3. Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonyms: hyperkinetic disorder, attention deficit disorder (ADD)

Attention deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity and impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development. The Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10) uses the term hyperkinetic disorder for a more restricted diagnosis. It differs from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classification in that all three problems of attention, hyperactivity, and impulsiveness must be present. For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:[1]

  • Meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder) and
  • Are associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and
  • Are pervasive, occurring in two or more important settings, including social, familial, educational and/or occupational settings.

The DSM-IV diagnostic criteria for attention deficit hyperactivity disorder

  1. Either 1 or 2 (six of the nine symptoms in each section must be present for a 'combined type' diagnosis of attention deficit hyperactivity disorder (ADHD):[1]Some hyperactive-impulsive or inattentive symptoms that caused impairment should be present before age 7 years.
    • Inattention: at least six of the following symptoms persisting for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      • Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities.
      • Often has difficulty sustaining attention in tasks or play activities.
      • Often does not seem to listen to what is being said to him or her.
      • Often does not follow through on instructions and fails to finish schoolwork chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).
      • Often has difficulty organising tasks or activities.
      • Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort.
      • Often loses things necessary for tasks or activities, eg school assignments, pencils, books, tools or toys.
      • Often easily distracted by extraneous stimuli.
      • Often forgetful in daily activities.
    • Hyperactivity/impulsivity: at least six of the following symptoms of hyperactivity or impulsivity for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      • Hyperactivity:
        • Often fidgets with hands or feet and squirms in seat.
        • Leaves seat in classroom or in other situations in which children are expected to remain seated.
        • Often runs about or climbs excessively in inappropriate situations (in adolescents or adults this may be limited to feelings of restlessness).
        • Often has difficulty playing or engaging in leisure activities quietly.
        • Is often on the go or often acts as if driven by a motor.
        • Often talks excessively.
      • Impulsivity:
        • Often blurts out answers to questions before the questions have been completed.
        • Often has difficulty waiting in line or awaiting his or her turn in games or group situations.
        • Often interrupts or intrudes on others.
  2. Some impairment from symptoms must be present in two or more settings (eg at school or work and at home).
  3. There must be clear evidence of significant impairment in social, school or work functioning.
  4. The symptoms should not happen only during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder. The symptoms should not be better accounted for by another mental disorder (eg mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
  • The prevalence of attention deficit hyperactivity disorder (ADHD) is estimated to be around 2.4% of children in the UK.[2]
  • ADHD is most often diagnosed in children aged 3-7 years, but it may not be recognised until later in life and sometimes not until adulthood.[2]
  • ADHD is more commonly diagnosed in boys than girls.
  • ADHD is more common in first-degree relatives of affected children and studies of twins suggest a significant genetic contribution. There are a number of genes that are thought to have a small effect, eg DRD4 and DRD5, but it is unlikely that any individual genes have a large effect.[3]
  • ADHD is more common in learning-disabled children, and if there has been prenatal exposure to cannabis.[4][5] Other environmental risk factors include obstetric complications and family conflict.[3]

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  • Young people and adults with attention deficit hyperactivity disorder (ADHD) may have associated problems, eg self-harm, a predisposition to road traffic (and other) accidents, substance misuse, delinquency, anxiety states and academic underachievement.[1]
  • ADHD is a part of a spectrum of disorders. 70% also have other conditions such as generalised or specific learning difficulties (eg dyslexia, language disorders, autistic spectrum disorder), dyspraxia, Gilles de la Tourette's syndrome or tic disorder.
  • Oppositional defiant disorder or conduct disorder is present in most children with ADHD; 20% have coexistent mood disorder, 25% coexistent anxiety disorder, and 20% specific developmental disorders such as dyslexia or dyspraxia.[6]
  • Attention deficit hyperactivity disorder (ADHD) should be considered in all age groups. Diagnosis should only be made by a specialist psychiatrist, paediatrician or other healthcare professional with training and expertise in the diagnosis of ADHD. Diagnosis should be based on:
    • A full clinical and psychosocial assessment. Discuss behaviour and symptoms in the different domains and settings of the person's everyday life
    • A full developmental and psychiatric history, and
    • Observer reports and an assessment of mental state.
  • An assessment should include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people there should also be an assessment of their parents' or carers' mental health.
  • Determine the severity of behavioural and/or attention problems suggestive of ADHD and how they affect the child or young person and their parents or carers in different domains and settings.
  • As part of the diagnostic process, include an assessment of needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people also include an assessment of the parents' or carer's mental health.
  • Anxiety.
  • Depression.
  • Drugs, eg anticonvulsants, antihistamines, beta-agonists, antisocial conduct disorder, disinhibited attachment disorder (seen in children who have passed through many adoption/foster placements and who have been unable to develop healthy attachments or friendships).

