Working in children’s mental health, we come across children with a range of diagnoses, and many with no diagnosis at all. One of these diagnoses, ADHD, is relatively common, affecting up to 9% of children. The criteria for an ADHD diagnosis require that a person has at least 6 significant symptoms of inattention and / or hyperactivity, for a prolonged period, which is having a detrimental impact in at least 2 different settings, usually home and school (Alder et al., 2015).  Main symptoms include difficulty concentrating, forgetfulness, problems sitting still or impulsiveness (NHS, 2021) and it can lead to more complex behavioural problems such as risk taking, substance abuse, academic and social struggles (Korb et al., 2019).

An ADHD diagnosis is primarily useful as it enables access to treatments including medication, parenting courses and therapy (NICE, 2018). The symptoms are more likely to go unnoticed in girls, who are undereferred, underdiagnosed or misdiagnosed (NICE, 2018) which prevents their access to appropriate treatment. This is reflected in my own professional experience. I have also seen situations where accommodations in the school environment don’t require a diagnosis according to school policy, but in practice the schools are reluctant to put accommodations in place without a label, or do not understand the underlying cause of observed challenging behaviours. This can lead to counterproductive behaviour measures being used and miss the opportunity to support the child with movement breaks, headphones or verbal reinforcement (NICE, 2018). While an ADHD diagnosis is helpful in getting this support, it could be argued that a change in approach from parents and schools ought to take place as soon as a child is identified as ‘struggling’, by directly addressing the issues they are experiencing rather than waiting for diagnosis (a process which is currently taking many months in the UK). Medication, on the other hand, does require diagnosis. Although there are established benefits to medication, it can cause problems socialising or loss of appetite and other physical health risks (Thompson and Miller, 2013; NICE, 2018) which could outweigh the benefits for some. Additionally, Thompson & Miller (2013) propose that ADHD is over diagnosed due to medicalisation of childhood behaviours and motives of profit-making companies, which, could mean some children are facing side effects of medications they don’t need. Then again, if people report medications are helping them, then this could be considered justification for their use.

Before pathologizing young people’s distress with a diagnosis such as ADHD, other possibilities should be considered. Those with intellectual disabilities are more likely to be diagnosed with ADHD than the general population (Korb et al., 2019) and these children may need additional support for this, but it could be that these children are at greater risk of pathologisation than those without intellectual disabilities. Comorbidities are extremely common with ADHD (Alder et al., 2015) such as Autism, Oppositional Defiant Disorder, and anxiety - some symptoms of these overlap with ADHD making it less clear why the young person is sturggling (Korb et al., 2019). Cultural differences and familial expectations can influence whether ADHD symptoms are debilitating in a particular setting; Barkley (2015) considered the impact of environment on presentation of ADHD children. It may be more useful to look holistically at the experiences of the child, such as parenting style, socioeconomic status, exposure to early stress (Weissenberger et al., 2017) as well as protective factors. Support could tailored to individuals by understanding weaknesses and harnessing strengths.

I have witnessed the wide range of experiences of young people with ADHD while working in hospitals, schools and the community. Having seen the extremes of the ADHD experience in inpatient CAMHS, I am more pro diagnosis and pro medication than I might otherwise have been. Now working in the community, I am mindful of the potential consequences of poor ADHD treatment. Looking into my future practice, I am in a position to provide non-pharmacological support in line with the NICE guidance (2018) such as parenting support, psychoeducation and advising on reasonable adjustments. While I cannot prescribe medication, I can provide information to parents within the scope of my practice. Based on the evidence, support I offer should be based on the child’s own presentation and personal circumstances, rather than making assumptions because they do or don’t have a diagnosis in place.

References

Adler, L., Spencer, T., & Wilens, T. (2015). Attention-Deficit Hyperactivity Disorder in Adults and Children. Cambridge: Cambridge University Press. doi:10.1017/CBO9781139035491

Barkley, R. (2015). Beyond DSM-IV diagnostic criteria: What changed and what should have changed in DSM-5. In L. Adler, T. Spencer, & T. Wilens (Eds.), Attention-Deficit Hyperactivity Disorder in Adults and Children (pp. 53-62). Cambridge: Cambridge University Press. doi:10.1017/CBO9781139035491.006

Korb, L., Perera, B., & Courtenay, K. (2019). Challenging behaviour or untreated ADHD? [Untreated ADHD] Advances in Mental Health and Intellectual Disabilities, 13(3), 152-157.

NHS (2021) Symptoms: Attention Deficit Hyperactivity Disorder (ADHD). Online: www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/ [Accessed: 16/11/21].

NICE (2018) Attention deficit hyperactivity disorder: diagnosis and management. Online: www.nice.org.uk/guidance/ng87/chapter/Recommendations [Accessed: 6/12/22].

Thompson, & Miller, N. J. (2013). ADHD cognitive symptoms, genetics and treatment outcomes. Nova Biomedical.

Weissenberger, Ptacek, R., Klicperova-Baker, M., Erman, A., Schonova, K., Raboch, J., & Goetz, M. (2017). ADHD, Lifestyles and Comorbidities: A Call for an Holistic Perspective - from Medical to Societal Intervening Factors. Frontiers in Psychology, 8, 454–454. https://doi.org/10.3389/fpsyg.2017