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29 Sep 2017

Leahy LG. J Psychosoc Nurs Ment Health Serv 2017; 55: 10-16

This article reviews the history of ADHD since its initial description, the identification of symptoms and the range of diagnostic labels for children with ADHD, as well as subsequent treatment options. In addition, the article acts as a discussion guide for healthcare professionals to educate parents, family members, teachers and others who may query the diagnosis and treatment of ADHD in children.

Since the first description of symptoms associated with ADHD in 1775 by Melchior Adam Weikard, a number of discoveries and developments have led to the current understanding and treatment of the disorder, with investigations in the 1960s establishing the three core symptoms of modern ADHD as inattention, impulsivity and hyperactivity. Adult ADHD was not recognised until 1987 in the Diagnostic and Statistical Manual of Mental Disorders – 3rd edition revised (DSM-III-R) guidelines, with the disorder formerly termed ‘ADHD’. Today, individuals with ADHD are identified according to the diagnostic criteria indicated by the DSM-5TM, which has recently been updated to more easily diagnose adults with ADHD.

It has long been considered that serotonin, dopamine and noradrenaline underlie the majority of symptoms associated with ADHD. The prefrontal cortex (PFC) is responsible for executive functioning (e.g. planning, organisation, reasoning and impulsivity), and reduced levels, inefficient transport and reduced number of serotonin, dopamine and noradrenaline receptors in the PFC are thought to contribute to ADHD symptoms. In addition, a list of genes related to ADHD has also been compiled, and although genetic disposition is only one component of ADHD, meta-analysis of 1800 genetic studies determined that the heritability of ADHD is between 75–91%, and that multiple genes, rather than one single gene, are likely to contribute to presentation of ADHD. Therefore, a range of factors (e.g. external, environmental and genetic) must be considered when confirming a positive diagnosis of ADHD, particularly if pharmacotherapy is a potential treatment option.

In line with changes to the diagnostic criteria for ADHD, pharmacological treatments for ADHD have also changed over time, with most psychostimulant medications acting to increase levels of dopamine and noradrenaline in the PFC. In 1937, the first psychostimulant (racemic amfetamine) was introduced to the market for the treatment of narcolepsy, postencephalitic Parkinsonism and minor depression in adults. However, a position statement from the American Academy of Paediatrics’ Council in 1975 was the first official statement regarding the use of psychostimulant drugs in children.

Until more recently, methylphenidate was the gold standard in treating children with ADHD, until mixed amfetamine/dextroamfetamine salt agent was introduced to the market in 1996. More recently, sustained-release products are now available and may help to provide efficacy throughout the day and improve adherence through fewer daily doses. In addition, various non-stimulant medications are also available for the management of ADHD.

The authors concluded that ADHD has undergone a wide range of revisions and changes in its diagnostic labelling and pharmacological treatment options over the last 80 years. Although ADHD has been identified as a disorder in children since 1980, it has only been recognised as a disorder in adults since 2013. ADHD has complex aetiology, with external, environmental and genetic factors playing a role in the manifestation of the disorder. Therefore, it is important for clinicians and healthcare professionals to take this into account when considering potential treatment options for this highly treatable and old disorder. The wide range of treatments allows for personalised regimens to be designed for patients with ADHD, which should also include psychosocial therapies, behaviour modification strategies and environmental management.

Read more about the history of ADHD here

Leahy LG. Attention-deficit/hyperactivity disorder: a historical review (1775 to present). J Psychosoc Nurs Ment Health Serv 2017; 55: 10-16.

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