developed pragmatic language skills (receptive and expressive) related to their typically developing peers. They also suffer from a developmental delay in onset of talking. As a result, social problems are reported in 52-82% of children with ADHD: such as having fewer reciprocated friendships, and being more often disliked by their peers.
Social problems arise due to symptoms of impulsivity (e.g. interrupting, difficulty waiting their turn), and inattention (e.g. not listening). This means that a child with ADHD has a greater chance of getting into trouble at school and then when called in to explain to the teacher what really happened, struggles to verbalise the experience, as a result may be judged as defiant. Subsequently peer rejection and education failure has been associated with negative long-term outcomes such as substance abuse, delinquency and academic problems.

• Is ADHD a valid diagnosis in adults? ADHD is a common behavioural disorder that is associated with significant adult psychopathology, social and academic impairments and the risk for negative long­ term outcomes. There is no doubt that in many cases ADHD symptoms persist into adult life and cause significant clinical impairments. ADHD diagnosed in childhood
• tracks on through to adulthood, with 4-15% of adults retaining the full diagnosis and
• 50-66% of YP presenting in partial remission of ADHD symptoms.11·12•13 The main clinical
• issue is recognition of the disorder in adults and quantifying the impact on adult mental health.12
• To date there has been considerable debate on whether ADHD is a disorder solely present in YP or whether there is evidence that ADHD symptoms persist through to adult life. The latter hypothesis, is strongly supported by research,11 which found that symptoms of ADHD persist in 65% of adults. Furthermore, it is thought that the ADHD symptoms do not resolve in adulthood, but rather adults develop the required social skills to control and mask their ADHD symptoms and adapt to social
• requirements.11 On the other hand, Moncrieff has argued that the validity of symptoms
• in adults do not automatically follow those used to diagnose children and concluded that the rapid growth in interest in adult ADHD could be the result of the drug companies seizing the opportunity to expand on a lucrativemarket.14
• Clinical presentation in adults Adults with ADHD clinically present with more symptoms of poor attention
• (rather than hyperactivity) and ceaseless mental activity (distracted mind) such as procrastinating to start a job, then trying to multitask and carry out a number of jobs at the same, without ever finishing any of these jobs or finishing them with careless mistakes. Hyperactivity (over activity) is not as prominent symptom in adults, since adults learn to manage their
• behaviour, on the one hand through learning
• to adapt to social norms and also due to development (maturity) of the pre-frontal cortex. Mood dysregulation and lability are common symptoms in adults with ADHD.
• These symptoms lead to low tolerance
• of frustration, falling out with peers and colleagues, and as a result this effects their self-esteem and can lead to poor performance at the work place.
• Adults with ADHD prefer occupations
• that are exciting and busy and that have an element of risk, such as: sales, stock broking, entrepreneurial ventures. They undergo frequent changes in employment, have poor planning abilities, e.g.: organising finances, handling course work at college, live and work in a messy environment, enjoy reckless driving, have trouble maintaining stability within their relationships and as a result
• may suffer from social isolation. They may choose to engage in leisure activities that are highly absorbing or stimulating, such as downhill skiing or high-contact sports. Adults with ADHD usually have difficulty organising their homes, such as cooking regular meals, cleaning and managing their children (e.g. packing their lunches, getting them to appointments and school on time).15
• Newly diagnosed adults with ADHD have presented in adulthood, the commonest precipitant factors for these include: infection (e.g. Rheumatic fever), degenerative disorders (e.g. early onset
• dementia), acquired brain injury (e.g. punch drunk syndrome) and intoxication (e.g. heavy metal poisoning).
