Attention Deficit Hyperactivity Disorder (ADHD)

*Xenofon Sgouros

Attention deficit hyperactivity disorder is a neuro-developmental disorder that makes an individual more likely to have short attention spans, and be impulsive and hyperactive. Many of us might have one of these problems, but we do not have all of them. In neuro-developmental disorders the development of the central nervous system, e.g. brain, has somehow been disrupted usually in the first few years after birth, or during early childhood. They can manifest as neuropsychiatric problems or problems with motor function, attention and learning, language, non-verbal communication, etc.

To have a diagnosis of ADHD, problems must appear before a person is twelve years old, be present for more than six months, and be bad enough to interfere with at least two of the following:

How you get on with other people
How you get on at work or school
How you get on in your free time or hobbies
Your self-confidence/ self-image

Some individuals with ADHD also have difficulties regulating their emotions, or problems with executive function and self-regulation skills. These are mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. Additionally, there is a strong association with other mental or neurological disorders, such as depression, sleep and anxiety disorders, autism spectrum disorder, Tourette’s syndrome, Epilepsy, and substance abuse. Individuals with ADHD also present with a range of learning difficulties, such as Dyslexia. Although, ADHD can impair an individual’s performance and can sometimes have debilitating effects in social and work/academic life, many people with ADHD can have sustained attention for tasks they find interesting or rewarding (known as hyperfocus). Additionally, many children go through phases where they’re restless or inattentive. This is often completely normal and does not necessarily mean they have ADHD. You should consider raising concerns with your child’s teacher, or their school’s special educational needs coordinator or a GP if you think their behaviour may be different from most children of their age. It is also a good idea to speak to a GP if you’re an adult and think you may have ADHD, but were not diagnosed with the condition as a child.

How common is ADHD?

Within the UK, it is estimated that affects about 3-5% of children and 2% of adults and it is considered to be more common in males than females. However, it is often overlooked in girls because their symptoms can differ from those of boys. About 30-50% of people diagnosed in childhood continue to have symptoms into adulthood, although in adults, inner restlessness, rather than hyperactivity, may occur. Adults often develop coping skills which make up for some of their difficulties. The condition can be difficult to tell apart from other conditions, as well as to distinguish from high levels of activity that are still within the range of normal behaviours.

What can cause ADHD?

In individuals with ADHD, their brain networks have developed in a way that causes them difficulty in filtering out external stimuli that are irrelevant to the task they perform, and in regulating and organising their activity. The causes of this are not clear, but we do know that people who have a parent or sibling with the condition are more likely to be affected. It has also been suggested that low birthweight, premature birth, smoking or other alcohol or substance abuse during pregnancy, exposure at a young age to other toxins, such as lead, or brain injuries, may play a role too. It is not directly related to the style of parenting or discipline, although children who have been emotionally or physically neglected, or have been abused is more likely to develop ADHD symptoms later in life. It is also known that Individuals with ADHD present with lower levels, or functionality of a brain chemical (neuro-transmitter), which is called dopamine. Dopamine is a chemical that controls our level of arousal and our ability to sustain attention in tasks. Most medications that are used in ADHD increase the levels of dopamine in the brain.

What are the signs and symptoms of ADHD?

Short attention span, hyperactivity (restlessness in adults), disruptive behaviours, and being impulsive are common in ADHD. Academic difficulties are frequent as are problems with relationships. The symptoms can be difficult to define, as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring treatment begin. The following is a list of some of the most common symptoms/signs of ADHD. It is not an exclusive list and different individuals can present with different sets of symptoms (or signs).

Inattention

Difficulty paying close attention to details
Trouble holding attention on tasks
Trouble organising tasks and activities
Often losing things necessary for tasks
Appearing forgetful in daily activities, or day-dreaming
Having a shorter attention span and being easily distracted
Difficulty with structured schoolwork
Difficulty completing tasks that are tedious or time-consuming

Hyperactivity-impulsivity

Unable to sit still
Fidgets, squirms in seat
Leaves seat in inappropriate situations
Takes risks with little thought for the dangers
Feeling “on the go” or “driven by a motor”
Talking more than others
Often answers quickly and without conscious thinking
Has trouble awaiting their turn
Interrupts or intrudes in conversations

Psychiatric diagnostic systems, like DSM-5 or ICD-10, recognise three different subtypes of ADHD: predominantly inattentive (so called ADD), predominantly hyperactive-impulsive, and combined. Girls with ADHD tend to display fewer hyperactivity and impulsivity symptoms but more symptoms pertaining to attention. Symptoms of hyperactivity tend to go away with age and turn into “inner restlessness” in teens and adults with ADHD.

People with ADHD at all ages are more likely to have problems with social skills, such as social interaction and forming and maintaining friendships. They may also have problems in processing verbal and non-verbal communication which also negatively affects social interaction. They may drift away in conversations, miss social cues, and have trouble learning social skills. Difficulties managing anger are also common as are poor handwriting, dyslexia, problems in learning maths, delays in speech and language development, and delays in development of motor and coordination skills (dyspraxia). However, many children and adults with ADHD have an attention span equal or better than that of other children for tasks and subjects they find interesting.

Although, ADHD is associated with various learning difficulties, it does not overall affect your intelligence. Most children and adults with ADHD have the same or sometime higher intelligence than most people. It may affect though your ability to learn or work in traditional settings.

