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Post No.: 0640adhd


Fluffystealthkitten says:


The increase in the rate of clinical diagnoses of ADHD in recent decades is more likely due to an increased awareness and recognition of ADHD over this time, rather than an increased prevalence of the disorder. As parents and schools have become more aware of this disorder, many have also pushed for a diagnosis for their children or pupils because a diagnosis is required before services and medications to treat it can be utilised or obtained; whereas historically these children would not have been diagnosed or therefore treated at all. An earlier diagnosis will enable a child to receive appropriate support sooner rather than spend any number of years being misunderstood, losing academic years, and experiencing damaging experiences.


Still, under-diagnosis is potentially happening in places like the UK because ADHD isn’t diagnosed and treated under primary care, so it’s often missed and there are long waiting lists to see specialists. Meanwhile, over-diagnosis is potentially happening in places like the USA because ADHD is diagnosed and treated under primary care, and it’s about private healthcare profits, direct-to-consumer advertising for pharmaceutical treatments and getting as many people on medications as possible. (Most children in North America receive prescription drugs as their first line of treatment.) School funding is also tied to pupil performance on standardised tests, which leads to a greater incentive to send children to their doctors in search for solutions.


There’s a high probability that there’s a huge under-diagnosis amongst girls because they’re less likely to develop misconduct problems compared to boys for having more inattentive rather than hyperactive and impulsive symptoms (please check out Post No.: 0634). The current screening, referral and diagnostic process is more geared towards assuming those with ADHD will be boys too. (This sort of problem is present with autism diagnoses too.) Even so, the most conservative estimate is that there are 2:1 boys to girls. The gender ratio is narrower with adults, but this might be because women are more likely to initiate referrals to mental health services than men? (Parents and teachers are usually the ones to refer children.)


ADHD appears to be highly heritable, with small but additive effects of multiple genes rather than just one or two genes being responsible. It’s ~70-80% genetic and ~20-30% non-shared environmental influences.


So it isn’t 100% genetic, which suggests a small chance that it is preventable. (Something can be highly heritable yet any problems still not be inevitable – just like someone with naturally dark skin will have a greater difficulty in synthesising vitamin D from sunlight during the winters, but vitamin D deficiency isn’t inevitable if the person gets enough through their diet or supplements.) Yet it might not be reasonably preventable.


Nonetheless, ADHD can be intervened, treated and managed with early diagnoses; within an inclusive and supportive environment; and via appropriate medications and therapy. Meow!


Smoking or alcohol consumption or even stress during pregnancy, and extreme early adversity postnatally, are associated with a higher risk of ADHD. But parental nurture (or the lack of it) is just one component part of the environmental factors, and research doesn’t suggest that parents are to blame if their children have or develop ADHD. However, there are lots of upsides and few downsides to attempting early prevention or amelioration approaches, just in case. (Now a parent might think ‘I don’t care if my child develops ADHD because I will love her/him no matter what’ – but is this freedom of parenting or irresponsible parenting? If it’s not parents/guardians forcing their choices onto children, it’s authorities or others i.e. children and the adult paths they’re initially set on are always determined in part by others, for good and bad e.g. vaccination choices, religious upbringings, diets, educational opportunities, etc..) Also, whether a condition could’ve reasonably been prevented or not, it won’t make it less real – it’d be like believing that someone won’t be truly blind if they got stabbed in the eyes because they weren’t born blind(!)


A bad diet does appear to have a small and weak link – particularly some artificial colourings like tartrazine. Omega-3 and omega-6 fatty acid supplements, on the other paw, might be beneficial. Too much sugar or videogames aren’t linked to ADHD, yet there are other reasons to not overindulge in them.


A ‘gene-environment correlation’ (rGE) is when one’s genes correlate with one’s environment. But it can be incredibly complicated to work out the causal direction, if one exists. There are 3 possible causal mechanisms…


The first is a ‘passive gene-environment correlation’ – this is when your biological parents’ genes, which you inherit, also shape the home environment they put you in (e.g. your parents are highly anxious, which is partly heritable, hence they’ll not only genetically pass on some of their predisposition for anxiousness onto you but also raise you in an environment that’s full of expressed anxiety).


The second is an ‘evocative gene-environment correlation’ – this is when your genes evoke an environmental response (e.g. your natural impatience leads to your parents treating you in a certain way, rather than the other way around).


And the third is an ‘active gene-environment correlation’ – this is when your genes lead you to seek a particular environment (e.g. preferring playgrounds over libraries because you’re naturally highly active, rather than the other way around).


So your genes, in you and possibly also shared with your parents, partly shape the environment that shapes you, for which your parents are a part of your environment too. Therefore, for instance, the apparent link between your mother smoking during pregnancy (because of her genetic risk for ADHD) and your later ADHD, might actually be genetically passed onto you rather than because of the smoking? Social deprivation is linked with ADHD too – but it might be the case that it’s the ADHD genes (that run in the family) that’s what actually breeds those social circumstances? All this makes it hard to disentangle the role of genes and the role of environment, and which is cause and which is effect.


