Attention Deficit Hyperactivity Disorder or ADHD is a condition that affects those parts of the brain that control attention, impulses and concentration. The person can not concentrate easily and so has problems at school, play and work.

About 1 in 30 (3.5%) children and youngsters have a full set of ADHD symptoms. In adults, about 1 in 200 (0.5%) have the full set of symptoms, and 1 in 60 have some symptoms (1.8%). This may be lower in adults because their symptoms change and they learn to cope.

^{Updated 7.11}

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Attention deficit hyperactivity disorder (ADHD) is also known as hyperactivity or hyperkinetic disorder, although hyperactivity is a symptom of ADHD. People with ADHD can be:

• restless, fidgety and overactive

• chatter all the time and interrupt people

• are easily distracted and do not finish things

• cannot concentrate on tasks

• are impulsive, suddenly doing things without thinking first and have difficulty waiting their turn in games, in conversation or in a queue

• cannot delay reward, which means that they will choose a smaller reward sooner rather than a larger reward later  

Not surprisingly, this can lead to poor schooling, with the youngsters being thought of as trouble-makers or not very bright. Obviously if not treated, then these youngsters will not get much out of school, which will have a major effect on the rest of their lives.

Although being like this is common in many children for a while, it can become a problem when this is exaggerated, compared to other children of the same age, and when the behaviour affects the child's social and school life. The symptoms usually start before 7 years of age and usually begins to fade in the later teens, or the person learns how to control or manage their symptoms enough to be able to cope.

^{Updated 7.11}

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Oh yes. As Linda Sheppard (ADHD Suffolk) said "Sufferers don't just wake up on their 18th birthday feeling fine after years of living with it. " Sadly, many people (including Psychiatrists, GPs, Health Trusts) don't think adult ADHD exists.

There are 3 types of adults with ADHD:

• People with ADHD as children who still have symptoms
• People with ADHD as children who stop the medication and then realise after a few years that they can't cope and want to go back on medication
• People with a "new" diagnosis. Nearly all of these are people who had ADHD as children but never had a diagnosis. Starting with new symptoms as an adult is probably very rare indeed, and usually means a different cause or diagnosis.

About 1 in 30 adults have major symptoms of ADHD e.g. being overactive, disorganised, often late, choosing busy jobs, poor sleep, often have road accidents and get caught for traffic offences, have poor concentration (the main symptom in 9 of 10 adults), and frequently change jobs even when things are going well. It is easily helped in adults, with the same medications as in younger people, but at higher doses. The usual trouble is getting this diagnosed and treated.

Adults with ADHD may also sometimes take amphetamines ("speed") illegally. They will say that they take them to feel normal or to help concentrate, rather than to feel high. Adults with ADHD are often not diagnosed and many thus go untreated, ending up with relationship problems, in trouble with the law (see below).

There are, of course, many other possible causes for these symptoms (see next questions) and so a proper diagnosis is needed before any treatment.

^{Updated 12.11}

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of ADHD. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed.

• Substance misuse e.g. taking amphetamines, excess alcohol, excess tobacco, or other illicit drugs. People (especially adults) with untreated ADHD are five times more likely to abuse substances, although part of this might be self-medicating e.g. alcohol to help sleep, or amphetamines to help concentration.

• Bipolar mood disorder e.g. hypomania or mania. Up to half of people with ADHD can be diagnosed with bipolar disorder. Bipolar symptoms don't start before 7 years of age (ADHD does), tend to change by getting better and worse and can change without reason (ADHD symptoms are the same almost all the time) and stimulants usually makes bipolar symptoms worse (ADHD improves).

• Personality Disorder

• Insomnia - which would in turn be caused by something else, Many of the symptoms of ADHD can be caused simply by not enough sleep.  

• Depression, particularly agitated

• Anxiety or GAD (Generalised Anxiety Disorder)

• Seasonal Affective Disordere.g. summer highs

• "Antisocial behaviour disorder" or "oppositional defiant disorder" - with arrests, detention and aggression. It has been estimated that up to 1 in 10 people in young offender institutes actually have ADHD, about 10 times more common than the general population

• Medical conditions such as overactive thyroid, underactive parathyroid or lead poisoning

• Child abuse

• Obstructive sleep apnoea (OSA) - this is where the person doesn't sleep well due to breathing problems, and lack of sleep causes lack of attention. Symptoms of OSA include snoring, sleep walking, bed-wetting, and seeming restless in bed.

Adults tend to under-estimate their symptoms of ADHD because they've got used to them and feel that they are part of their personality, rather than something that might be treated or helped.

