ADHD is much more than a disorder of naughty boys – new clinical guidelines are hoping to help children, adults and older people

The rates of attention-deficit/hyperactivity disorder (ADHD) diagnosis have risen significantly in Australia since the onset of the pandemic, paving the way for new, world-leading clinical guidelines and renewed interest in a condition long thought to be “a disorder of naughty boys”.

Australian experts say that extended lockdowns in cities such as Melbourne and Sydney may have pushed people with undiagnosed ADHD “over the edge,” as bans on socialising and exercising restricted key coping mechanisms for many with the condition.

“During this time [COVID-19], a lot of people hit the wall, and have since begun to search for a diagnosis,” says Dr John Kramer, Chair of RACGP Specific Interests ADHD, ASD and Neurodiversity and a member of the new ADHD Guidelines Development Group.

Social media, too, has had an effect, with platforms such as TikTok, Instagram and YouTube shining a light on the condition by popularising ADHD-related content under tags #adhdtiktok and channels such as How to ADHD. Experts argue that this has added to an increased demand for adult ADHD assessment and treatment services, and highlighted a significant gap in Australian health care provision.

Experts hope that the new guidelines will not only demystify the condition, but also help clinicians identify symptoms earlier.

“Social media has played a role in spreading awareness, and we have much quicker access to information — not all of it good quality — but still there,” Kramer says.

Despite the relatively recent focus on ADHD, not much is known about the disorder in both the medical and broader communities, Kramer adds, with most health professionals such as doctors, speech pathologists, psychologists, nurses, psychiatrists and occupational therapists learning on the job.

“ADHD is not well taught in health courses and medical schools,” he says. “The knowledge base isn’t great, so it’s difficult to teach when it’s barely in the curriculum.”

This will hopefully change soon. Experts hope that the new guidelines will not only demystify the condition, but also help clinicians identify symptoms earlier.

What is ADHD, and how does it affect our brains?

As with many neurodevelopmental disorders, ADHD exists on a spectrum and presents differently in every person. ADHD includes problems with sustaining attention, resisting distraction, and moderating activity levels to suit the environment (for example, sitting in a classroom). There are three main types of ADHD: hyperactive-impulsive, inattentive and a combination of both.

While we don’t know exactly why some people have ADHD (scans don’t show any brain biomarkers, and while studies have shown a genetic link, we’re not sure exactly how risk genes for ADHD affect the developing brain) research suggests a link between neurochemicals in the brain, such as dopamine and noradrenaline, and the development of ADHD.

Dopamine is a type of neurotransmitter that has several important functions in the brain and body: its levels can affect a person’s mood, attention, motivation, and movement. Dopamine also regulates the brain’s reward system, with its levels increasing in the brain when a person experiences something pleasurable.  Noradrenaline, on the other hand, is particularly important for attention and concentration.

“Many girls with ADHD don’t get recognised in childhood.”

Dr Tamara May

Because medications such as the psychostimulants serve to increase levels of dopamine and noradrenaline in the brain, it was thought for a long time that their levels might be lower in people with ADHD.  It has, however, been remarkably difficult to find solid evidence for differences in these chemical signalling systems between those with and without ADHD.

Yet, modern genetics is now providing important clues, as some of the newest genes identified seem to play a role in dopamine signalling. Still, there is much work to be done in order to understand the complex interplay of genes and the environment on the developing brain in ADHD.

To date, symptoms of hyperactivity such as fidgeting, squirming or being destructive, which tend to be present more often in boys, have had more public awareness, while symptoms of inattention — such as making careless mistakes and having trouble focusing, and which are more frequently seen in girls and easier to overlook — have received relatively little attention.

There is also some suggestion that the current diagnostic framework, developed on male-dominated samples, does not suit girls and therefore more boys get a diagnosis.

Read more: Disordered diagnosis: the problem with establishing – or excluding – a mental health condition

“Around 2 to 3 boys for every 1 girl have ADHD, yet in adulthood, a similar number of men and women have ADHD,” points out Melbourne psychologist, Dr Tamara May. “What this likely means is that many girls with ADHD don’t get recognised in childhood, and some boys with ADHD have a reduction in their symptoms so that they might not meet ADHD criteria in adulthood”. May adds that women are also more likely to seek help than men.

To make things even more complicated, adult ADHD looks different to child ADHD.

Dr Beth Johnson, a senior research fellow from the Turner Institute for Brain and Mental Health who has a particular interest in autism and ADHD says in fact, you can’t actually develop it after age 12. Symptoms that look like those of ADHD which present in adulthood for the first time are usually due to something else, such as trauma or anxiety.

“Conservative estimates put the number of Australians with ADHD at 1.5 million — perhaps only one quarter have been formally identified.”

