Summary

ADHD is a neurodevelopmental disorder 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 two or more settings (home, school, work). ADHD affects 5-7% of children and 2.5-4% of adults worldwide. It is increasingly recognised in adults, often presenting as executive dysfunction, emotional dysregulation, and underachievement. Treatment combines medication (stimulants are first-line) with psychological interventions. ADHD has significant heritability (70-80%) and is associated with alterations in dopaminergic and noradrenergic neurotransmission.

Key Facts

• Definition: Neurodevelopmental disorder with persistent inattention, hyperactivity, and impulsivity
• Prevalence: 5-7% children; 2.5-4% adults
• Sex ratio: Male:Female 3:1 in children; closer to 1:1 in adults (females underdiagnosed)
• Heritability: 70-80%
• Subtypes: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, Combined
• First-line treatment (children): Methylphenidate
• First-line treatment (adults): Lisdexamfetamine or Methylphenidate

Clinical Pearls

Girls Are Missed: Females often present with inattentive subtype (daydreaming, disorganisation) rather than hyperactivity. They are frequently diagnosed later in life after years of struggling.

ADHD Doesn't End at 18: 60-70% of children with ADHD continue to have symptoms into adulthood. Adult ADHD is underdiagnosed but highly treatable.

It's Not Just About Focus: Executive dysfunction (planning, organisation, time-blindness), emotional dysregulation, and rejection sensitivity are core features often overlooked by diagnostic criteria.

Why This Matters Clinically

ADHD is associated with significant impairments in academic achievement, occupational functioning, relationships, and mental health. Untreated ADHD increases risk of substance misuse, accidents, and comorbid anxiety/depression. Early diagnosis and treatment improve long-term outcomes. NICE guidelines now emphasise the importance of diagnosing and treating adults.

Structured Approach

General:

• Observe during consultation: fidgeting, interrupting, eye contact
• Note organisation of belongings
• Assess mental state

Psychiatric Assessment:

• Detailed developmental history (ideally collateral from parents/school reports)
• Symptoms across settings (home, work, relationships)
• Functional impairment assessment
• Comorbidity screen (anxiety, depression, autism, substance use)

Special Assessments

Physical Examination

• Height and weight (growth monitoring in children)
• Blood pressure and heart rate (baseline before stimulants)
• Cardiovascular examination
• Neurological examination if indicated

Natural History

• ADHD is a chronic condition; symptoms persist into adulthood in 60-70%
• Hyperactivity tends to diminish; inattention and executive dysfunction persist
• Untreated ADHD associated with poor academic achievement, job instability, relationship difficulties

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Early diagnosis and treatment
• Good response to medication
• Supportive family/environment
• Higher IQ
• Absence of comorbidities

Poor Prognosis:

• Late diagnosis
• Comorbid conduct disorder / oppositional defiant disorder
• Comorbid learning difficulties
• Substance misuse
• Adverse childhood experiences

Key Guidelines

1. NICE NG87 (2018, updated 2019) — Attention deficit hyperactivity disorder: diagnosis and management. NICE NG87
2. BAP Consensus Statement (2021) — Evidence-based guidelines for management of ADHD in adults.
3. SIGN 112 (2009) — Management of attention deficit and hyperkinetic disorders in children and young people (Scotland).

Landmark Trials

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

• 579 children; 14-month RCT
• Key finding: Medication was more effective than behavioural therapy alone
• Key finding: Combined treatment had modest additional benefits
• Clinical Impact: Established stimulants as first-line; emphasised medication as cornerstone

ADORE Study (2006) — Real-world cohort of ADHD treatment

• Key finding: Treatment improves quality of life and functioning
• Clinical Impact: Supported effectiveness in naturalistic settings

Evidence Strength

What is ADHD?

ADHD is a brain-based condition that makes it harder to concentrate, control impulses, and sit still. It is NOT about being lazy, naughty, or unintelligent. People with ADHD often have brains that need more stimulation to focus on tasks that seem boring but can hyperfocus on things they find interesting.

Why does it matter?

Without treatment, ADHD can cause problems with school or work, relationships, and self-esteem. People with untreated ADHD are more likely to have accidents, struggle with jobs, and experience anxiety or depression. The good news is that treatment works very well for most people.

How is it treated?

1. Medication: Most people with ADHD benefit from medication. The most common type (stimulants like methylphenidate or lisdexamfetamine) actually helps the brain focus better, despite the name. Non-stimulant options are also available.

2. Therapy and coaching: Learning strategies to manage time, organisation, and emotions is very helpful. CBT (cognitive behavioural therapy) can help manage patterns of thinking that make ADHD harder.

3. Lifestyle changes: Regular exercise, good sleep, structured routines, and breaking tasks into smaller steps all help.

What to expect

• Medication often works within days to weeks
• Finding the right dose takes time (titration)
• Side effects (reduced appetite, trouble sleeping) often improve or can be managed
• ADHD is a lifelong condition, but many people do very well with support

When to seek help

Contact your doctor if:

• Your medication is not helping or causing significant side effects
• You are feeling very anxious, depressed, or having thoughts of self-harm
• You are having heart palpitations or chest pain
• You want to start or stop your medication