ADHD - An Overview for Professionals Working with Young People

If you are a professional working with young people, you have a legal and ethical responsibility to ensure that you understand the issues involved with ADHD and that the services you provide meet the needs of those affected.

This page gives a summary of the symptoms of the condition, the impact of ADHD on everyday life, the effectiveness of different approaches to treatment, and the guidelines set by NICE for local practice.

ADHD’s genetic link ( Latest news Septeber 2010 )

A team of University scientists have revealed the first direct genetic link to attention deficit/hyperactivity disorder (ADHD).

The study, published in The Lancet, found that children with ADHD were more likely to have small segments of their DNA duplicated or missing than other children.

What is ADHD/ADD?

Attention Deficit Hyperactivity Disorder is a condition that affects the ability to control activity levels, reduces attention span, and produces impulsive behaviour.  It is associated with a number of specific cognitive functioning difficulties.

ADHD is accepted by NICE (The National Institute for Clinical Excellence, the UK body responsible for providing evidence based guidance on medical treatments) as a valid diagnostic category.  Its causes are however not yet clearly understood.

Research so far indicates that brain chemistry, genes and environmental factors can all be linked to ADHD, but that it's not usually possible to establish what causes any individual case.

ADD is a term that has been used for the condition without the hyperactivity element.  ADHD is however now the most widely accepted name for the condition, with or without hyperactivity.
Ages Affected

ADHD develops in childhood and is most commonly noticed around the age of 5.  Research suggests that 80% of children diagnosed with ADHD continue to experience symptoms through adolescence and 67% still have symptoms as adults.

ADHD Symptoms

The symptoms fall into three distinct categories:

Hyperactivity

People find it hard to:

• Stay still. Children will fidget, get up from seats, and want to be on the move constantly. Young people and adults may be restless, but without the constant movement.
• Keep quiet. Children find it hard to play quietly, and want to talk all the time. Teenagers and older people still talk excessively, and often appear random in their conversations.
• Impulsivity

People struggle to:

• Control social interactions. Children don't understand how to take turns and will often butt into conversations and games and blurt out answers in class. Young people and adults may still fail to understand social cues - they will talk over others and share inappropriate information.
• Judge consequences and make sensible decisions. Children may not learn from their mistakes and can do the same ‘naughty' things again and again; young people can be tempted to try drink, drugs and other potentially dangerous activities.

Inattentiveness

People find it hard to:

• Sustain attention when playing, at school or at work.
• Pay attention to detail, leading to careless mistakes.
• Focus on and finish tasks without being distracted.
• Remember and act on instructions.
• Get motivated.
• Organise themselves. The struggle to plan ahead and understand what needs to be done leads to increasing problems as children grow into teenagers and young adults.
• Approach tasks that will require sustained mental effort. Knowing how draining they will find it, both children and adults will often try to avoid such activities.

Different people experience different levels of difficulty in the three areas.  For this reason, ADHD is now divided into three sub-types:

• Predominantly hyperactive/impulsive.
• Predominantly inattentive.
• Combined (most cases).

Symptoms also vary according to gender and age.

How the Symptoms Affect Day-to-Day Life

Difficult social relationships

Because of their hyperactive and impulsive behaviour, children with ADHD can be seen as bossy and aggressive, silly or clumsy.  Other children often don't want them to play and don't choose them when selecting teams - but will enjoy winding them up just to get a reaction.  As a result, the ADHD child often feels rejected and isolated, and can often develop low self-esteem.

In young people and adults, ADHD behaviour can be interpreted as rude, uncaring or negative.  This makes relationships challenging, particularly when you add in the potential for forgetfulness and distraction.  To be popular, ADHD teenagers may often take the role of class clown, or become promiscuous - without being able to make sensible judgements about the risks involved.    Alternatively, they can withdraw and become increasingly isolated and depressed.

Pressures on the Family

Life in a family with an ADHD child or teenager can be very wearing, and parents will often be tired and stressed. 

Practical pressures include constantly monitoring what their child is doing, keeping them on task, and finding lost items.  Emotional pressures include handling the child's mood swings, anxiety about their happiness, and worries about progress at school.

As teenagers become more independent, parents also worry about their ability to cope and to stay safe.

There can also be guilt, as parents blame themselves for getting cross when they know the child can't help their behaviour.  Parents may also feel responsible - unnecessarily - for the child's challenging behaviour, and worry that they don't know what to do for the best.  Disagreements about how to handle issues can cause relationship difficulties between parents, whilst brothers and sisters can feel neglected because the ADHD child takes all the parents' time and emotional energy.

These problems are intensified where a parent has ADHD. Given the genetic component of the condition, professionals should always be aware of this as a possibility - many adults with ADHD will never have been diagnosed.

Struggles at School

Young children with ADHD can miss things because they are fidgeting and don't hear what the teacher has said.  As they grow up, it's often increasingly hard for them to keep up with their peers.  Even academically bright ADHD children frequently struggle to start and finish work, remember they have homework, produce written work quickly (or at all), remember facts or complete maths problems.  Where they do work quickly, it's often because they have rushed the task, or focused only on one part of the question.

These academic difficulties are made worse by their problems in being on time, planning, and controlling their emotions.  Teachers often fail to recognise the problem, and can get very frustrated with teenagers who seem to just not care.  Teenagers can become very angry with themselves and with others, and self-esteem levels - already low - can worsen.

