in prac tice

in practice

Winter 2017 | Volume 9 Number 223 | Comment | Implementation is key Rob Rodrigues Pereira

24 | Management | ADHD and the Functioning Profile Michiel Noordzij

27 | Service provision | The role of support groups Valerie Ivens

30 | Review | ADHD and unintentional injury risk David C Schwebel

34 | Abstract watch | Biological markers, group visits, social deficits and consent Nigel Humphrey

35 | Investigation | Internet memes: what professionals need to know Nathan Hodson

Other features | 39 Diary dateswww.adhdinpractice.com

ADHD in practice is supported by an unrestricted educational grant from MEDICE, with no editorial input into the content of this publication.

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down-to-earth needs-based assessment andneeds-based support. It does not require labellingand the intervention can come from both skilledand non-skilled people in the differentenvironments of the child. The FP can also beused as pre-diagnosis if the child has no benefitfrom the intervention. Even in children with anADHD diagnosis, the FP can aid in decision-making on how best to support the child. It givesa much wider assessment than an ADHDdiagnosis and prevents over- and under-diagnosis. If you are interested, Dr Noordzij isready to install the FP in your practice and toteach you how to use the software and othertools, even in English!

We, as professionals, are aware of risk factorsfor individuals with ADHD, but their exactmechanisms are not known. It may have to dowith impulsivity or inattentiveness or comorbidconditions. In recent years in the Netherlands,for example, there has been a sharp rise in streetaccidents caused by drivers texting while driving.Around 50% of drivers admitted that they look attheir mobile phone occasionally while driving. So,if they are distracted or bored due to their ADHDtrait, they should be treated before driving.Texting during driving is as dangerous as drinkdriving and will be fined in the same way by thepolice. For the price of one prescription,[ok?] youcan treat one patient for one year with long-acting methylphenidate. So, choose your battles!In some countries, the police employ drug tests todetect drivers using illicit drugs, butdexamphetamine also gives a positive result.Normal therapeutic doses are not consideredpunishable, but some patients need high doses toprotect themselves (and others) against baddriving or even road rage, so, according to thecurrent law, they will be fined. An additionalproblem is self-medication of cannabis which canbe detected days or weeks after use.

Nathan Hodson writes about a newphenomenon, the use of memes. Maybe you don’tknow what memes are (like me!), which is a goodincentive to read this interesting article. Youradolescent patients are almost all dedicated usersof social media and will appreciate yourknowledge in this field.

Enjoy this issue CReferences1. The National Institute for Health and Care Excellence. Attentiondeficit hyperactivity disorder: diagnosis and management. ClinicalGuideline 72. www.nice.org.uk/guidance/cg72 (last accessed07/11/17)

Rob Rodrigues Pereira, Editor

BEvery five to ten years the guidelines forADHD diagnosis and treatment must berefreshed. This year, The National Institutefor Health and Care Excellence (NICE)guidelines are in the process of beingupdated and will replace the 2008 version.1

The committee have updated or added newrecommendations on recognition,information and support, managing ADHD(including non-pharmacologicaltreatment), medication, follow-up andmonitoring, adherence, discontinuationand review of medication. This is a hugejob, but the evidence found in the big pile ofnew articles is, like in the former guideline,still not very strong – especially concerningnew diagnostics or therapeutic measures.Of course, there are some changes, such asthe use of lisdexamphetamine (if available)as first choice medication, thendexamphetamine or methylphenidate, thenatomoxetine, which is the only medicationthat has a UK marketing authorisation forthis indication in adults at the time ofconsultation (September 2017). In children,the order is: long-acting methylphenidate,lisdexamphetamine, atomoxetine orguanfacine (all licensed). The mainrecommendation is, however: patient-tailored therapy by mutual agreement.

Although the guideline is excellent and up todate, implementation will be the difficult part. Itdepends on the perception and framing of ADHDin the media and lay people, financial structures,perverse incentives, fear of labelling andinadequate knowledge of school teachers andGPs. What I mentioned in the last edition ofADHD in practice is still valid: it is a long marchfor any individual with ADHD traits to get whathe or she is looking for.

Everyone should read up on the struggles offamilies with a child with a disability. In ValerieIvens’ article, you feel the anger and hope of aparent. A diagnosis can come as a huge relief, butwhat comes next? Realising what patients andfamilies have to deal with might provide theincentive to address these issues in your ownpractice. And don’t forget to embrace the support groups!

Michiel Noordzij’s article is not so muchabout DSM categorisation, as it is about directhelp after measuring concerns about thefunctioning of the child. The Functioning Profile(FP) is an instrument that consists of a very

www.adhdinpractice.com | 23ADHD in practice | 2017; Vol 9 No 2

Implementation is key

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EditorRob Rodrigues Pereira MD Paediatrician

(Behavioural Paediatrics), Medical CenterKinderplein, Rotterdam, the Netherlands.

