Attention Deficit Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is commonly diagnosed in childhood and often lasts into adulthood. ADHD affects both children and adults, and it can interfere with or reduce the quality of social interactions, school performance, and work performance. For something exciting skip to ADHD Scam Clinics.

Table of Contents

• Introduction
• History
• Epidemiology
• Costs
• Associated brain abnormalities
  • Other research
• Changing landscape
• Diagnosis
  • DSM-5 criteria
  • ADHD rating instruments
  • Historical Data and Observer Reports:
  • Direct Clinical Interview:
  • Combination (Self-Report, Observer Reports, and/or Historical Data):
• ADHD scam-clinics and practitioners
• Treatment
  • Pharmacological
  • Effects of ADHD Medication on the Brain
    • References for the above.
  • Non-pharmacological
• Concluding remarks

Introduction

1. ADHD is the third most common mental health disorder worldwide, following depression and anxiety. The prevalence of ADHD in the worldwide paediatric population has been stable over the past 30 years except in the United States, where cases have increased. The  prevalence of ADHD is estimated to be about 5-7% in children and 2.5-4.4% in adults, depending on the specific population being studied and the diagnostic criteria being used. ADHD affects around 25 per cent in prisoners, 12 per cent of those with drug addiction disorders, and 15 per cent of patients presenting to adult mental health services. By comparison schizophrenia has a much lower prevalence. According to the World Health Organisation, the global prevalence of schizophrenia is estimated to be about 0.3% to 0.7% of the population. This means that in adults ADHD is between 6 and 8 times more prevalent than schizophrenia, and that’s serious.
2. The exact cause of ADHD is not known, but it has been shown to run in families, and research indicates that genetics play a role. It is also believed that environmental factors and brain injuries may contribute to the development of ADHD. The aetiology of ADHD is not clearly understood, but it likely involves a combination of genetic, neurological, and environmental factors. Family, twin, and adoption studies have suggested that ADHD is highly inheritable. Prenatal factors, such as the mother’s lifestyle during pregnancy, and perinatal factors, like very low birth weight, can also contribute to the development of ADHD. See follow up article: The Genetic Basis of ADHD and its Impact on Brain Structure and Function (2024-12-19).
3. ADHD is often conceptualised as a disorder of childhood that gradually diminishes over the lifespan. However, recent studies have challenged this assumption, suggesting that more than two-thirds of individuals with adult ADHD never had childhood ADHD.
4. The diagnostic assessment of ADHD can be complicated due to overlapping symptoms with other disorders like mood and anxiety disorders, substance use disorders, learning disabilities, personality disorders, and information processing disorders.
5. Treatment considerations should be informed by functional outcomes including symptom reduction, increased quality of life, and improved daily, academic, and occupational functioning. First-line treatments for ADHD are pharmacological, including stimulants and nonstimulants. Psychosocial treatments, including behavioural management interventions and cognitive behavioural therapy (CBT), are also effective.
6. ADHD, if left untreated, carries a greater risk of accidental injuries and substance abuse. Therefore, careful assessment is crucial for proper diagnosis and treatment. There’s no cure for ADHD, but treatments can significantly help manage symptoms.

ADHD is characterised by three main groups of behaviour symptoms:

1. Inattention: This involves difficulties with concentration and focus. A person who has predominantly inattentive ADHD might struggle with remembering details, following instructions, completing tasks, or organising daily activities. They might also be easily distracted and often forget to do daily activities.
2. Hyperactivity: This involves excessive activity and feelings of restlessness. In children, this might mean being unable to sit still in class. In adults, it might manifest as an inability to relax or always feeling the need to be “on the go”.
3. Impulsivity: This involves making hasty actions that occur in the moment without thought. These actions may have high potential for harm or may aim to satisfy immediate desires. An individual might act without considering the consequences, interrupt others, struggle to wait their turn, or react in a quick, emotional manner.

Diagnosis is not simply a matter of checklists. It is also about how any of the above may express themselves in an individual’s life. Hence ADHD signs and symptoms may explain parts of what appears at the surface to be addiction disorders (including sex-addiction), mood disorders or personality problems. Diagnosis requires deep thought and effort, as I will explore in this article.

History

In the early history of what we know today as ADHD, some of the core symptoms and signs were emerging. They were mostly found in brain related conditions such as encephalopathies and brain damage. This is not to imply that modern-day ADHD does not have a physical or brain-related basis.

Epidemiology

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorders in childhood and adolescence, affecting 2.2 to 17.8% of all school-aged children and adolescents in Africa. [Source March 2021].

