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From: Irish Medical Times, 30th September 2020
Academic Psychologist Dr Kate Carr-Fanning addresses the challenges of diagnostic guidelines in ADHD, particularly a need for greater recognition for ADHD in girls, which has to be followed up with a multimodal approach to treatment in all identified patients
Have you come across attention deficit hyperactivity disorder (ADHD) in your practice? It is so common it would be almost impossible not to. A safe bet would be that you have come across it more often than you realise. There are the “well-known” aspects of ADHD, the classic image of the hyperactive child “bouncing off the walls”, unable to sit still or focus on anything. But, there is a lot that can go unrecognised. Sometimes children and adults fall through the cracks, and may have secondary issues treated, while ADHD goes unnoticed.
What is more, the impact of ADHD, across many, if not all, areas of life, means its effects can be found in doctors’ offices, hospital emergency rooms, courts of law, the Social Welfare Office, the family home, entrepreneurial roadshows, as well as the stereotypical image of the school principal’s office.
ADHD is a neurodevelopmental disorder characterised by hyperactivity, impulsivity, and/or inattention.1
It affects approximately 5-6 per cent of children.2 While there is some variability, and both severity of ADHD and comorbidity have an impact, for those diagnosed in childhood, the majority will continue to meet the diagnostic criteria or struggle as a result of their ADHD into their adult life.3,4
Presentation of ADHD
According to the Diagnostic and Statistical Manual (DSM5),1 ADHD presents itself in one of three ways, with diagnostic rates varying based on presentation.
One epidemiological survey found that in childhood, the combined presentation (hyperactivity-impulsivity-inattention) was the most common, followed by hyperactivity-impulsivity, with the inattentive presentation being the least diagnosed.5
Inattention may go unrecognised, because these children do not fit into that stereotypical view of the hyperactive child; as a parent once said to me, “I couldn’t believe he had ADHD, sure he’s almost horizontal …’. These children and adults can lose focus often and easily, may process information more slowly, forget or lose things frequently, and may seem like they live in a daydream and/or in chaos.
ADHD is far more commonly diagnosed in boys in childhood, about five to one in most studies, however, diagnostic rates even out between genders in adulthood to a 1:1.6
At one point, this was attributed to the fact that girls tend to present with inattention and internalising problems (e.g., anxiety and depression), and with less externalising difficulties (e.g., hyperactivity).7
These ‘quiet’ children are often not disruptive at home and in school, and so they may fly under the radar.
However, other factors may also be involved,
evidence from the Zurich Cohort Study suggests that symptomatology varies (across genders) in early adolescence, with symptoms not becoming apparent for many girls until this age.
However, other factors may also be involved, evidence from the Zurich Cohort Study suggests that symptomatology varies (across genders) in early adolescence, with symptoms not becoming apparent for many girls until this age.8
This creates challenges for diagnostic guidelines, which require presentation before the age of 12 years.1 Moreover, there is clearly a need for greater recognition for ADHD in girls, indeed, for anyone with the inattentive presentation.
To understand ADHD, we must consider its impacts, that is, how it affects the lives of those with the condition, the people closest to them, and to the wider community. ADHD can have detrimental effects across many, if not all, areas of life, which has consequences not only for the person, but also for society (e.g., impacts on social welfare and the criminal justice system).
A compressive review would take too long to set out, and so a select few are considered here.
Children with ADHD tend to have poorer social skills, be less liked by their peers, have fewer friends, and experience rejection from an early age.10,14
This — together with risk-taking behaviours described above — may be linked with tendencies to associate with more deviant peer groups in adolescence.15 Children with ADHD have been found to be more likely to be both victims and perpetrators of bullying.16
Children with ADHD who also present with aggression may be even more likely to be victimised. These types of behaviours seem to be viewed by their peers as particularly unacceptable, and so the child with ADHD is targeted as a result.
There is some relationship between ADHD and the perpetration of bullying. However, we might need to be cautious on this one, because children with ADHD might respond to victimisation with aggression, and as a result be viewed by teachers as bullies.17 Conversely, positive relationships characterised by acceptance and understanding, may provide much-needed buffers for people with ADHD.7
Unfortunately, however, other relationships also seem to be characterised by conflict, such as those with teachers and family members.14
Indeed, ADHD is associated with greater family dysfunction – having a child with ADHD can cause a lot of stress for parents and siblings, and can contribute to conflict and financial difficulties (e.g., sometimes one parent cannot work, treatments often cost money, or lost items need to be replaced).
