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ADHD Pathway

General ADHD Pathway:

(this pathway may change besed on your needs and presentation)

You suspect that you have ADHD or you have been told by others that you may have ADHD.

You should consider to research about ADHD and  take a standard screening test. like ASRS.

It will be helpful to arrange a review with your GP and get a referral for ADHD assessment.  I advise you to have initial discussion with your GP and arrange a referral to ensure safe treatment and clear communication with your GP.

After initial contact and booking your appointment, we will contact you and explain different stages of your journey with us in detail and will send you relevant pre-assessment forms. 

 

You don't need to do any preparation before the review and if you feel anxious before the review just send me an email. and I will do my best to contact you prior to our review. During our review, based on our review and collateral information, we will  explore symptoms of ADHD and establish how your life is affected by these symptoms since you were very young, we will also  need to rule out any alternative diagnosis.

We will discuss treatment option including medication and other non-pharmacological treatments of ADHD and I will arrange your prescription as soon as possible if there are no concerns regarding safety of medical treatment.  other treatment such as coaching once you are on treatment.

You will need  at least two brief follow ups to reach to the optimum level of pharmacological treatment. We aim to treat you with a dose that  gives best results which is not necessarily the highest dose. I encourage people not to take medication every day , unless I treat you with non-stimulant medications. At this stage, we can arrange you Shared Care Agreement.

I advise to have 6 monthly brief follow-ups after you are discharged back to primary care. If your Shared care agreement is not accepted (this happens in %5-10 cases, I will be happy to monitor your treatment but you will need to get your medication privately until you are transferred to another surgery where they accept your Shared Care Agreement.

ADHD – in adults

Common  misconceptions about ADHD:

1.    Not everyone with ADHD needs to have history of hyperactivity and disruptive  behaviour as a child. 
2.    Being successful or well educated does not mean that it is  not possible for someone to have ADHD. 
3.    Being diagnosed with other mental health disorders does not rule out ADHD,.
4.    ADHD treatment would not change your personality and creativity.
5.    Being diagnosed with ADHD is not  just another excuse for being lazy and not caring.

 

What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental conditions in the world. It comprises of a combination of symptoms which can be traced back to childhood, usually appearing between the ages of 3-7yrs and later in some cases. However, the condition is not always recognised and diagnosed in childhood resulting in adults experiencing ADHD without realising they have thecondition. Literature suggests that symptoms of ADHD can improve with age, however full resolution of symptoms is rare and many adults continue to experience impairment as a result. 

 

People with ADHD live with a certain pattern of behaviour which affects the way they live and in many cases, it can go unnoticed for years, leading them to believe that part of their positive and negative behavioural traits is normal and part of their personality. Due to certain variations in Brain Structure and levels of neuro biological chemicals, these individuals cannot maintain focus especially when they are dealing with mundane activities and can get easily distracted. 

 

They cannot maintain good level of focus to anything for any length of time which can affect areas of a persons life such as education, employment, relationships. As a result, they may struggle to achieve their potentials. 

 

They tend to procrastinate and leave their tasks to last minute and as a result they have background anxiety which can affect their mental and physical wellbeing.  Large proportion of people with neurodiversity are diagnosed with anxiety and depression but their response to antidepressant medication is very limited.  

 

Focus and having enough headspace and not feeling pressures are essential in decision making as we need to gather information by structured research and weigh up relevant information.  As a result, people with ADHD tend to procrastinate or make decisions without enough consideration make decisions which can have negative consequences.   

 

A brief history 

ADHD symptoms have been recognised and described in literature from around the world for more than 200 years. In the 1790’s Dr Crichton, a Scottish doctor, first recorded a description of symptoms such as poor focus and children who were more easily distractible than peers. But it wasn’t until 1902 when Sir George Still gave a series of lectures and case reports that the modern diagnostic criteria for ADHD began to developed. He described 15 boys and 5 girls of normal IQ who were impulsive, unable to attend and lacked self-control. In 1937 Dr Bradley first used stimulants in children to improve school performance for those with hyperactivity. Methylphenidate (also known as Ritalin) which is used today to treat ADHD became available in 1944. It is now recognised that ADHD can present with symptoms of hyperactivity, inattention or a combination of both.

 

Prevalence 

The estimated rates of ADHD in the UK are around 5% of the population, in the USA the rates are higher at around 10%. There are several reasons for this but following an extensive review of the available literature Faraone et al 2003 postulated this was due to differences in diagnostic practice (ie attributing symptoms to other conditions such as conduct disorder), cultural views and lack of knowledge about the disorder, rather than actual differences in occurrence of ADHD. They surmised that the rate of ADHD worldwide was the same as the rate in the USA, this means it is likely underdiagnosed elsewhere.

