategies to use to help them to improvetheir behaviour and daily functioning.

In adults, medication is recommendedas part of a comprehensive treatmentprogramme.

This should also include psychologicaltreatment, advice on behaviourmanagement and assistance witheducation and employment.


What is the prognosis (outlook)?Up to 8 in 10 children with ADHD willcontinue to experience symptoms intotheir teenage years.

This decreases to about 5 in 10 whocontinue to have some symptoms intoadulthood. With age, the symptoms mayalter. For example, a child who wasalways restless may feel a lot of innertension as an adult. It is also likely thatthe symptoms will reduce in severity andcause less disruption over time.

Children with ADHD are more likely thanaverage to have other problems as adultssuch as unemployment, relationshipdifficulties, substance misuse and crime.

However, treatment aimed at improvingbehaviour at an early age aims to reducethe long term impact of the condition.

Further help and information

ADDISS (Attention Deficit DisorderInformation and Support Service)PO Box 340, Edgware, Middlesex HA89HL

Telephone 020 8952 2800www.addiss.co.uk

Hyperactive Children’s Support GroupTelephone 012 4353 9966

www.hacsg.org.ukThis group is a leading proponent of adietary approach to the problem ofhyperactivity.


References

Attention deficit hyperactivity disorder(ADHD), NICE Clinical Guideline(September 2008); Attention deficithyperactivity disorder: Diagnosis andmanagement of ADHD in children, youngpeople and adults

Evidence-based guidelines formanagement of attention-deficit/hyperactivity disorder in adolescentsin transition to adult services andin adults, British Association forPsychopharmacology (2006)

Kendall T, Taylor E, Perez A, et al;Diagnosis and management ofattentiondeficit/ hyperactivity disorder inchildren, young people, and adults:summary of NICE guidance. BMJ. 2008Sep 24;337:a1239. doi:10.1136/bmj.a1239.

Kemp A; Food additives andhyperactivity. BMJ. 2008 May24;336(7654):1144.

Coghill D; Use of stimulants for attentiondeficit hyperactivity disorder: FOR. BMJ.2004 Oct 16;329(7471):907-8.

Marcovitch H; Use of stimulantsfor attention deficit hyperactivitydisorder: AGAINST. BMJ. 2004 Oct16;329(7471):908-9.


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