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression - this is quite common. About 1 in 2 people (50%) have both ADHD and depression ^{(Van Ameringen 2010)}

• Insomnia and sleep disturbances are very common with ADHD

• Obsessive Compulsive Disorder - OCD is 4 times more common with ADHD, and ADHD will make OCD symptoms worse ^{(Van Ameringen 2010)}

• PTSD (Post-Traumatic Stress Disorder)

• GAD or anxiety - up to 1 in 4 (23%) may have ADHD and anxiety ^{(Van Ameringen 2010)}

• Substance misuse e.g. drug dependence or alcohol dependence, which is 3 times more common in ADHD. Remember that adults and adolescents with ADHD may drink alcohol to get to sleep and find they function better with amphetamines

• Antisocial behaviour disorder, ODD (Oppositional Defiant Disorder) or impulse control problems - about 1 in 4 people (25-30%) with ADHD have this, although one can lead to the other ^{(Van Ameringen 2010)}

• Bipolar mania or hypomania or bipolar mood disorder - 50% of people with ADHD can also be diagnosed as having Bipolar. There may be a connection with ADHD, or it could just be a few the same symptoms  

• Tourette's syndrome and tics

• Learning disabilities - as a result of poor schooling caused by the symptoms (about 9 times as common in young people with ADHD). This can include autism (or Autistic Spectrum Disorders)

• Dyslexia

• Epilepsy or seizures - apparently up to 1 in 3 people with epilepsy have ADHD (20339664)

• Getting migraines - having ADHD roughly doubles your chances of getting migraines

• Having an eating disorders, especially if you are an adult female

• Social phobia - nearly 1 in 2 (39%) may have both ^{(Van Ameringen 2010)}

^{Updated 9.11}

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Basically, anyone can get ADHD. However, there are some "risk factors" that make it more likely that someone will get ADHD. This is not a complete list but some of the main ones include:

• Genetics - having a parent or relatives with ADHD (75% children with ADHD have a parent with it as well), although it is more complicated than this. Genetics may mean that there is a problem with the brain's "reward system". When you have something you like, dopamine (a chemical messenger in the brain) will be released in the "reward centre". Some people may not have enough dopamine (which makes them feel unpleasant and on edge) so always crave anything to release this dopamine as soon as possible.

• The mother smoking a lot of nicotine in pregnancy. If the mum smokes 10 or more cigarettes a day during pregnancy the child has 2-3 times the chance of getting ADHD ^{(Lindblad 2010)}. Smoking after the child has been born more than doubles the risk of getting ADHD. However, the mother smoking both during and after pregnancy means the child has 8 times the chance of getting ADHD ^{(Kahn 2010)}.

• The mother drinking a lot when pregnant

• Poor sleep or sleep deprivation (just not getting enough) - the less sleep a person has, the worse the ADHD symptoms can get. And the worse the ADHD symptoms the worse the sleep.

• Poor housing, not much money, less family support

• Being male

The mum drinking lots of caffeine during pregnancy, or the person having a twin, low birth weight or birth complications do not increase the risk (although some people thought they did). Diet e.g. food additives and allergies, is entirely unproven.

People who abuse drugs get a buzz from that drug increasing the amount of dopamine in the brain. When they do not have the drug, dopamine levels drop and they then crave the drug, to increase their dopamine levels. One way to look at ADHD is that the person always has low amounts of dopamine in the brain. It is almost like the person is in a permanent state of drug withdrawal, but that is the way the brain happened, not because the person has taken drugs. Reward, thrills, excitement, gambling, risk-taking, getting things, amphetamines, cannabis all increase dopamine. As does methylphenidate.

The net result is that it seems that the area of the brain that controls concentration, reward and attention is underactive. This area uses dopamine and noradrenaline as its chemical messengers. It may be that dopamine and noradrenaline are not active enough. Some of the medications for ADHD boost dopamine or noradrenaline and so help boost concentration and attention.