ADHD teenagers may be put into lower sets or streams than their ability merits, which only makes problems worse.  They may underachieve, not getting the exam passes they need in order to go on to careers where they can use their talents.

Struggles at Work

Adults with ADHD can find it hard to hold down a job.  They frequently struggle to meet deadlines and remember responsibilities, and their poor social skills can make workplace relationships difficult.  Being easily bored, they often fail to keep on top of tasks.  Knowing they find sustained mental activity difficult, they may put off projects requiring focus and concentration.

Dangers

Whilst young ADHD children are more likely to have accidents than others, the problems really intensify through the teenage years.

ADHD teenagers have a higher risk of becoming dependent on drink or drugs, of developing eating disorders, catching sexually transmitted diseases and becoming pregnant, and causing traffic accidents.  They are also at greater risk of getting involved in shoplifting and more serious crime.

ADHD teenagers may calm down as adults, but are still at risk of getting into serious trouble.  Sudden anger, for example, can still lead to violence and aggression, and impulsive spending can cause financial problems.

Psychological and psychiatric disorders can develop alongside ADHD, or as a consequence.  These include obsessive compulsive disorder, anxiety, and depression.

Professionals working with young people in trouble or presenting challenging behaviour should always consider undiagnosed ADHD as a possible contributory factor.

How ADHD is Diagnosed

NICE guidelines state that GPs should not make the initial diagnosis of ADHD.  Instead, children and young people should be referred to a child psychiatrist, paediatrician, or specialist ADHD CAMHS teams.  Adults presenting for the first time should be referred to a mental health specialist trained in the diagnosis and treatment of ADHD.  Adults who were diagnosed as children but present with symptoms suggestive of continuing ADHD should be referred to general adult psychiatric services for assessment.

Doctors can only diagnose ADHD where the symptoms:

• Are greater than expected in the context of age and intelligence.
• cause significant impairment in functioning in two or more settings (for example, home and school - or work, in the case of an adult).
• Have been present for at least six months and don't happen only during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder.
• Can't be better accounted for by other conditions such as mood disorder, anxiety disorder or dissociative disorder.

Treatment and Support

Drugs

There are three drugs typically prescribed for ADHD:  Methylpenidate (Ritalin), dexamfetamine, and atomoxetine.  All work in different ways to regulate chemicals in the brain that affect thinking processes.

The evidence

Medication can be very effective at reducing core symptoms whilst it is being taken and so can be very useful for children, young people and adults who need to be able to concentrate at school or at work.  The drugs don't however work for everyone, and some people suffer significant side effects.  Unless symptoms are severe, medication should only be offered to children if other approaches haven't been successful.

Drug treatment is not recommended for pre-school children. There is no evidence that it is effective for this age group. 

There are still many questions about the longer term balance of risk against benefit.  None of the drugs cure symptoms in the long term, and some studies indicate that their effectiveness reduces as children grow into adolescence.

Medication is focused on narrow clinical outcomes and doesn't help with the many secondary or co-existing issues.
Non-Pharmacological Interventions

Most ADHD in children and adults is associated with behavioural problems and coexisting mental disorders, typically depression, anxiety, defiant and oppositional behaviour, low self-esteem, relationship difficulties and learning problems.  Proven psychological therapies can help to manage symptoms and behaviour, and to reduce the problems that arise from ADHD.

These therapies include behavioural management and parent training, cognitive behavioural therapy (CPT), social skills training, and family therapy.

Other approaches with adults and young people include solution-focused therapy and coaching, which helps people identify and make the most of their strengths, as well as manage their problems and cope with daily life.

Children, young people and adults can benefit from a wide range of leisure activities, meeting their need for stimulation and helping them burn off energy.

The evidence

Parent-training programmes can improve children's behaviour.  Established programmes such as Triple P can be suitable, when supplemented by ADHD-specific elements. To be effective, however, it is important that programmes follow NICE guidelines.

School-age children up to 12 benefit from a combination of Cognitive Behavioural Therapy and social skills training group sessions, run alongside parallel group sessions for parents.

Written manuals for parents are also effective in improving children's behaviour.

Teachers who know and implement specific strategies have a significantly beneficial effect on children's behaviour.

There isn't yet any evidence about what works best for young people of 13 and over, but it is likely that a similar combination of CBT and social skills training will be effective.

There is very little research about how to best help older teenagers and adults with ADHD.  What  evidence there is suggests that CBT can be helpful, particularly where people have persistent difficulties in day-to-day functioning.  This can often be delivered cost-effectively in a group setting.  Anecdotal evidence suggests that mutual support groups are very beneficial.  By sharing experiences, people learn to understand the condition, improve their ability to manage their own lives and increase their self-esteem.

Diet and ADHD

There is no evidence of any direct link between diet and ADHD, though some children's behaviour can be more strongly influenced by particular foods than others.  Normal advice about healthy diet and exercise for children therefore applies.
Positive Outcomes

With support and encouragement, children, young people and adults can be helped to adjust for the negative aspects of the condition and to understand that there are positives too. High levels of energy and a readiness to take risks are personality traits shared by many successful people. 
Nice Recommendations for Service Provision

NICE recommend that mental health trusts, and children's trusts that provide mental health/child development services, should form multidisciplinary specialist ADHD teams and/or clinics for children and young people and separate teams and/or clinics for adults.

These teams and clinics should have expertise in the diagnosis and management of ADHD.

Every area should develop a  multi-agency group to oversee implementation of its guidelines, co-ordinate training for professionals, and develop education programmes for parents.