7 - ADHD

what are the 2 domains of ADHD?

• inattention

• hyperactivity/impulsivity

what are the 3 presentations of ADHD?

• inattention

• hyperactivity

• combined

most have combined, some have only inattention, some have only hyperactivity

prevalence (data of diagnosed ppl)

• 4-6% of children

• 2-3% of adults

• ADHD often persists into adolescence (50-80%) and adulthood (30-50%) → diff symptomatology

demographic differences

• 2.5 to 1 M:F ration in CYP (referral bias)

• no sig diff b/t LMIC + HIC (diff in conceptualisation + symptomatology

CYP diagnosis

conduct a psychiatric interview and use diagnostic criteria to make final decision

• rating scales/neuropsychological tests can support clinician’s judgement.

diagnostic criteria

• age misalined hyp-imp/inatt for 6+ months

• hyp-imp + inatt detected in at least 2 diff settings (e.g., home/school)

• significant impact on everyday life + functioning

• some symptoms present in ealry-mid childhood

issues with the diagnostic criteria focusing on symptoms in childhood

• may be probematic, especially for women who may not remember the symptoms they present

• ppl are discovering that some ADHD symptoms begin to arise and impact function later in life

aetiology - liability threshold model

individually genetics and environ aren’t strong contributors to ADHD. the two interact and accumulate and when a certain threshold is reached, symptoms present

aetiollogy - genetics

it’s hereditary, more likely to have if a family member has

aetiology - environment

maternal stress, alcohol/smoke during pregnancy, low birth weight, poverty and trauma, stress

executive functions & ADHD

• deficits in vgialnce, WM, response inhibition, starting tasks

• structural + functional changes of pre-frontal, fronto-parietal, and fronto-striatal circuits

state regulation + ADHD

ADHDers struggle to regulate their arousal levels in specific conditions

• cortical + autonomic hypo-arousal: inatt

• hyperact: strategy to increase arousal and attention

• emotional dysregulation: difficulties in regulating autonomic arousal (transdiagnostic)

delay aversion + ADHD

altered processing of rewards and difficulties in waiting for a delayed reward (impulsivity)

• would rather get £5 now than £50 in 7 days

ADHD + neg everday outcomes

• reduced academic performance and employment

• addiction, unhealthy eating/drining, higher risk of physical injury

• health problems: obesity, vision disorders, allergies

• QoL (social/emotional functioning

• emotional and conduct problems (bullying, criminal behaviour)

• teen pregnancies

ADHD + positive everyday outcomes

ppl with ADHD can become very exceptional at something. adaptive characteristics:

• hyperfocus

• resilience

• energy

• cognitive dynamism (spontaneous thought processes)

ADHD management in pre-schoolers <5yrs (NICE, 2018)

• never provide medication until above 6yrs

• if ADHD symptoms still impairing across 1+ domain: obtain specialist advice then consider meds

ADHD management in CYP 5+yrs (NICE, 2018)

• group based ADHD-focused support

• if symptoms still impair across 1+ domain medication should be given in a specific order (Cortese et al., 2018): stimulant → stimulant → non-stimulant

• if ODD/CD co-occur train the parents

• adolescents: CBT if symptoms still impairing w/meds

ADHD management in adults (NICE,2018)

• medication in this order: stimulant → non-stimulant

• supportive psych inteventions if patient asks and/or medication is ineffective

non-pharmacological interventions

psychological symptoms don’t treat the symptoms but instead work on managing the symptoms:

• CBT (for reducing perceived stress)

• mindfulness & mutli-nutrient supplementation

what’s a downside of non-pharmacological interventions?

they don’t show a consistent strong effect on ADHD symptoms unlike meds. they do work, but they need to be done hand-in-hand

co-occuring conditions + symptoms

• CD/ODD

• depression

• anxiety disorder

• autism, intellectual disability, tics

• emotional dysregulation

• sleep disorders

• sluggish cognitive tempo

what approach is necessary for ADHD?

considering all the other comorbidities, a transdiagnostic approach is needed to account for all other potential symptoms