How is ADHD diagnosed?

Research indicates prevalence rates between 1-2%, some say 3-5%.  ADHD, like other mental illness and neurodevelopmental disorders, is frequently missed, especially in a 'hard to reach' population where children and/or their families do not ask for help.  Some children present with significant or severe behavioural problems and the focus remains on the behaviour instead of focusing on a systemic and bio-psycho-social understanding of a child's presentation.  Unfortunately ADHD is also often misdiagnosed in children and young people with mood or anxiety disorders, or in children with medical, learning or attachment problems.

Bio-psycho-social factors should be carefully considered by a Child and Adolescent Psychiatrist who will be able to provide a detailed formulation from a neurodevelopmental, as well as mental health and general health point of view.  Identifying medical, psychological and social risk factors are not only important in considering the assessment and diagnosis, but also in the treatment plan and prognosis.  

It is important to know that many other psychiatric disorders, mental illnesses and medical problems can present very similar to ADHD (differential diagnoses) in terms of poor concentration, impulsivity and hyperactivity, and that ADHD is often a complex assessment and diagnosis to make. 

Differential Diagnoses:  (This list is not comprehensive) 
Depression and other affective or mood disorders
Anxiety disorders such as PTSD or Generalised Anxiety Disorder
Psychotic disorders
Attachment problems or disorders (problems with trust and relationships) 
Chronic psycho-social stressors including environmental stressors or abuse
Developmental and neurodevelopmental disorders and difficulties 
Medical problems such as relating to brain injuries or epilepsy (epilepsy can be difficult to detect) 
Medication causing cognitive or behavioural disturbances (including herbal medication) 

ADHD also has a very high co-morbidity rate, which means many children and young people with ADHD also presents with other mental health difficulties.  Research indicates that more or less 50% of all children and young people diagnosed with ADHD present with at least 2 comorbidities.

Comorbidities:  (This list is not comprehensive)
Language disorders 75%
Learning problems or disabilities 40%
Anxiety disorders 25%
Depression 15%
Behavioural problems 75%  

It is important to ensure that the professionals you meet with for assessment have medical training and specialist experience in working with children with complex mental health difficulties and ADHD.
We would recommend ensuring that any specialist ADHD team or clinic also offers assessment, management and treatment of any comorbidities or complications that may be identified, to prevent referral to another service and a delay in treatment.  Comprehensive care should be the priority.  

A comprehensive assessment is important to accurately identify and treat or manage relevant factors and concerns.  Professionals often obtain reports of the child's or young person's presentation and behaviour at school and at home, and the child or young person might be observed in clinic and/or at school.  Meetings with teachers are often arranged.  It is also important to carefully consider the developmental history from a social, emotional, cognitive, language and physical point of view. Chronological and developmental age are therefore considered, together with levels of distress and functional impairment in different contexts and environments.  Children with ADHD usually have difficulties in all areas of their lives, including their favourite activities.


How is ADHD treated?

There are various treatment options available and it is important to discuss the options with the professionals who diagnosed your child, as they will be in the best position to advise you.

Options may include behavioural intervention, individual, family or group sessions, liaison with school, and/or medication.  Working closely with Education as well as involving children in normative, enjoyable and meaningful activities after school hours with non-delinquent peers and adults with similar interests, where children can experience the opportunity to learn skills, achieve goals and develop from an emotional, social, cognitive and physical point of view, are also important components of supporting children. 

Most professionals will try to avoid medication as a first line option, especially when symptoms are not severe. 

Psycho-education (sessions to discuss what the diagnosis means, the implications, possible complications, possible co-morbid diagnoses, prognosis and treatment options) is essential and professionals will meet with families, young people and children to ensure that they understand the disorder.


Medication in ADHD

Methylphenidate and Dexamphetamine are two stimulant medications used to treat ADHD.  Both are classed as controlled drugs.  There are other options, such as Atomoxetine, which is a newer, non-stimulant medication. 

All medications can have serious side-effects and the potential benefits need to be weighed carefully with the potential risks.

It is also important to know that any medication can interact with other medications, sometimes causing serious medical problems or symptoms.  We advise that you check with your doctor, GP or pharmacist before taking any additional medication.

Some of the possible side-effects of Methylphenidate and Dexamphetamine:  

Increased blood pressure and heart rate, as well as arrhythmias (irregular heart beat)

Impaired growth (reduced rate of length and/or weight gain) 

Decreased appetite and/or sleep difficulties

Emotional difficulties, such as sadness, anxiety, irritation, agitation and aggression

Tics/twitches and/or other movement disorders

Abdominal pain and/or headaches

Thrombocytopenia and/or leucopenia (low platelets or white blood cells)

Some of the possible side-effects of Atomoxetine:  

Similar to Methylphenidate and Dexamphetamine, although some differences, e.g. tics are less likely

Nausea and vomiting

Liver problems
Look out for the following 4 symptoms: 
Jaundice (yellow discolouration of sclera and skin)
Dark urine
Light stools
Tiredness

Some children and young people comment on increased 'suicidal feelings' as side-effects of Atomexetine.  Child Psychiatrists monitor carefully for possible side-effects during every appointment and it is important that children and young people speak to their parents or carers and doctor regarding any concerns that they have regarding medication or possible side-effects.  

What to do when you experience side-effects:

Tell your doctor/seek medical advice immediately.  If your symptoms are very mild and not serious, such as a mild headache or slight nausea, your doctor might recommend that you watch and wait to see if the symptoms improve in a few days or that you reduce the dosage slightly.  If your symptoms are more severe or serious, causing significant discomfort, your doctor might decide to stop the medication, change the dosage of medication significantly, or try a different medication.  Your doctor might also ask for blood tests and an ECG.

It is important to communicate with your doctor immediately when you feel unwell on medication.  If your doctor or their medical colleagues are not available, you can always get emergency advice via your GP or the Emergency Department at any hospital.   

How often do you need check-ups if you are on medication?

Before you start the medication your doctor is likely to check your physical health.  After you start the medication, as well as after every change in dosage, your doctor needs to check for possible side-effects, which is likely to include taking your blood pressure and heart rate.  Once you are on the correct dosage, your doctor still needs to see you regularly for the first year and after that, at least once every year, providing your medication does not change.  Many doctors will want to see you 2-4 times a year for follow up appointments, even though your presentation is stable and you have no side-effects to your medication.  Specialists sometimes arranges annual follow ups and ask GPs to monitor ADHD medication more regularly.

Doctors are likely to monitor your medication and health in a specifically tailored way, depending on your own physical health and the type and dosage of medication, so do check with them what they recommend for you specifically. 

Every 1-2 years, your doctor may recommend that you take a break in medication, to see if you still need it.  Most young people 'grow out of' ADHD as their brain develops.  It is important to know that you can always contact your doctor to ask for an appointment if you have any concerns or queries about the medication.

For how long do you need to take the medication?

Many young people stop needing medication in their mid teens.  Medication breaks can be very important to make sure it is still helpful to take the medication.