Summary

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition characterised by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning and development. Symptoms must be present before age 12 and occur in multiple settings (home, school, work). ADHD affects 5-7% of children and persists into adulthood in 50-65% of cases. Early diagnosis and multimodal treatment (behavioural interventions plus medication) significantly improve long-term outcomes including academic achievement, employment, and mental health.

Key Facts

• Prevalence: 5-7% of children; 2.5-4% of adults
• Male:Female ratio: 3:1 in childhood; 1.5:1 in adulthood (females underdiagnosed)
• Persistence: 50-65% continue to have symptoms into adulthood
• Heritability: 70-80% (highly genetic)
• Key management: Behavioural interventions first; medication (stimulants) for moderate-severe
• Comorbidities: Anxiety (25%), depression (20%), conduct disorder (40%), learning difficulties (30%)

Clinical Pearls

The Triad Varies by Age: Hyperactivity often decreases by adolescence, but inattention and impulsivity persist. Adult ADHD manifests as disorganisation, poor time management, and emotional dysregulation.

The Female Presentation: Girls often present with inattentive subtype — "dreamy" rather than disruptive. They are frequently diagnosed later and have higher rates of comorbid anxiety and depression.

The 6-Month Rule: Symptoms must be present for at least 6 months, start before age 12, and cause impairment in at least 2 settings to meet diagnostic criteria.

Why This Matters Clinically

Untreated ADHD significantly impacts academic achievement, employment, relationships, and mental health. Children with ADHD are at higher risk of academic failure, substance misuse, accidents, and criminal behaviour. Early identification and treatment markedly improve outcomes and reduce these risks.

Structured Approach

General:

• Observe behaviour during consultation (restlessness, distractibility)
• Note interaction style (interrupting, impulsivity)
• Assess emotional state (anxiety, low mood common)

Developmental Assessment:

• Gross and fine motor skills
• Language development
• Academic achievement relative to IQ
• Social skills and peer relationships

Physical Examination:

• Growth (height, weight) — baseline before stimulants
• Cardiovascular: HR, BP — baseline and monitoring on treatment
• Neurological: Exclude alternative diagnoses

Special Tests

Natural History

• Untreated ADHD associated with significant functional impairment
• Hyperactivity tends to decrease with age; inattention persists
• 50-65% continue to meet criteria in adulthood
• High rates of comorbid mental health conditions

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Early diagnosis and treatment
• Higher IQ
• Supportive family environment
• Fewer comorbidities
• Good response to medication

Poor Prognosis:

• Late diagnosis
• Comorbid conduct disorder
• Family dysfunction
• Substance misuse
• Poor treatment adherence

Key Guidelines

1. NICE NG87 (2018) — Attention deficit hyperactivity disorder: diagnosis and management. NICE NG87
2. SIGN 112 — Management of attention deficit and hyperkinetic disorders in children and young people.
3. CADDRA Guidelines (2020) — Canadian ADHD Resource Alliance clinical practice guidelines.

Landmark Trials

MTA Study (1999) — Multimodal Treatment Study of Children with ADHD

• 579 children randomised to 4 treatment arms
• Key finding: Medication alone or with behavioural therapy superior to behavioural alone or community care
• Clinical Impact: Established medication as effective treatment for moderate-severe ADHD

PATS Study (2006) — Preschool ADHD Treatment Study

• 303 preschoolers with ADHD
• Key finding: Methylphenidate effective in preschoolers but with more side effects
• Clinical Impact: Behavioural interventions first-line in preschoolers

OROS-MPH Studies — Long-acting methylphenidate formulations

• Multiple RCTs
• Key finding: Once-daily formulations effective and improve adherence
• Clinical Impact: Long-acting stimulants now standard of care

Evidence Strength

What is ADHD?

ADHD stands for Attention Deficit Hyperactivity Disorder. It is a condition where the brain works differently in ways that make it harder to concentrate, sit still, and control impulses. Think of it like a car with a very sensitive accelerator and weaker brakes — the brain has lots of energy but finds it harder to slow down and focus.

Why does it matter?

Without support, ADHD can make school, work, and relationships much harder. Children may struggle at school, get into trouble, and feel frustrated. Adults may have difficulty keeping jobs, managing time, or maintaining relationships. The good news is that with the right support and sometimes medication, people with ADHD can thrive.

How is it treated?

1. Understanding and support: Learning about ADHD helps you and your family understand what is happening and reduces frustration.
2. Changes at home and school: Structured routines, fewer distractions, and breaking tasks into smaller steps help enormously.
3. Parent training: Programmes teach strategies to manage behaviour positively.
4. Medication: If symptoms are moderate to severe, medication (usually methylphenidate or lisdexamfetamine) can significantly improve concentration and reduce hyperactivity.

What to expect

• Getting a diagnosis takes time — involving assessments with you, your child, and teachers
• Medication, if used, is usually taken long-term and monitored carefully
• Many children continue to do well into adulthood, especially with ongoing support
• Height, weight, and heart rate are checked regularly if on medication

When to seek help

Contact your doctor or specialist if:

• Symptoms are affecting school, friendships, or family life
• Your child seems very unhappy, anxious, or talking about harming themselves
• Medication side effects are causing problems (not eating, not sleeping, mood changes)
• New symptoms develop (tics, chest pain, palpitations)