A Psychiatric disorder – Attention Deficit Hyperactivity Disorder causes developmental impairment and behavioural problems including inattentiveness, hyperactivity, or acting impulsively that is not appropriate for a person’s age
Introduction
Symptoms of ADHD
Causes of ADHD
Diagnosing ADHD
Treating ADHD
Coping with ADHD
Resources
Introduction
History of ADHD
The Early History of ADHD
As early as 1798, Sir Alexander Crichton, a Scottish-born doctor, studied what he called “mental restlessness” in children that every schoolteacher must have seen. More than 100 years later, Sir George Frederick Still of the UK observed behaviors in 20 children that included defiance, spitefulness, and inhibition and could not be traced back to poor child-rearing practices. He called the children’s behavior, “a morbid defect in moral control.”
While not exactly the terminology used today, many experts believe the characteristics Still saw in those children in 1902 would be classified as ADHD today. In 1904, the premier British medical journal The Lancet published a humorous poem called “The Story of Fidgety Philip:” “He won’t sit still/He wriggles/And giggles/And then, I declare/Swings backwards and forwards/And tilts up his chair…” This was perhaps the first documentation of ADHD symptoms in medical literature.
In the 19th century, the preferred “treatment” method for “immoral” children was corporeal punishment. Thankfully, this began to change after the turn-of-the-century, when experts began to explore the link between “bad” behavior and underlying biological traits.
In 1934, Eugene Kahn and Louis H. Cohen first connected the symptoms of ADHD—distractibility, impulsivity, and restlessness—to a known disease, in this case, the encephalitis epidemic of 1917-18. The first major success in treating this behavioral disorder was in 1937, when Dr. Charles Bradley introduced the use of Benzedrine to treat children with hyperactivity. Though he couldn’t explain why, the stimulant medication worked and set the stage for current pharmaceutical treatments.
The Modern History of ADHD
By the late 1950s, ADHD was labeled “hyperkinetic syndrome” and was routinely treated with stimulants, including Ritalin. In 1968, it was given the clinical name “hyperkinetic reaction of childhood” in the second edition of the official Diagnostic and Statistical Manual of Mental Disorders. Throughout the 1960s and 70s, doctors came to understand that the disorder was not caused by poor parenting or “bad behavior,” but was in fact a biological condition that tended to run in families.
Critics (then and now) argued that ADD and ADHD were myths propagated by psychiatrists to excuse lax parents and out-of-control children. Through research into the connection between brain structure and ADHD (which continues today), this argument has been thoroughly debunked.
In 1970, C. Kornetsky first hypothesized that stimulant medications work well for ADHD children because they increase the amount of neurotransmitters, such as dopamine and norepinephrine, in the brain. Neurotransmitters are chemicals that carry messages among the brain’s neurons. We still don’t know precisely which neurotransmitters (or lack thereof) are responsible for ADHD, but we do know beyond a doubt that the condition is caused by faulty brain chemistry, not “immorality.”
(History credits – Healthline.com)
Common signs of ADHD include:
- a short attention span or being easily distracted
- restlessness, constant fidgeting or overactivity
- being impulsive
ADHD can occur in people of any intellectual ability, although it is more common in people with learning difficulties. People with ADHD may also have additional problems, such as sleep and anxiety disorders.
Symptoms of ADHD tend to be first noticed at an early age, and may become more noticeable when a child’s circumstances change, such as when they start school. Most cases are diagnosed in children between the ages of 6 and 12.
The symptoms of ADHD usually improve with age, but many adults who are diagnosed with the condition at a young age will continue to experience problems.
Books about ADHD
The Symptoms of ADHD
The symptoms of attention deficit hyperactivity disorder (ADHD) can be categorised into two sets of behavioural problems.
These categories are:
- inattentiveness
- hyperactivity and impulsiveness
Most people with ADHD have problems that fall into both these categories, but this is not always the case.
For example, some people with the condition may have problems with inattentiveness, but not with hyperactivity or impulsiveness. This form of ADHD is also known as attention deficit disorder (ADD), and it can sometimes go unnoticed because the symptoms may be less obvious.