How is ADHD diagnosed?

In children and adolescents, ADHD is diagnosed by a clinical assessment by a specialist Child and Adolescent Psychiatrist; this includes ruling out the effects of drugs, medications and other medical or psychiatric explanations for their symptoms. It often considers feedback from parents and teachers with most diagnoses begun after a teacher raises concerns. Similarly, in adults, ADHS is diagnosed by a specialist clinical assessment, which considers feedback from parents or other people who know the individual since childhood. There are several structured or semi-structured diagnostic tests that can aid the clinical assessment. The most widely used is called Diagnostic Interview for ADHD in adults (DIVA-5) or the Young DIVA-5 for use in children 5-17 years old.

How do you treat ADHD?

Both psychological therapies and medications can be used to improve the symptoms of ADHD. Psychological therapies focuses on helping a person to manage their behaviour and improve their self-confidence, while medication can help improve attention span and reduce impulsive behaviour.

Education about ADHD and techniques that help you to become more aware about your behaviours are important components of any treatment for ADHD. The most frequently used psychological therapies are Cognitive Behavioural Therapy (CBT) and Mindfulness techniques. These can help you to find ways to make sure that you do important tasks and organise your life better, get self-critical thoughts into perspective, and so feel better about yourself, and reduce unhelpful feelings of anxiety.

Medications for ADHD are mostly “stimulant” medications, related to amphetamines. It may sound strange that they can be useful in people with ADHD, but there is good evidence that they are. They include Methylphenidate (Ritalin, Concerta, Medikinet, Equasum), Dexamphetamine (Dexadrine) and Lisdexamfetamine (Elvanse). They work quickly but the effects wear off during the night. There are now slow-release forms of some of these drugs, which means that you can take tablets just once a day. The side effects include increase of blood pressure and fast heart rate, anxiety, weight loss, sleep problems, and occasionally psychosis. Most of these side effects can be managed by adjustment on the dose, or how often you take the drug in the day. Frequent monitoring of your blood pressure, heart rate, weight and for psychiatric symptoms, is essential for safe treatment. Blood tests before and during treatment are also important in ruling out conditions like liver and kidney problems that can affect treatment with medications. They are also important to rule out conditions that can mimic symptoms of ADHD like overactive thyroid, and rule out deficiencies of iron, magnesium, and zinc that can affect your ADHD symptoms.

Atomoxetine (also known as Stratera) is a “non-stimulant” medication. It can be useful in people who have side effects or where stimulant medication is less suitable. It takes several weeks to begin to have an effect. Side effects can include stomach cramps and diarrhoea, and some people have reported ideas of self-harm.

Changes in your diet or taking supplements like Zinc may also be useful, although there is not sufficient evidence that they definitely help people with ADHD. However, decreased consumption of foods or drinks with artificial food colouring, and coffee and energy drinks may be helpful. Taking Zinc supplements is advised only if there is lack of zinc in your blood.

What can I do to help myself?

In the Royal College of Psychiatrists website (https://www.rcpsych.ac.uk/mental-health/problems-disorders/adhd-in-adults) you can find very useful information about what you can do to find out more about ADHD, what makes things better or worse, do things that help your difficulties, and how to ask for help. It is worth noting that regular physical exercise, and particularly aerobic exercise, is an effective add-on treatment for ADHD in children and adults, particularly when combined with stimulant medication. Exercising when on stimulant medication augments the effect of medication on executive functioning, improves self-esteem, reduces anxiety and depression, and improves social behaviour.

There are also various books that can help you understand ADHD, and how to manage your symptoms better. These will help you to understand that ADHD can be managed, and that sometimes can be a “gift” rather than a “curse”. Some examples of good books (available on Amazon or other booksellers):

ADHD: A Comprehensive Guide to Attention Deficit Hyperactivity Disorder in Both Adults and Children, Parenting ADHD, and ADHD Treatment Options, by Andrew Benson
Thriving with ADHD Workbook: Guide to Stop Losing Focus, Impulse Control and Disorganisation Through a Mind Process for a New Life, by Gerald Paul Clifford
ADHD: A Hunter in a Farmer’s World, by Thom Hartmann
A Radical Guide for Women with ADHD: Embrace Neurodiversity, Live Boldly, and Break Through Barriers, by Sari Solden

There are also books that offer a rather unconventional approach to understanding and managing ADHD. Examples are:

Scattered Minds: The Origins and Healing of Attention Deficit Disorder, by Gabor Mate
Overload: Attention Deficit Disorder and the Addictive Brain, by David Miller and Kenneth Blum

Finally, these are examples of books that will help you to make changes in your diet, which can help in managing some of the symptoms, or help you with drug side effects. As said above, dietary changes DO NOT replace conventional treatments but they can supplement them, and also support a generally healthier lifestyle.

Finally Focused: The Breakthrough Natural Treatment Plan for ADHD that restores Attention, Minimizes Hyperactivity, and Helps Eliminate Drug Side Effects, by James Greenblatt and Bill Gottlieb
The ADHD Diet Cookbook for Beginners: 60+ Recipes for Attention Deficit Hyperactivity Disorder control and prevention in kids and adults, by Sharon Bronson

*Consultant Psychiatrist, Devon Partnership Trust, Exeter, England