Editorial: Attention-deficit hyperactivity disorder (ADHD)


Welcome to the second Virtual Issue of Child and Adolescent Mental Health (CAMH). This issue pulls together a number of papers published in CAMH in recent years that have focused on attention-deficit hyperactivity disorder (ADHD). This issue provides an opportunity to distil key clinical practice and research messages from papers that were published prior to and since the publication and dissemination of the National Institute for Health and Clinical Excellence ADHD guidelines [National Institute for Health & Clinical Excellence (NICE), 2008]. These guidelines were extremely timely, given that there continues to be considerable societal and professional debate about the condition. The endorsement of ADHD as a valid clinical entity and the need for timely and accurate assessment and diagnosis with provision of evidence-based interventions were important. ADHD is a neuro-developmental disorder that often persists into adolescence and adulthood. Conservative estimates using rigorous epidemiological methodological approaches estimate its prevalence as at least 3–4% of the school-age population when defined in strict accordance with the diagnostic criteria. The core symptoms of inattention, hyperactivity and impulsivity are associated with impairment for the child across different settings and situations. Given that the prevalence of the condition exceeds the finite resources of specialist child and adolescent mental health services (CAMHS), there is a crucial role for other health service partners (such as primary care and paediatric services) and education services to support affected children and their families. To reflect these various facets, the articles selected for this virtual issue cover topics such as some of the relatively neglected comorbidities and types of impairment associated with ADHD, the role of teachers and schools in identifying children with these difficulties and providing interventions in these settings, the use of assessment tools within clinical settings to aid case identification and diagnostic accuracy, different models of service organisation, eliciting young people's perspectives in informing evidence-based guidelines and factors influencing access to and continuity of care.

The first two papers in the virtual issue investigate teacher recognition of children with mental health problems, including ADHD, using case vignette methodology. The findings from the study by Loades and Mastroyannopoulou (2010) suggested that teachers had greater concern about a child described with symptoms of a behavioural disorder rather than an emotional disorder. Their findings also suggest that teachers are more likely to accurately recognise behavioural problems in boys than in girls. In contrast, using case vignettes that focused on different subtypes of ADHD, Moldavsky, Groenewald, Owen and Sayal (2012) did not find that gender influenced teacher recognition of ADHD. Although this might reflect teacher awareness about ADHD in girls, teachers did not tend to conceptualise inattentive-only symptoms as being ADHD. Teachers tended to be very positive about the roles of behavioural and psychological interventions for ADHD, but relatively few thought that medication might be helpful. Given that teachers are key professionals in identifying ADHD-related behaviours in children and are a source of information for parents, these studies highlight areas that might be addressed in initial or in-service teacher training about childhood behavioural problems.

Attention-deficit hyperactivity disorder is conceptualised as a heterogeneous condition reflecting the wide variation in which symptoms predominate at an individual level. Furthermore, comorbidity with other conditions is regarded as the rule rather than the exception, particularly in clinical samples. Although mental health clinicians are generally highly aware of related mental health comorbidities, other comorbidities may be overlooked. In particular, comorbidity with developmental coordination disorder (DCD) has led to conceptualisations about the overlap between these conditions, such as the DAMP hypothesis. A commentary by Edmund Sonuga-Barke (2003) highlights the importance of this co-morbidity and the need for further research to investigate the validity and utility of this conceptualisation. A study in the Netherlands of children participating in the International Multicentre ADHD Genetics (IMAGE) study investigated the presence of motor difficulties in children with ADHD (Fliers et al., 2010). Over a third of these children had motor problems as rated by teachers or parents; however, only half of these children had received physiotherapy treatment. In terms of other impairments, many children with ADHD experience peer relationship difficulties as well as interpersonal difficulties with parents, siblings and teachers. In a review of the social competence of children with ADHD, Elizabeth Nixon (2001) highlights the roles of social functioning and social cognitive difficulties as well as the outcomes of social difficulties. Although some of these difficulties may reflect the underlying neurodevelopmental disorder and possible traits of autistic spectrum difficulties, these social relationship difficulties have a great impact on future development and outcomes into adulthood. It is important for clinicians and other professionals working with children with ADHD to be aware of these social functioning difficulties.

In terms of the use of tools to optimise approaches to assessment, the paper by Sayal, Letch and El Abd (2008) highlights the utility of using parent and teacher questionnaires for screening purposes prior to offering an assessment to evaluate the presence of ADHD. This process contributed to an increase in the proportion of assessed children receiving a clinical diagnosis of ADHD. Although such approaches can help optimise the use of limited clinical resources, the heterogeneous nature of ADHD means that the risk of false positives needs to be kept in mind. Where clinical resources are available, the use of neuropsychological and cognitive tests assessing executive function may further optimise the accurate identification of children with ADHD. The study by Holmes et al. (2010) suggests that where time or resources are limited, tests assessing response inhibition and working memory have the greatest utility in discriminating between children with and without ADHD. The use of these assessment tools can also enhance feedback provided to teachers and parents about areas of particular difficulties that could be the focus of interventions. Vogt and Williams (2011) describe the use of a continuous performance test within their clinical service to assess for treatment response to stimulant medication. They employed the Qb Test System to assess the response to a single test dose of stimulant medication, and used the results to determine treatment response and inform titration towards optimal doses of medication.