 

 

 

ADHD is twice as common in boys as girls. The majority of ADHD cases are diagnosed when a child enters the formal education system (between 3-7yr), this is partly due to the diagnostic criteria which requires that symptoms are seen in more than one setting (ie at home and at school). However, the rate of ADHD is likely underestimated and many adults with the symptoms of ADHD remain undiagnosed, we know that in 80% of people the symptoms of ADHD will continue into adulthood. This often results in adults, with undiagnosed ADHD, presenting to GP or psychiatry with different conditions (depression, anxiety) with their ADHD unrecognised. 

 

High functioning ADHD adults often compensate for their symptoms of ADHD and can feel they are underperforming at home/work/socially but without understanding why this might be the case. They also tend to under report their symptoms and difficulties because they have built in a series of compensatory skills to help manage their ADHD symptoms. 

 

 

Causes 

The cause of ADHD is not known, however neuroimaging studies have shown that there are differences in the brains of children with ADHD compared to their peers, these differences are seen in children as young three. This strongly implies either a genetic or factors in pregnancy/very early life which cause the condition.

 

ADHD has been shown to be associated with:

- Being born prematurely (before 37th week in pregnancy)

- Being born with a low birthweight

- Maternal smoking, alcohol or drug use in pregnancy

 

ADHD runs in families and ADHD is more common in those with other neurodevelopmental conditions such as autism or Learning difficulties.

 

While the exact cause is not known, it is clear that there are very real and measurable differences in the brains of people with ADHD. This condition causes symptoms that are not within the persons control or something they can simply ‘overcome’. Just as you wouldn’t tell a person with diabetes to start making their own insulin, you can’t tell someone with ADHD to start paying attention, organising themselves or to stop moving!

 

Five take away points

1. ADHD is a combination of symptoms which start in childhood and for most persist into adolescence and adulthood 

2. ADHD is common and experienced worldwide 

3. ADHD is likely underdiagnosed. 

4. ADHD is a neurodevelopmental condition as a result of genetics or factors in pregnancy/very early life

5. People with ADHD have measurable differences in their brains which make it hard to simply ‘overcome’ symptoms 

 

Symptoms 

There are 2 broad categories of symptoms of ADHD:

1) Inattentiveness (problems concentrating and focusing)

2) Hyperactivity and impulsiveness 

It is important to understand that around 20-30% do not experience hyperactivity and these cases can be harder to identify. 

 

Symptoms should be present for 6months, be inappropriate for the developmental age (or more frequent than in peers of a similar age/life stage) and have begun in childhood (usually between the ages of 3-7yrs)

 

Inattentiveness 

- Often unable to give close attention to detail or make careless mistakes

- Often unable to sustain attention on a task

- Often appear to not be listening when spoke to directly

- Often fail to follow through on instruction/fail to finish jobs/fail to meet obligations

- Often find it difficult to organise tasks and activities

- Often avoid tasks that require sustained mental effort

- Often lose things

- Easily distracted by unseen stimuli

- Often forgetful in daily activities

 

Hyperactivity and impulsiveness 

- Often move hands or feet in restless manner or fidget 

- Find you have to stand in situations where you are expected to sit

- Feeling restless

- Find hard to engage in leisure and relaxation activities

- Often on the go as if driven by a motor

- Talk excessively 

- Give answers before questions have been completed

- Find it difficult to wait your turn

- Find you interrupt the activities of others

 

Impact

- Performing worse at work than expected by IQ. 

- Find it hard to maintain social contacts

- Become impatient and can get into altercations as a result 

- Avoid certain activities like going to lectures 

- Forget appointments, birthdays, anniversaries 

- Difficulties with relationships 

- Losing things

- Being late

- Being disorganised 

- Find it hard to complete tasks

- Day dreaming

- Careless mistakes

- Can’t finish a book, struggle watching a movie

 

Risk 

- More likely to commit motor offences

- Develop substance abuse problems 

- Increased use of smoking and alcohol

- Poorer mental and physical health 

- Decreased life expectancy 

- Increased risk of physical injury

- Parents, siblings, relatives experience increased stress as a result of your behaviour

- Higher rates of divorce

- Increased risk of financial problems

 

Compensations 

1) Organisational skills: for example check lists, electronic devices, reminders, lists, avoidance of using paper, rapid changing of task (to keep interest), rigid structure.

2) Motoric skills: playing sports, moving foot/tapping hand/tapping pen, restrains (heavy blankets, pillows on lap, tie self to chair).

3) Attentional skills: minimise stimuli in environment, better in 1:1 situations (social and work meetings), solitude, use of music or white noise.

4) Social skills: don’t commit to firm events that restrict and cause anxiety (concerts, gym classes etc), socialisingwith lots of people at one to minimise the impact of behavioural disinhibition

5) Pharmacological: use of substances to help manage symptoms (often cocaine, nicotine, MDMA, amphetamines, alcohol, caffeine, LSD, benzodiazepines and cannabis) in excess in comparison to peers. Caffeine, nicotine and alcohol were perceived to have a calming effect as was cocaine. MDMA helped to enhance cognitive performance and cannabis helped with relaxation well as sleep.