• There is, thus, clear evidence that ADHD is evident in adults but the diagnosis of adult ADHD is complex and the diagnostic criteria may be unreliable. Untreated YP with ADHD symptoms who are exposed to high expressed emotion within their families and experience poor social interactions, have a higher risk
• of developing conduct disorder (anti-social personality traits) symptoms in adulthood.16•17
• Epidemiology – how common is ADHD? The worldwide prevalence of ADHD in children O – 18 years was reported to be 5.29% in a systematic review and meta­ regression analysis conducted by Polanczyk et al,18 with minor differences found between countries around the world. For example in the United Kingdom it was estimated that the prevalence of ADHD is 2.23% of children age 5-15 years.19 Whilst in the United
• States of America, the National Health Interview Survey (NHIS) in 2006 estimated the prevalence of ADHD among children age 3-17 is 7%.20 The possible reasons for the significant difference in prevalence rates
• between these two countries has been widely debated; the most common reasons for the low prevalence reported in the UK is due to the strict adherence to ICD-102 as opposed to the DSM-5 in the USA. Furthermore,
• Biederman et al 19 reported that the USA have higher rates of social deprivation and
• experiences of trauma as a country when compared to the UK. In addition, one of
• the reasons apart from the more lax DSM-5 criteria for diagnosing ADHD, is that for parents to get clinician reviews refunded by insurance, a diagnosis needs to be given. It is reported that ADHD is more common in YP living in urban rather than rural communities and there is a link with low socio-economic status. It is believed that ADH D is an under­
• identified and under treated disorder.21
• In adulthood, the overall pooled prevalence rate for adult ADHD was 2.5%22 reported in a robustly conducted meta-analysis. Furthermore, Simon et
• al reported that children do not outgrow the disorder (ADHD) but they outgrow the diagnostic criteria (ICD-10, DSM-5),
• therefore this means that there may be an underestimation of the true prevalence of this disorder in adults. Some of the reasons for the possible underestimation include:
• different methodological and diagnostic differences used in the different studies lead to differences in results, symptom recall bias, the use of DSM-5 diagnostic
• criteria to diagnose adult ADH D23 which were written for YP, not adults,12 and the overlap of the symptoms of adult ADHD with other disorders, as well as the adult co-morbid
• disorders.12
• ADHD is more prevalent in males than females, 24 however the ratio varies depending on the study design of populations. The reported range varies
• between 9 males is to 1 female and 2.5 is to 1. 25 Further analysis has gone into why

18           Journal of the Malta College of Pharmacy Practice

of aetiology at pathophysiology of several conditions in medicine. Neuropsychological impairments, neuroimaging and electrophysiological paradigms for ADHD show potential to move molecular genetics research forward. However, familial or genetic overlaps between these constructs still remain unclear. The identification of an ‘endophenotype’ to help clarify which ‘at risk’ subjects will go on to develop ADHD could help reduce this high rate of disability.32
Environmental factors also play a role in the development of ADHD, these include severe neglect resulting in attachment
disorders.36 A lot of work and research has come out of the seminal Bucharest studies, these are large scale studies conducted on children raised in very deprived conditions in the Romanian orphanages in the times of Caucescu. The findings reveal that children who suffered from maternal and nutritional deprivation at the ages of O to 1 year are likely to have under developed right limbic systems and as a result suffer from emotional dysregulation.37 Further environmental factors include, obstetric complications38 although this theory is currently disputed, very low birth weight
(<lOOOg), pre or post-natal insults, exposure to lead poisoning, head trauma25 and nutritional deficiency were expansively shown to contribute to the development of
ADHD.39

• Proportion of co-morbidity in people suffering from ADHD
• If ADHD is under or misdiagnosed or not managed well, the prognosis for YP is poor; this means that there will be negative social, academic and vocational consequences. A large proportion (78%) of YP with ADHD
• tend to present with at least one co­ morbidity, the commonest include mood
• disorders (40%), substance dependence (35%), anxiety disorders (25%).
• Furthermore, co-morbid psychiatric
• conditions are not uncommon in adults with ADHD. By comparing adults with ADHD with a sample of YP without the childhood psychopathology, the results show high rates of antisocial personality disorders with poorer prognosis, 24 these rates vary
• from 12%12 to 23%13• Other co-morbidities include a high rate of substance abuse,12,24 depression, 40 anxiety and bipolar disorder41 Social impairment, repetitiveness or perseveration, rigidity and inflexibility42 are also common co-morbidities.