Specialist referral is needed to confirm the diagnosis and to start management. Referral may be to a specialist paediatrician, a child psychiatrist, Child and Adolescent Mental Health Services (CAMHS), or an adult psychiatrist, depending on the age of the person and local service provision. Adults suspected of having attention deficit hyperactivity disorder (ADHD) and adults with continuing ADHD from childhood should be referred to a psychiatrist.[2]

  • Parents and affected children need a great deal of explanation and support. There is a great deal of unproven advice available for parents and it is very important that time be taken to explain properly and to discuss the diagnosis and appropriate treatments. Consider providing parents and carers with self-instruction manuals and other materials (such as videos) based on positive parenting and behavioural techniques.
  • Stress the value of a balanced diet, good nutrition and regular exercise for children and young people with ADHD.
  • Eliminating artificial colouring and additives from the diet is not recommended as a generally applicable treatment for ADHD.
  • Dietary fatty acid supplements are not recommended for the treatment of ADHD.
  • Advise parents or carers to keep a diary if there are foods or drinks that appear to affect behaviour. If the diary supports a link between any foods or drinks and behaviour, offer referral to a dietitian.
  • Further management (such as elimination of specific foods) should be jointly undertaken by the dietitian, mental health specialist or paediatrician, and the family.

Initial management[1]

  • If the problems are having an adverse impact on development or family life, consider:
    • Watchful waiting for up to 10 weeks
    • Offering referral to a parent-training/education programme; this should not wait for a formal diagnosis of ADHD.
  • If the problems persist with at least moderate impairment, refer to secondary care, ie paediatrician, child psychiatrist or specialist ADHD CAMHS.
  • If the problems are associated with severe impairment, refer directly to secondary care.
  • Do not diagnose or start drug treatment for ADHD in children and young people in primary care.
  • If a child or young person is currently receiving drug treatment for ADHD and has not yet been assessed in secondary care, refer to a paediatrician, child psychiatrist or to specialist ADHD CAMHS as a clinical priority.

Drugs[1]

  • Drug treatment is usually not recommended for preschool children with ADHD, for whom parent-training/education programmes for parents or carers are normally first-line treatment.
  • For school-age children and young people with ADHD, drug treatment should be reserved for those with severe symptoms and impairment or for those with moderate levels of impairment who have refused nondrug interventions, or whose symptoms have not responded sufficiently to parent-training/education programmes or group psychological treatment.
  • Following treatment with a parent-training/education programme, children and young people with ADHD and persisting significant impairment should be offered drug treatment.
  • In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based parent-training/education programme.
  • Where drug treatment is considered appropriate, methylphenidate, atomoxetine and dexamfetamine are recommended.[7]
  • Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
  • Baseline physical assessment before starting drug treatment should include measurement of pulse, blood pressure, weight and height (plotted on centile charts). An ECG should also be considered on an individual basis.[8]
  • When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:
    • Methylphenidate for ADHD without significant comorbidity
    • Methylphenidate for ADHD with comorbid conduct disorder
    • Methylphenidate or atomoxetine when tics, Gilles de la Tourette's syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
    • Atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.
  • Adults with ADHD:
    • Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.
    • Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.
  • Dexamfetamine should be considered when symptoms are unresponsive to a maximum tolerated dose of methylphenidate or atomoxetine.
  • If there is no response to methylphenidate, atomoxetine or dexamfetamine, the affected person should be referred to tertiary services. Further treatment may include drugs unlicensed for ADHD, (eg bupropion, clonidine, modafinil and imipramine) or combination treatments (including psychological treatments for the parent or carer and the child or young person).
  • Follow-up and monitoring:
    • Drug treatment should be reviewed at least once every 6 months.
    • Review should include physical review (height, weight, blood pressure and general health), medication review for efficacy, safety and compliance and a review of the child's functioning at school, at home, socially and psychologically. Monitoring should include regular feedback from parents, teachers and others in close contact with the child.