Editorial BoardAndrea Bilbow OBE President,

ADHD Europe; Founder and CEO, AttentionDeficit Disorder Information and Support

Service, London, UK.Andy Bloor BA(Hons) MEd FHEA

Senior Lecturer in Primary Education (SEN, Inclusion and Diversity), Canterbury

Christ Church University, UK.Barry Bourne BA MSc AFBPsS CSci CPsychol

Independent Educational Psychologist, Wirral, UK.

Hervé Caci MD PhD Child and AdolescentPsychiatrist, Nice Paediatric Hospitals,

University Hospital Centre Lenval, Nice, France.

Søren Dalsgaard MD PhD Senior Researcher,National Centre for Register-Based

Research, Aarhus University, Denmark.Isabel Hernández Otero MD MSc MS(Psychopharm)

Director, Department of Child andAdolescent Psychiatry, University Hospital

Virgen de la Victoria, Malaga, Spain.Nigel Humphrey BA(Hons) MSc Clinical

Psychologist, Child and Adolescent MentalHealth Service, Guernsey, Channel Islands.

Frank W Paulus PhD Head Psychologist,Psychotherapist and Supervisor

(BT and CBT), Department of Child and Adolescent Psychiatry, Saarland

University Hospital, Germany.Noreen Ryan RGN RMN ENB 603 ENB 998 BA(Hons) MSc

Nurse Consultant, Child and AdolescentMental Health Service, Royal Bolton Hospital

NHS Foundation Trust, UK.Susan Young DClinPsy PhD CSi AFBPS

Clinical Senior Lecturer in Forensic Clinical Psychology, Centre for MentalHealth, Imperial College London, UK.

Corresponding MemberDaryl Efron MBBS FRACP MD ConsultantPaediatrician, The Royal Children's

Hospital, Melbourne, Australia.

Comment

Management

| www.adhdinpractice.com24 ADHD in practice | 2017; Vol 9 No 2

SADHD and theFunctioningProfile

&Michiel Noordzij[please addqualifications] Child-and AdolescentPsychiatrist 1 andMedical Director 2

1 [please addaffiliations]

2 ChildPoint, TheNetherlands

■ The FunctioningProfile allows the user to measure theprogress of the child’scurrent situation inboth specialisedsettings and in low-skilled areas, by youthcare professionals,parents and teachers.

ttention deficit hyperactivity disorder(ADHD) has multiple manifestations. It is

more than a DSM-5 1 classification made in aconsulting room, and more than adequatemedication and psychoeducation given to thechild and its parents. The many manifestations ofADHD that are encountered in schools and youthservices need to be considered in decision-makingabout the next steps for the child. This requiresputting the additional knowledge and skills fromthose who work and interact with the children ona daily basis into practice. This article describesthe Functioning Profile (FP),2 an instrument thatallows a needs-based assessment in the child’severyday environment, taking into account themultiple manifestations of ADHD and specialistknowledge and skills. The outcomes from the FPassessment contribute to organising support forchildren in youth care, schools and at home,without the risk of early medicalisation.

The complexity of ADHDADHD can be considered a complex disorder because ofits varied manifestations and its extensive consequencesfor development. The support of children with ADHDrequires insight into the factors that play a role in theircurrent situation. In order to achieve needs-based support,a specific needs-based assessment of the child needs to be

carried out. This requires the organised handling of amultitude of data.

The complexity of ADHD can be described on different levels: ● symptom level ● developmental level● contextual level ● organisational level.

The symptom level describes the functioning of thechild. This level identifies the possible co-morbidities –the regulatory and other behavioural issues that canmanifest themselves in the child.

At the level of development, the various developmentalareas of the child and the status of maturational delays aredescribed.

The child’s contextual level analyses the interactionsof the child with his/her environments, including: home, school and leisure. The cultural background of the child, religion, educational and parenting styles, lifeevents, trauma's and unsafe situations are all consideredat this level.

The organisational level of ADHD applies to the microlevel of treatment, where it is decided how to address thedisorder, developmental delays and interactions, in amethodical coherence. An order needs to be arranged inhow to treat or support the child at this level. Theorganisational level also applies to the meso level of regionalco-operation: how is ‘who does what’ determined, and how

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Management

is adequate communication across the child’s supportsystem achieved? At macro level, decisions are made aboutthe allocation of resources. This level demonstrates the needof the government and the municipalities to demedicalise.It is about providing support to children in their livingenvironments without sticking with medical labels. It goeshand-in-hand with the need to save on budgets.