• stop shop at a psychiatrist for a Methylphenidate prescription considered good practice?
• According to NICE guidelines 200843, a diagnosis of ADHD should follow
• a multimodal approach. Therefore,
• the diagnosis needs to be made by a multidisciplinary team (MDT) specialised in ADHD. These include a clinical assessment of the YP, the ADHD symptoms in the different domains and settings over the past 6 months, substantiated by using standardised rating scales e.g. Connors’,44 SNAP-IV45
• The initial assessment is then followed by a developmental (including prenatal,
• infant and early years) and neuropsychiatric history (ADHD symptoms e.g. DIVA 2.046
• and assessment of co-morbidities e.g. anxiety, depression, learning disorders, autism spectrum disorders, tics, substance misuse), obtaining a collateral history
• and assessment of the YP’s current mental
• state. A school or home observation are valuable adjuncts to reviewing the YP in their natural environment. Furthermore, obtaining a family psychiatric history, especially concerning learning problems, attention and behaviour problems, ADHD and tics and enquiring about all first-degree relatives (parents, siblings and offspring)
• is necessary. A physical examination to rule out medical causes of symptoms (e.g.,
• serious head injury, seizures, heart problems, thyroid problems) or contraindications
• to medical therapy (e.g., hypertension, glaucoma) and to get baseline recordings of heart rate, blood pressure, weight and height are also required.
• There are some controversies around the use of cognitive testing, however, there are centres of excellence such as the Tees Esk and Wear NHS Foundation Trust who recommend the use of a Weschler Intelligence scale for children – WISC V47 and the administration of the TEACH.48 The former assesses not only the intelligence quotient of the child, but also gives
• an indication of the working memory and processing speed of the YP. Lower scores in these domains could give rise to the suspicion of attention problems.
• Furthermore, the actual assessment process gives the psychologist the time to
• subjectively observe the level of attention, hyperactivity (ability to sit) and impulsivity (when answering questions) the YP displays in clinic. On the other hand, the TEACH is a computer test, which objectively measures various forms of attention e.g. sustained and
• joint attention.
• The diagnosis of ADHD is then made at a MDT meeting where all the reports of
• the YP are brought together and discussed. This diagnosis is then made based on the chosen diagnostic criteria and level of functioning of the YP. The diagnosis is presented together with the strengths and weaknesses of the YP and recommendations are given at a feedback session, accompanied by a report to parents or care givers and YP.
• Can a diagnosis be made in children under the age of 5?
• Published literature suggests that neuropsychological symptoms of ADHD are present from birth, but the disorder is rarely diagnosed at preschool age. The reasons for this is that the brain is still
• undergoing neural pruning and developing cranio-frontally under the age of 5, therefore most children at the age of 3 will present with little executive function ability (which is derived from the pre­ frontal cortex). As a result, the brain would appear to be almost all overactive and with a poor ability to concentrate and make rational decisions over impulsive ones. As a result, an early diagnosis
• would often result in a number of false positive results, furthermore, side effects from treatment with stimulants in under 5 year olds are as high as 33%, which is much higher than reported in school age children. However, research does report that ADHD symptoms could be identified as early as 15 months in females and 24 months inmales.49 Behavioural correlates
• to ADHD in preschool age children include difficult temperament and regulatory disturbances e.g. increased irritability, crying, hyperactivity and sleep problems.50 A higher prevalence of externalising and internalising symptoms,51 social problems,52 learning problems53 in preschool age children are all linked to an increased risk for developing and being given an ADHD diagnosis in later years.
• NICE recommends that the first line of treatment for pre-school age
• children is parent-training and education programmes.43 These programmes are
• the same as those recommended for the parents or carers of other children with conduct disorder. Drug treatment is not recommended for preschool children with ADHD.