The prevalence of parent-reported ADHD diagnosis was 9.4% among U.S. children and adolescents in 2016 [Source]

A meta-analysis of 175 research studies worldwide on ADHD prevalence in children aged 18 and under found an overall pooled estimate of 7.2% (Thomas et al. 2015). The US Census Bureau estimates 1,795,734,009 people were aged 5-19 worldwide in 2013. Thus, 7.2% of this total population is 129 million—a rough estimate of the  number of children worldwide who have ADHD. Based on DSM-IV screening of 11,422 adults for ADHD in 10 countries in the Americas, Europe and the Middle East, the estimates of worldwide adult ADHD prevalence averaged 3.4% (Fayyad et al. 2007) [Source]

Based on results of the US Adolescent Brain Cognitive Development (ABCD) Study, the national prevalence of current ADHD for children aged 9-10 years old using strict criteria that met or exceeded the clinical scale of ADHD according to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Cordova et al, 2022):

ADHD prevalence: 3.53 percent

• Sex, male: 67.10 percent
• Race
  • White, non-Hispanic: 61.36 percent
  • Black: 18.40 percent
  • Asian: 0.62 percent
  • Native American/Alaskan Native: 0.98 percent
  • Native Hawaiian/Pacific Islander : 0.01 percent
  • Multiracial: 16.18 percent
  • Ethnicity: Hispanic/Latinx: 18.86 percent
• A fivefold increase in prevalence of ADHD in youth prison populations (30.1%) and a 10-fold increase in adult prison populations (26.2%). – Yiung et al, Psychol Med. 2015 Jan; 45(2): 247–258.
• High rates of ADHD in high-risk populations: around 25 per cent in prisoners, 12 per cent of those with drug addiction disorders, and 15 per cent of patients presenting to adult mental health services. 
• Prescribed ADHD medication: 44.65 percent

Prevalence rate of comorbid (coexisting) psychiatric disorders, adjusted prevalence rate of coexisting psychiatric disorders (probability of displaying comorbidity with ADHD diagnosis)

• ADHD with any disruptive behaviour disorder (“includes oppositional defiant disorder and conduct disorder”) (Cordova et al, 2022): 30.9 percent
• ADHD with any mood disorder (“includes major depressive disorder, disruptive mood dysregulation disorder, and unspecified depressive disorder”): 2.1 percent
• ADHD with any anxiety disorder (“includes agoraphobia, generalised anxiety disorder, panic disorder, specific phobia, posttraumatic stress disorder, unspecified anxiety disorder, separation anxiety, and social anxiety”): 27.4 percent

Costs

The real costs of ADHD are difficult to calculate or estimate. 

In a 2012 study the estimated total annual total UK costs of ADHD for adolescents alone was £670 million. [Telford, C., Green, C., Logan, S. et al. Estimating the costs of ongoing care for adolescents with attention-deficit hyperactivity disorder. Soc Psychiatry Psychiatr Epidemiol 48, 337–344 (2013). https://doi.org/10.1007/s00127-012-0530-9]

But note that the study “These costs are based on adolescents previously diagnosed with ADHD and there would be additional costs associated with young people newly diagnosed with ADHD within this age range, who are likely to require a higher level of service access while treatment is initiated. They further exclude those children with ADHD who have additional intellectual disability (IQ < 70), neurological conditions, Tourette syndrome, pervasive developmental disorder or who are looked after by the local authority, who are also likely to require additional input related to their comorbid difficulties.”

ADHD discovery has been rising exponentially since that time. The true costs today will probably be double or treble. This is serious stuff!

The true economic cost may be of the order of £2 billion at 2023 – but this is a wild guess considering impact on GDP etc. Keep in mind that ADHD overlaps and is often confused with or masked by other diagnosed conditions (see below). 

Associated brain abnormalities

The word ‘associated’ is important because in complex issues one cannot say for certain ‘this is the cause’. The situation is similar for schizophrenia, obsessive compulsive disorder, bipolar disorders, where there are numerous associated brain abnormalities but no single ’cause’.

