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The neurological and genetic mechanisms underpinning attention deficit hyperactivity disorder (ADHD) are becoming increasingly more recognised and understood in recent years, meaning this is a very exciting and fast-evolving area of medicine. It is hoped that these insights will help enable medical professionals to more accurately identify specific subtypes of the condition, and tailor treatment approaches to individual patients. Despite this, there are numerous challenges that still need to be overcome so that our increased understanding results in significant benefits for children with the condition, which can be debilitating and even reduce life expectancy.1 These challenges include ensuring that referrals and diagnosis is always as early as possible and reducing levels of stigmatism that are still around. To discuss these topics and more, we spoke to Dr Maite Ferrin, Consultant Psychiatrist at the Re:Cognition Health Clinic, London, UK, an organisation that provides a wide-ranging diagnosis and care programme for cognitive impairment disorders, including ADHD.
Interest in ADHD
Dr Ferrin, who has always held a strong interest in neurodevelopmental disorders and child psychiatry in general, became fascinated with ADHD for a number of reasons during her time training under the tutelage of the distinguished Prof Eric Taylor at Maudsley Hospital, London, UK. One of these is in relation to the multi-faceted nature of the condition, which regularly combines neurodevelopmental issues with comorbid disorders, such as anxiety and depression. She also finds that children with ADHD are often colourful and engaging characters, who can channel the positive attributes of the condition if guided in the right way.
Dr Ferrin was one of the first psychiatrists in the South of Spain to diagnose ADHD and autism spectrum disorder (ASD) back in 2005, emphasising a huge lack of understanding with the condition up until relatively recently. “It was very challenging at times because people didn’t understand ADHD or ASD and just thought they were naughty children,” said Dr Ferrin, reflecting on that period working in Spain. “It took time to create awareness and for professionals – teachers and doctors – to understand that they were not just naughty children but they had a problem. And so at that time these disorders were hardly recognised and parents were the ones being blamed. But since then I can see that there has been better understanding and recognition of the disorder.”
She continued: “Obviously the research has improved and we know more about the disorder, there are more treatments available, and there’s a better understanding of what really works for ADHD. However, I think there is still a lot of stigma around the condition, a lot of misconceptions, false beliefs, and this needs to be addressed.”
Role of Neurobiology and Genetics
Dr Ferrin went on to explain how current research is clearly displaying the heterogeneous nature of ADHD, with its various subtypes and aetiologies. Researchers are also uncovering the neurological mechanisms associated with the condition, involving areas of the brain like the prefrontal cortex and anterior cingulate.2 Genetic factors are also believed to play a substantial role, for example genetic abnormalities in the dopamine system, which is one of the neurotransmitters to the brain.3 It has even been estimated that genetics could be the cause in as many as 70–80% of cases.4 Currently, neuroimaging or genetics cannot be used to diagnose ADHD at an individual level, largely due to the heterogeneity of the condition. Dr Ferrin hopes that, with growing knowledge in these areas, there will be the possibility of neuroimaging or genetic testing being more useful at a clinical level in the next 10 years. “I think for the future it would be helpful to overcome these difficulties because both genetics and neuroimaging would be helpful to better identify specific forms and subtypes of ADHD,” she explained. “So hopefully in the future we are able to get a more specific idea of all the mechanisms involved in a particular case and target interventions in a more tailored manner.”
Signs and Symptoms
In the meantime, it is vitally important that the signs and symptoms of ADHD are better understood so that referrals for testing are made as soon as possible, especially by teachers and GPs. There have certainly been improvements in this respect; for example, the high heritability of the condition means that many parents who were diagnosed with ADHD themselves are now recognising the same traits in their own children. Nevertheless, there remains a lack of knowledge of many of the symptoms, particularly those that are not easy to spot. “The warning symptoms are obviously the three core symptoms like inattention, hyperactivity, and impulsivity, but it’s also about being aware of children who might present with low self-esteem or who spend a long time doing their homework, that might be a sign of inattention for instance,” elucidated Dr Ferrin. “Also, in girls these symptoms are less noticeable and they may present with a combination of not belonging to a social group or being a bit distracted, or just with high levels of anxiety and depression; they are usually not as impulsive or hyperactive as boys.”
Part of the issue seems to be levels of stigmatism that still remain. Greater education amongst the wider public is key to combatting this according to Dr Ferrin, particularly in emphasising that ADHD is essentially caused by neurological and genetic factors. Although totally different conditions, she gave the parallel of Down’s syndrome, a condition for which numerous campaigns took place that gradually reduced its stigma amongst the wider public. She would also like to see greater psychoeducation for professionals interacting with children, such as teachers.