Symptoms in children and teenagers
The symptoms of ADHD in children and teenagers are well defined, and they are usually noticeable before the age of six. They occur in more than one situation, such as at home and at school.
The main signs of each behavioural problem are detailed below.
Inattentiveness
The main signs of inattentiveness are:
- having a short attention span and being easily distracted
- making careless mistakes – for example, in schoolwork
- appearing forgetful or losing things
- being unable to stick at tasks that are tedious or time-consuming
- appearing to be unable to listen to or carry out instructions
- constantly changing activity or task
- having difficulty organising tasks
Hyperactivity and impulsiveness
The main signs of hyperactivity and impulsiveness are:
- being unable to sit still, especially in calm or quiet surroundings
- constantly fidgeting
- being unable to concentrate on tasks
- excessive physical movement
- excessive talking
- being unable to wait their turn
- acting without thinking
- interrupting conversations
- little or no sense of danger
These symptoms can cause significant problems in a child’s life, such as underachievement at school, poor social interaction with other children and adults, and problems with discipline.
Related conditions in children and teenagers
Although not always the case, some children may also have signs of other problems or conditions alongside ADHD, such as:
- anxiety disorder – which causes your child to worry and be nervous much of the time; it may also cause physical symptoms, such as a rapid heartbeat, sweating and dizziness
- oppositional defiant disorder (ODD) – this is defined by negative and disruptive behaviour, particularly towards authority figures, such as parents and teachers
- conduct disorder – this often involves a tendency towards highly antisocial behaviour, such as stealing, fighting, vandalism and harming people or animals
- depression
- sleep problems – finding it difficult to get to sleep at night, and having irregular sleeping patterns
- autism – this affects social interaction, communication, interests and behaviour
- epilepsy – a condition that affects the brain and causes repeated fits or seizures
- Tourette’s syndrome – a condition of the nervous system, characterised by a combination of involuntary noises and movements called tics
- learning difficulties – such as dyslexia
Symptoms in adults
In adults, the symptoms of ADHD are more difficult to define. This is largely due to a lack of research into adults with ADHD.
ADHD is a developmental disorder; it is believed that it cannot develop in adults without it first appearing during childhood. However, it is known that symptoms of ADHD often persist from childhood into a person’s teenage years, and then adulthood. Any additional problems or conditions experienced by children with ADHD, such as depression or dyslexia, may also continue into adulthood.
By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives.
The symptoms in children and teenagers, which are listed above, is sometimes also applied to adults with possible ADHD. However, some specialists say that the way in which inattentiveness, hyperactivity and impulsiveness affect adults can be very different from the way they affect children.
For example, hyperactivity tends to decrease in adults, while inattentiveness tends to get worse as the pressure of adult life increases. Also, adult symptoms of ADHD tend to be far more subtle than childhood symptoms.
Therefore, some specialists have suggested the following list of symptoms associated with ADHD in adults:
- carelessness and lack of attention to detail
- continually starting new tasks before finishing old ones
- poor organisational skills
- inability to focus or prioritise
- continually losing or misplacing things
- forgetfulness
- restlessness and edginess
- difficulty keeping quiet and speaking out of turn
- blurting out responses and often interrupting others
- mood swings, irritability and a quick temper
- inability to deal with stress
- extreme impatience
- taking risks in activities, often with little or no regard for personal safety or the safety of others – for example, driving dangerously
Additional problems in adults with ADHD
As with ADHD in children and teenagers, ADHD in adults can occur alongside several related problems or conditions.
One of the most common conditions is depression. Other conditions that adults may have alongside ADHD include:
- personality disorders – conditions in which an individual differs significantly from an average person, in terms of how they think, perceive, feel or relate to others
- bipolar disorder – a condition that affects your moods, which can swing from one extreme to another
- obsessive-compulsive disorder (OCD) – a condition that causes obsessive thoughts and compulsive behaviour
The behavioural problems associated with ADHD can also cause problems such as difficulties with relationships, social interaction, drugs and crime. Some adults with ADHD find it hard to find and stay in a job.
Causes of ADHD
The exact cause of attention deficit hyperactivity disorder (ADHD) is not fully understood, although a combination of factors is thought to be responsible.