• Modi N, et al. Development of a New Once-a-Day Formulation of Methylphenidate for the Treatment of Attention-deficit/Hyperactivity Disorder. Arch Gen Psychiatry. 2003;60:204-211.
• Kooij JS, Francken MH. Diagnostic interview for ADHD in adults (DIVA). The Netherlands: DIVA Foundation; 2010.
• Wechsler D. Wechsler Intelligence Scale for Children’ – Fourth Edition Integrated (WISC” – IV Integrated). WISC-V: 2014. Psychological scoring scale.
• Camilleri N, Samer M. ADHD: from childhood into adulthood. MMJ. 2013;25(1):2-7.
• Arnett AB, Macdonald B, Pennington BF. Cognitive and behavioral indicators of ADHD symptoms prior to school age. J Child Psychol Psychiatry. 2013;54(12):1284-1294.
• Nigg JT, Goldsmith H, Sachek J. Temperament and Attention Deficit Hyperactivity Disorder: The Development of a Multiple Pathway Model. J Clin Child Adolesc Psychol. 2004;33(1):42-53.
• Larsson H, Dilshad R, Lichtenstein P, Barker ED. Developmental trajectories of DSM-IV symptoms of attention-deficit/hyperactivity disorder: genetic effects, family risk and associated psychopathology. J Child Psycho[ Psychiatry. 2011;52(9):954-963.
• DuPaul GJ, McGoey KE, Eckert TL, VanBrakle J. Preschool Children With Attention-Deficit/ Hyperactivity Disorder: Impairments in Behavioural, Social, and School Functioning. J Am Acad Child Adolesc Psychiatry. 2001;40(5):508-515.
• Pennington BF. Nature and nurture. In: Guilford Press The development of psychopathology. New York: Guilford Press; 2002.
• Webster-Stratton C, Reid MJ, Hammond M. Preventing Conduct Problems, Promoting Social Competence: A Parent and Teacher Training Partnership in Head Start. J Clin Child Psychol. 2001;30(3):283-302.
• Brown TE. Executive Functions and Attention Deficit Hyperactivity Disorder: Implications of two conflicting views. Int J Disabil Dev Ed. 2006;53(1):35-46. FDA. Concerta®. 2008. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/ label/2008/021121s015s017lbl.pdf; Accessed 28 July 2017.
• FDA. Metadate CD®. 2008. Available from: http:// www.accessdata.fda.gov/drugsatfda_docs/ label/2009/021259s021lbl.pdf; Accessed 28 July 2017.
• Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry. 2003;53(2):112-120.
• Sonuga-Barke E. Do psychosocial/ non-pharma interventions work?. Controversies in ADHD – Emanuel Miller Lecture and National Conference. London: Royal College of Physicians 2016.
• Jensen PS, Arnold LE, Swanson JM, Vitiello B, Abikoff HB, Greenhill LL, et al. 3-Year Follow-up of the NIMH MTA Study. J Am Acad Child Adolesc Psychiatry. 2007;46(8):989-1002.
• Richardson AJ, Montgomery P. The Oxford-Durham Study: A Randomized, Controlled Trial of Dietary Supplementation With Fatty Acids in Children With Developmental Coordination Disorder. Paediatr. 2005;115(5)1360-1366.
• Johnson MH. Executive function and developmental disorders: the flip side of the coin. Trends Cogn Sci. 2012;16(9):454-457.
• Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, et al. Nonpharmacological interventions for ADHD: systematic review and meta­ analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry. 2013;170(3):275-289.
• Faraone SV, Spencer T, Aleardi M, Pagano C, Biederman J. Meta-analysis of the efficacy of methylphenidate for treating adult attention deficit hyperactivity disorder. J Clin Psychopharmacol. 2004;24(1):24-29.
• Bolea-Alamaiiac B, Nutt DJ, Adamou M, Asherson P, Bazire S, Coghill D, et al.Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(3):179-203.

–  Journal of the Malta College of Pharmacy Practice