ADHD – Causes, risk factors and treatment

What is ADHD?

ADHD stands for Attention Deficit/Hyperactivity Disorder. It is a neurodevelopmental disorder that usually begins in childhood. For many people affected, the symptoms persist into adulthood. Worldwide, around 5 in 100 children and young people have ADHD. Boys are diagnosed significantly more often than girls. However, experts believe that ADHD is more frequently overlooked or diagnosed later in girls.

What are the causes and risk factors for ADHD?

The exact causes of ADHD are not yet fully understood. Based on current knowledge, ADHD arises from the interaction of several factors. These include, above all, genetic influences as well as various environmental and developmental factors. Key factors are:

• Family history: ADHD is more common in some families. Studies suggest that it is approximately 70 per cent hereditary.
• Changes in the brain: Differences in the structure and function of certain areas of the brain have been observed in people with ADHD.
• Factors during pregnancy: Factors such as smoking, alcohol consumption or drug use during pregnancy are associated with an increased risk of ADHD in the child.

Important: According to current understanding, ADHD arises from a complex interplay of several factors. A single trigger cannot usually be identified, and research is ongoing into exactly how these factors interact.

What types of ADHD are there?

ADHD can manifest in very different ways. Experts often distinguish between three main types, depending on which symptoms are most pronounced.

Predominantly hyperactive-impulsive type

People with this subtype are often very restless. They find it difficult to sit still or wait patiently, and have a strong urge to move around. They often act spontaneously, without thinking about the consequences. In adulthood, the pronounced physical restlessness may diminish and manifest more as inner restlessness or a constant feeling of being driven.

Predominantly inattentive subtype

In this subtype, inattention is the main feature. This is also referred to as ADD (Attention Deficit Disorder). Those affected usually have difficulty:

• concentrating for long periods
• planning and organising tasks
• paying attention to details
• completing tasks

Combined type

In the combined type, both inattention and hyperactivity and impulsivity are clearly evident. Those affected, for example, find it difficult to concentrate and organise tasks, whilst at the same time being restless and impulsive. Important: Symptoms can vary in severity and change over the course of a person’s life.

What are the symptoms of ADHD?

The symptoms of ADHD mainly affect three areas:

• Inattention
• Hyperactivity
• Impulsivity.

Those affected may, for example, find it difficult to concentrate for long periods, to focus their attention on specific tasks, or to see tasks through to the end. Hyperactivity often manifests as physical restlessness and a strong urge to move. Impulsivity means, amongst other things, that those affected act spontaneously or find it difficult to wait. Which symptoms occur and how pronounced they are varies from person to person. Some people with ADHD mainly struggle with attention, whilst for others, hyperactivity and impulsive behaviour are more prominent. Age and life circumstances can also influence how the symptoms manifest.

When is a diagnosis of ADHD made?

Being inattentive, restless or impulsive does not automatically mean that someone has ADHD. Such behaviours also occur in people without ADHD – particularly in children. ADHD is diagnosed when the symptoms:

• persist over a prolonged period
• are pronounced and occur in at least two areas of life, for example at school or at work, within the family or when interacting with others
• significantly interfere with daily life

The way ADHD manifests itself can change over the course of a person’s life. In younger children, physical restlessness and a strong urge to move are often the main features. In adolescence and adulthood, visible hyperactivity may decrease and be perceived more as inner restlessness or a sense of being driven. Problems with attention, organisation and impulse control, on the other hand, may persist. ADHD often occurs alongside other mental health conditions or disorders. Which comorbid conditions are particularly common varies to some extent depending on age.

Comorbid conditions in ADHD

ADHD often occurs alongside other mental health or neurological conditions. The specific comorbidities that arise can vary depending on age. They can further exacerbate symptoms and complicate diagnosis. Common comorbidities include, for example:

• Social behaviour disorders
• Reading and spelling difficulties
• Learning, language or motor development disorders
• Tic disorders
• Anxiety disorders
• Depression
• Autism spectrum disorders

When making a diagnosis, it is therefore important not only to consider the typical ADHD symptoms, but also to take into account any possible co-morbidities and other causes of similar symptoms. This is also important when choosing a treatment.

What happens if ADHD is left untreated?

If ADHD goes undiagnosed or is not treated adequately, the symptoms can have a long-term impact on school, education, work, relationships and everyday life. The severity of these effects varies greatly from person to person. Possible consequences include, for example, poorer academic or professional performance, difficulties in relationships, and an increased risk of accidents, co-occurring mental health conditions and substance use disorders. An early diagnosis and appropriate treatment or support can help to reduce the symptoms and their consequences. The most appropriate measures depend, amongst other things, on the person’s age, the severity of the symptoms and any co-occurring conditions.

How do ADHD symptoms change with age?

Babies

ADHD cannot yet be reliably diagnosed in infants. Some children who go on to develop ADHD stand out from an early age due to severe restlessness, sleep problems or difficulties with self-regulation. However, such signs are non-specific and also occur in many children without ADHD.

Young children and pre-schoolers

At pre-school age, prominent signs may include marked motor restlessness, impulsivity and difficulty sustaining attention on a task for any length of time. For example, children often switch between activities, find it difficult to wait their turn, or react very spontaneously. As many of these behaviours are also seen in other children, it is important to consider how pronounced and persistent they are, and to what extent they interfere with daily life.