Genetics
ADHD tends to run in families and, in most cases, it is thought the genes you inherit from your parents are a significant factor in developing the condition.
Research shows that both parents and siblings of a child with ADHD are four to five times more likely to have ADHD themselves.
However, the way ADHD is inherited is likely to be complex and isn’t thought to be related to a single genetic fault.
Brain function and structure
Research has identified a number of possible differences in the brains of people with ADHD compared to those who don’t have the condition, although the exact significance of these is not clear.
For example, studies involving brain imaging scans have suggested that certain areas of the brain may be smaller in people with ADHD, whereas other areas may be larger.
Research has also shown that the brain may take an average of two to three years longer to mature in children with ADHD, compared to children who don’t have the condition.
Other studies have suggested that people with ADHD may have an imbalance in the level of chemicals in the brain called neurotransmitters, or that these chemicals may not work properly.
Other possible causes
Various other causes have also been suggested as having a role in the development of ADHD, including:
- being born prematurely (before the 37th week of pregnancy)
- having a low birthweight
- brain damage either in the womb or in the first few years of life
- drinking alcohol, smoking or misusing drugs while pregnant
- exposure to high levels of toxic lead at a young age
However, the evidence for many of these factors is inconclusive, and more research is needed to determine if they do in fact contribute to ADHD.
Diagnosing ADHD
If you are worried about your child, it may help to speak to their teachers before seeing your GP, to find out if they have any concerns about your child’s behaviour.
Your GP can’t formally diagnose ADHD, but they can discuss your concerns with you and refer you for a specialist assessment, if necessary.
When you see your GP, they may ask you:
- about your symptoms or those of your child
- when these symptoms started
- where the symptoms occur – for example, at home or in school
- whether the symptoms affect your or your child’s day-to-day life – for example, if they make socialising difficult
- if there have been any recent significant events in your or your child’s life, such as a death or divorce in the family
- if there is a family history of ADHD
- about any other problems or symptoms of different health conditions you or your child may have
If your GP thinks your child may have ADHD
They may first suggest a period of “watchful waiting” lasting around 10 weeks – to see if your child’s symptoms improve, stay the same or get worse. They may also suggest starting a parent training or education programme to teach you ways of helping your child (see treating ADHD for more information).
If your child’s behaviour doesn’t improve, and both you and your GP thinks it is seriously affecting their day-to-day life, your GP should refer you and your child to a specialist for a formal assessment (see below).
For adults with possible ADHD, your GP will assess your symptoms and may refer you for an assessment if:
- you were not diagnosed with ADHD as a child, but your symptoms began during childhood and have been ongoing since then
- your symptoms cannot be explained by a mental health condition
- your symptoms have a significant impact on your day-to-day life – for example, if you are underachieving at work or find intimate relationships difficult
You may also be referred to a specialist if you had ADHD as a child or young person, and your symptoms are now causing moderate or severe functional impairment.
ADHD Assessments
There are a number of different specialists you or your child may be referred to for a formal assessment, including:
- a child or adult psychiatrist
- a paediatrician (a specialist in children’s health)
- a learning disability specialist, social worker or occupational therapist with expertise in ADHD
Who you are referred to will depend on your age and what is available in your local area.
There is no simple test to determine whether you or your child have ADHD, but your specialist can make an accurate diagnosis after a detailed assessment that may include:
- a physical examination, which can help rule out other possible causes for the symptoms
- a series of interviews with you or your child
- interviews or reports from other significant people, such as partners, parents and teachers
The criteria for making a diagnosis of ADHD in children, teenagers and adults are outlined below.
Diagnosis in children and teenagers
Diagnosing ADHD in children depends on a set of strict criteria. To be diagnosed with ADHD, your child must have six or more symptoms of inattentiveness, or six or more symptoms of hyperactivity and impulsiveness.