Parents might struggle with their own sense of parent efficacy, such as viewing themselves as a ‘bad mother’ and they might feel stigmatized and judged by others, and so isolate themselves.14
Due to high heritability there may be multiple family members with ADHD in the home, which leads to even greater stress and dysfunction in the home.
Adults with ADHD may struggle to stick to routines, provide structure, and remain calm, which are essential skills when raising a child with ADHD.18
As a result, intervention may need to adopt a holistic approach, providing support for the whole family and, where necessary, providing parents with treatment for their own ADHD-related challenges.
The majority of children with ADHD experience some degree of academic dysfunction, independent of their intellectual ability. These students are more likely than their non-disorder peers to experience failure, be held back a year, and drop out of secondary school.15,19
A longitudinal study in the USA found that students with ADHD were less likely to attend university.20 However, findings consistently point to two predictors: “academic problems” and “disciplinary problems”; students with ADHD who also have higher levels of one or both of these, are less likely to progress to third level.20
These findings are significant, because if we know what areas to target we can provide educational and healthcare interventions, to support children with ADHD completing their education, which has benefits not only for them, but also for society. Indeed, given these issues in education it is unsurprising that occupational outcomes are also not as positive for those with ADHD. Adults with ADHD are more likely to earn less, be unemployed, and either get fired or “job hop”.15,20
Perhaps one of the least acknowledged effects of ADHD would be its strengths. The ADHD community boasts many famous and talented people among its ranks from entrepreneurs and inventors, to musicians and actors.
A question has always been do these people succeed because of their ADHD or in spite of it? While this research area is definitely in its infancy, a survey of 174 experts across 11 disciplines and 45 countries identified a range of positive attributes, such as creativity, energetic, fun to be around, the ability to be flexible and multi-task, along with resilience and risk-taking.7
Another study found that university students with greater ADHD-like behaviours were more likely to have entrepreneurial intentions.9 Indeed, while risk-taking might be associated with concerns in adolescence (e.g., substance misuse or sexual behaviour), it is generally true that you have to be willing to take risks if you want to set up on your own.
David Neeleman, founder of JetBlue, might have struggled with his ADHD in childhood, but credits his success in part to his willingness to take risks and think outside the box.21
A struggle to cope
Notwithstanding the enormous potential of people with ADHD, the condition tends to co-occur with other difficulties, indeed, this is the rule, rather than the exception.
As a result, in contrast to current trends around “living your best life” people with ADHD often struggle to cope. They may feel more stress and overwhelmed trying to live up to social expectations.7,14
It is possible that this struggle to cope, in part, is responsible for the fact that ADHD is linked with a range of psychosocial difficulties and disorders.
People with ADHD report more negative self-concepts and lower self-esteem, as well as higher levels of anxiety, depression, self-harm, and suicide.7,10,11 ADHD is also linked with externalising problems. A substantial body of evidence suggests that there are higher percentages of people with ADHD-like behaviours in incarcerated populations, than in the general population.13
This link is unlikely to be based on chance alone. However, what this research finding does not show is whether these people had received any specific support earlier in life, leaving one to wonder if these longer term outcomes are linked to untreated ADHD.
All people are ‘packages’
We are all a ‘package’ — made up of strengths and difficulties — and this is no exception for people living with ADHD. However, people with ADHD may experience a lot more challenges and struggle to cope with the demands of life.
Indeed, the quality of life and outlook across a range of critical areas for those with ADHD looks pretty bleak. Is it any wonder then that people with ADHD also have a lot of psychosocial difficulties? One of the most frustrating aspects of all of this is that ADHD is extremely treatable.
With the right kinds of support and understanding, people with ADHD can go on to be successful and live happier lives. Perhaps Ireland’s next great entrepreneur is sitting in a classroom somewhere trying to focus on what her maths teacher is saying.
I sincerely hope she gets the supports she needs and deserves. This requires identification and a multimodal approach to treatment, with healthcare professionals working in partnership with other stakeholders (e.g., schools, patient organisations, etc.).
Dr Kate Carr-Fanning is a Senior Lecturer in the School of Psychological, Social, and Behavioural Sciences in Coventry University, UK. Written for Irish Medical Times, September 2020.
- American Psychiatric Association (2013). Diagnostic and Statistical Manual (5th Ed.).
- Polanczyk, G. et al. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am. J. Psychiatry, 164(6), 942-948.
- Uchida, M. et al. (2018). Adult outcome of ADHD: an overview of results from the MGH longitudinal family studies of pediatrically and psychiatrically referred youth with and without ADHD of both sexes. J. of Attention Disorders, 22(6), 523-534.