 

Benefits of ADHD

- Increased energy for sports, life, socialising 

- Spontaneous, more likely to try new things, be open to new experiences 

- Creativity, have a different and innovative approach to tasks with a thoughtful eye

- Hyper focus, able to intently focus on a task to the point that they are able to shut out the world around them, this happens in short but intense bursts

- Well liked in social situations, funny, outgoing, sociable and entertaining to others.

- Resilient, have adapted and compensated throughout life for their differences, often means they are resilient later in life

 

Co-morbidities

Depression – three times as likely as normal population 

Dysthymia – six times as likely as normal population

Any mood disorder (including anxiety and bipolar affective disorder) – four times as likely as the normal population

Substance abuse disorder – twice as likely as the normal population 

Autistic spectrum disorder

 

Five takeaway points

1) The diagnosis of ADHD is dependent on the presence of symptoms of hyperactivity, impulsiveness and/or inattention from childhood which persist and carry more impairment than experienced by peers. 

2) Significant and far reaching impact in work, home and social life

3) Associated with risks including substance misuse, worse physical and mental health outcomes

4) Individuals can develop compensatory mechanisms to help them manage their symptoms of ADHD and these can subsequently mask diagnosis

5) There are some wonderful benefits of ADHD which help make you a unique and gifted person. 

 

Diagnosis 

Diagnosis of adult ADHD in those without a childhood diagnosis should be given by a mental health specialist trained in the diagnosis and treatment of ADHD.

 

The diagnosis will involve an interview with a specialist lasting 1-2hours where they will seek to establish:

- Symptoms began in childhood and persisted throughout life

- Screen for co-morbid psychiatric conditions

- Have caused moderate or severe psychological, social, educational or occupational impairment. 

The assessment will involve a clinical and psychological assessment of symptoms, a developmental and psychiatric history along with information from informant where possible. Rating scales will be used to help assist with diagnosis (for example DIVA, Conners’).

 

In order to diagnose ADHD accurately and reduce any chance of misdiagnosis, over-diagnosing as well as sub-optimal treatment, you need to be assessed by a mental health specialist who has been trained to assess and diagnose variety of other mental and physical health disorder which can coexist with ADHD.

 

 

Treatment 

Treatment should involve a combination of psychological interventions, medication, social/work/home life adjustments and support with wellbeing. 

 

Psychological interventions

- CBT (help with self-critical thoughts, reduce anxiety and improve mood, feel better about yourself and put thoughts into perspective)

- Mindfulness techniques (assist relaxation) 

- Psychoeducational groups (organisation and prioritising tasks, learning skills to manage your ADHD)

 

Medication 

The first line treatment for ADHD is stimulants:

- Methylphenidate which comes in short, intermediate and slow release (Ritalin, Concerta, Equsym) 

- Deamphetamine (Dexadrine)

- Lisdexamfetamine (Elvans)

 

Second line treatment for ADHD is non-stimulant medication 

- Atomoxetine (Strattera)

This is usually offered to those who are unable to tolerate stimulants. 

 

Efficacy of medication 

First-line treatments for ADHD have a treatment response rate of 70-80%

 

Some of the Medication side effects

Weight loss ((weight is checked at 3 and 6months and then every 6 months)

Increased heart rate

Increased blood pressure 

Tics

Lower Seizure Threshold (General advice from neurologist is that treatment of ADHD in people with Epilepsy improves the overall outcome by improving life style habits and mental well being but in every case needs to assessed and benefits and risks also needs to carefully assessed)

Sleep problems

Life adjustments

Working with your ADHD rather than against it can be helpful. Making reasonable adjustments at work and within education can make the condition more manageable. 

 

Your wellbeing

It is important to take care of yourself, especially when you are managing ADHD, there are a few things that people with ADHD can do to improve their mental wellbeing:

 

- Balanced diet is important for everyone and more so for those with ADHD, however you do not need to restrict or eliminate anything from your diet

- Regular exercise can help with energy levels and improve focus

- Think about your condition, recognise things that help and things that make it worse, try to use this list to help to proactively manage your ADHD

- Think about things that relax you – listening to music, white noise, watching old cartoons or shows you are familiar with (and require little concentration) 

- Try short mindfulness exercises (body scan or breathing techniques) for 2-4mins a few times per day rather than longer classes 

- Try some simple organisational techniques (diaries, reminders, plans, set small manageable goals)

- Try to avoid those who encourage you to drink too much or use drugs 

- Ask for help, your employer, your teacher, self-help groups, family members can all help

- Reward yourself for things you have done well, accept that some things are difficult, try to anticipate problems

Five takeaway points 

1) Diagnosis should be made by a specialist mental health professional 

2) There are medication and non-medication treatment options

3) The treatments are effective and help improve symptoms in most people

4) It is important to think of a holistic approach in your ADHD management, psychological, medication and work/life adjustments

5) Your wellbeing is critical, find ways to support and look after yourself 

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