In the latest in our CPD series, specialists in neurodivergence Dr Sarah Michaels and Caroline Gordon discuss key issues in the management of attention deficit hyperactivity disorder (ADHD) in primary care, including how to identify symptoms and support someone with ADHD, how to refer appropriately and the recommended pharmacological and non-pharmacological treatments. Read the full module on Nursing in Practice 365 today.
Learning objectives
This module will extend your knowledge and understanding of:
- How ADHD is defined and its relationship with other neurological, psychiatric and physical disorders
- What to screen for in primary care and how to refer someone for specialist assessment
- How to offer support to children and their parents or carers, or adults, when ADHD is suspected and after diagnosis
- The recommended non-pharmacological management options
- Recommended pharmacological treatments and how these are given
- Specific issues for adults when diagnosed in childhood and transitioning to adult services, and when diagnosed in adulthood
We often see stressed out parents with toddlers or young children in the practice, who tell us they’re worried their child might have ADHD. What are the main symptoms in children? How can nurses judge whether symptoms might be more likely to be due to other behavioural or mental health problems and how should they advise parents about this?
ADHD is a neurodevelopmental difference (or ‘disorder’ in medical language) that has cross-over with the other neurodevelopmental differences, such as autism, developmental co-ordination disorder, developmental speech disorder, Tourette’s, dyslexia, dyscalculia and foetal alcohol spectrum disorder. Many clinicians and neurodivergent people now prefer to see ADHD as part of this wider neurodivergent ‘umbrella’ rather than a siloed discrete diagnosis.
The current diagnostic criteria for ADHD given by the DSM-5 (fifth edition of the Diagnostic and Statistical Manual of Mental Illnesses) are broken down into two main domains. One domain is attention (‘A’). The other domain is hyperactivity / impulsivity (‘H/I’). Each domain has nine main symptoms.
To satisfy the diagnostic criteria, children must experience six or more symptoms from either domain (A or H/I), or both domains (A and H/I).
Adults must experience five symptoms of either or both.
Related Article: Mythbuster: ‘You can’t have ADHD if you’re able to hold down a job’
The 18 symptoms, which can be seen throughout the lifespan, are given in Box 1.
Box 1. Symptoms of ADHD used in the DSM-5 diagnostic criteria
A 1: Often fails to give close attention to details or makes careless mistakes
A 2: Often has difficulty sustaining attention in tasks or play activities
A 3: Often does not seem to listen when spoken to directly
A 4: Often does not follow through on instructions and fails to finish tasks
A 5: Often has difficulty organising tasks and activities
A 6: Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
A 7: Often loses things necessary for tasks or activities
A 8: Is often easily distracted by extraneous stimuli
A 9: Is often forgetful in daily activities
H/I 1: Often fidgets with or taps hands or feet or squirms in seat
H/I 2: Often leaves seat in situations when remaining seated is expected
H/I 3: Often moves about in situations where it is inappropriate
H/I 4: Often unable to play or engage in leisure activities quietly
H/I 5: Is often “on the go,” acting as if “driven by a motor”
H/I 6: Often talks excessively
H/I 7: Often blurts out an answer before a question has been completed
H/I 8 Often has difficulty waiting their turn
H/I 9: Often interrupts or intrudes on others
Experiencing the ADHD symptoms is one part of the diagnostic criteria.
The other part is that symptoms are seen in more than one setting (eg, at home and at school, although any settings can be enquired about), are present for at least 6 months and noted before the age of 12, are impairing (ie, contributing to difficulties in social or academic function), and are not due to other causes.1
The official ADHD symptoms overlook other potential markers of a neurodivergent young person, such as: other neurodevelopmental differences;2 family history of similar difficulties; addictive or risky behaviours; circadian rhythm disorder and sleeping difficulties; disordered eating; friendship and relationship difficulties; difficulty engaging with, or exclusion from, the education system; social vulnerability to grooming, abuse and other safeguarding risks; and the many associated physical health conditions (related to inflammation, dysautonomia, hypermobility and accidents).3
Note also that many clinicians feel that the ADHD diagnostic criteria are outdated and fail to reflect lived experience of issues such as ‘rejection sensitivity dysphoria’ (a strong visceral emotional response to real or perceived criticism), difficulty regulating emotions and overall executive dysfunction. In addition, the criteria might mean that a child with five severe symptoms of each domain would not get a diagnosis and the support that comes with this, despite very clear impairment, and potentially risky dopamine-seeking behaviour.
ADHD, and wider neurodivergence, is not a mental health condition. It is a difference in brain and body ‘wiring’. What can seem to be a behavioural problem might be a manifestation of distress or other triggers.