Dr John Kramer

Many adults with undiagnosed childhood ADHD may have grown up in a supportive environment with lots of structure around them, or were interested and motivated by academic topics, allowing them to focus and sustain their attention on schoolwork.

“More recent data has found that the prevalence of ADHD is 2.5% in adults who also meet childhood ADHD criteria, but in adults who only meet the adult criteria (and not childhood criteria) the prevalence is higher at almost 7%,” May says. “This means these adults didn’t meet the symptom count for ADHD in childhood.”

May points to a recent report on stimulant use in Australia in children, adolescents and adults, which found that stimulant and non-stimulant ADHD medication increased from 0.5% to about 1% of the population between 2013 and 2020.

“This is well below the prevalence of ADHD in children (around 6% to 8%) and adults (2.5%) and suggests a lot of people don’t receive evidence-based treatment for ADHD,” she says.

Kramer believes that “conservative estimates put the number of Australians with ADHD at 1.5 million — perhaps only one quarter have been formally identified”.

Australia’s new ADHD guidelines

Enter the new guidelines, which, according to a group of experts in the field, are now the most up-to-date globally. President of the Australian ADHD Professionals Association Professor Mark Bellgrove — part of a team of clinical professionals, researchers and people with lived experience who, over two years, developed the Australian guidelines — says that until a few months ago, we’ve never had a set of NHMRC approved clinical practice guideline of ADHD in Australia. 

“Clinical practice guidelines are really important to ensure uniformity of diagnosis, treatment and support for a condition,” says Bellgrove. “The approval of the ADHD guideline from the peak medical research body, the NHMRC, is a landmark moment for both Australian clinicians but also those who live with ADHD”.

Working off the 2018 UK guidelines (which were, until now, the most up-to-date) Bellgrove says the team looked at thousands of clinical trials to come up with 111 clinical recommendations and 450 pages of evidence.

“We see it as both the bible and the best way to diagnose, treat and manage ADHD.”

Professor Mark Bellgrove

“We see it as both the bible and the best way to diagnose, treat and manage ADHD,” he says. “There are also elements in the guidelines that highlight areas where we need more knowledge, which include knowing the impacts of puberty on girls, clinical presentation across the pre-pubertal phase – and if that is a trigger point”.

Because women and girls have not really been recruited into studies of ADHD, we know very little about its impacts on all females, including older women. Bellgrove says it’s equally important we study how menopause in older women impacts ADHD and the effectiveness of treatment during that period.

Little is also known about co-occurring ADHD and autism, which occur together in up to 40% of ADHD cases, says Johnson.

“We know that kids with ADHD and autism co-exist at high rates, and we know they have more functional impairment and higher symptoms,” she says. “Generally, they are double-loaded for risk of both.”

What is the treatment?

Treatment for ADHD is a multi-tiered approach, encompassing stimulant medication that increases the availability of dopamine in the brain, as well as support from psychiatrists, psychologists, allied health professionals, occupational therapists and increasingly, ADHD coaches (a person specifically trained to help adults, teens and kids with ADHD to better manage their lives).

In Australia, medications mainly used to treat ADHD include dexamfetamine, methylphenidate and lisdexamfetamine, and the dose and combinations are decided in conjunction with a specialist ADHD practitioner, doctor or skilled expert.

Line between neurodiversity and ADHD

In a highly distractible world where smartphones reign supreme, many workplaces are designed to be open-plan and a stream of content is available 24/7, it can be difficult to draw a line between normal human neurodiversity and ADHD.

Yet clearly there is a line, which experts define as the point where symptoms come to impact significantly on daily function.

“It’s down to the individual,” says Johnson. “The descriptions of behaviours and symptoms that characterise ADHD won’t all negatively impact us. Some, like hyper-focus, can be advantageous for some, while for others it will negatively impact their relationships and daily living.”

“This is where the public often misses the point in their understanding of ADHD: to live with the disorder is to have a profound level of functional impact on an everyday basis.”

Professor Mark Bellgrove, President of the Australian ADHD Professionals Association

To be diagnosed, a person has to feel like they can no longer cope with everyday life. It is often at this point that they come seeking a diagnosis, Johnson adds. “It’s often the case that the traits have been there but at a point they cause some degree of disability or difficulty and impact daily functioning.”

Perhaps more than any other condition, ADHD can be considered a “continuity trait” which everyone in the general population can have, says Bellgrove. The disorder part is the “extreme end of that bell curve”, and to become diagnosed, the symptoms must have a profound impact on a person.

“They also have to be pervasive and across multiple settings,” he adds.

“This is where the public often misses the point in their understanding of ADHD: to live with the disorder is to have a profound level of functional impact on an everyday basis across different settings”.