The study titled “Anomalous Brain Development Is Evident in Preschoolers With Attention-Deficit/Hyperactivity Disorder”  in the Journal of the International Neuropsychological Society (March 2018) investigates the differences in brain development between pre-schoolers with ADHD and typically developing peers. Here are the key points:

1. ADHD symptoms are often evident early in development. By age 4 years, as many as 40% of children exhibit parent-reported problems with attention or hyperactivity-impulsivity corresponding to diagnostic criteria for ADHD.
2. ADHD has been associated with widespread structural brain abnormalities in school-aged and adolescent youth, including smaller overall cerebral volumes, reductions in total grey matter volumes, and delays in cortical maturation. More specific findings have consistently centred on networks important for attentional control, including regional structural anomalies in prefrontal and premotor areas, supplementary motor complex, and basal ganglia.
3. The study hypothesised that cortical, particularly frontal, development would be anomalous in young children with ADHD, relative to their typically developing peers.
4. The study investigated differences in regionally specific cerebral volume among 90 medication-naïve preschool children (ages 4–5 years) with and without ADHD, exploring associations between particular regional brain volumes and symptom severity.
5. The findings revealed that children with ADHD had significantly reduced grey matter volumes in multiple areas, including bilateral frontal, temporal, and parietal lobes, with the largest effect sises noted for right frontal and left temporal lobe volumes.
6. Within the ADHD group, there were specific associations between grey matter volumes and symptom severity. Higher ratings of hyperactivity were associated with reduced cortical volumes.
7. The study concluded that there is strong evidence for anomalous cortical development in pre-schoolers with ADHD. This early onset of brain anomalies underscores the importance of early detection and intervention.

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In a study “The brain anatomy of attention-deficit/hyperactivity disorder in young adults – a magnetic resonance imaging study” at PlosOne 2017, one of the first to examine the structural brain anatomy and connectivity associated with ADHD diagnosis and symptoms in young adults, the following key points are of note:

1. The study hypothesised that an adult ADHD diagnosis, particularly childhood symptoms, are associated with widespread changes in the brain macro- and microstructure, which can be used to develop a morphometric biomarker for ADHD.
2. The study used voxel-wise linear regression models to examine structural and diffusion-weighted MRI data in 72 participants (31 young adults with ADHD and 41 controls without ADHD) in relation to diagnosis and the number of self-reported child and adult symptoms.
3. The findings revealed significant associations between ADHD diagnosis and widespread changes to the maturation of white matter fibre bundles and grey matter density in the brain. Structural shape changes (incomplete maturation) were observed in the middle and superior temporal gyrus, and fronto-basal portions of both frontal lobes.
4. ADHD symptoms in childhood showed the strongest association with brain macro- and microstructural abnormalities. At the brain circuitry level, the superior longitudinal fasciculus (SLF) and cortico-limbic areas are dysfunctional in individuals with ADHD.
5. The morphometric findings predicted an ADHD diagnosis correctly up to 83% of all cases, suggesting that MRI-based assessments are a promising strategy for the development of a biomarker.
6. The study concluded that an adult ADHD diagnosis and particularly childhood symptoms are associated with widespread micro- and macrostructural changes. The SLF and cortico-limbic findings suggest complex audio-visual, motivational, and emotional dysfunctions associated with ADHD in young adults.

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Shaw et al (200&  found “[brain] maturation to progress in a similar manner regionally in both children with and without ADHD, with primary sensory areas attaining peak cortical thickness before polymodal, high-order association areas. However, there was a marked delay in ADHD in attaining peak thickness throughout most of the cerebrum: the median age by which 50% of the cortical points attained peak thickness for this group was 10.5 years (SE 0.01), which was significantly later than the median age of 7.5 years (SE 0.02) for typically developing controls (log rank test chi(1)(2) = 5,609, P < 1.0 x 10(-20)). The delay was most prominent in prefrontal regions important for control of cognitive processes including attention and motor planning. Neuroanatomic documentation of a delay in regional cortical maturation in ADHD has not been previously reported.”

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Other research

1. Sharon Morein-samir et al (Journal of Abnormal Child Psychology 2008 November)  found that dopamine dysfunction may be involved with symptoms of inattention but may also contribute to substance abuse comorbidity.
2. Pinchen Yang et al (Psychiatry Research 2010 March 31) using proton magnetic spectroscopy, demonstrated right prefrontal neurochemical changes in adolescents with ADHD.
3. Research from Denmark found that maternal use of valproate, but not other anti-epileptic drugs (AEDs), during pregnancy was associated with an increased risk of ADHD in the offspring.
4. Sourander et al (Pediatrics March 2019) found a dose-dependent relationship between nicotine exposure during pregnancy and offspring ADHD.
5. Narad et al (JAMA Pediatrics 2018) found that early childhood traumatic brain injury (TBI) was associated with increased risk for Secondary ADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.

There is a whole lot more brain research out there but the above is enough to say ‘Yes – there is an underlying physical basis in the brain.‘ Similarly, we can say the same about schisophrenia – for example – but that does not mean that one day we will find the ‘magic bullet’ to cure these mental disorders. The reason for that is because it is unlikely that one brain sub-system or abnormality explains the ‘syndrome’ of expression that we see in terms of signs and symptoms. This is my opinion – not advice.