Psychosocial treatments

  • Parents or carers of preschool children with ADHD should be offered a referral to a parent-training/education programme as the first-line treatment if the parents or carers have not already attended a programme or the programme has had a limited effect.[1]
  • Teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD.
  • If the child or young person with ADHD has moderate levels of impairment, the parents or carers should be offered referral to a group parent-training/education programme, either on its own or together with a group treatment programme (cognitive behavioural therapy (CBT) and/or social skills' training) for the child or young person.
  • CBT, behaviour modification and intensive contingency treatment have been used. The latter two treatments are more effective than CBT in improving behaviour and academic performance.[8]
  • Family therapy without medication may help to develop structure in the family, help to manage children's behaviour, and may help families cope with distress from the presence of the disorder.
  • Underlying learning difficulties will require additional individual or small-group remedial instruction.
  • Other allied health professionals may be involved. Occupational therapists can provide specific programmes for handwriting or gross motor difficulties. Speech therapists may be required for language difficulties.

Psychological treatment for adults with ADHD[1]

  • Consider group or individual CBT for adults who:
    • Are stabilised on medication but have persisting functional impairment associated with ADHD.
    • Have partial or no response to drug treatment or who are intolerant to it.
    • Have made an informed choice not to have drug treatment.
    • Have difficulty accepting the diagnosis of ADHD and accepting and adhering to drug treatment.
    • Have remitting symptoms and psychological treatment is considered sufficient to treat mild-to-moderate residual functional impairment.
  • Offer group therapy first because it is the most cost effective.

Alternative treatments

Many of the alternative treatments that have been promoted are not supported by clinical trials.[9]

A recent meta-analysis of follow-up studies of children with attention deficit hyperactivity disorder (ADHD) found that:[10]

  • About 15% continued to have ADHD.
  • 65% had persistence of some symptoms and continuing functional impairment, with psychological, social, or educational difficulties.
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Further reading & references

  1. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults; NICE Clinical Guideline (September 2008)
  2. Attention deficit hyperactivity disorder (ADHD), Clinical Knowledge Summaries (June 2009)
  3. Biederman J, Faraone SV; Attention-deficit hyperactivity disorder. Lancet. 2005 Jul 16-22;366(9481):237-48.
  4. Fried PA, Smith AM; A literature review of the consequences of prenatal marihuana exposure. An emerging theme of a deficiency in aspects of executive function. Neurotoxicol Teratol. 2001 Jan-Feb;23(1):1-11.
  5. Hill P; Attention deficit hyperactivity disorder. Arch Dis Child. 1998 Nov;79(5):381-4.
  6. Goldschmidt L, Day NL, Richardson GA; Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000 May-Jun;22(3):325-36.
  7. Attention deficit hyperactivity disorder (ADHD) - methylphenidate, atomoxetine and dexamfetamine; NICE (2006)
  8. Management of attention deficit and hyperkinetic disorders in children and young people, Scottish Intercollegiate Guidelines Network - SIGN (October 2009)
  9. Arnold LE; Alternative treatments for adults with attention-deficit hyperactivity disorder (ADHD). Ann N Y Acad Sci. 2001 Jun;931:310-41.
  10. Faraone SV, Biederman J, Mick E; The age-dependent decline of attention deficit hyperactivity disorder: a Psychol Med. 2006 Feb;36(2):159-65.
Original Author: Dr Colin Tidy Current Version:
Last Checked: 26/10/2010 Document ID: 1831  Version: 21 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.