It’s possibly about ‘gene-environment interactions’ (GxE), where a genetic vulnerability (or strength) will only express as a phenotype if combined with the wrong (or favourable) environment?


ADHD is also a risk factor for mental health problems. Comorbidity is when problems are often seen to co-occur alongside other conditions – and comorbidities with ADHD include developmental delay, early social difficulties and anxiety. Attachment disorders or difficulties in a child’s relationship with their parents could be a consequence of ADHD instead of a cause – being temperamental is going to make a child more difficult to manage and develop a sensitive relationship with. Parents of children who have ADHD may have some aspects of ADHD too, and it could be this that (also) contributes to a difficulty in establishing relationships? That’s why we need to find the root cause(s) of problems – solving that would solve a whole host of related problems.


Any social stigma can lead to a lowered self-esteem, loneliness and depression too. The diagnosis and proper label of ADHD isn’t a problem in itself – it’s the other labels such as ‘naughty kid’, ‘lazy child’ or worse. The misconceptions held by many laypeople don’t help. The usual intuition is ‘they’re just bad kids’ and/or ‘it’s bad parenting’ but – although bad parenting and/or childhood adversity can lead to misbehaving children (a child’s environment, upbringing and life events will physically shape her/his brain hence bad parenting can be a contributory factor for certain mental health or behavioural problems in children, and it’s not just a consequence of reacting to a ‘problem child’ but a parent creating one) – ADHD shows us that misbehaving children can result even with good parenting and without childhood adversity. So we need education over common beliefs.


If you are a parent and are concerned about your child’s behaviour – the first thing to do is check with your child’s teacher to see if your child’s behaviour is evident in more contexts than just at home. Then see your family doctor, who might refer your child to a local specialist. However, the process towards diagnosis, if there’ll be one, might take months. And on occasion, even professionals can get diagnoses wrong (e.g. when assuming a child will soon grow out of it). People can be too specialised and assume that the symptoms a child exhibits fit their particular specialty. You may also be signposted to community paediatric services and ADHD support groups.


There’s presently no known cure, but treatment and management should be personalised and involve multiple approaches. The primary approach should be modifying the child’s environment if possible (e.g. making information simpler for them to process). Medications are effective at reducing the core symptoms, whilst psychosocial therapies can help with managing symptoms (e.g. cognitive training, promoting private speech or talking oneself through a difficult task, or teaching a child adaptive strategies for if/when they’re being constantly told off for their behaviour). Mindfulness meditation could possibly train a child to become more focused on the present and less distracted.


Some fear that ADHD medications will turn their kids into fuzzy zombies. But that’s only due to overdosing. With the right dosage, they’re highly effective as drugs go, and some can be fast-acting. They improve one’s ability to exert self-control by stimulating functions that relate to self-control. Some drugs however might not work for some, no drug is without side-effect risks, and some produce tolerance effects. Working out the optimal drug, dosage and administration times (dose titration) for each individual can take trial and error.


Parenting doesn’t automatically come with a manual but there are courses, and parent training can help with managing oppositional encounters, improve parent confidence and reduce self-criticism and criticism aimed towards one’s child (e.g. by rewarding positive behaviours). It’s more challenging to parent or teach a child with ADHD so learn that it’s no one’s fault. Teacher training and classroom management will help in school (e.g. seating the child at the front of the class so that all the distractions are behind them, providing regular opportunities to expend energy, or using physical objects to signify and remind kids when it’s time to talk or when it’s time to listen). With a naïve, under-resourced or uncaring school, such pupils will suffer – but with a well-informed, inclusive and supportive school, such pupils can flourish.


There are consequence-based interventions (e.g. using a daily report card and a token economy), antecedent-based interventions (e.g. changing the delivery of instruction via technology or games), and self-management/self-regulation interventions (e.g. changing the teaching strategy via the use of mnemonics). Of course, we should always aim to meet a child’s needs and bring the best out of them irrespective of diagnosis!


Psychoeducation can help others, like other classmates, be more understanding of a child’s difficulties. Neurofeedback (learning to hone one’s brain activation through operant conditioning e.g. when hooked up to an NIRS-NF headset, an image of a rocket will shoot up and perhaps play a certain sound every time the patient manages to recreate the brain activation pattern related to staying focused, which will therefore train the patient to focus in a gamified way i.e. it’s like mindfulness meditation but with external feedback) and non-invasive brain stimulation (e.g. TMS or tDCS) methods might potentially provide longer-lasting changes than medications. These are currently being clinically trialled.


We should help struggling children, especially if they’re at risk of poor life outcomes that affect not only themselves but society too, for it’ll be more cost-effective in the long run. Prognoses are highly individual, but with personal adaptation, understanding from others, focusing on one’s capabilities and strengths, and some of the other treatment and management approaches mentioned above – a person with ADHD will likely be fine. By adulthood, only ~40% of children with ADHD will remain with major problems.


Meow. If you have ADHD then, by using the Twitter comment button below, you can tell us about your personal experiences with the treatment and management options you’ve used or use?


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