Changing landscape

ADHD was first recognised in children. As the research progressed it was realised that ADHD in children did not just wear off, as it was originally thought the case. Now evidence has emerged that ADHD affects the adult population in far greater numbers than say schizophrenia. Diagnostic services have seen rapidly increasing demands. At the time of this post it would appear that demand is well exceeding supply. Some NHS waiting lists for ADHD assessments are up to 4 years but no one knows the big picture for the UK. It is a closely guarded secret.

The reasons for the under-recognition of ADHD in adults are multifaceted and can include a combination of factors:

1. Lack of awareness: Historically, ADHD was seen primarily as a childhood disorder, and it was thought that children would “grow out” of it. We now know that ADHD often persists into adulthood, but not all healthcare providers are aware of this. Additionally, many adults aren’t aware that the problems they’re facing might be due to ADHD, so they do not seek help.
2. Diagnostic criteria: The diagnostic criteria for ADHD were initially developed with children in mind, and some of the classic symptoms of ADHD (like hyperactivity) often present differently in adults. For example, physical hyperactivity in children might manifest as restlessness or an internal feeling of being “on the go” in adults. This can make it harder for healthcare providers who are not familiar with ADHD in adults to recognise the symptoms.
3. Presentation of symptoms: ADHD symptoms can be more subtle in adults than in children. Adults with ADHD may have developed coping strategies over time that mask their symptoms. Additionally, adult life often involves managing a wider range of tasks and responsibilities than childhood, and ADHD-related difficulties might only become apparent when the demands of adult life exceed the individual’s coping strategies.
4. Comorbidity: ADHD in adults is often accompanied by other mental health conditions, like depression, anxiety, or substance use disorders. These conditions might be more apparent or familiar to the individual and their healthcare provider, leading to a focus on treating those conditions and potentially overlooking the underlying ADHD.
5. Access to diagnostic services: Diagnosing ADHD in adults typically involves a comprehensive evaluation, including a detailed personal history, symptom assessments, and often input from family members or others who know the individual well. Not all adults have access to healthcare providers who can perform this kind of evaluation.

Increasing awareness of ADHD in adults, along with ongoing research and education for healthcare providers, is helping to improve the detection and treatment of ADHD in adults. If an adult suspects they might have ADHD, they should discuss their symptoms with a healthcare provider who is familiar with the disorder.

Diagnosis

As ADHD will be considered a life-long condition that may require taking medications for life, it is absolutely important that the diagnosis is well founded on a reliable body of evidence and made by a well trained health professional.

Diagnosing ADHD involves a comprehensive evaluation to identify symptoms, rule out other potential causes, and assess the impact of symptoms on daily functioning. While specific practices can vary, here are some key components that are typically included in a robust ADHD diagnostic assessment:

1. Clinical Interview: This is an essential part of the evaluation. The healthcare provider will ask about the individual’s symptoms, when they started, how they’ve changed over time, and how they affect different areas of life (like work, school, or relationships).
2. History: This includes information about the individual’s medical, developmental, educational, and psychiatric history. It is also helpful to gather information about any family history of ADHD or other psychiatric disorders.
3. ADHD Symptom Checklists and Rating Scales: There are several standardised checklists and rating scales that are used to help identify and assess the severity of ADHD symptoms. These can provide a more objective measure of symptoms and can be helpful for monitoring changes over time. A list of standard rating scales will not be given here. The diagnosis of ADHD is not made by rating scales. Diagnosis is a clinical activity which may (or not) be assisted by rating scales or checklists.
4. Observations: In some cases, especially for children, observations of the individual in different settings (like school or home) can be helpful. These observations can provide information about how the individual’s behaviour may vary in different contexts.
5. Input from Others: Getting information from others who know the individual well can provide additional insights. For children, this often includes teachers, parents, and sometimes other caregivers. For adults, this might include a spouse, other family members, or close friends.
6. Rule Out Other Causes: ADHD symptoms can sometimes be caused by other medical or psychiatric conditions, or they can be mimicked by certain lifestyle factors. Part of the evaluation process involves ruling out these other potential causes. This can include a physical examination, laboratory tests, and/or a review of the individual’s psychiatric history. Note below the considerable overlap of other psychiatric conditions:

7. Assessment of Functioning: It is important to assess how the individual’s symptoms affect their daily functioning, including their performance at work or school, their relationships, and their ability to carry out daily tasks.

