By EK Wills
There has been much discussion about ADHD in the media and it appears like an epidemic of ADHD is upon us. Just this week, Australia has released its first clinical practice guidelines and as a psychiatrist and parent, it is an area of study that I am interested in.
For those who haven’t focussed on this (pun intended), ADHD stands for Attention Deficit Hyperactivity Disorder and is a neuro-developmental condition. The symptoms of this condition are listed in the DSM-5* and ICD-11**.
In order to be diagnosed with this condition then several features need to be present, pervasive from an early age, as well as cause clinically significant impairment. This means it needs to have an impact on your life that is noticed and detrimental.
It is important to note, that symptoms are not always easy to spot as some people, particularly girls, are good at ‘masking’ them. In addition, hyperactivity is not always present if the type is more inattentive and/or it can improve with maturity.
The symptoms of ADHD may also overlap with symptoms of other related conditions, so careful consideration of the onset and course of symptoms is required to make decisions about the diagnosis. Other similar presentations include medical, neurodevelopmental and/or mental health conditions and need to be ruled out.
Furthermore, co-occurring conditions often present and can differ depending on the age of the person. For example, for children, autism or learning disorders can co-occur. For adults, the most commonly occurring conditions include anxiety and depression or substance use disorders.
Diagnosis can be made by a neuropsychologist, clinical psychologist or psychiatrist. Generally, this means an out of pocket expense as the public health system often copes with acute issues rather than chronic underlying ones. Referrals need to come from your GP and it is good to keep the GP informed of your health concerns as the central coordinator of care. They may have to do some physical health checks before you proceed to the assessment phase in order to rule out the potential medical causes of your symptoms.
If you are looking for help with your child or teen, then a Child & Adolescent Psychiatrist (or neuro- or clinical psychologist) will need to assess them. It is not impossible to have assessments conducted in the public system, although this can be challenging to navigate and may take longer to be seen than in the private sector.
Professionals vary in their approach to this concept and often it relates to their prior exposure in the workplace. Some professionals still doubt the validity of the diagnosis, further challenging stigma around this diagnosis. Others do not have the training as it is often conducted in the private setting for adults.
In addition, there are a variety of ways to diagnose the condition, from screening and rating scales to comprehensive neuro-psychometric testing.
The assessment I conduct for adults, usually involves several sessions to conduct a comprehensive history, obtain collateral from others such as school reports, and to assess current symptoms and function. The onset, duration and functional impact can help differentiate the effects of ADHD from those of other condition, and to help guide the treatment plan. If there is further diagnostic clarification required, then a neuropsychological assessment can be obtained.
In establishing a diagnosis, it is important to consider the co-occurring conditions. Often, the most severe, or one involving the more risk potential, needs to be addressed initially. For example, if someone is using illicit substances, a period of ‘detox’ or abstinence may be required before it can be clear how to proceed with treating ADHD or, in fact, how much of contribution ADHD makes to the clinical picture.
One session can be dedicated to the discussion of the diagnosis and the treatment options. Treatment is planned collaboratively with you and, with your consent, with the family or support people such as partners.
It is not always a focus on medication as there are many approaches to establish good habits that will support people with ADHD. For example, time management skills can be learnt and reminders in the form of apps, calendars and alarms can help organise routines.
There are psychological approaches such as ADHD coaching or CBT (cognitive behavioural therapy) and various ages and stages can benefit from these. If there are relationship concerns, then counselling and supports can be helpful.
In addition, safety needs to be considered. For example, can the person concentrate well enough to drive a car?
If the impact on function is severe, then medication is considered the first line approach. These generally involve stimulants, but any safety concerns such as ‘diversion’ of medication needs to be considered. That means, if there is a substance use disorder, risk needs to be mitigated by careful control measures. It is important to know that stimulants are a controlled medication and can only be prescribed by one provider for your treatment. It is not unusual to be required to provide urine drug screens.
Medication type needs to decided and ‘titrated’ (or increased) to effect. This needs monitoring and will require more visits with your prescriber. Side effects such as dizziness, headache, appetite changes, nausea, vomiting, bowel changes, irritability or anxiety, insomnia need to be checked and any changes in blood pressure or heart rate. There are some situations that mean a stimulant ideally should not be used such as heart conditions. In these cases, there are other medications to consider and include antidepressants and mood stabilisers.
Once the right medication and right dose is established then monitoring can be spaced out further. However, it is recommended to continue to have reviews, at least every year, to consider ongoing treatment options such as medication reduction or requirements.
There are also measures that can be put in place to assist you in education or employment settings which can be discussed with your care provider.
With the popularity of ADHD at the moment, it is important to consider whether your symptoms are new or whether they could be related to the recent upheaval that CoVid has presented us with. It may be that you have symptoms more related to anxiety or depression and a discussion with your GP or psychologist is your first point of contact before you consider the path to ADHD diagnosis.
All of this can be an expensive exercise but if it means you can gain clarity about what you need to improve your quality of life, then your health is worth it.
*Diagnostic Statistical Manual 5th Edition
**International Classification of Diseases 11th Edition
