Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental condition, affecting 5% of the global population. There are three core symptoms of the condition including inattention, hyperactivity, and impulsive behaviours, however how they present and affect people can vary.
ADHD and the subtypes
Primarily hyperactive-impulsive ADHD presentation is the type most people are more familiar with. Typical symptoms include fidgeting, interrupting, and struggling with sitting still.
Primarily inattentive ADHD presentation (previously called ADD) is more closely related to concentration and focus. Patients may struggle with memory, losing things, and organisation.
Combined ADHD presentation is a combination of the above when symptoms of both inattention and hyperactivity-impulsivity exist.
A robust ADHD evaluation process is one that combines objective and subjective measures to get a balanced and holistic understanding of your patient’s symptoms.
ADHD diagnosis and treatment
Only a qualified healthcare professional can diagnose ADHD. Evaluations must use objective and subjective tools including, but not limited to:
- Physical examination
- Clinical interviews
- Rating scales
- An objective ADHD test gather data on the three core symptoms of ADHD
Only when symptoms meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5)* can your patient be diagnosed.
Pharmacological ADHD treatments
Types of medication
Stimulants are a first-line treatment for ADHD and are among the most effective and most studied psychotropic medications. They work by raising the levels of the neurotransmitters norepinephrine and dopamine in the synapses. Over the past decade, as the diagnosis of ADHD increased, so did the use of stimulants.
A few examples of stimulants are methylphenidate and different versions of amphetamine (dexametafmine and lis-dexamfetamine).
However, some patients (around 30%) don’t respond positively to them. If the stimulants do not adequately treat the ADHD symptoms, are not tolerated, or are in the presence of contraindications for the use of stimulants, non-stimulants may be prescribed.
Examples of non-stimulants are atomoxetine, guanfacine, modafinil, clonidine, and bupropion.
When to expect results
Stimulants have a quick onset of action, reaching maximum effect in 1-2 hours. Effects also wear away quite rapidly, so most of the medications in this class are prescribed as extended-release formulations.
Atomoxetine, a non-stimulant medication, has a much slower onset of action. It continues to work several days after your patient has stopped taking it.
Potential side effects
When using stimulants, common side effects include:
- Delayed onset of sleep or insomnia
- Headaches
- Appetite suppression
- Transient stomachaches
- Behavioural rebound (sudden or severe return of ADHD symptoms)
- Tics or emotional dysregulation (less common)
Clinical considerations
When prescribing medication for ADHD, the age of your patient, severity of their condition and any existing comorbidities must be considered to optimize treatment effectively.
Patient outcomes
When starting treatment for ADHD, best practice is to first choose a stimulant class (e.g., MPH or AMPH) and then the duration of the treatment based on your patient’s profile. Dosage must be individually optimised for each patient based on the drug’s therapeutic efficacy and side effect profile.
Non-pharmacological treatments
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy is a commonly used form of therapy for a wide range of mental health conditions. We spoke with Dr. Ramsay, co-founder and co-director of the University of Pennsylvania’s Adult ADHD Treatment and Research Program, to learn more about how CBT can help manage a patient’s ADHD.
Meditation and mindfulness
Mindfulness is quickly becoming a popular tool to help with everyday stress and conditions such as anxiety and depression. We asked psychotherapist and mindfulness coach Stacey Camacho how meditation and mindfulness can help with ADHD management.
Nutrition
It is commonly said “we are what we eat.” So, is there a link between nutrition and ADHD? Leading ADHD author and researcher Dr. Joel Nigg discusses the association of diet with ADHD symptoms.
Registered nutritional therapist Rebecca King, and Simon Mundie discuss the relationship between ADHD and nutrition.
Sleep
We spoke to two leading pediatricians Dr. Anu Sheth, founder of Pediatric Associates of Lawrenceville, and Dr. Rashad Nawaz an ADHD specialist working in partnership with Together Trust’s project Sleep Tight Trafford to find out how sleeping habits affect ADHD symptoms.
ADHD and related conditions
Around 51.8% of people with ADHD have at least one comorbid mental health condition.
The most common conditions that co-occur with ADHD in adults are anxiety, depression and autism (ASD).
ADHD and anxiety
50% of adults with ADHD may also have anxiety disorders.
Overlapping symptoms:
- Excessive apprehension/worry (inattentive/hesitancy/caution)
- Feeling restless or keyed up
- Difficulty concentrating or mind-blanking
- Losing track of items of necessity
Distinguishing symptoms:
- Symptoms must persist for six months through two or more settings
- Irritability, muscle tension, and sleep disturbance
- Symptom severity can vary by task or event
- Symptoms more likely related to social events than day to day tasks
- Can typically be tied back to a specific event or time in which symptoms began (symptoms not present before this event)
Behavioural paediatrician Dr. Nerissa Bauer talks about ADHD and anxiety
Why is it common that children with ADHD also have anxiety?