8. Neuropsychological Testing: While not required for a diagnosis of ADHD, in some cases, neuropsychological testing can be useful. This can include tests of attention, memory, executive functioning, and other cognitive abilities.

People with ADHD may have been diagnosed already with other mental disorders. The expert ADHD assessor must have absolutely good knowledge of other mental disorders. But as there are no ‘X-rays’ to assist psychiatric diagnosis, the assessor should be a psychiatrist who has a mindset for deep investigation and analytical thinking. From my long experience over 32 years, I know that psychiatrists tend to suffer with unconscious biases for their colleagues’ previous diagnoses. It is easier to run with previous diagnoses than to exert the degree of mental analytical effort required to pare off ADHD from some other condition as complex as personality disorder. I am not saying that ADHD can or should replace diagnoses already made of say, personality disorder. I am talking about primarily discerning what is attributable to ADHD and what may be attributable to personality disorder (or some other condition).

DSM-5 criteria

The following is not intended for self-diagnosis. All diagnosis requires consideration of criteria by a suitably trained health professional.

1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
   • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
   • Often has trouble holding attention on tasks or play activities.
   • Often does not seem to listen when spoken to directly.
   • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
   • Often has trouble organising tasks and activities.
   • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
   • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
   • Is often easily distracted
   • Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
   • Often fidgets with or taps hands or feet, or squirms in seat.
   • Often leaves seat in situations when remaining seated is expected.
   • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
   • Often unable to play or take part in leisure activities quietly.
   • Is often “on the go” acting as if “driven by a motor”.
   • Often talks excessively.
   • Often blurts out an answer before a question has been completed.
   • Often has trouble waiting their turn.
   • Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

• Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
• Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
• Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

ADHD rating instruments

A word of caution: rating instruments do not make diagnoses. Trained clinicians make diagnoses. Rating instruments are there to standardise assessments, assist with gathering data. What is gathered into the instrument then needs interpretation. It is not that ‘you’ come out above a certain score and that means ‘You’ve got it’. 

Historical Data and Observer Reports:

1. Conners’ Comprehensive Behaviour Rating Scales (CBRS): While this tool is used for current behaviours, it relies heavily on teacher and parent (or other observer) reports, thus making historical data crucial, especially when gauging the persistence of symptoms over time.
2. Vanderbilt ADHD Diagnostic Rating Scale (VADRS): This scale includes both parent and teacher rating scales and is used to gather information about a child’s historical and current behaviours.
3. Child Behaviour Checklist (CBCL): A parent-report questionnaire that gathers data about a wide range of behavioural and emotional problems, both current and past.

Direct Clinical Interview:

1. DIVA 5.0 (Diagnostic Interview for ADHD in Adults): This is a structured clinical interview designed to ascertain ADHD symptoms in adulthood and during childhood, making it one of the tools that heavily rely on retrospective/historical data but is conducted as a direct interview.

Combination (Self-Report, Observer Reports, and/or Historical Data):

1. Conners’ Adult ADHD Rating Scales (CAARS): This includes self-reports and observer ratings, gathering information on current symptoms but also asking about past behaviours and symptoms.
2. Adult ADHD Self-Report Scale (ASRS-v1.1): Primarily a self-report about current symptoms, but understanding the historical persistence of symptoms is essential for a diagnosis.
3. Behaviour Rating Inventory of Executive Function (BRIEF): Although it is focused on current executive functioning behaviours, it relies on observer reports (parents or teachers) which can provide a historical perspective.
4. Brown ADD Scales: It includes versions for different age groups and captures data on current symptoms through self-report, but also requires historical data to ensure symptoms have been persistent.
5. ADHD Rating Scale-IV: This scale is focused on current symptoms but requires information from parents and/or teachers to ensure symptoms have been consistent over a period of time.

Remember, while some instruments might focus more on current symptoms or behaviours, ADHD diagnosis always requires a demonstration that the symptoms have been present and impactful over a significant period, usually traced back to childhood. This is why historical data, even when not the primary focus of an instrument, is often integral to the assessment process.

ADHD scam-clinics and practitioners

A comprehensive ADHD assessment should be conducted by a healthcare provider with expertise in ADHD. The process should be thorough and take into account a variety of information sources. The goal is to develop a full understanding of the individual’s symptoms and challenges to guide treatment planning. It is highly unlikely that the above sort multi-pronged assessment can be concluded in 60 minutes. More likely it would take a total of between three to six hours. We’re talking about a life-long diagnosis and possibly life-long treatment. Getting it right is pretty important. Anyone seeking a diagnostic assessment for ADHD should ask very early on ‘How long in total will a full assessment take?‘ If the answer is ‘About an hour‘, move on without asking questions to seek a better assessment. It is based on a recent scandal exposed by the BBC.

