FIrstly about 1 in 10 children have ADHD and about half will grow out of it leaving 1 in 20 adults with ADHD. The long term studies in adults have not been done but the oldest patient I have diagnosed and treated with ADHD was 68.

There is a strong genetic component and it is almost certain that other members of the family will have symptoms of ADHD. There is also a greater than average association of ADHD with bipolar disorder and dyslexia.

People with ADHD often present with an inexplicable failure to succeed in life. In other words they are intelligent and affable and try to apply themselves but they fail.

ADHD can make is so difficult to function that there is a high incidence of depression and anxiety alcohol and substance use.

It is also not an uncommon cause of relationship problems amongst couples as the ADHD person will be impatient and irritable and impulsive and difficult to communicate with.often appearing not to listen.

Notably of patients diagnosed with clinical depression then 25% will have ADHD and unless it is treated the depression will not resolve.

As a child ADHD can have severe direct and indirect consequences on self esteem, socialisation and general ability to function and be consistent which are all hugely involved in success in life.

One can imagine a child with ADHD being relentlessly hyperactive impulsive and inattentive will be hard to manage for the parents who typically chastise verbally and physically. This negativity erodes the green shoots of self esteem . The child gets used to criticism, and also gets used to failure and comes to expect both.  One patient was so out of control that his father used to take him out into the garden and hose him down with cold water. They will have difficulty with socialisation and will tend misbehave as a consequence of the ADHD at school and be punished.

There are two issues as far as schools are concerned. 

ADHD -unless it is very mild- is a disability and is covered under the Disablity discrimination act 2010. Additionally even if the child is treated with medication the disability criterion applies as if the child is not on medication. Therefore if the school is sanctioning a child for behaviour as a result of disability or if they are insisting on behavioural targets such as a behavioural contract then they are setting up the child to fail.

Not making reasonable adjustments is part of disability discrimination and is illegal.

The second is abuse by neglect. If either parent or school knowingly do not take steps to help their child once they know they have ADHD then that is abuse by neglect.

Parents should be wary of the paradoxical reinforcement of shouting or physical punishment. Either may arouse the child so much that their dopamine goes up producing a compliant calm child. The parent in desperation learns this is an effective way of curbing unruly ADHD behaviour and the child gets used to being scolded criticised and punished and absorbs that into their self esteem and personality. One of my patients as a child was so hyperactive the only way his father could get him to calm down was to take him out and turn the high pressure water hose on him. That raised his dopamine.

This is also the rational when an occupational therapist recommends ‘Play breaks’ at school if an ADHD is getting unrully or for quiter play ‘hard putty’. All these provide physical stimulation hence raising dopamine.

Far preferable of course to take a simple tablet rather than treating the child differently to the others.


Medication for ADHD:

Stimulants: Methylphenidate and different types of preparation of this. They come is standard release or sustained release (modified release)

In the USA there is also Dexedrine (adderall) which is a mixture of standard and slow release salts.

All these are Class B drugs and have to be prescribed with a CD Pad (controlled drug pad)

National Institute of Clinical Excellence Guidlines state that one a consultant psychiatrist has made the diagnosis and continues supervision of the patient then the GP can prescribe it. Many GPs however do not. Either because they dont understand it, or they are anxious about a class B drug or they don’t believe in ADHD.

Unlicensed stimulant : Modafanil (Provigil) is a histaminergic agent which at high dose has been shown to treat ADHD. note that antihistamines sedtate so histaminergic agents will stimulate.

Non stimulant medications:

Atomoxetine (Strattera) : this raises dopamine and noradrenaline but it is a cumulative effect similar to an antidepressant and needs to be taken constantly . Stimulant medication can be taken according to the requirements and then not taken if not required.

Guanfacine: a central alpha 2 receptor agonist which raises dopamine in the Pre Fronatl Cortex.


