ADHD in Ireland

ADHD in Ireland

Siobhán Woods, Michael Keane, Rosemary Keane

 

What is ADHD?

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, or a disorder involving the development of the nervous system, and is characterised by a combination of key symptoms:

1. hyperactivity;

2. impulsivity and

3. inattention [1].

These symptoms do not occur in one specific setting only, such as in school, but across many areas of life [2]. Based on the types of symptoms experienced, ADHD can be divided in three different subtypes:

  1. ADHD mainly inattentive, which is associated with significant difficulty in concentration
  2. ADHD mainly hyperactive-impulsive, which involves a need for constant movement or action, and
  3. ADHD combined, which is a mixture of both [3].

Since ADHD was first recognised as a clinical disorder [4], there have been significant advances in our understanding of it, both clinically and among the general population [5]. We know that ADHD can have a significant impact on an individual’s life, but equally it is a very manageable condition (see ‘ADHD treatments in Ireland’ below) and, when diagnosed and managed appropriately, the impact on an individual can be significantly reduced.

 

"We know that ADHD can have a significant impact on an individual’s life, but equally it is a very manageable condition and, when diagnosed and managed appropriately, the impact on an individual can be significantly reduced"

 

How Prevalent is ADHD?

Variations in criteria used in diagnosis, as well as variations in information sources used in research make it difficult to estimate the exact number of people who have ADHD [6]. Based on findings from a comprehensive review, Willcutt [7] estimated that between 5.9% - 7.1% children and young adults have ADHD, with rates found to be similar across cultures [6]. There is currently no specific data on the prevalence of ADHD in Ireland, with recent census data failing to distinguish between specific disabilities. However, data from the 2016 census indicates that 156,968 (3.3%) people experience difficulty learning, remembering or concentrating [8], with this being the most common category of disability experienced by children of school going age. While these categories and numbers may well represent ADHD numbers closely, the broad nature of this categorisation means it is impossible to identify specific data about ADHD.

ADHD has been shown to be more common in boys than girls, with boys approximately four times more likely to be diagnosed with  ADHD than girls [9]. This is reflected in data from the Central Statistics Office in Ireland (CSO), with almost twice as many boys ages 5-19 reported to experience learning, memory or concentrating difficulties when compared to girls.


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ADHD Diagnosis - How Is It Done?

ADHD is a complex disorder that can only be diagnosed by a professional using a number of different tests. Should you suspect that you or your child has ADHD, you have a number of options. You may, wish to first contact your GP [10]. Your GP will ask a range of questions, such as what symptoms are shown, when they started, where and how often they occur, and how these symptoms affect quality of life [10]. Your GP will then decide whether or not to refer you or your child to a Specialist, such as a Psychologist, Psychiatrist, Paediatrician or  mental health services [11]. The Specialist will carry out a comprehensive assessment, which can include interviews with you, your child, and with significant others. It may also include some type of physical examination to rule other potential issues, and tests to assess abilities such as concentration, problem-solving and short-term memory [10].

 

"ADHD is a complex disorder that can only be diagnosed by a professional using a number of different tests. Your GP can help you to decide whether you need to see a Specialist"

 

Best Practice Guidelines: In line with the National Institute for Health and Care Excellence (NICE) guidelines [12] , ADHD should only be diagnosed based on the combination of findings from a full developmental and psychiatric history, a full clinical and psychosocial assessment, including the tests outlined above, and observations and reports of the individual’s mental state. A multidisciplinary team of Specialists should be used in the diagnosis and treatment of ADHD, with size of the team varying depending on the specific case [12]. It is essential that the psychological services provided, as well as all communication with the individual and their family, are tailored to the specific age and abilities of each person [14]. Important recent additions (March 2018) to these guidelines include the requirement to establish an individual’s behavioural baseline, or their standard behaviour, and to account fully for any environmental factors that may be at play [14]. The guidelines also state that, in cases of children under the age of five, parents must complete an accredited parent training course before a diagnosis of ADHD can be given, and that the advice of an additional professional should be considered prior to making a diagnosis [14].

A diagnosis of ADHD will only be given using one of two ways to classify/diagnose - either International Classification of Diseases, 10th revision (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5), if an individual fits a number of strict diagnostic criteria.  Using DSM 5, a child must display six or more of the symptoms of hyperactivity and impulsiveness or six or more of the inattentiveness symptoms [3], listed below. Symptoms must have persisted for at least 6 months and be negatively impacting social and academic or work-related activities [3]. It is important to note that symptoms can differ in adults with ADHD, as outlined in the ‘Adult ADHD’ section below.