Increases in the administrative prevalence of children with clinically diagnosed ADHD require optimal organisation of healthcare services across primary and secondary care. The current role for GPs in relation to children with ADHD is limited to a gate-keeping function determining referral to specialist services and, in certain areas, provision of repeat prescriptions to enable maintenance treatment. In their review, Salmon and Kirby (2007) make a case for developing a role using the General Practitioner with a Special Interest (GPwSI) model to improve training and support to interested primary care clinicians and optimise the delivery of services. There remain considerable national and international variations in terms of whether children with ADHD are seen by and treated by mental health or paediatric services. Although there is some overlap in provision regardless of service location, both types of service tend to have access to different professionals and, to some extent, there are group differences in approaches to assessment and interventions offered. The survey of Salmon and Kemp (2002) highlights that paediatricians are more likely to prioritise clinical investigation and developmental assessment, whereas child and adolescent psychiatrists focus more on other aspects of mental health assessment and have greater access to provision of psychological interventions. Although the NICE guidelines did not specify a particular type of service model, it is important that access to appropriate assessment (to minimise risk of misdiagnosis) and evidence-based interventions should be equitable, regardless of the setting in which the child or young person is initially seen. In terms of exploring young people's attitudes and to enhance the evidence base for the NICE guideline development, Singh et al. (2010) carried out a qualitative study with young people with ADHD to elicit their views about taking stimulant medication. In general, they were positive about taking medication and could highlight potential benefits for them. They described experiences of stigma and bullying, but more often related these to the underlying ADHD than to taking medication. They also highlighted the potential benefits of physical activity such as sports. These findings were useful in enhancing the evidence base upon which the NICE guidelines were drawn up.

Two papers investigate the receipt of services and treatment. A clinical case series of open ADHD cases (Foreman, 2010) highlighted a considerable reduction in the duration between referral and receiving a prescription for medication for ADHD following the publication of the initial NICE guidance on ADHD in 2000. Nevertheless, the average duration for receipt of medication was around 18 months after referral with older child age and referral from educational sources predicting a shorter duration between referral and treatment. In terms of continuity of care, Ford, Fowler, Langley, Whittinger and Thapar (2008) followed up a clinical sample of children with ADHD 5–7 years post diagnosis. Two thirds of children continued to meet criteria for ADHD at follow-up and the majority remained in contact with CAMHS. There were also high rates of use of other services including educational services and the criminal justice system. These findings highlighted the long-term needs of these children into adolescence and early adulthood and the role for input from a range of services to optimise their functioning.

The final set of papers focus on interventions and factors that might influence their success. The NICE guidelines have highlighted the pivotal role of offering parent training and education interventions. The possibility of offering interventions to parents at an early child age is particularly attractive. However, Beernink, Swinkels, Van der Gaag and Buitelaar (2012) highlight that early oppositional/aggressive and attentional/hyperactive behaviours have differential effects on parenting stress at the age of 2 years. In particular, an increase in attentional/hyperactivity behaviours over time has a greater impact on parent–child interactions and attachment. In contrast, high levels of early oppositional/aggressive behaviours are associated with maternal role restriction and social isolation. These findings are useful in informing the content and timing of early parenting intervention programmes for children with ADHD-type difficulties. The families of children with ADHD often ask about the role of dietary interventions, both elimination and supplementation approaches. Pelsser et al. (2012) report on a randomised trial carried out in the Netherlands investigating the family environment of children participating in a trial investigating the role of a restricted elimination diet. Although there was a positive effect of the restricted elimination diet on ADHD symptoms, there was no change in family environment over the course of the 5-week intervention, suggesting that these improvements were not mediated by changes in family environment. Nevertheless, family relationships were inversely associated with the number of ADHD and ODD symptoms highlighting the importance of enquiring about family relationships when assessing and managing children with these behavioural difficulties.

These articles (reflecting expert commentary, review articles, and original research) provide a comprehensive guide across a full range of debate around identification, recognition, associated problems, assessment, service organisation and interventions. We hope that this issue will act as a useful and readily available resource for those with an interest in these areas. By gathering these articles into a single collection, our aim is to increase awareness and knowledge about their key messages and to stimulate debate amongst key stakeholders including children and young people, parents, teachers and other education-based professionals, healthcare professionals and researchers.


Kapil Sayal is partly funded by the NIHR Collaborations for Leadership and Applied Health Research and Care (CLAHRC) in Nottinghamshire, Derbyshire and Lincolnshire. He was a member of the UK NICE Guideline Development Group (GDG) and Implementation Group for ADHD. This Editorial and the selection of the articles for the Virtual Issue were commissioned by the Editors of Child and Adolescent Mental Health.