ADHD is a lifelong neurodevelopmental difference (or ‘disorder’). Symptoms first show early in childhood, usually before age 12, and continue consistently throughout many different environments including home and school. By contrast, mental health or behavioural problems like anxiety or depression often start later, may vary greatly over time and are more obviously related to previous trauma or life difficulties.
Similar symptoms to those of ADHD, such as ongoing struggles with restlessness, impatience or distractibility, may be seen with behavioural or mental health problems. However, such psychological or behavioural problems connect directly to emotional discomfort, anxiety or trauma triggers, whereas in ADHD the symptoms occur regardless of mood or emotional state.
As a consequence, children with ADHD may not really benefit from conventional behavioural support, especially if not assisted by environmental changes. Conversely, children with behavioural or mental health problems often react favourably to treatments aimed at the underlying emotional concerns or stressors, such as counselling, anxiety management techniques or behavioural therapy.
In addition, think about family history and comorbidities: ADHD usually coexists with other neurodevelopmental disorders including dyslexia, Tourette’s and autism. Often, a strong family history of neurodivergent disorders indicates ADHD. Other relevant family histories could include mood disorders, substance use disorders, anxiety disorders and trauma. By contrast, behavioural or mental health problems usually have clear emotional, social, or environmental triggers.
Related Article: Adults with ADHD ‘living shorter lives than they should’, study suggests
A simplified approach to use in clinical practice is outlined in Box 2.
Box 2. How to distinguish ADHD from mental or behavioural problems
Where a child has had ADHD traits since early childhood, regardless of situational stress, is inattentive and disruptive both at school and at home and struggles consistently with tasks demanding sustained effort, then ADHD is most likely.
Conversely, a child whose disruptive actions started following parental separation, are mostly seen at school and are much lessened at home or on holidays is more likely to have underlying emotional or behavioural causes than ADHD.
Always back clinical judgement and decision-making with thorough histories, observations from several sources, parents, teachers and evidence-based screening tools (such as SNAP-IV or Conners scores; see below).
What should you advise parents when they present, concerned that their child might have ADHD?
Firstly, it is important to address and validate parental concerns, and normalise the uncertainty many parents experience.
They may be concerned about the stigma that can still come with an ADHD label, or about the potential negative social, educational and physical health risks associated with ADHD. Even if comfortable with the ADHD in itself and the many strengths that come with it (such as creativity, problem-solving, resilience and passion), they may have concerns about long waiting lists for NHS diagnosis and management.
Enquire about the behaviours they have seen, when they started, and whether these happen in many environments including school, home and social events. Look into any emotional reactions the child is having, such as low self-esteem, anxiety, or frustration.
It is important to define ADHD to parents. Clarify that ADHD is a neurodevelopmental difference, not a parental failing or a behavioural issue by itself. Explain that children and young people (CYP) with ADHD usually battle attention, impulsivity, and/or hyperactivity and that these are related to their brain’s information processing and emotional control.
A useful guide is to follow these steps:
- If ADHD appears probable, cover the referral process (eg, to Child and Adolescent Mental Health Services, community paediatrics, or via Right to Choose).
- Consider putting the child onto a waiting list for assessment and further support. Check the waiting times for Right to Choose pathways (but ensure that the provider can prescribe as well as diagnose) and manage expectations for Shared Care within your GP practice.
- Tell parents that support doesn’t have to wait for a diagnosis. Support should be started before a diagnosis is made, and support needs will vary by individual. Many ICBs have a page with support links for neurodivergent children and adults.
- Ask for sensible changes at school, for example to provide alternative seating, chunked instructions and movement breaks.
- Find neurodivergent-specific parenting resources. Reach out to local or online support groups. Consider calm-down spaces, reward systems, and visual planners among other resources.
- Offer signposting: Link to reliable resources including ADHD Foundation and local SENDIASS. Suggest parents check their Local Authority’s ‘Local Offer’ site for support services.
- Encourage parents to look after their own health, and provide assistance if they are having difficulties.
A key learning point for nurses in primary care and the community in particular is to remember that you don’t need a diagnosis to begin support.
Related Article: School nurses key to providing ‘safety net’ for children with ADHD
To complete the full module and log 1.5 CPD hours visit Nursing in Practice 365
Dr Sarah Michaels is a GP specialising in autism and ADHD, and ADHD advanced practitioner at Clinical Partners. Caroline Gordon is a senior nurse and clinical director at Clinical Partners
References
- BMJ Best Practice. Attention deficit hyperactivity disorder in children. BMJ Publishing Group Ltd. Last updated: May 29, 2024
- Cleaton M, Kirby A. Why do we find it so hard to calculate the burden of neurodevelopmental disorders. J Child Dev Disord 2018;4(3):10
- Alabaf S, Gillberg C, Lundström S et al. Physical health in children with neurodevelopmental disorders. J Autism Dev Disord 2019 Jan;49(1):83-95