- van Lieshout, M. et al. (2016). A 6-year follow-up of a large European cohort of children with attention-deficit/hyperactivity disorder-combined subtype: outcomes in late adolescence and young adulthood. Eur. Child Adolesc. Psychiatry, 25(9), 1007-1017.
- Larsson, H. et al. (2011). Developmental trajectories of DSM-IV symptoms of ADHD: genetic effects, family risk and associated psychopathology. J. Child Psychol. Psychiatry, 52(9), 954-963
- Kooij, S.J. et al. (2010). European consensus statement on diagnosis and treatment of adult ADHD: The European network adult ADHD. BMC Psychiatry, 10, 67.
- de Schipper, E., et al. (2015). A comprehensive scoping review of ability and disability in ADHD using the International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY). European Child & Adolescent Psychiatry, 24(8), 859-872.
- Murray et al. (2019). Sex differences in ADHD trajectories across childhood and adolescence. Developmental Science, 22(1), e12721.
- Verheul, I., et al. (2015). ADHD-like behavior and entrepreneurial intentions. Small Business Economics, 45(1), 85-101.
- Wehmeier, P.M., et al. (2010). Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. Journal of Adolescent Health, 46(3), 209-217.
- Harpin, V.A. (2005). The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child, 90, i2–i7.
- Anastopoulos, A. D., et al. (2011). Self-regulation of emotion, functional impairment, and comorbidity among children with AD/HD. J. Atten. Disord. 15, 583–592.
- Young, S., et al. (2015). Co-morbid psychiatric disorders among incarcerated ADHD populations: a meta-analysis. Psychological Medicine, 45(12), 2499-2510.
- Carr-Fanning, K (2015). A study of stress, emotion, and coping in children with ADHD. Ph.D. from Trinity College Dublin.
- Barkley, R.A. (2013). Attention-Deficit/Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th edition), Guilford Press, New York, NY.
- Žic Ralić et al. (2016). The relation between school bullying and victimization in children with ADHD. Journal of Sp.Ed. and Rehabilitation, 17(3-4), 105-121.
- Wiener J., & Mak M. (2009). Peer victimization in children with attention-deficit/hyperactivity disorder. Psychol Sch 2009; 46(2):116–131. doi: 10.1002/pits.20358.
- Carr-Fanning, K. & McGuckin, (under review). “I find it really difficult to control myself too”: A qualitative study of the effects on the family dynamic when parent and child have ADHD.
- Breslau, J. et al.(2011). Childhood and adolescent onset psychiatric disorders, substance use, and failure to graduate high school on time. Journal of Psychiatric Research 45(3), 295–301.
- Kuriyan, A.B. et al. (2013). Young Adult Educational and Vocational Outcomes of Children Diagnosed with ADHD. Journal of Abnormal Child Psychology 41(1):27–41.
- Dimov, D. (2017). Why ADHD can be a valuable bonus for entrepreneurs. The conversation: http://theconversation.com/why-adhd-can-be-a-valuable-bonus-for-entrepreneurs-75255.
The Department of Psychology team at University of Limerick is currently recruiting a small number of children diagnosed with ADHD (aged 8-12 years) and their parents to take part in home-based attention training research.
The training is designed to improve children’s attention and concentration through playing fun, interactive card games at home with a parent or guardian.
Keeping Track is an attention training programme that is designed to improve children’s attention through engaging in fun, interactive games at home with parents. The team are currently recruiting a small number of children with ADHD (inattentive or combined presentation types) and their parents to take part in the Keeping Track Project.
This project aims to evaluate the effectiveness of “Keeping Track” an intervention to help improve children’s attention. Attention can be improved with practice of a task known to exercise related brain areas. Keeping Track requires children to exercise their attention while engaging in fun, interactive card games at home with a parent or guardian.
WHO CAN TAKE PART?
In order to be eligible to participate, your child must be diagnosed with ADHD (inattentive or combined presentation types) and be aged 8 to 12 years. Parents and children must have fluent English. Parents and children must have access to a computer/laptop with internet.
To find out more about this research project, please click here
Have you found that either yourself or your child has been referred for assessment or treatment for ADHD to a specialist, but you are not really sure what the difference is between a psychologist and a psychiatrist?
Many people come to us at ADHD Ireland for advice on where to go next once they discover that either they or their child may need an ADHD assessment.
