ADHD 1

Guest editorial: Attention deficit hyperactivity disorder has come of age

Attention deficit hyperactivity disorder (ADHD) has seemingly ‘come of age’ in the mid-2020s in Australia (Box 1). There is more than a touch of irony in that development, given that the genetic footprint for ADHD has perhaps been in place in our species since humans first walked this earth. 

The general consensus regarding the origins of ADHD is that it is a predominantly inherited condition. It is thought that genetics accounts for 80% of the phenotypical expression, while environment contributes 20%.¹ That accounts for the variations observed between closely related ADHD individuals, including identical twins.²

Estimates for the prevalence of ADHD vary widely,³ but my sense of it is that at least 10% of the population could be considered neurodiverse in some way, and ADHD is the most common form thereof. Perhaps one explanation for the general underestimates is that no one was really looking for it until recently.

The stereotypical perception of a hyperactive little boy creating havoc everywhere they go is but the most obvious clinical variety of ADHD. That incomplete understanding has perhaps led to it being regarded as a predominantly male preserve. Increasing awareness of its myriad presentations is perhaps the prime cause of its apparently increasing incidence.

It is also essential to keep in mind that ADHD individuals can be found on a wide spectrum of phenotypical expression, ranging from mild to severe, and including everything in between.⁴ The extent of the negative impact on day-to-day executive function can also vary considerably, depending on the context of the individual.

Humans are extremely adept at developing ways to counteract any difficulties they might experience with performing important daily activities. These ‘workarounds’ are emblematic of our ability to adapt, in order to survive and prosper. Neurodiversity might be considered the key to this process, given the recognised ability of that ‘tribe’ to problem solve, create new things and evolve to better perpetuate the species.

The large majority of human history has been spent in the ‘hunter-gatherer’ mode. It has only been perhaps in the last 10–15,000 years that humans came to live in small settlements which gradually became towns and cities.⁵ The existence of early humans was perforce nomadic. It needed the discovery of fire and the development of tools to begin the process of ‘civilisation’.

The distinctive positive traits possessed by ADHD individuals would have been essential to the survival of the human species. Many will have heightened sensory capacities in the basic areas of vision, hearing, smell etc, as well as less defined capacities such as intuition. These enhanced abilities must have provided great advantage in the quest for food and shelter and in the avoidance of danger. Creativity and problem-solving ability are frequently greater than that found among the neurotypical, however defined.⁶

By conferring significant survival advantage, the neurodiverse genotype would have been actively selected in the human species. A subset of early humans without these genes would have been at greater risk of harm because of lesser ability to find food, avoid danger and create tools to solve problems. Nature has always been an unforgiving force!

The gradual transition to village and town life for much of humanity brought with it a need for systems and structure. Inevitably these must have evolved into ways that suited most of the population. That process has never stopped.

The first major clash between the neurodiverse and society typically begins with entry into formal education. The expectation that small children will quickly learn to sit still and follow instructions was never going to work with the ADHD cohort. Some individuals worked out ways to get by, the inattentive subtypes daydreamed and did not rock the boat, typically not reaching their potential and often developing anxiety due to the internalisation of their emotions. Those with multiple manifestations of neurodiversity such as autism, learning disorders and oppositional defiant disorder were struggling from the outset (Table 1). 

When puberty arrived, the smouldering embers of many ADHD children erupted with the onset of seemingly flammable hormones. By then, a large range of adaptations had developed, some functional, many dysfunctional. Any firefighter can tell you that the best way to put out a fire is when it first begins, not when it has taken hold of the building.

The lucky ones were blessed with above average intelligence and stable home lives. The less fortunate were often on a fast train to socioeconomic and health disadvantage. Society is now trying to work out what to do, while the fire is blazing on many fronts!

In this issue readers will learn that ADHD management can begin with a wide range of non-pharmacological strategies.⁷ In a significant number, their implementation can prevent the need to utilise stimulants or at least defer their introduction until further along the child’s educational journey.

The use of stimulants brings an additional responsibility to the prescriber.⁸ Stimulants are classified as Schedule 8 medications, with an additional layer of regulatory monitoring that varies between jurisdictions. The development of real time prescription monitoring has made this aspect of clinical care much safer for all concerned.

The initiation of stimulants is a new activity for almost all Australian general practitioners (GPs). Readers will find the detailed advice on this topic extremely useful.

General practice is the most varied clinical environment in our society. Here you can read about some of the innovative models of GP-centric ADHD care that have sprung up in recent years, including my own on the Mid North Coast of New South Wales.^9,10 It is true that ‘there is more than one way to skin a cat’!