Psychological:

This is required often due to the direct negative effects of ADHD and the indirect  effects eg therapy will teach good habits such as reflection, communication, impulse control. We also have to fix fractured self esteem. All this is almost completely useless -although it depends on the precise degree of ADHD-  if the patient is not on medication as they cannot concentrate enough to cooperate.

Family Therapy is important as the parents need to be educated on how to best help their child and also be reassured they are not bad parents.

I help them try and be mindful using a visualisation based on the film the Mask with Jim Carrey who played a gentle hopeless romantic with no confidence. Putting on the Mask exponentially magnified these qualities restoring his confidence and turning him into a mischievous charming hyper energetic caricature of himself. I say they are are getting angry with the Mask of ADHD not their child but their child absorbs all negative input and chastisement into their personalities.

Parents also benefit from education about the law as it applies to their child’s eduction:

All publicly funded nurseries, per-schools, state schools and local authorities must try and identity and assess children with Special Education Needs(SEND).

There must usually then be an Educatinoal Health Care Plan (EHCP) which must be reviewed annually and from Year 9 there must be a full review preparing the child for adulthood.

From the age of 5 onwards it is the law that every child has a right to full time education.

Schools will need to take appropriate steps such as expert assessment by educational psychologists, occupational therapists, speech therapists and referral to local child and adolescent mental health services. If necessary the EHCP will be submitted to the local health authority for extra funding if one to one is required although most schools do have some extra budget themselves for this but of course they dont like using it and usually need ‘encouragement’ by an ‘informed’ parent. The trouble is not all parents are informed. I remember seeing a Polish mother picking up her 7 year old son at lunchtime as the school had enforced half day attendance. This is illegal and refers back to one my basic rules of human behaviour: people do what you let them.

Private schools are bound by OFSTEAD and usually align themselves on their website to rights of equal access to full time education for all. I recently had to write a report for a 15 year old with ADHD -and the school knew he had ADHD- who had been put by the school on a behavioural contract which he broke as he could not stick to it and was sanctioned for it. This is not only failure to make reasonable adjustments but direct harm to the child. It is disability discrimation and therefore illegal. 



As far as physical treatment goes the American Text Book of Psychiatry states that after assessing for diagnostic criteria in DSM V then a definitive diagnosis is obtained by a positive trial of treatment with a stimulant, the point being that only someone with ADHD would become calm and focused on a stimulant and everyone else without ADHD would experience the stimulant effect.

Indeed many people with ADHD will self medicate with some kind of stimulant ie sippling coffee or coca cola throughout the day. Many will resort to Cannabis that does not so much focus the mind as give a blanket of relaxation that some equate with better functioning but it is not a direct cognitive effect and in some results in an amotivational syndrome.

Highly suggestive of ADHD is someone who has no difficulty getting to sleep after an espresso. Some people with ADHD also report paradoxical responses to cocaine so that while everyone was partying the night away after a line of coke they sat quietly on the sofa. (this will depend on the dose of cocaine as I will explain later).

Indeed Donald Trump drinks 6 diet cola day and will well known to not be able to sit through meetings and tends to be impulsive and disinhibited. Look at Boris Johsnon, impulsive and disinhibited and who apparently is not interested in the roll of prime minister, just the position of power. Since the work of the prime minister is not interesting to him he actually genuinely cannot do it. However he is a classic scholar and self professed lover of ancient Greece the writings of which have been the basis of study of oratory and because he likes the classics he has no difficulty writing a book on Ancient Greek.

The neurotransmitter deficit is dopamine. People with ADHD do not have enough dopamine and treatment seeks to bring dopamine levels back into the normal range. Taking too much stimulant may push dopamine above normal levels whereupon overstimulation would occur.

Precisely because the idea is to bring dopamine back to normal levels there should be few if any side effects.

Since dopamine is the pleasure neurotransmitter then this is why people with ADHD can focus if they like something  their dopamine goes up into the normal range so performance at school can be starkly binary being either great or awful at something. Indeed if they like something they can hyperfocus.