(see The Symptoms of ADHD above)
To be diagnosed with ADHD, your child must also have:
- been displaying symptoms continuously for at least six months
- started to show symptoms before the age of 12
- been showing symptoms in at least two different settings – for example, at home and at school, to rule out the possibility that the behaviour is just a reaction to certain teachers or parental control
- symptoms that make their lives considerably more difficult on a social, academic or occupational level
- symptoms that are not just part of a developmental disorder or difficult phase, and are not better accounted for by another condition
Diagnosis in adults
Diagnosing ADHD in adults is more difficult because there is some disagreement about whether the list of symptoms used to diagnose children and teenagers also applies to adults.
In some cases, an adult may be diagnosed with ADHD if they have five or more symptoms of inattentiveness, or five or more symptoms of hyperactivity and impulsiveness, that are listed in diagnostic criteria for children with ADHD.
As part of your assessment, the specialist will ask about your present symptoms although, under current diagnostic guidelines, a diagnosis of ADHD in adults cannot be confirmed unless your symptoms have been present from childhood.
If you find it difficult to remember whether you had problems as a child, or you were not diagnosed with ADHD when you were younger, your specialist may wish to see your old school records or talk to your parents, teachers or anyone else who knew you well when you were a child.
- underachieving at work or in education
- driving dangerously
- difficultly making or keeping friends
- difficulty in relationships with partners
If your problems are recent and did not occur regularly in the past, you are not considered as having ADHD. This is because it is currently not thought that ADHD can develop for the first time in adults.
Treating ADHD
Although there is no cure, ADHD can be treated using medication or therapy, but a combination of both is often the best way to treat it.
Treatment will usually be arranged by a specialist, such as a paediatrician or psychiatrist, although your condition may be monitored by your GP.
Medication
There are four types of medication licensed for the treatment of ADHD:
- methylphenidate
- dexamfetamine
- lisdexamfetamine
- atomoxetine
These medications are not a permanent cure for ADHD, but they can help someone with the condition concentrate better, be less impulsive, feel calmer, and learn and practise new skills.
Some medications need to be taken every day, but some can be taken just on school days. Treatment breaks are occasionally recommended, to assess whether the medication is still needed.
In the UK, all of these medications are licensed for use in children and teenagers. Atomoxetine is also licensed for use in adults who had symptoms of ADHD as children.
If you were not diagnosed with ADHD until adulthood, your GP and specialist can discuss which medications and therapies are suitable for you.
If you or your child is prescribed one of these medications, you will probably be given small doses at first, which may then be gradually increased. You or your child will need to see your GP for regular check-ups, to ensure the treatment is working effectively and to check for signs of any side effects or problems.
Your specialist will discuss how long you should take your treatment but, in many cases, treatment is continued for as long as it is helping.
Methylphenidate
Methylphenidate is the most commonly used medication for ADHD. It belongs to a group of medicines called stimulants that work by increasing activity in the brain, particularly in areas that play a part in controlling attention and behaviour.
Methylphenidate can be used by teenagers and children with ADHD over the age of six. Although methylphenidate is not licensed for use in adults, it may be taken under close supervision from your GP and specialist.
The medication can be taken as either immediate-release tablets (small doses taken two to three times a day), or as modified-release tablets (taken once a day in the morning, and they release the dose throughout the day).
Common side effects of methylphenidate include:
- a small increase in blood pressure and heart rate
- loss of appetite, which can lead to weight loss or poor weight gain
- trouble sleeping
- headaches
- stomach aches
- mood swings
Dexamfetamine
Dexamfetamine is also a stimulant medication that works in a similar way to methylphenidate, by stimulating areas of the brain that play a part in controlling attention and behaviour.
Dexamfetamine can be used by teenagers and children with ADHD over the age of three. Although it is not licensed for use in adults, it may be taken under close supervision from your GP and specialist.
Dexamfetamine is usually taken as a tablet once or twice a day, although an oral solution is also available.
Common side effects of dexamfetamine include:
- decreased appetite
- mood swings
- agitation and aggression
- dizziness
- headaches
- diarrhoea
- nausea and vomiting
Lisdexamfetamine
Lisdexamfetamine is a similar medication to dexamfetamine, and works in the same way.
It can be used by children with ADHD over the age of six if treatment with methylphenidate hasn’t helped. You may continue to take it into adulthood if your doctor thinks you are benefitting from treatment.
Lisdexamfetamine comes in capsule form, which you or your child usually take once a day.