She also detailed the problems of long waits for children who are referred for psychiatric assessment in the UK, which can have major negative implications. More funding for services such as this and in mental health in general is needed to help improve matters.
At Re:Cognition health, a comprehensive programme is provided that encompasses a thorough assessment and diagnosis, as well as a range of treatment options, both pharmacological and non-pharmacological. The best diagnostic method to date is an interview with a specialist in the field, who collects enough information about the child to make a final clinical judgement; this process also includes assessments for other neurological or psychiatric comorbid conditions like ASD, anxiety, depression, oppositional defiant disorder, and sleep disorders amongst others. Other tools that assist in making an accurate diagnosis include different screening and neurocognitive tests such as the QbTest;5 Dr Ferrin estimates that in combination, this gives a 90% probability of whether or not the child has ADHD.
Dr Ferrin stressed that ADHD is most certainly a treatable condition, and there are a range of options available. “I think it’s important to say that because the condition is so heterogeneous you have to consider different approaches when treating people with ADHD. All of them can be really useful when dealing with not just ADHD but also the problems associated with ADHD,” she emphasised.
The type of therapy given depends not only on the preference of the patient and their family, but also on the specific symptoms displayed by every diagnosed child. For example, Dr Ferrin explained that a child with ADHD without behavioural problems might not require parenting programmes. A child with very mild symptoms can benefit from Omega-3 supplementation or diet exclusion. For those with symptoms that are particularly impacting on their lives, pharmacological medication would need to be considered, which can be effective in certain children. “What we offer is more identifying what we think is going to be the treatment that is going to work better for that specific child,” she added, explaining that at the clinic they offer the first programme that is scientifically based on improving ADHD symptoms.
Positives of ADHD
Another key aspect of the therapy programme is to emphasise the positive aspects that ADHD can bring to a child and teach how these can best be channelled. Attributes such as high energy levels and creativity are common in these children, but there are other features that are not as well known. “Most of them have social empathy and charisma, and if they use this in a positive way and with the right support the opportunities are amazing,” stated Dr Ferrin, noting examples of famous people who have had the condition and been highly successful in later life, such as Bill Gates.
In terms of her own research, Dr Ferrin will be looking to continue her focus on two main areas. One of these is the neurocognitive aspects of ADHD; for example, the effect of anxiety and depressive symptoms on working memory deficits in children with the condition.6 Another is exploring the efficacy of various non-pharmacological therapies for the condition, including behavioural interventions,7 cognitive training,8 and psychoeducation.9 In regard to the latter, Dr Ferrin is also aiming to publish the first manual for psychoeducation to be available online for professionals in the field.
She concluded our discussion by explaining the positive impact that new insights and therapies have provided children with ADHD in her own experience. “I’ve worked in the field for the last 12 years or so, and I’ve dealt with many children, adolescents with ADHD, and their families, and learnt lots through that,” she said. “And I think it’s been really beneficial because people still contact me years later to express gratitude and say how much this has helped them. So this is really what keeps me going and motivated to continue.”
There is clearly much still to learn about ADHD, but the benefits of further increasing our knowledge will undoubtedly soon be seen in the lives of children and families affected by the condition.
- Dalsgaard S et al. Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: A nationwide cohort study. Lancet. 2015;385(9983):2190-6.
- Vaidya CJ. Neurodevelopmental abnormalities in ADHD. Curr Top Behav Neurosci. 2012;9:49-66.
- Duggal N. Attention deficit hyperactivity disorder (ADHD): The role of dopamine. 2016. Available at: https://www.healthline.com/health/adhd/adhd-dopamine. Last accessed: 15 May 2018.
- Molly NA, Alexandra BS. Genetic and environmental influences on ADHD symptom dimensions of inattention and hyperactivity: A meta-analysis. J Abnorm Psychol. 2010;119(1):1-17.
- QbCheck. Get informed to act in ADHD. Available at: http://www.qbtech.com/qbcheck/abouttest. Last accessed: 15 May 2018.
- Ferrin M, Vance A. Differential effects of anxiety and depressive symptoms on working memory components in children and adolescents with ADHD combined type and ADHD inattentive type. Eur Child Adolesc Psychiatry. 2014;23(12):1161-73.
- Daley D et al. Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder. J Child Psychol Psychiatry. 2017. [Epub ahead of print].
- Cortese S et al. Cognitive training for attention-deficit/hyperactivity disorder: Meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. J Am Acad Child Adolesc Psychiatry. 2015;54(3):164-74.
- Ferrin M et al. Evaluation of a psychoeducation programme for parents of children and adolescents with ADHD: Immediate and long-term effects using a blind randomized controlled trial. 2014;23(8):637-47.
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