An internationally-renowned expert on ADHD and conduct disorders believes that while there has been a greater recognition of ADHD, clinicians are still only correctly diagnosing a fraction of such cases. Pat Kelly reports.
Dr David Coghill is a senior member of the European Network for Hyperkinetic Disorders (EUNETHYDIS) who has taken a leading role in the development of European guidelines for the assessment and management of ADHD and a programme to aid clinicians to implement these guidelines into practice.
He is also Associate Editor for the Journal of Child Psychology and Psychiatry and European Child and Adolescent Psychiatry and is the Senior Author of the Oxford Specialist Handbook on Child and Adolescent Psychiatry.
In addition, he is joint Lead for the Developmental Disorders Team within NHS Tayside Child and Adolescent Mental Health Services and has developed evidence-based clinical pathways for the assessment and management of ADHD that have been used as a template for other services around the world.
“In the past 10 years, there has been much more acceptance in general — both by the medical community and the general public — that medication can play an important part in the treatment of ADHD,” Dr Coghill told IMT.
“One of the important pieces of clinical information that we now have is that for children with mild or moderate ADHD, we perhaps should be thinking of non-drug treatments as a first option, but for those with severe ADHD, non-pharmacological treatments are unlikely to be enough on their own.”
Dr Coghill pointed out that rather than there being an increase in incidence of ADHD in recent years, it is more accurate to say that there has been a heightened recognition of the condition among clinicians. “There has been a combination of an increase in both clinical skills and awareness among clinicians, but also greater awareness among the general population, such as among teachers, for example, and also among GPs.
“There is now a greater awareness that when a child has problems, ADHD may be one of the potential causes and there is a rise in the numbers of people being referred and a big increase in people’s recognition of what they are seeing when they do encounter ADHD.
“However, in the UK — and I believe this to be the case in Ireland also — we really only recognise a very small proportion of those who do have ADHD. Probably at best, we get one-in-five but the figure is more likely to be one-in-10 of these children who receive a correct diagnosis,” Dr Coghill suggested. “So even though there has been a big increase, ADHD is still very much under-recognised and under-treated.”
He pointed out that recognising and gauging the severity of the condition was key in this regard. “We recognise the severe cases, but with the less severe cases, people often say, ‘it’s a behavioural problem’, without actually wondering why the problem exists and what kind of problem it is.”
Dr Coghill advised: “For clinicians on first presentation, it is important, of course, to ask about symptoms such as over-activity, ability to concentrate and impulsiveness, but it is more important to establish whether these are occurring to the extent that they are interfering with everyday life. If this is the case, then specialist assessment is appropriate.”
In terms of the communication that is necessary between different clinicians and specialists along the care pathway, Dr Coghill commented: “There is always room to improve communication to improve outcomes. In the UK, as in Ireland, doctors are working under enormous pressure with time constraints and volume of work. But if we do not communicate well, we are not going to have the best level of care.”
Dr Coghill explained that important new treatment options were in the pipeline for the treatment of ADHD. “The new medical prodrug treatments emerging are most promising,” he explained. “The real benefit is not that it is better than existing treatments, but that it is different. We know that the first-line existing treatment is effective, but is only effective in about seven out of every 10 people who try it,” said Dr Coghill. “Lisdexamfetamine [new treatment] is also effective in seven out of every 10, but it is a different seven. So with the two medications, we can go up from success in seven out of every 10, to around 19 out of 20, which is a real benefit for those children who do not respond [to previous treatment].”
However, he revealed that interesting non-pharmaceutical treatments were also evolving. “A treatment called neurofeedback [a treatment that involves real-time EEG displays to illustrate brain activity] is on the horizon,” Dr Coghill told IMT. “This can feed information from the brain back into the brain and it’s a completely painless, harmless option where the information is fed back to the brain.
“There is some indication that in the future, once we understand how to really focus that, it could be a really helpful treatment for ADHD. This is still at the experimental stage but there are indications that it works, but still needs to be honed to make it more effective.
“It’s not quite ready to put out there in the clinics yet but it is ‘in the mail’, as they say. So there a number of treatments on the horizon that make me really hopeful,” he concluded.