When parents come to seek a diagnosis for ADHD, they will typically report outward symptoms. A lot of times those symptoms can look like either ADHD or anxiety, especially the inattentive form of ADHD. When a parent says their child is distracted, making careless mistakes, it looks like they’re daydreaming – it raises the question – is this ADHD, anxiety, or is it both?
Any advice for parents and teachers dealing with ADHD and anxiety?
We know that a child’s behaviour can be reflective, not just in terms of what is going on internally, but the environment – like home and school. I would say that parents who are concerned should be partnering with the teacher to understand their child’s behaviours and then bring the child’s doctor on board to further investigate potential underlying causes for the behaviour. It’s important to first look and compare to other children the same age and in the same setting.
What treatments are available for ADHD and anxiety?
It’s important that upon receiving a diagnosis of ADHD, anxiety or both, we don’t automatically assume medication is the first-line treatment. Sometimes medication is needed to improve overall functioning. A combination approach with behavioural therapy is often more effective than medication alone.
The child’s paediatrician can determine whether parenting and educational support are also required to further round out the treatment plan.
ADHD and autism
An estimated 20-50% of children with ADHD also meet the criteria for autism spectrum disorder (ASD).
Overlapping symptoms:
- Restricted or repetitive behaviours
- Difficulty focusing on tasks of low interest
- Difficulty being redirected or adapting to change
- Repetitive motor movements
Distinguishing symptoms:
- Symptoms must be present ages 3-7
- Social communication and social interaction deficits across multiple domains
- Unusual interest in sensory aspects
- Deficits in verbal and/or non-verbal communication
- Deficits in maintaining or understanding relationships
Dr. Sheila Woods talks about ADHD and ASD
What is the prevalence of co-occurring ADHD and ASD?
In my professional experience, approximately 50% of kids with ASD also have ADHD. ASD is usually diagnosed first, and then, as a child grows older, we may see more difficulties with their attention span, levels of activity, and impulsiveness.
If these symptoms occur in addition to the ASD symptoms, that is when we would consider a combined diagnosis. It is not as common for ADHD to be diagnosed before a diagnosis of ASD. From an early age, it is clear that social communication skills are lacking – which is a symptom of ASD.
What treatments are available for ADHD in those with autism?
For kids who have ASD and ADHD, stimulant medications and/or atomoxetine have been effective in treating ADHD symptoms. However, if a child is particularly aggressive and irritable, which can be attributed to symptoms of ASD, then Risperidone or Abilify (second-generation antipsychotics) may work better to target those symptoms**.
For most mental health conditions including ADHD, ASD, depression, and anxiety, children manage better with a therapist using tools like cognitive behavioral therapy (CBT).
For ASD, there are two popular forms of therapy – applied behavioural analysis (ABA) and dialectical behavioural therapy (DBA). There is also a version of CBT adapted specifically for ADHD.
ADHD and depression
The prevalence rate of depression in adults with ADHD is estimated up to 30%.
Overlapping symptoms:
- Psychomotor agitation (excessive movement)
- Diminished ability to think or concentrate
- Feeling slowed or delayed cognitively (indecisiveness)
Distinguishing symptoms:
- Markedly diminished interested or pleasure in activities
- Weight loss when not dieting
- Recurrent thoughts of death, recurrent suicidal ideation with (or without) specific plan
- Insomnia or hypersomnia
Psychiatrist Dr. Jennie Byrne talks about ADHD and depression
What is the link between ADHD and depression?
In real-world experience, the link between ADHD and depression can go two ways. They can be comorbid problems, meaning that somebody just happens to have both of those problems. In my experience, this occurs at the same rate as those without ADHD.
The other type at risk of depression is those who have untreated or under-treated ADHD, especially if they are being diagnosed as an adult. They have a much higher likelihood of depression related to having undiagnosed and untreated ADHD.
Do signs of depression differ in people with ADHD compared to people without?
Patients who are particularly hyperactive and/or impulsive will often externalise their feelings. They tend to be angry and irritable and think the world is a bad place.
In contrast, those who are more inattentive commonly internalise their feelings. When they express their feelings, they will usually think something is wrong with them rather than the outside world.
What treatments are available for ADHD and depression?
It depends on the severity of the depression. If I have somebody come in and they are very depressed, and I think they may have ADHD, then normally I’ll treat the depression first – usually with medication or therapy. My aim is to get them to a place where their depression is much lower and then we can begin to treat ADHD.
Disclaimer: This list is intended to be a quick reference guide only. Please refer to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM–5) for the full diagnostic criteria
*Please note: In Europe, the International Classification of Mental and Behavioural Disorders 10th revision (ICD-10) may be used as medical classification system, which includes different diagnostic terminology and criteria to the DSM-5.
**Licensed indication varies between countries; views are of Dr Woods rather than Qbtech