What is ADHD?
Attention Deficit Hyperactivity Disorder is “developmentally inappropriate levels of motor activity, attention and impulse control, caused by differences in brain neurobiology”, says Dr Blánaid Gavin consultant child and adolescent psychiatrist and associate professor of child and adolescent psychiatry at University College Dublin. The prevalence rate is 5 per cent of children and adolescents, but it can remain undiagnosed, particularly in girls.
Is it passed down through families?
Like many conditions, a genetic predisposition is inherited. If your child has ADHD, there is a 33 per cent likelihood that you or the other parent has it too. Gavin says she has seen many adults who “stumbled across their own diagnosis” after seeing their child go through the process. A sibling has a 25 per cent chance of also having it.
What are the signs that my child might have the condition?
There are three types of ADHD: hyperactive/impulsive, inattentive, or a combination of both. The way the core characteristics are expressed in a child will vary considerably, depending on age. What impulse control deficit looks like in a three year-old is very different to how it might present in a 15 year-old, although the core issue is the same, says Gavin.
“You have a toddler who absolutely can’t wait their turn, has to be top of every queue, has to be given everything immediately and is butting in, interrupting and it’s constant, constant, constant — over and above that you would regard as typical for a toddler.”
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In an older child or teenager, it might be blurting out inappropriate comments in the classroom, jumping into a conversation, saying something that is hurtful but not deliberate, poking somebody or lashing out in unthinking fashion — but to an onlooker that would appear to be a deliberate act.
Lack of organisational skills is part of inattention. “Someone who can’t manage themselves in, for example, morning routines and needs constant direction and redirection” over and above the guidance that every child needs. Messiness with materials is also common, and the child may seem oblivious to time constraints.
They can have difficulty in listening to, and following through instructions. In conversation, they may appear to zone out or come in at a tangent on the topic being discussed. Their inattention can be most marked when it comes to mundane activities, or ones that need sustained mental application.
“One of the commonest things that parents would say is ‘he’s grand when he’s on the Xbox’ or ‘he’ll sit watching the telly, no problem’, but that’s a very different type of attention and focus that’s required,” she explains.
“Hyperactivity” may conjure up the image of somebody “climbing the walls”, but it is essentially a heightened level of motor activity. For some children, it might be getting in and out of a chair, but for others it may be flopping about; being squirmy in the chair or displaying restlessness and fidgetiness. Motor control improves for all children as they get older, but for those with ADHD there will still be a gap between them and their neurotypical peers.
Teenagers with the condition often have what they might describe as inner restlessness, as opposed to overt overactivity, explains Gavin.
At what age can it be diagnosed?
ADHD is most commonly diagnosed over the age of six but can be very apparent in younger children, says Gavin. However, because there are so many developmental changes going on in early childhood, care has to be taken about other diagnostic possibilities.
“At later developmental stages, you’ve more data to go on, more experiences to judge the child against and more context, given observations of the child for that much longer and from external settings.”
Is it a case of the earlier the diagnosis the better?
“The earlier you intervene to shape the behaviour, the more positive the results can be,” the psychiatrist says. With smaller children, there are more positive outcomes related to parent training after diagnosis than there is relative to older ages. A significant proportion of children with ADHD will have oppositional issues or oppositional defiant disorder alongside ADHD and giving parents skills to cope with this earlier has been proven to be more beneficial.
A common misconception, which can be very hurtful to parents, is believing that the recommendation of parent training is inferring that there is something wrong with their parenting. Gavin stresses that parenting is not a causal factor but raising a child with ADHD can be highly challenging.
“If a child is constantly demanding attention, and maybe using negative means to try and attract attention, parents can get into a dynamic with the child that unintentionally maintains that sort of a cycle.” They need to be empowered with a greater range of skills than a parent typically needs when dealing with a small child.
What should I do if I have concerns?
The first point of contact is the GP and hopefully yours will be one of the “slim majority” of GPs who have a positive attitude towards ADHD, as identified in a study led by Dimitrios Adamis and published in the Irish Journal of Medical Science in 2019.
Gavin says myths about ADHD and scepticism of the diagnosis and treatment persist among key people who could pick up the problems and among those who act as gatekeepers to the system. Ambivalence about referrals is compounded, she suggests, if the experience of GPs and parents is that there is no service available to meet the child’s needs.
How is it diagnosed?
There’s no definitive test, such as a brain scan or blood test. It is a clinical diagnosis using, depending on the age, a mix of information from parents, the school and the child, and observation.
Why is diagnosis helpful?
Parents will often say that being given an understanding of their child was the single most helpful thing that happened through a diagnosis process. “Typically, parents erroneously carry blame,” says Gavin. But hearing that this has a name, and it’s not your child trying to be deliberately provocative or you doing something wrong, can be very helpful. It also offers a way forward.
“It can be a form of currency in terms of access to resources and supports at school,” she says. While the Department of Education is moving to a more needs-based allocation of resources, many schools still look for the diagnosis and find it helpful. For the affected child or teenager, diagnosis can help them understand many of their experiences and reduce self-blame.
How is ADHD treated?
Understanding the characteristics of the condition and their impact on an individual child is fundamental to the way forward. Parent training, as mentioned above, is also very important.
“Depending on the age and profile of the child, different types of therapy may be helpful,” says Gavin. Other conditions often co-exist with ADHD, such as dyspraxia or dyslexia. “Sadly children with this profile are more predisposed to mental health conditions, like anxiety and depression,” she continues, and appropriate therapy will be needed to address those issues. Organisational skills and support can also be helpful.
For moderate to severe ADHD, medication is recommended as part of the treatment. Under guidelines from the UK’s National Institute for Health and Care Excellence, methylphenidate, sold under brand names such as Ritalin and Concerta, is the first choice. If that doesn’t seem effective or is causing significant side effects, other types can be tried.
“Medicines that are used for ADHD are among the most researched medicines in all of paediatrics,” says Gavin and are proven to be very safe and effective.
Will they grow out of it?
Research on this is still evolving, says Gavin. It used to be estimated that up to 40 per cent may grow out of it, “but that’s not clear cut” and the figure is shifting downwards as awareness of adult ADHD grows. While hyperactivity lessens with time and impulse control will probably improve, inattention is one of the most enduring core symptoms. The consequences of having lived with ADHD can also be lifelong, she warns, particularly if it goes undiagnosed. Falling short in other people’s estimation, constantly being told to stop doing things, can have an impact on self-esteem.
“The way I would see it for lots of children is that by the time they are teenagers, they don’t just have an attention deficit, they have a motivation deficit: no matter what they have tried, it hasn’t worked, so there is no point in trying. They typically have an attitudinal deficit because they have had so much kickback from authority figures.” They may also have a skills deficit because they haven’t had the opportunity to do things in the same way as other people and to apply themselves, she suggests. They may not have learnt to work around problems
However, despite the challenges, there are countless people with ADHD who are totally content, fulfilled and happy in their lives, she adds, and that includes those who had it diagnosed as children and those who didn’t. “The possibility of a very fulfilled life is very realistic.”