Common side effects of lisdexamfetamine include:
- decreased appetite, which can lead to weight loss or poor weight gain
- aggression
- drowsiness
- dizziness
- headaches
- diarrhoea
- nausea and vomiting
Atomoxetine
Atomoxetine works differently to other ADHD medications.
It is known as a selective noradrenaline uptake inhibitor (SNRI), which means it increases the amount of a chemical in the brain called noradrenaline. This chemical passes messages between brain cells, and increasing the amount can aid concentration and help control impulses.
Atomoxetine can be used by teenagers and children over the age of six. It is also licensed for use in adults who are continuing treatment after taking the medication as a teenager. It is not licensed for use in adults newly diagnosed with ADHD, but your GP and specialist may prescribe it under their supervision.
Atomoxetine comes in capsule form, which you or your child usually take once or twice a day.
Common side effects of atomoxetine include:
- a small increase in blood pressure and heart rate
- nausea and vomiting
- stomach aches
- trouble sleeping
- dizziness
- headaches
- irritability
Atomoxetine has also been linked to some more serious side effects that it’s important to look out for, including suicidal thoughts and liver damage.
If either you or your child begin to feel depressed or suicidal while taking this medication, speak to your doctor.
Therapy
As well as taking medication, different therapies can be useful in treating ADHD in children, teenagers and adults. Therapy is also effective in treating additional problems, such as conduct or anxiety disorders, that may appear with ADHD.
Some of the therapies that may be used are outlined below.
Psychoeducation
Psychoeducation means you or your child will be encouraged to discuss ADHD and how it affects you. It can help children, teenagers and adults make sense of being diagnosed with ADHD, and can help you to cope and live with the condition.
Behaviour therapy
Behaviour therapy provides support for carers of children with ADHD, and may involve teachers as well as parents. Behaviour therapy usually involves behaviour management, which uses a system of rewards to encourage your child to try to control their ADHD.
If your child has ADHD, you can identify types of behaviour you want to encourage, such as sitting at the table to eat. Your child is then given some sort of small reward for good behaviour, and removal of a privilege for poor behaviour. For teachers, behaviour management involves learning how to plan and structure activities, and to praise and encourage children for even very small amounts of progress.
Parent training and education programmes
If your child has ADHD, specially tailored parent training and education programmes can help you learn specific ways of talking to your child, and playing and working with them to improve their attention and behaviour. You may also be offered parent training before your child is formally diagnosed with ADHD.
These programmes are usually arranged in groups and can last several weeks. They aim to teach parents and carers about behaviour management (see above), while increasing your confidence in your ability to help your child, as well as improving your relationship.
Social skills training
Social skills training involves your child taking part in role play situations, and aims to teach them how to behave in social situations by learning how their behaviour affects others.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave. A CBT therapist would try and change how your child feels about a situation, which would in turn potentially change their behaviour.
CBT can be carried out with a therapist individually or in a group.
Other possible treatments
There are other ways of treating ADHD that some people with the condition find helpful, such as cutting out certain foods and taking supplements. However, there is no strong evidence these work, and they should not be attempted without medical advice.
Diet
People with ADHD should eat a healthy, balanced diet. Do not cut out foods without medical advice.
Some people may notice a link between types of food and worsening ADHD symptoms. For example, sugar, food colourings and additives, and caffeine are often blamed for aggravating hyperactivity, and some people believe they have intolerances to wheat or dairy products, which may add to their symptoms.
If this is the case, keep a diary of what you eat and drink, and what behaviour this causes. Discuss this with your GP, who may refer you to a dietitian (a healthcare professional who specialises in nutrition).
Do not change your (or your child’s) diet without medical advice.
Supplements
Some studies have suggested that supplements of omega-3 and omega-6 fatty acids may be beneficial in people with ADHD, although the evidence supporting this is very limited.
It’s advisable to talk to your GP before using any supplements, because some can react unpredictably with medication or make it less effective.
You should also remember that some supplements should not be taken long term, as they can reach dangerous levels in your body.
Coping with ADHD
Caring for a child with attention deficit hyperactivity disorder (ADHD) can be draining.
