www.georgestillforum.co.uk
This leaflet is produced by George Still Forum for parents/carers of children and young people with ADHD.
ACKOWLEDGEMENTS: George Still Forum acknowledges the following members for producing this leaflet-
1. Dr Somnath Banerjee, Community Paediatrician, East Kent Hospitals University
NHS Foundation Trust
2. Dr Hamilton Grantham, Higher Speciality Trainee, Community Paediatrics, Mersey
3. Dr Geoff Kewley, Consultant Paediatrician, Learning Assessment centre, Horsham
4. Dr Diana Leaver, Community Paediatrician, Borders NHS Trust, Scotland
5. Dr Neel Kamal, Community Paediatrician, Hull and East Yorkshire Hospitals NHS
Trust
6. Dr S J Perera, Community Paediatrician, Southend University Hospital NHS
Foundation Trust
7. Dr Chinnaiah Yemula, Community Paediatrician, Bedfordshire Community Health
Services
Version: 1
Date of production: 9 September 2011.
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INTRODUCTION
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ADHD stands for Attention Deficit Hyperactivity Disorder.

ADHD is a condition that causes persistent inattention, hyperactivity, and/or impulsivity.

Boys are three to four times more commonly affected than girls.

Approximately 60% of children with ADHD continue to have problems with the condition as adults.

Children with ADHD have trouble functioning at home and in school and often have trouble with keeping friends.

If left untreated, ADHD has also been shown to have ill effects on academic progress as well as social and emotional development.

As they grow older, children with untreated ADHD may experience drug abuse, antisocial behaviour, and are prone to accidental injuries of all kinds.

No one knows for sure whether ADHD is more common today, but what is very clear is the number of children getting treatment for ADHD have increased especially over the last decade. Some of the increase in diagnosis and treatment is due in part to greater media interest, heightened public awareness, and the availability of effective treatments.

Some experts feel that ADHD is over-diagnosed while others feel it is underdiagnosed. Whether the frequency of the disorder itself has risen remains unknown.
SYMPTOMS

Symptoms of ADHD can differ from person to person but involve some combination of difficulty regulating activity level (hyperactivity), inhibiting behaviour (impulsivity), and attending to tasks (inattention).

The symptoms of hyperactivity and impulsiveness appear to diminish with age but
 difficulty in paying attention persists through to the adulthood.
In most children, ADHD symptoms appear in preschool years.

An inattentive child has difficulty in keeping his/her mind on one thing and may get bored with a task after only a few minutes. They can only engage themselves in brief activities, and change activities frequently. They do not persist with a task long enough to profit from them or to get them right. They may seem to drift away into their own thoughts or lose track of what was going on around them.

Children who are hyperactive always seem to be in motion. They do not sit still. They may roam around the room, squirm in their seats, wiggle their feet, touch everything, or noisily tap a pencil. They may also feel intensely restless. When required to be quite, they appear unable to stop moving. Hard times for a hyperactive child are carpet times, car journeys, meal times, and in other places, which needs sitting calm.
Children who are impulsive seem to be unable to think before they act. As a result they may blurt out answers to questions or run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take turns in games. They may grab a toy from another child or hit out when they are upset. They often have difficulty in making and keeping friends. An impulsive child often interrupts others in their conversations.
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
Most healthy children exhibit many of these behaviours at times especially in the preschool years. For example, parents may worry that a 3-year old who cannot listen to a story from beginning to end or finish a drawing may have ADHD.

Preschoolers usually have a short attention span and are not able to stick with one activity for long.

Even in older children and adolescents, attention span often depends on the level of interest in a particular activity. Most teenagers can listen to music or talk to their friends for hours but may be a lot less focussed about homework.

The same is true of hyperactivity. Young children are naturally energetic- they often wear their parents out long before they are worn out themselves. They may also become more active when they are tired, hungry, anxious or in a new environment.

Some children just naturally have higher activity level than others.

However; when children have ADHD, when stimulated, they can quickly get out of control and sometimes aggressive or even physically or verbally abusive.

Children with ADHD do not necessarily have all the symptoms of the disorder.

ADHD symptoms may be different in boys and girls. Boys are more likely to be hyperactive and impulsive and girls tend to be inattentive.

Girls who have trouble paying attention often day dream, so the diagnosis may be overlooked in them since they are not being disruptive in the classroom.

Inattentive boys are more likely to fiddle aimlessly. Boys also tend to be less compliant with teachers and other adults, so their behaviour is often more conspicuous.

Whereas hyperactivity/impulsivity can be noticed by parents and play group/nursery teachers in young children, inattentive types become more obvious when a child starts school and faces a structured environment for the first time.

The symptoms of ADHD may not be evident in highly structured (i.e. one to one) situations or in novel settings such as clinics.

Often ADHD coexists with other conditions such as depression, anxiety, conduct disorder, oppositional defiant disorder and autism spectrum disorder. Sometimes symptoms may overlap with other medical conditions.
Causes

The cause is unknown. There are a number of factors involved.

Some studies have shown that parts of the brain are not working, as they should.

ADHD tends to run in families. Children who have it usually have at least one close relative who also has ADHD and if one parent had problems with overactivity or inattention in childhood then the risk to an offspring is just over 50%.

Even more convincing of a possible genetic link is that when one twin of an identical twin pair has the disorder, the other twin has a 100% chance of having ADHD.