School-age

ADHD symptoms in primary school-aged children can take many forms. The following issues, for example, are common:

• easily distracted
• reduced tolerance to frustration
• forgetfulness
• frequent disruption of lessons
• Specific learning difficulties such as dyslexia, reading difficulties or maths difficulties are common
• inner restlessness
• impulsive behaviour such as tantrums
• low tolerance for frustration

Adults

ADHD is often less obvious in adults than in children, and the symptoms change. Visible physical restlessness often diminishes and is perceived more as inner restlessness or a sense of being driven. Typical complaints include:

• Difficulties organising daily life or work
• Difficulty concentrating (particularly when a sustained attention span is required)
• Impulsivity
• Inner restlessness
• Mild irritability
• Low tolerance for frustration
• low self-esteem

How is ADHD diagnosed?

The diagnosis of ADHD is very complex and involves several steps. These include:

• a detailed discussion of the patient’s medical history
• a physical examination
• a psychological or psychiatric assessment
• Discussions with family members or other significant others
• observations of behaviour
• standardised questionnaires and checklists

In addition, other conditions and disorders must be ruled out. The exact process of diagnosis depends on the individual situation. A thorough diagnosis is important in order to plan the appropriate treatment and support.

What is the difference between ADD and ADHD?

In both ADS and ADHD, those affected find it difficult to concentrate and pay attention. In ADHD, hyperactivity and restlessness are also present. In ADS, hyperactivity is minimal or non-existent. People with ADS are easily distracted and often find it difficult to focus their attention on a task for any length of time. Their restlessness often manifests itself internally rather than through conspicuous behaviour. This is why ADS is frequently diagnosed later, or not at all.

How is ADHD treated?

The treatment of ADHD is complex and is tailored to the individual. The treatment plan depends on the person’s age and the specific presentation of the condition. This is influenced, amongst other things, by the severity of the symptoms, the level of distress, the functional impairments and any co-occurring conditions. Often, several forms of treatment are combined. Experts refer to this as multimodal therapy. Possible components of treatment include:

• Information and counselling: An important first step is providing information about ADHD. This should involve not only the child affected and their parents, but also the child’s teachers or childcare workers. The aim is to gain a better understanding of the condition and to develop helpful strategies for everyday life.
• Counselling for parents and structured parenting training: Parenting training is a key part of treatment, particularly for younger children. Through this, parents learn how to better support their child in everyday life and how to manage difficult situations.
• Support at nursery and school: Children with ADHD often benefit from good cooperation between parents, teachers and educational staff. Together, they can develop measures that make learning and everyday life easier.
• Psychotherapy: In behavioural therapy, those affected learn to cope better with the challenges of ADHD. Together with a therapist, specific solutions are worked out for difficult everyday situations. The aims of the therapy include, for example:
  • strengthening social skills
  • solving problems independently
  • better controlling impulses
  • improving attention
• Medication: In some cases, medication can be a useful addition to treatment. Medication to treat the symptoms of ADHD may be considered from the age of six, following a thorough consultation. So-called psychostimulants are frequently used. The best-known active ingredient is methylphenidate. It can improve concentration and reduce hyperactivity and impulsivity. Depending on the situation, other active ingredients such as lisdexamfetamine, atomoxetine or guanfacine may also be considered. Medication is considered safe, but should always be administered under medical supervision and monitored regularly. There are no known long-term side effects or risks of dependency. Medication is usually prescribed when:
  • the ADHD symptoms are severe
  • ADHD significantly impairs daily life
  • behavioural therapy does not achieve the desired results

• Supportive measures: Depending on individual needs, further measures may be helpful, for example:
  • occupational therapy
  • social skills training to improve interactions with others
  • Individual and group psychotherapy can help to boost self-esteem and cope with problems with peers.
  • Neurofeedback can help to train attention and concentration. This involves providing the person with feedback on their bodily signals and brain activity via a screen.
  • Regular exercise

How can parents support a child with ADHD in everyday life?

Supporting a child with ADHD in everyday life can be challenging for the whole family. Children with ADHD often display noticeable restlessness and, at times, uncontrolled behaviour. This frequently leads to arguments within the family and problems at school or nursery. The following strategies may be helpful in everyday family life:

• Establish a daily structure: Regular routines give the child a sense of direction and greater security in their daily life.
• Agree on clear rules: The child should know what the rules are and what the consequences of certain behaviour are.
• Give clear instructions: Tasks should be described in specific terms so that the child knows exactly what to do. Offer praise: It is important to praise the child repeatedly when they have done something well. Positive feedback boosts self-confidence.
• Avoid sensory overload and excessive demands: Parents should be mindful of which stimuli or situations trigger the problematic behaviour. The child should then be given the opportunity to take a break or leave the situation. It is advisable to talk to the child about this during calmer moments.
• Set realistic expectations: Difficulties should be tackled step by step. Too many demands at once can overwhelm the child.
• Look after your own needs: If everyday family life is consistently very stressful, counselling services, self-help groups or therapeutic support can provide relief.