Treatment

Pharmacological

Treatment with any sort of medication should be with consent of the patient if an adult or with the consent of a parent (if treating a child). No patient (or parent) should come away from a consultation wondering about treatment information that was not provided. Many people will naturally want to know ‘What’s the best treatment for ADHD?’. That is similar to asking ‘what’s the best treatment for schisophrenia’ or ‘high blood pressure’. The proper practice of medicine is not just to make the diagnosis and write a prescription. It is about understanding how the patient is affected by the medical condition and working with the patient to select the treatment that may best match their individual circumstances. Matters such as age, health circumstances, work situation, commitments to education and many more things will need to be considered. Psychiatrists should always aim to select medications that cause the least side-effects. Side-effects are not usually permanent. The body/brain tends to adapt and they tend to lessen with time.

Stimulant Medications

Stimulant medications are the most commonly prescribed treatments for ADHD. These include:

1. Methylphenidates: This group includes medications such as Ritalin, Concerta, and Daytrana. They work by increasing the levels of certain chemicals in the brain that help with thinking and attention.
2. Amphetamines: This group includes medications such as Adderall, Vyvanse, and Dexedrine. Like methylphenidates, they increase the levels of certain chemicals in the brain that help with thinking and attention.
3. Lisdexamfetamine, sold under the brand name Vyvanse among others, is a stimulant medication used to treat Attention-Deficit/Hyperactivity Disorder (ADHD) and Binge Eating Disorder (BED). Mechanism of Action: Lisdexamfetamine is a prodrug, which means it is inactive until it is metabolised in the body. Once ingested, it is converted to dextroamphetamine, which increases the levels of dopamine and norepinephrine in the brain, thereby helping to reduce the symptoms of ADHD and BED.

Stimulant medications can have side effects including sleep problems, reduced appetite, weight loss, and increase in blood pressure and heart rate. They can also potentially be misused, so they need to be used under the supervision of a healthcare provider.

Non-Stimulant Medications

Non-stimulant medications can also be used to treat ADHD. These include:

1. Atomoxetine (Strattera): This medication works differently from the stimulants. It increases the level of norepinephrine, a brain chemical that helps with attention and impulse control.
2. Clonidine (Kapvay): originally developed to treat hypertension was found to be beneficial for ADHD. It may be used for individuals who do not respond well to or cannot take stimulants.
3. Guanfacine is a non-stimulant medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children and adolescents. Guanfacine is an alpha-2 adrenergic agonist. It is thought to work by strengthening the functioning of the prefrontal cortex, a part of the brain that is involved in attention, impulse control, and working memory. Several clinical studies have shown that guanfacine can be effective in reducing the symptoms of ADHD. A study published in the Journal of the American Academy of Child & Adolescent Psychiatry (2010) found that guanfacine significantly improved ADHD symptoms compared to a placebo in children aged 6-17. The improvement was seen in both inattentive and hyperactive-impulsive symptom clusters. Like all medications, guanfacine has potential side effects, which can include sleepiness, fatigue, stomach pain, nausea, and a decrease in blood pressure or heart rate. It is also important to note that it should not be stopped suddenly, as this could cause a rapid increase in blood pressure.  Guanfacine is often used when stimulant medications are not well-tolerated, not effective, or contraindicated due to medical reasons. It can also be used in combination with a stimulant medication to enhance the effectiveness of treatment.
4. Bupropion (Wellbutrin): Bupropion is an antidepressant that’s sometimes used off-label to treat ADHD. It works by inhibiting the reuptake of dopamine and norepinephrine, thus increasing their concentrations in the brain. It is typically used when first-line treatments are ineffective, contraindicated, or cause unacceptable side effects.
5. Tricyclic Antidepressants: This class of drugs includes medications such as imipramine (Tofranil), desipramine (Norpramin), and nortriptyline (Pamelor). These medications increase the levels of norepinephrine and other neurotransmitters in the brain, but they’re usually only considered when other treatments have been unsuccessful due to their potential for serious side effects, including heart problems.
6. Modafinil (Provigil): Modafinil is a medication primarily used to treat narcolepsy, but it is sometimes used off-label to treat ADHD. Its exact mechanism of action is not well understood, but it is thought to increase dopamine levels in the brain.

These non-stimulant medications can have side effects including sleepiness, fatigue, stomach pain, and decreased appetite.