The impulsive, fearless and chaotic behaviours typical of ADHD can make normal everyday activities exhausting and stressful.
Ways to cope
Although it can be difficult at times, it’s important to remember a child with ADHD cannot help their behaviour. People with ADHD find it difficult to suppress impulses, which means they do not stop to consider a situation or the consequences before they act.
If you are looking after a child with ADHD, you may find the below advice helpful.
Plan the day
Plan the day so your child knows what to expect. Set routines can make a difference to how a child with ADHD copes with everyday life. For example, if your child has to get ready for school, break it down into structured steps, so they know exactly what they need to do.
Set clear boundaries
Make sure everyone knows what behaviour is expected, and reinforce positive behaviour with immediate praise or rewards. Be clear, using enforceable consequences if boundaries are overstepped (such as taking away a privilege) and follow these through consistently.
Be positive
Give specific praise. Instead of saying a general, “Thanks for doing that,” you could say, “You washed the dishes really well. Thank you.” This will make it clear to your child that you are pleased, and why.
Giving instructions
If you are asking your child to do something, give brief instructions and be specific. Instead of asking, “Can you tidy your bedroom?” say, “Please put your toys into the box, and put the books back onto the shelf.” This makes it clearer what your child needs to do and creates opportunities for praise when they get it right.
Incentive scheme
Set up your own incentive scheme using a points chart or star chart, so good behaviour can earn a privilege. For example, behaving well on a shopping trip will earn your child time on the computer or some sort of game. Involve your child in it and allow them to help decide what the privileges will be.
These charts need regular changes or they become boring. Targets should be:
- immediate (for example, daily)
- intermediate (for example, weekly)
- long-term (for example, three-monthly)
Try to focus on just one or two behaviours at a time.
Intervene early
Watch for warning signs. If your child looks like they are becoming frustrated, overstimulated and about to lose self-control, intervene. Distract your child if possible, by taking them away from the situation, which may calm them down.
Social situations
Keep social situations short and sweet. Invite friends to play, but keep playtimes short so your child does not lose self-control. Do not aim to do this when your child is feeling tired or hungry, such as after a day at school.
Exercise
Make sure your child gets lots of physical activity during the day. Walking, skipping and playing sport can help your child wear themselves out and improve their quality of sleep. Make sure they are not doing anything too strenuous or exciting near to bedtime.
Eating
Keep an eye on what your child eats. If your child is hyperactive after eating certain foods, which may contain additives or caffeine, keep a diary of these and discuss them with your GP.
Bedtime
Stick to a routine. Make sure your child goes to bed at the same time each night and gets up at the same time in the morning. Avoid overstimulating activities in the hours before bedtime, such as computer games or watching TV.
Night time
Sleep problems and ADHD can be a vicious circle. ADHD can lead to sleep problems, which in turn can make symptoms worse. Many children with ADHD will repeatedly get up after being put to bed and have interrupted sleep patterns. Trying a sleep-friendly routine can help your child and make bedtime less of a battleground.
Help at school
Children with ADHD often have problems with their behaviour at school, and the condition can have a negative impact on a child’s academic progress.
Speak to your child’s teachers or their school’s special educational needs co-ordinator (SENCO) about any extra support your child may need.
For Adults with ADHD
If you are an adult living with ADHD, you may find the following advice useful:
- make lists, keep diaries, stick up reminders and set aside some time to plan what you need to do if you find it hard to stay organised
- let off steam by exercising regularly
- find ways to help you relax, such as listening to music or learning relaxation techniques
- if you have a job, speak to your employer about your condition, and discuss anything they can do to help you work better
- talk to your doctor about your suitability to drive, as you will need to tell the Driver and Vehicle Licensing Agency (DVLA) if your ADHD affects your driving
- contact or join a local or national support group – these organisations can put you in touch with other people in a similar situation, and they can be a good source of support, information and advice
Resources
AADD-UK – The site for and by adults with ADHD
AADD-UK also has a list of adult support groups across the UK.
ADHD Foundation – The ADHD Foundation provides training services to support Schools. This can either be delivered ‘In-School’ to whole groups of staff; or individuals can access the training at one of our ‘Open Venues’.