ADHD impact and the right Diagnosis
The Impact of ADHD
Around 4-6% of the School Age population receive a diagnosis of ADHD but not all of them require medication. This is around one child in every classroom. In accordance with NICE Guidelines we only treat the children who are severely affected by the condition with medication (or children who are moderately affected where behavioural strategies and advice have not benefitted them) and for the children in the mild range we recommend behavioural strategies and advice.
Young people with ADHD that is unrecognised or poorly managed are more likely to participate in fights, feel frustrated in school which can lead to school refusal or truancy and have a higher risk of having an associated reading disability. Often parents have been trying to access an ADHD assessment for their child for a prolonged period of time and this coupled with growing waiting lists means that a third of people with ADHD are thought to have to wait over two years before they are formally diagnosed.
Around 30 percent of young people with ADHD may present with an associated depression or anxiety disorder. Up to half of girls with ADHD may attempt self harm. ADHD impacts on all areas of a young person’s life and can significantly impact on daily functioning of the family. It can affect the young person’s relationship with their siblings and peers. We know that those living with ADHD are more likely to end up in prison than those without it, have more difficulties in the workplace and have more relationship difficulties in adulthood. This is why it is vital that we recognise potential symptoms and make a timely referral into appropriate services.
Again I feel it is important for Young people and their families to be aware that there can be many positives associated with ADHD. Many hugely successful people have taken advantage of their high energy levels, endless enthusiasm and drive to accomplish their goals in life. Justin Timberlake, Jamie Oliver, Will Smith, Michael Phelps, Jim Carrey and Sir Richard Branson have all been diagnosed with ADHD at some point in their lives and have used it to their advantage .
NICE Guidelines for ADHD have been updated in March 2018. There have been some minor changes but overall the principles for diagnosis and medication have largely stayed the same. NICE have recommended a formal transition service to aid the young people and their families as they leave our Paediatric Clinics and move into the Adult Services. It is hoped that Paediatrics and Child and Adolescent Mental Health Services will work jointly with Adult Psychiatry Services to ensure the Young People and their families continue to receive the right support and advice. A review of the problems the Young Person presents with will be carried out to ensure they continue to benefit from their ADHD medications, that there are no co-morbid Mental health difficulties affecting the Young Person and to recommend any additional Services that the Young Person and their family may benefit from in addition to medication. The importance of the provision of Behaviour Support Services/ Psychological Services for these Young People and their families was also highlighted as a deficit in provision for Services in a significant number of regions.
The NICE Guidelines also reviewed the use of Fish Oils and dietary modification in Young People with an ADHD diagnosis and has advised Medical Professionals that these strategies should not be recommended to families as there is no medical evidence to support their perceived benefits. The importance of a healthy varied diet as well as regular exercise both for physical health and mental health benefits was encouraged. Currently mindfulness if being trialled as an adjuvant therapy for ADHD in the United States with some early positive findings.
The Importance of getting the diagnosis right
As part of a thorough ADHD assessment NICE recommends that we do not rely on information from one source only to base our diagnosis on. We should continue to gather information from home, school or some other setting where the Child/Young Person is regularly placed. A thorough History, physical examination and observational information from parents and school along with our clinical judgement should form the basis of our assessments. In cases where evidence from parents or school varies we can use an observational tool such as QB testing to provide additional evidence to add to our assessment.
It is so important to get the diagnosis right as the label we apply lasts for the lifetime of the individual. There are a number of professions that the individual may be prevented from entering such as the Armed Forces and The Police. The medications that we use in the management of ADHD in moderate to severe cases can have significant side effects or be unhelpful if the young person doesn’t actually have ADHD but another condition instead.
There are a number of other conditions that may present in a similar way to ADHD but would not benefit from stimulant medication and may in fact worsen anxiety/ aggression and unmask tic disorders. These are Dyslexia, Learning Difficulties, Autism Spectrum Disorder and Attachment Disorders.
It is also extremely important that we address any other problems that the Young Person may have such as Oppositional features and Conduct Problems. I do not use the terms Oppositional Defiant Disorder and Conduct Disorder as I feel they are unhelpful terms for both Parents and Young People when their difficulties can appropriately be described by their ADHD. Any difficult behaviours need to be addressed with appropriate behaviour management and we need to ensure parents are given as much support as possible to do this. For Young People also presenting with offending behaviours we need early intervention to protect them from becoming involved in the criminal justice system. Being aware of their diagnosis will not stop them from being prosecuted but enable those involved with them to be fully aware of the Young Person’s difficulties in relation to their ADHD.
In Summary whilst ADHD presents many challenges to the young people and their families dealing with it they often have exceptional strengths such as being highly creative and driven, thinking outside the box and providing solutions “neurotypicals” may never consider and with the right support they have great potential. As professionals we need to work towards more equitable and efficient service provision that is patient centred and work as part of a multi-disciplinary team wherever possible.