This short guide outlines the difference between both professionals, so that you can be informed in your decision on taking the next step in your ADHD treatment:
The 3 Key Differences:
- Psychiatrists are qualified medical doctors, psychologists are not.
- Psychiatrists can prescribe medication, psychologists cannot.
- Psychiatrists can diagnose, manage treatment, and provide a range of therapies for all levels of mental illnesses, including ADHD. Psychologists can diagnose mental illnesses, but their form of treatment and therapy focuses primarily on non-medication-based treatment such as psychotherapy (talk therapy) to help patients.
Psychiatrists are medical doctors with at least 12 years’ training, or more. They first do a medical degree at university before qualifying as a doctor and then they complete at least six years of training in the diagnosis and treatment of mental health problems.
They can treat complex conditions including severe depression, schizophrenia, bipolar disorder, etc.
Their methods of treatment include prescribing medication, psychological treatments, cognitive-behavioural therapy (CBT) and general medical care, including your health and response to medications.
Currently in Ireland, all consultant child psychiatrists and psychiatrists working with children and adults with intellectual disability can diagnose and treat ADHD. However, many consultant adult psychiatrists are not yet trained to do so. This training is now being provided for trainee adult psychiatrists as a first step in addressing this issue. This is organised by the HSE Adult ADHD National Clinical Programme in association with the College of Psychiatrists of Ireland.
Psychologists have at least 6 years of university training and supervised clinical experience. They may also hold a Masters or Doctorate level qualification in psychology. If they have a Doctorate (PhD) a psychologist can call themselves ‘Dr’, but they are not medical doctors.
Clinical psychologists have special training in the diagnosis and treatment of mental health problems.
Psychologists are more likely to see people with conditions that can be helped effectively with psychological treatments. This might include behavioural problems, learning difficulties, depression, and anxiety. Not all psychologists are trained in the diagnosis and treatment of ADHD.
If you would like more information, please contact us on 01-8748349 or [email protected]
ADHD Ireland is delighted to announce a partnership with Specialisterne Ireland, a specialist consultancy that recruits and supports talented people with neurodiverse needs. Together, we are launching a pilot, which aims to support adults with ADHD to move closer to achieving their career goals.
Many individuals who are neurodiverse struggle with interviews and benefit from a step by step approach to the interview process used by current employers. Specialisterne’s experience helps employers recruit and retain talented people and grow diverse, effective teams.
Specialisterne Ireland provides an intensive interview skills programme with individualised assessment, CV preparation, and interview training at no cost to the individual. They provide guidance on workplace etiquette and the corporate environment. They help candidates to identify the best of their educational and workplace experience for upcoming interviews and provide mock interviews to prepare.
Specialisterne Ireland have several fantastic partner companies such as SAP, DPS Group, Northern Trust, Pfizer, Accenture, AIG and many more. Through their employer partnerships, they arrange for candidates to be recruited through a neurodiverse friendly process.
To find out more click here
Are you interested in a course which explores how to understand and support your child with ADHD?
We are delighted to have teamed up with Education Elephant who bring you a series of comprehensive online courses to help you manage your child’s ADHD.
The courses are divided into three – or you can book into a bundle of all three of them, depending on your preference:
- Understanding ADHD in Children and Young Persons
- Managing Anxiety in Children with ADHD – a Parent Guide
- Self Regulation and Behaviour Support Strategies for ADHD Children at Home and School (6 – 13 years)
- Bundle – all three courses
We are delighted to offer you an exclusive discount code for all courses with a 20% discount off the three individual courses or a 33% discount off the bundle. Full details are outlined below.
All courses are online and can be accessed at your own leisure, complete a self-paced online course which you can decide when to start and finish. You will have access to the course content – videos lessons and downloadable resources – for life. You can access them again and again as often as you wish.
The courses are run by Dr Kieran Merriman, PhD and the team at Education Elephant.
Understanding ADHD in Children and Young Persons, €79 (or €63.20 with discount code ADHDIreland20)
Knowledge is Power. Understanding what ADHD is and how it effects the brain and behaviour of the ADHD child is the first step to supporting them. This course, written by psychologists, presents the most current research and thinking around what ADHD is and both the positive and negative effects the diagnosis can have on the child and their family. The course will show you how the brain of a person with ADHD functions differently to that of a typical person and show you how much of the child with ADHD does is out of their awareness and control. The course will give an overview of the different supports that are available for the ADHD child and discuss the most effective interventions. The course is suitable for anyone working with ADHD children including parents and teachers.
Total course length: 48 minutes approx.