^{Updated 9.11}

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There are risks from anything and everything, but ADHD has some extra risks. Some of the risks of having untreated ADHD are: 

• Road accidents - people with ADHD are twice as likely to have regular traffic accidents compared to people of the same age (Ludolph 2009), which is important as road accidents are the number one cause of death in young adults

• Poor relationships, sometimes due to "intimate partner violence" (ie violence to wife, girlfriend, husband, boyfriend) (Fang 2010)

• Conduct disorder (Fang 2010) or oppositional defiant disorder (define)

• 10 times as likely to be bullied at school, or 4 times a likely to be a bully Holmberg 2008

• Twice as likely to have regular stomach pain (Holmberg 2010)

• More likely to change jobs a lot. This is partly from wanting to be busy, and partly from social rejection as it can be more difficult to make friends with someone with ADHD (Jastrowski 2007)

• Having accidents that cause serious injuries (especially in younger people and males) (Merrill 2009) e.g. burns (Badger 2008)

• Adults with ADHD may have lower educational achievement levels e.g. not many GCSEs, "A" levels etc. But this is not because of low IQ Antshel 2009. It is even worse if there is a lot of cannabis smoking and limited parental control (Trampush 2009)

• Twice as likely to be arrested, 3 times as likely to be convicted, and 15 times more likely to end up in prison than other people of same age, especially for aggression (Mannuzza 2008)

• Increased tobacco use or to be exact nicotine dependence - seems people with ADHD get more reward from nicotine (Wilens 2008)

• Excess cannabis use

• Alcohol dependence or dangerous alcohol use (up to 1 in 3 have a major problem), especially if the person also has a conduct disorder (Knop 2009)

• Ending up in prison - a Swedish study showed that up to 40% of long-term prisoners have ADHD, but that only 1 in 15 had ever been diagnosed (Ginsberg 2010), and all had abused substances lifelong

• Three times as likely to get dementia (Lewy Body Dementia) (Golimstok 2011)

• More likely to have depression and then are 4 times more likely to become bipolar, especially if there is a history of mood disorders in the family (Biederman 2009)

• Having an adult personality disorder, especially antisocial and paranoid (Miller 2008)

• Having an eating disorder, mainly bulimia nervosa and especially if you are an adult female (Nazar 2008). Someone with ADHD is also slightly more likely to have Binge Eating Disorder (Davis 2009)

• Slightly more likely to be overweight or obese (well, it is in the USA) (Pagoto 2009)

^{Updated 8.11}

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The list here includes most of the main options but does not say what works and doesn’t. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have. Obviously, these web pages are about choice and medication and so we will concentrate on medicines.

Our aim is to try to help people who are taking medicines (or should be) get the right medicine, dose and take it regularly for as long as is best. Any medicines should usually be part of the overall treatment, although some people are quite happy to just stick with medicines or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Self-help

• Changing diet and avoiding additives (which may help a few but generally isn’t very helpful in most people)

• Getting enough sleep - making sure bedtime is regular, not late, can make a massive difference to the symptoms. In fact, depriving a youngster of enough sleep can produce the symptoms of ADHD [and by the way, teenagers are genetically designed to want to go to bed a couple of hours later but also get up a couple of hours later than adults, so they're not always just being lazy]

• Taking any medicines regularly and reliably

• Putting help from others into practice regularly e.g. attending groups, learning the skills etc

Medicines

• Medicines are the first choice treatment (e.g. stimulants such as methylphenidate or dexamfetamine) to help the person concentrate and reduce hyperactivity. Interestingly, use of "stimulants" like these actually reduces other substance misuse rather than increasing it. Atomoxetine is a newer medicine and is not a stimulant.

Help from others

• Psychological management (such as how to manage difficult behaviour, communication, teaching support) can help with problem-solving skills, by coaching, prompting and correcting. Positive Behavioural Support is a way of dealing and helping with behaviour in school. These have nearly all been used with stimulants such as methylphenidate. The therapies are often in groups, 10-12 sessions and last about 45 minutes. They can be very helpful IF the person sticks with the training and puts all the learning into action. But they don't help if the person doesn't put the new skills into action.

• Cognitive Behavioural Therapy (CBT) can be of some use in combination with the stimulant medicines and help them to be more effective 

• Sensory Integration Therapy can help. It is often carried out by O.Ts (Occupational therapists) and helps the person cope with life and events.

• Managing any other problems e.g. mental health problems (such as mood, anxiety), general advice and "life coaching"

• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can usually be used in conjunction with (but not relied on to replace) conventional treatments. There is very little evidence for these treatments in ADHD. All of these can be used in conjunction with other therapies. If they work for you then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbal products etc, and some useful links).

• Several studies have shown that Family Therapy and Meditation Therapy are unlikely to help

^{Updated 11.11}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or any local agreements)
• national policies (e.g. NICE, SIGN – see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it’s more likely to work again)

The main medicine treatment options are listed below. They are divided in “Main medicines” and “Others”.

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). “Others” are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

One big problem is that the medicines below are licensed in UK for ADHD in children and adolescents, but not in adults. So, many people aged 18 or older can have problems getting GPs to prescribe methylphenidate for them. One hope is that Medikinet is now licensed in Germany for adult ADHD and their manufacturers Flynn Pharmaceuticals hope this will now allow a similar license in UK, possibly in 2012.