 

List of Symptoms:

Inattentiveness (DSM-V [3])

  • Fails to give close attention to detail or makes careless mistakes
  • Has difficulty sustaining attention
  • Does not seem to listen when spoken to directly
  • Does not follow through on instructions, fails to finish tasks
  • Has difficulty organising tasks and activities
  • Avoids/dislikes/is reluctant to engage in tasks that require sustained mental effort
  • Often loses things necessary for tasks
  • Often easily distracted by extraneous stimuli
  • Often forgetful in daily activities

 

Hyperactivity/Impulsivity (DSM-V [3])

  • Often fidgets with/taps hands/feet, or squirms in seat
  • Often leaves seat in situations where remaining seated is expected
  • Often runs around/climbs in situations where it is inappropriate
  • Often unable to play/engage in leisure activities quietly
  • Often ‘on the go’
  • Often talks excessively
  • Often blurts out answers before the questions has been finished
  • Often has difficulty waiting his/her turn
  • Often interrupts others

 

ADHD Specialist Groups in Ireland:

There are a number of Irish organisations dedicated specifically to ADHD. The main public service for children and young people is CAMHS: Child and Adult Mental Health Services (CAMHS) [13]. CAMHS are a multidisciplinary HSE service providing specialist assessment and treatment for young people experiencing mental health difficulties, including ADHD. Individuals are usually referred to CAMHS by their GP, and will then get the opportunity to meet members of the CAMHS team who will assess whether the service can be of benefit to them. (See here for more information)

In addition, there are many groups who help with information and support for ADHD. Two of the main ones are INCADDS and HADD.

  • INCADDS: The Irish National Council of ADHD Support Groups [16] is an umbrella group that is responsible for the coordination of ADHD support groups around the country, and for providing information on the disorder to the Minister of Education and the Minister of Health and Children. The organisation aims to develop and promote early diagnosis of the disorder, as well as supporting person-centred treatment and raising awareness of ADHD.

  • HADD Ireland: HADD Ireland [15] is a voluntary organisation dedicated to providing those affected by ADHD with high quality information, resources and support on the disorder. This includes information and support groups for adults with ADHD, as well as parents and teachers of children with ADHD (http://www.hadd.ie).


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Adult ADHD

Despite the common misconception that ADHD occurs in childhood only, research has shown that the disorder commonly persists into adulthood [17]. However, the symptoms of adult ADHD differ from that of childhood ADHD, in that they are often more subtle [18]. It is estimated that adult ADHD in the general population occurs in about 2.5% [19] to 4.4% [20] of people. Unlike childhood ADHD, there is no specific list of adult ADHD symptoms, but associated symptoms are listed below. As with children, if you are an adult and suspect you have ADHD, you can visit your GP [21], and they will decide whether or not you should see a Specialist. Alternatively, Specialists (including Psychologists, Psychiatrists or the mental health services) may be able to arrange for an adult ADHD assessment. In line with strict diagnostic criteria, a Specialist cannot give a diagnosis of adult ADHD unless your symptoms have been present since childhood [3].

 

"Despite the common misconception that ADHD occurs in childhood only, research has shown that the disorder commonly persists into adulthood. However, the symptoms of adult ADHD differ from that of childhood ADHD, in that they are often more subtle"

 

Symptoms associated with adult ADHD [21]:

  • carelessness and lack of attention to detail
  • continually losing or misplacing things
  • continually starting new tasks before finishing old ones
  • inability to focus or prioritise
  • poor organisational skills
  • forgetfulness
  • restlessness/edginess
  • often interrupting others, find it difficult to keep quiet
  • blurting responses, and poor social timing when talking to others
  • irritability and a quick temper
  • extreme impatience
  • mood swings
  • inability to deal with stress
  • taking risks, often with little/no regard for safety of themselves or others

 

ADHD treatments in Ireland:

You may often hear that there is no known cure for ADHD [22], but there are a number of effective treatment/management options available to you or your child if diagnosed. These include a range of medications and behaviour therapies, and often a combination of both. Medications can provide a short-term improvement in symptoms with each dose, allowing for better concentration, reduced impulsivity, and a calmer demeanor [23]. Numerous types of therapies can also be used in ADHD treatment, including Psychotherapy, Behaviour therapy and Positive Behaviour Support (PBS), Cognitive Behavioural Therapy (CBT) and social skills training, as well as training for parents and teachers [23]. Most often, the Specialist who makes the ADHD diagnosis will be well placed to give you advice on treatments, or may provide the treatment themselves or through a network of professionals.

Your Specialist will discuss all your treatment options with you, and advise you on what is most suitable for you or your child [10]. We have provided some information on the range of treatment options below.

  • Stimulant medications, which are mainly comprised of Amphetamine and Methylphenidate compounds, are commonly used to treat ADHD [26]. Such medications have been shown to be effective in improving symptoms of the disorder [27]. However, medications have also been associated with effects including insomnia, anxiousness, nightmares, and appetite suppression [28]. If using these medications, you or your child will be required to attend regular check-ups with your Specialist to assess what kind of improvements or adverse effects are being experienced.