To register for Understanding ADHD course, click here
Managing Anxiety in Children with ADHD – a Parent Guide, €39 (or €31.20 with discount code ADHDIreland20)
A large number of people with ADHD suffer from anxiety and even depression. Sometimes anxiety can be hard to spot in children because they don’t tell you, or don’t know how to tell you, that they are feeling anxious. Anxiety in young children is very upsetting not just for the child but for their parents and family too. This course will show you how to identify anxiety and how to help children identify their feelings. The course will present a number of simple techniques that can be used at home to help reduce anxiety in children with ADHD.
Total course length: 17 minutes approx.
To register for Managing Anxiety course, click here
Self Regulation and Behaviour Support Strategies for ADHD Children at Home and School (6 – 13 years), €79 (or €63.20 with code ADHDIreland20)
The best support for a child with ADHD comes when both home and school work together. Understanding the key challenges both face as well as how to manage them is the first step towards planning effective support. This course will demonstrate how self regulation and executive function can make home and school life for a child with ADHD and will show both parents and teachers what they can do to help. Self Regulation is a key area of support in ADHD. Self regulation refers to our ability to manage our own internal world, our emotions, our impulses and our behaviour. Through no fault of their own many children with ADHD have difficulties with self regulation and these difficulties can get them in trouble and lead to poor self esteem. Interestingly, it’s not just the child’s regulation skills that can cause problems but also the parent and teachers regulation skills that can also cause problems! This course will teach how self regulation is effected in the ADHD brain and show you the role that you will play in supporting them. The course will present a number of different regulation strategies and techniques which can be used at home and in school to support the ADHD child.
Total course length: 78 minutes approx.
To register for Behavioural Support Strategies course, click here
Bundle – all three courses, €149 (or €99 with code ADHDIreland99)
This course is part of a 3 course package which includes:
Course 1: Understanding ADHD (48 mins 29 secs)
Course 2: Managing Anxiety in Children With ADHD (17 mins 38 secs)
Course 3: Behavioural Support Strategies for Children with ADHD (77 mins 54 secs)
Total course length: 2 hours 49 minutes
To register for the Bundle of all three courses, click here
Course Tutor Biography: Dr. Kieran Merriman
Dr. Merriman holds a PhD in Clinical Psychology from University College Dublin and was awarded a Doctorate in Counselling Psychology from Trinity College Dublin. Dr. Merriman recently received the Therese Brady Award from University College Dublin in 2019 for his work in the area of families and children with additional needs. Dr. Merriman has specialised in several areas of psychological therapy and research including Autism, parents of children with additional needs and is an accredited Early Start Denver Model Practitioner.
Dr. Merriman has also conducted published research on Autism with a special interest in group based interventions for parents of children with additional needs and has ample experience delivering interventions to children, families and parents struggling with behavioural, emotional and adaptive difficulties. Dr. Merriman works for several public and private bodies and with client groups of all ages experiencing a range of mental health difficulties and disabilities.
For further information or to register for any of the courses outlined above, click here
We’re delighted to share the slides from Dr Alison Doyle, Caerus Education from our recent webinar on Back to School 2020, in which Alison outlines the challenges of the transition for students going from Primary School to Post-Primary School.
View the slides Transition from primary to post-primary in 2020
If so, you might be interested in participating in the following project. Wellcome Trust- Mental Health Priority Areas Team are producing a report on the best ways to promote well-being and reduce psychological ill-health in children and adolescents. They are putting a call out for young people to contribute to their panel and here are the details:
We’d like your help!
We are looking to recruit a panel of young people who have experience of or a special interest in
mental health to advise us on a special insight report we are preparing. We are looking at a
phenomenon called “psychological distancing”, which exists in a number of psychological
therapies. Ideas that affect meaningful changes in well-being often begin by listening to those
experiencing the symptoms we want to understand.
What are the benefits of being on our panel?
We think psychological research is done best when we include the people actually experiencing difficulties. By being part of our panel, you will be informing psychological treatments and helping guide us to make our research accessible to other young people. As an advisor, you would also receive compensation for your time.
What would you have to do?
We would invite you to participate in small group discussions where we present the ideas we have for our report and get your feedback on them. We would also want feedback on how best to share our research with young people and other stakeholders, such as other scientists and teachers. All you would need to bring is your opinion and experience!
If you’d like to know more or feel interested in taking part, please email [email protected]
We’d love to hear from you!
We were delighted to have Zak Powers, psychotherapist host a fasinating webinar recently on Adult ADHD and Anxiety.
To watch the webinar back, please click the link below.