Effects of ADHD Medication on the Brain

Effects on Structural Development:

• No evidence that stimulant medication impairs brain development or structure. (van Elst et al., 2016; Pretus et al., 2017; Hoogman et al., 2017, 2019)
• Limited prospective studies, primarily in adults, make definitive conclusions difficult. (van Elst et al., 2016)
• Some studies suggest potential positive effects on basal ganglia development, but findings are controversial. (Nakao et al., 2011; Hoogman et al., 2017, 2019)

Effects on Brain Function:

• Stimulants increase activation in frontostriatal and frontoparietal regions, improving cognitive control and attention. (Rubia et al., 2014)
• Stimulants decrease activation of the default mode network, reducing mind wandering. (Rubia et al., 2014)
• Non-stimulants like Atomoxetine show similar effects on brain function. (Rubia 2018b)

Effects on Brain Chemistry:

• Stimulant medication may alter brain chemistry, specifically dopamine transporter (DAT) levels in the basal ganglia. (Fusar-Poli et al., 2012)
• Long-term stimulant use is associated with the upregulation of DATs, potentially leading to reduced dopamine availability and tolerance. (Fusar-Poli et al., 2012; Wang et al., 2013)
• This upregulation raises concerns about the long-term efficacy of stimulant medication. (Swanson, 2018)

Additional Considerations:

• Stimulant medication is effective for many individuals with ADHD, but long-term effects are still under investigation.
• Ethical concerns limit the ability to conduct long-term, randomized controlled trials in children.
• The need for alternative treatments that are effective in the long term is highlighted.

References for the above.

1. Fusar-Poli, P., Rubia, K., Rossi, G., Sartori, G., & Ballotin, U. (2012). Dopamine transporter alterations in ADHD: pathophysiology or adaptation to psychostimulants? a meta-analysis. American Journal of Psychiatry, 169, 264 -272.
2. Hoogman, M., Bralten, J., Hibar, D. P., Mennes, M., Zwiers, M. P., Schweren, L. S. J., . . . Franke, B. (2017). Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. Lancet Psychiatry, 4(4), 310-319. doi:10.1016/s2215-0366(17)30049-4
3. Hoogman, M. et al., (2019) Brain imaging of the cortex in ADHD: A coordinated analysis of large-scale clinical and population-based samples. American J Psychiatry, in press.
4. Nakao, T., Radua, C., Rubia, K., & Mataix-Cols, D. (2011). Gray matter volume abnormalities in ADHD and the effects of stimulant medication: Voxel-based meta-analysis. American Journal of Psychiatry, 168(11), 1154-1163.
5. Norman, L., Carlisi, C. O., Lukito, S., Hart, H., Mataix-Cols, D., Radua, J., & Rubia, K. (2016). Comparative meta-analysis of functional and structural deficits in ADHD and OCD. JAMA Psychiatry, 73(8), 815-825.
6. Pretus, C., Ramos-Quiroga, J. A., Richarte, V., Corrales, M., Picado, M., Carmona, S., & Vilarroya, O. (2017). Time and psychostimulants: Opposing long-term structural effects in the adult ADHD brain. A longitudinal MR study. Eur Neuropsychopharmacol, 27(12), 1238-1247. doi:10.1016/j.euroneuro.2017.10.035
7. Rubia, K., Alzamora, A., Cubillo, A., Smith, A. B., Radua, J., & Brammer, M. J. (2014). Effects of stimulants on brain function in ADHD: a systematic review and meta-analysis. Biol Psychiatry, 76(8), 616-628. Rubia, K. (2018). ‘Brain function in ADHD’. In T. Banaschewski, Coghill, D. Zuddas, A. (Ed.), Oxford Handbook for ADHD. Oxford: Oxford University Press.
8. Rubia, K., Halari, R., Christakou, A., & Taylor, E. (2009). Impulsiveness as a timing disturbance: neurocognitive abnormalities in attention-deficit hyperactivity disorder during temporal processes and normalisation with methylphenidate. Philos Trans R Soc Lond B Biol Sci, 364(1525), 1919-1931. doi:364/1525/1919 [pii] 10.1098/rstb.2009.0014
9. Rubia, K., Halari, R., Taylor, E., & Brammer, M. (2011). Methylphenidate normalises fronto-cingulate underactivation during error processing in children with Attention-Deficit Hyperactivity Disorder. Biol Psychiatry, 70(3), 255-262.
10. Shaw, P., De Rossi, P., Watson, B., Wharton, A., Greenstein, D., Raznahan, A., . . . Chakravarty, M. M. (2014). Mapping the development of the basal ganglia in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry, 53(7), 780-789.e711. doi:10.1016/j.jaac.2014.05.003
11. Swanson, J. (2018). ‘The MTA study’. In T. Banaschewski, Coghill, D. Zuddas, A. (Ed.), The Oxford Textbook of Attention Deficit Hyperactivity Disorder. Oxford: Oxford Press.
12. Wang, G.-J., Volkow, N. D., Wigal, T., Kollins, S. H., Newcorn, J. H., Telang, F., . . . Swanson, J. M. (2013). Long-Term Stimulant Treatment Affects Brain Dopamine Transporter Level in Patients with Attention Deficit Hyperactive Disorder. Plos One, 8(5). doi:10.1371/journal.pone.0063023