Main medicines

• Atomoxetine (Strattera ®) - boosts noradrenaline in the brain

• Dexamphetamine or dexamfetamine (Dexedrine ®) - another stimulant

• Methylphenidate (Ritalin®, Concerta XL®, Equasym®, Medikinet®) - methylphenidate used to have to be taken three times a day but the new once-daily sustained release capsules are technological marvels. A once-a-day patch may also be available in the next few years.  

Others

• Bupropion (Zyban ®) - boosts dopamine, but is most usually used to help people stop smoking

• Clonidine - where other medicines have not worked and in combination with methylphenidate

• Tricyclic antidepressants - where other medicines have not worked

• Antipsychotics (such as risperidone used at low doses such as 0.5-2mg a day) can sometimes help when used in combination with methylphenidate. They seem to help some of the more aggressive or autistic symptoms.

• Melatonin - can sometime be useful as a short course (e.g. a few weeks) to help sleep. It is available as a sustained release capsule but sometimes a plain capsule is needed.

^{Updated 11.11}

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Download a handy summary chart comparing the main medications for ADHD e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Alternatively you can read the chart now in the window below. Use the controls at the bottom of the window to navigate through the chart and magnify the information. The 'Download', 'Print' and 'Fullscreen' links at the top of the window are particularly helpful.

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

There is concern in many countries about taking “stimulants”, especially in children and also that methylphenidate may possibly used a bit too often. This is a natural fear. There are, however, no known long-term side effects from these stimulants. Alternatively there many people who do NOT get methylphenidate who would benefit from it. ADHD can be a serious handicap, affecting schooling, social skills and jobs, which DO have long-term adverse effects.

Talking therapies can help reduce some of the hyperactivity symptoms, and possibly also help anxiety, low mood and low self-esteem. All the Talking Therapy studies have been carried out in people also taking methylphenidate and similar medicines. This is fairly sensible as you need some concentration to learn the ideas. The effects tend to wear off over a year or so, so a "top-up" may be needed. Medicines wear off in a few hours of course. And of course if the talking can help the person know what makes their symptoms worse they can do something about it.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

^{Updated 10.11}

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

• Methylphenidate and dexamphetamine – these stimulants usually have a fairly quick effect i.e. some effect within a few hours of a dose. However, the effect may gradually build, so you should give them about a month or so to fully assess their effect. 

• Atomoxetine – this is not a stimulant and can take about 3-4 weeks to work, and will gradually build up over 8-10 weeks so give atomoxetine a trial of at least a couple of months. In some people the effect can carry on building for up to 6 months. A few people's symptoms seem to improve in a few weeks. If you’re switching from methylphenidate you may need to take both together for a few weeks while the atomoxetine kicks in.

• Melatonin - if there is no effect in 3-4 weeks, it probably isn't going to help

• Risperidone - usually a calming effect is seen in a couple of weeks

^{Updated 9.11}

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• Methylphenidate and dexamphetamine - generally, the stimulants should be taken daily (perhaps missing out weekends) for at least several years. It is generally thought to be a good idea to try stopping for a week or so every 6 months or so (a so-called “drug holiday”, which is less fun than it sounds!) to see if the symptoms have got better. If they haven’t (which is usually the case), start again.

• The stimulants are not “BNF listed” or licensed for people above 18 so it can be difficult for GPs to prescribe them for adults, even though their needs may be just as great as for younger people. Concerta and atomoxetine can both be prescribed in adults, if the person was treated as a youngster with that medicine.

• Atomoxetine may also be needed for many years, although since it takes a month or so to start working and probably also to wear off, having a week off it may not prove much

• Melatonin usually only needs to be taken for 3-4 weeks to get the person's sleep pattern right again.

^{Updated 9.11}

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Usually either a stimulant (e.g. methylphenidate) or atomoxetine are used, unless you’re switching from one to the other. Sometimes low doses of some antipsychotics such as risperidone can help in combination with a stimulant.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the ADHD guidelines)

• Scottish Intercollegiate Guidelines Network (SIGN) guidelines for the Management of ADHD in children and young adults (October 2009)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

Updated 10.11

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The resources below provide more information about Attention Deficit Hyperactivity Disorder. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

ADHD and You, a website from Shire, who make Equasym XL, with some handy stuff on ADHD for parents/carers, teachers, professionals and, of course, people with ADHD

^{Updated 11.11}

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