Children are more likely to have ADHD if they were born prematurely, or if their mother smoked or misused alcohol or drugs when pregnant.
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Diagnosis

ADHD is a complex condition and is therefore sometimes difficult to diagnose. Because so many of the symptoms are related to child development, they can be normal at one age and not at another. In many cases, a child will show signs of the disorder in early childhood but go undiagnosed until they start school, when the demands of schoolwork make them more apparent.

Occasionally, ADHD is not recognised until in secondary school years or even in adulthood.

A diagnosis of ADHD in childhood and adolescence is usually made after discussing symptoms at length with the child, parents and teachers. Information about any family history of similar problems is gathered as well. The doctor will consider other possibilities, including other medical or psychiatric conditions.

There is no specific test for ADHD. A battery of tests is used to assess a child’s neurological and psychological status. In the UK, ADHD is managed by a child psychiatrist or a paediatrician with experience in diagnosing and treating ADHD.
Treatments options

Treatment of ADHD is a matter of debate.

Effective interventions for children with ADHD fall into three broad categories: drug therapy, behaviour management, and educational modifications in school.

Drug therapy: Brain stimulants are the most commonly prescribed medications.

Parents often wonder why stimulants are given to children who are already overstimulated.

Stimulants boost and balance the level of brain chemicals, which stimulate the inhibitory mechanism of brain. These chemicals also stimulate a part of the brain called reticular activity system , which maintains attention and arousal and helps to control impulsiveness.

Medications help to alleviate the symptoms of inattention, hyperactivity and impulsivity but they do not address other problems such as lack of academic achievements, poor social skills or conflict at home.

The most extensively used stimulant is methylphenidate (Ritalin, Medikinet). The other drug used is Dexamfetamine (Dexedrine). Both these drugs kick off in 20 to 30 minutes and the effect lasts between 3 –4 hours. There are three long-acting preparations of methylphenidate available in UK- Equasym XL (by Shire) and Medikinet XL (by Flynn-
Pharma) work up to 8 hours whereas Concerta XL (by Janssen) works up to 12 hours.
These sustained-release drugs are claimed to give an even effect through out the school day; avoiding the peak and troughs and the need for a lunchtime dose.

Non-Stimulants: In UK, atomoxetine is the only licensed non-stimulant medication that appears to work as well as the stimulants in treating ADHD and can be particularly helpful in children who suffer from anxiety.
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
Side effects: Every drug has some side effect. The common side effects of these drugs include loss of appetite, difficulty getting off to sleep, headache, tummy pains, nervousness and tearfulness especially in the first few days of the start of medication.
Regular monitoring by a doctor is important in order to detect side effects of medication.
It is important for the doctor to regularly check weight and blood pressure to determine whether the drug is causing a weight loss or blood pressure elevation. Parents also worry about the addiction risk. Drug dependence is not reported in children who take stimulants orally and in appropriate dose. This is because the drug level in the brain rises too slowly to produce a “high”.

Behaviour management: All children with ADHD often greatly benefit from behaviour modification programme, which may be provided by parents, teachers under the supervision of a psychologist, social worker or other mental health professional. In situations where such provisions are not available there are various websites from where parents can get information about behaviour modification programs. It is often given in conjunction with specific educational interventions, such as help with learning skills.

Managing behaviour at home : Parents can help their child by providing a structured environment with clear rules of acceptable behaviour. Good behaviour should be reinforced with rewards and bad behaviour should be ignored. When punishment is necessary this should be time-limited, for instance set periods of time alone in a separate room ("time out"). This type of behavioural management can be useful for modifying individual behaviours, such as antisocial behaviour.

School: A structured and orderly classroom without too many distractions, together with an understanding teacher, are helpful. Often, small-group or individual teaching helps. An educational psychologist may be helpful to determine the child's abilities.
Parents should make sure that the programs started at school should be continued at home as this will cause minimal confusion to the child.
Role of diet

Most of the dietary manipulations involve eliminating additives such as tartrazine (an orange food-colouring additive) and foods incriminated to increase hyperactivity, such as sugar, chocolate, and caffeine or common food allergens such as wheat, milk, and eggs.

Several medical studies have failed to support the beneficial effect of dietary manipulation on behaviour, except possibly in a very small percentage of children.

Current evidences suggest that diets are arduous to implement and some may be nutritionally deficient and a restriction of diet in children with ADHD is not advisable.

Some people believe supplements of certain vitamins; minerals or omega-3 fatty acids can help to treat ADHD. There is no firm scientific evidence for this.

The safety of high doses of supplements is unproven.

Eating a varied and balanced diet, including oily fish (e.g. mackerel, herring, trout), which is high in omega-3 fatty acids, certainly helps to promote healthy development in children.
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Cure

There is no proven cure for ADHD.

Many good treatment options are available. The outlook for children who receive
treatment for ADHD is encouraging.

Parent/s play an important part in providing effective treatment for the child.
Further information and support

Explore at following internet sites for support groups: www.addiss.co.uk
, www.adders.org
, www.addcontact.org.uk

Because an ADHD child may process information in faulty ways, s/he tends to be bombarded with corrections, leaving her/him with a low opinion of self. Do whatever you can to promote your child’s self-esteem.

Praise and reward good behaviour promptly.

Be consistent with discipline and make sure everybody in the family follow the same methods.

Make instructions simple and specific (“Brush your teeth now, get dressed”), instead of general (“Get ready for school”).

Encoura ge child’s strengths, particularly in sports and out-of-school activities.

Have set routines for meals, sleep, play and TV.

Don’t let homework monopolise all of their time after school; play and exercise are important.

Simplify your child’s room. Store toys out of sight.
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