  • Behaviour therapies/cognitive behaviour therapies come in a variety of forms [25], but the aim is always to help the individual to develop the tools and skills needed to better control their own behaviour, helping them to increase positive behaviours and reduce disruptive behaviours [24]. Behavioural interventions implemented by parents and teachers are also often recommended as an initial treatment option [24]. The key advantages of behavioural therapies are (1) they are based on learning, and include acquiring skills and (2) you can involve your family/partner/school etc. Some of the services outlined above, including CAMHS, offer additional support services and training to individuals with ADHD and their families.

  • Neuroscience-based interventions are also available for both adult ADHD and childhood ADHD, including Neurofeedback Training (NFT) [25]. NFT can be described as a form of ‘brain training’. The patient’s brainwaves are monitored using electrodes, and they are then given feedback based on whether the brain activity is seen as desirable or not. Recent research has demonstrated that NFT has sustainable, long-term positive effects on ADHD symptoms six-months after treatment, and that these effects continue to improve over time even without further NFT sessions. Research has also shown the effects of NFT after six months were equivalent to benefits of taking medication [25]. In terms of NFT providers, you should check whether your provider is Board Certified with the Biofeedback Certification International Alliance (www.bcia.org).


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References

1 DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools: Assessment and intervention strategies. Guilford Publications.

2 Biederman J, Faraone SV. Attention-deficit hyperactivity disorder. Lancet 2005; 366:237–48.

3 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

4 Cooper, A. M., & Michels, R. (1988). Diagnostic and statistical manual of mental disorders, revised (DSM-III-R). American Journal of Psychiatry, 145(10), 1300-1301.

5 Timimi, S., & Taylor, E. (2004). ADHD is best understood as a cultural construct. The British Journal of Psychiatry, 184(1), 8-9.

6 Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. International journal of epidemiology, 43(2), 434-442.

7 Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 9(3), 490-499.

8 CSO Ireland (2017) Census of population 2016 – Profile 9 health, disability and carers. Retrieved from http://www.cso.ie/en/releasesandpublications/ep/p-cp9hdc/p8hdc/p9tod/

9 Brown, R. T., Freeman, W. S., Perrin, J. M., Stein, M. T., Amler, R. W., Feldman, H. M., ... & Wolraich, M. L. (2001). Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings. Pediatrics, 107(3), e43-e43.

10 Health Service Executive. Diagnosing ADHD. Retrieved from https://www.hse.ie/eng/health/az/a/adhd/diagnosing-adhd.html

11 HADD Ireland. Diagnosis. Retrieved from http://www.hadd.ie/diagnosis

12 National Institute for Health and Care Excellence (2008). Attention deficit hyperactivity disorder: diagnosis and management. Clinical guideline (CG72). Retrieved from https://www.nice.org.uk/guidance/CG72/chapter/Recommendations#diagnosis-of-adhd

13   Health Service Executive. CAMHS. Retrieved from https://www.hse.ie/eng/services/list/4/mental-health-services/camhs/

14 National Institute for Health and Care Excellence (2018). Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline (NG87). Retrieved from https://www.nice.org.uk/guidance/ng87/chapter/Update-information

15 HADD Ireland. About us. Retrieved from http://www.hadd.ie

16 The Irish National Council of AD/HD Support Groups. About INCADDS. Retrieved from http://www.incadds.ie/about-us.html

17 Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & LaPadula, M. (1998). Adult psychiatric status of hyperactive boys grown up. American journal of psychiatry, 155(4), 493-498.

18 Wender, P. H., Wolf, L. E., & Wasserstein, J. (2001). Adults with ADHD. Annals of the New York academy of sciences, 931(1), 1-16.

19 Simon, V., Czobor, P., Bálint, S., Mészáros, Á., & Bitter, I. (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. The British Journal of Psychiatry, 194(3), 204-211.

20 Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., ... & Spencer, T. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of psychiatry, 163(4), 716-723.

21 Health Service Executive. Diagnosing ADHD, symptoms in adults. Retrieved from https://www.hse.ie/eng/health/az/a/adhd/diagnosing-adhd.html

22 Tarver, J., Daley, D., & Sayal, K. (2014). Attention‐deficit hyperactivity disorder (ADHD): an updated review of the essential facts. Child: care, health and development, 40(6), 762-774.

23   Health Service Executive. Treating ADHD. Retrieved from https://www.hse.ie/eng/health/az/a/adhd/

24 NICE (2008) Diagnosis and management of ADHD in children, young people and adults (National Clinical Practice Number 72). The British Psychological Society and the Royal College of Psychiatrists, London.

25 Van Doren, J., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. K. (2018). Sustained effects of neurofeedback in ADHD: a systematic review and meta-analysis. European child & adolescent psychiatry, 1-13.

26 Rajeh, A., Amanullah, S., Shivakumar, K., & Cole, J. (2017). Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies. Asian journal of psychiatry, 25, 131-135.

27 Spencer, T., Biederman, J., Wilens, T., Harding, M., O'donnell, D., & Griffin, S. (1996). Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. Journal of the American Academy of Child & Adolescent Psychiatry, 35(4), 409-432.

28 Efron, D., Jarman, F., & Barker, M. (1997). Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics, 100(4), 662-666.