Individualised Treatment

The choice of medication depends on the individual’s symptoms, the presence of any co-occurring conditions, their overall health, the medication’s side effects, and the individual’s response to medication.

It is also important to note that medication is just one part of a comprehensive treatment plan for ADHD. Behavioural therapy, lifestyle changes, and social support are also crucial components of managing ADHD.

Non-pharmacological

Several psychological treatments have been shown to be effective for ADHD in numerous scientific studies. These treatments can be used alone or in combination with medication. Often, a multi-modal approach that includes both medication and psychological interventions is recommended. Here are a few key examples:

1. Neurotherapies: Neurofeedback compared to sham neurofeedback improves clinical ADHD symptoms, cognitive performance in ADHD-relevant tasks and brain activation during an inhibition task as well as longer-term effects six months after the treatment. (Professor Katya Rubia’s research. Rubia K, Criaud M, Wulff M, Alegria A, Brinson H, Barker G, Stahl D, Giampietro V. (2019) ‘Functional connectivity changes associated with fMRI neurofeedback of right inferior frontal cortex in adolescents with ADHD’. Neuroimage. 188: 43-58. doi: 10.1016/j.neuroimage.2018.11.055. Epub 2018 Dec 1. See Alegria AA, Wulff M, Brinson H, Barker GJ, Norman LJ, Brandeis D, Stahl D, David AS, Taylor E, Giampietro V, Rubia K. (2017) ‘Real-time fMRI neurofeedback in adolescents with attention deficit hyperactivity disorder’. Hum Brain Mapp. 38(6): 3190-3209. doi: 10.1002/hbm.23584. Epub 2017 Mar 25.
2. tDCS: applies small electrical currents of one to two mA over certain brain regions. The method is safe and side effects are minimal (itching over the scalp). It has been found that when tDCS is combined with cognitive training, which probes the areas that are being stimulated, the effects of both methods are synergistic and more efficient than either method alone.
3. Behavioural Therapy: This is one of the most common forms of treatment for ADHD, especially for younger children. It involves helping individuals develop coping strategies and skills to deal with the symptoms of ADHD. It may involve one-on-one therapy as well as group or family-based interventions.
4. Cognitive Behavioural Therapy (CBT): This form of therapy helps individuals understand and change thought patterns that lead to harmful behaviours or feelings of distress. For individuals with ADHD, CBT often focuses on developing skills in areas such as organisation, time management, and planning, as well as dealing with impulsivity.
5. Parent Training and Education Programs: These are often used when children have ADHD. They help parents develop strategies to understand and manage their child’s behaviour. This can lead to more effective parenting strategies, reduced parent-child conflict, and improved child behaviour.
6. Social Skills Training: This can be helpful for individuals with ADHD who have difficulty with social interactions. This training can help individuals learn and practice appropriate social behaviours.
7. Mindfulness and Meditation: These techniques can help individuals with ADHD improve their focus and attention, reduce impulsivity, and manage stress. This area of treatment has been getting more attention in recent years, and some studies suggest that mindfulness and meditation can be beneficial for individuals with ADHD.
8. School-Based Interventions: For children and adolescents with ADHD, interventions within the school setting can be crucial. This can involve working with teachers and school counsellors to implement strategies that can help the child succeed academically. This might include accommodations such as extra time on tests, a quiet place to work, or regular breaks.

While these treatments can be effective, it is important to remember that each individual is unique, and what works best will depend on the individual’s specific symptoms, circumstances, and needs. A healthcare provider or therapist experienced in ADHD can provide guidance on the most appropriate treatment options.

Concluding remarks

ADHD is quite a common mental disorder, compared to other conditions such as schizophrenia.

Robust diagnosis is essential.

Brain research has found several structural abnormalities, activation abnormalities and receptor pathway problems.

There are several ‘scam clinics’ and ‘scam practitioners’ out there ‘doing the business’ – be very careful.

A treatment package should include pharmacological and non-pharmacological strategies.