Attention-deficit hyperactivity disorder (ADHD) is a heterogeneous disorder affecting an estimated 5 per cent of school age children in the UK.1
There are three elements to ADHD: inattention, hyperactivity and impulsivity (see box below).2 For a diagnosis of ADHD there are several criteria: symptoms of hyperactivity, impulsivity and/or inattention should meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder);3,4 they should be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings; they must also be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.
|The elements of ADHD2|
Distinguishing the disorder
Children with ADHD have difficulties with attention and concentration in more than one setting and over a period of time. A child who suddenly exhibits difficulties out of the blue is less likely to be a child with ADHD. ADHD has also been associated with a range of learning difficulties that may impact on attention and behaviour and this should be considered when a child presents to primary care with difficulties.
These include specific reading difficulties5,6 and dyslexia.7 For example, in one study it was found that approximately 50 per cent of children with ADHD were also found to have developmental co-ordination disorder,1 the symptoms of which impact on writing and ball skills, and have a long-term impact on future psychological development.8
There is extensive biological and genetic evidence to support the construct of ADHD. However, the environment set up for the child and how parents provide structure, rules and boundaries is extremely important.
There is clear evidence of an association of ADHD with a number of other psychiatric conditions including oppositional defiant disorder, conduct disorder and depression and anxiety disorders.9
Children and adults with ADHD often have affective disorders, mainly depressive episodes, substance use disorders and eating disorders with impulsive eating attacks, such as bulimia nervosa and binge eating disorders.10
In September 2008, NICE issued new guidelines in ADHD management with some key
- Parent-training/education programme is the first-line treatment.
- Behavioural interventions in the classroom should also be offered to help children with ADHD-like symptoms before referral to child and adolescent mental health services.
- If the child or young person with ADHD has moderate levels of impairment, the parents or carers should be offered referral to a group parent-training/education programme, either on its own or together with a group treatment programme (cognitive behavioural therapy and/or social skills training) for the child or young person.
- In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based education programme.
- Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
Parents, teachers and health professionals must work together. Strong communication will help to ensure consistent monitoring and management of the child at all times.
Parental guidance should be practical and realistic in the context of the dynamics of the family. If treatment is given monitoring is particularly important if treatment is given to measure change and improvement. Attention must be paid not only to the child’s symptoms, side-effects and performance in school, but also to their social and emotional development
and their home life. Consider their behaviour over 24 hours and not just at school.
Times of transition need planning and support and should be considered early so that they run smoothly. Consider guidance with organisational and independent living skills early on. Discuss areas of strengths in the child that can be developed. It is also important to bear in mind the overlap with other developmental disorders such as speech and language difficulties and co-ordination difficulties, as these are common.
- Professor Kirby is a former GP who founded and runs the Dyscovery Centre for children and adolescents with developmental disorders
1. NICE guidelines ADHD (2008) www.nice.org.uk accessed 21/10/08.
2. American Psychiatric Association Diagnostic and statistical manual of mental disorders, 3rd ed (DSM-III). 1980 Washington, D.C: American Psychiatric Association.
3. American Psychiatric Association DSM-IV Diagnostic and statistical manual of mental disorders. 1994 Washington DC: American Psychiatric Press.
4. World Health Organization (1992a) International statistical classification of diseases and related health problems (10th Edition), Vol. 1; ICD-10. Geneva: World Health Organization.
5. Lambert N, Sandoval J. The prevalence of learning disabilities in a sample of children considered hyperactive. J Abnorm Child Psychol 1980; 8: 33–50.
6. Dykman R A & Ackerman P T. Attention deficit disorder and specific reading disability: separate but often overlapping disorders. J Learn Disabil 1991; 24(2): 96–103.
7. Gilger J W, Pennington BF, De Fries JC. A twin study of the etiology of comorbidity: Attention deficit hyperactivity disorder and dyslexia. J Am Adolesc Psychiatry 1992; 31: 343–8.
8. Kadejso, B, Gillberg, C. The comorbidity of ADHD in the General Population of Swedish School-Age Children. J Child Psychol Psychiatry 2001; 42: 487–92.
9. Mannuzza S, Klein RG, Bessler A, et al. Adult outcome of hyperactive boys: Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry, 1993; 50: 565–76.
10. Sobanski, E., Bruggemann, D., Alm, B et al. Subtype differences in adults with attention-deficit/hyperactivity disorder (ADHD) with regard to ADHD-symptoms, psychiatric comorbidity and psychosocial adjustment. Eur Psychiatry 2008; 23(2): 142–9.