The distinctions between the four levels – symptomlevel, developmental level, contextual level andorganisational level – provide a complex approach toADHD. All play their role in the daily decision-makingabout how the child should be supported. A diagnosis andevidence-based treatment from a consulting room is nolonger enough and is sometimes no longer accepted. Inaddition, it must be remembered that many children withADHD never appear, or appear only briefly, in consultingrooms. Therefore, their behaviour and specific needs areshown and best observed in their living environments. Thequestion now is, how can the child be supported with acomplex and changing presentation of ADHD if they areunlikely to present in the consulting room? An additionalquestion is, how can the people who are busy with thespecific needs shown by this child on a daily basis besupported? To make a start, it is necessary to make thiscomplex and ever-changing set of factors available formaking decisions in the workplace.

Needs-based assessment and support with the FPTo respond adequately to the different needs at a given timeand, therefore, to changing manifestations ofsymptomatology, development and living conditions of thechild, it is necessary to be able to portray these. Based on 25years of clinical experience, a web-based application wasdeveloped that takes a survey of the child's current situationin all the areas mentioned – this is the FP. It captures animage of the filler’s concerns about a broad spectrum offunctioning, and interaction with the child and of any pointof concern could also be a stimulating factor. For example,if a child is showing behavioural problems, the appropriatefunctioning of his conscience can be a stimulating factor.The identified points of concern will be used as the basis forthe support that the child will receive. The FP is used tomonitor the results of the support given by simply filling outthe FP again. By repeating the FP, it is possible to portraythe child’s progress, but also to assess and correct theeffectiveness of actions taken. The FP shows the graphicaldisplay of previous results, so that it is easy to monitor thethe child’s progress. Any outcome of a repeatedly executedFP says something about the progress of the child and aboutthe outcome of the intervention performed.

Measuring the progress of a child’s current situation inmultiple places is important. The FP can be used both inspecialised settings and in low-skilled areas by youth careprofessionals, but also by parents and teachers. The childcan also participate in completing their FP from about 12years of age. With different people contributing to the FP

with a complex disorder like ADHD, ideas on the next stepscan differ between contributors, but the FP also facilitatesdiscussion with shared reference points. This is useful insituations where both professionals and non-professionalscome together and in which decisions must be made.

The FP can be used as a first measurement (pre-diagnosis) for concerns about the functioning of the child.It enables decisions to be made about whether (over-)medicalisation can be prevented, or whether furtherinvestigation of the child is appropriate. If there isprolonged suboptimal functioning in the child,unrecognised relapse in functioning, or if the schoolteacher is concerned about the progress of developmentor of the effect of measures taken, the FP can be deployed.The FP can be used to make an inventory of the child’sspecific support needs in special education upon entry andleaving the class. Both in youth care and at school, the FPhelps professionals improve their ability to work aroundthe child with the ability to evaluate and revise decisionsearlier. This helps to systematise the care process insometimes complex circumstances.

ADHD in practice | 2017; Vol 9 No 2

S Figure 1.Screenshots fromthe FunctioningProile showing theuse of the movingbubble, with thedesired situationhighlighted in pinkand action points toachieve the goal onthe right (1a) and anexample of a groupreport (1b)

1a

1b

Management

| www.adhdinpractice.com26

Information and Communications Technology (ICT)makes it possible to carry out a group analysis of a classor department and of children in a particular district,school or region. A group analysis gives an indication ofthe complexity of a group problem and helps in designinggroup interventions. On a larger scale, the group analysishelps allocate resources and assess their impact.

Using the ‘moving bubble’, another feature of the FP(see Figure 1), scenarios can be discussed with thoseinvolved with the child. If a bubble in a graphicalrepresentation of the results is moved to a more desiredlocation, the programme immediately calculates whatprevents the child from functioning at that level. Its usemakes it possible to discuss the feasibility of an idea orplan with all concerned.

The FP shows the child’s actual level of functioning,which may be at a high (green), moderate (yellow) or low(red) level. These three levels of functioning each havetheir own support guidance. For example, at green level asimple consultation is often enough, while adequatesupport at the red level requires more effort across thechild’s whole support system. The results from the adviceat red level are difficult to predict, require moreinvolvement from professionals and will be moreexpensive to obtain.

Whem the FP indicates areas or points that requiresupport, the level of functioning shows the feasibility of aplan of action. Using the FP, therefore, can play a role bothin conducting a needs-based assessment and planningneeds-based support. A link is made between a broadinventory of factors and the organisation of the approachto support the child.

The FP and ADHDIf a child has an ADHD diagnosis, it does not mean thatthere is a clear indication of how support will be provided.Although we have to use DSM-5 to classify ADHDunambiguously,1 there is no uniform manifestation of thedisorder – either with the same child over time or withdifferent children at the same time. The consequence ofrepeated application of a wide profiling with the FP is that,even in complex ADHD, there are no actions that are not

specifically aimed at the needs of the child in his/hercontext. In addition, the measures taken can be correctedas necessary.

If the child presents his/her ADHD in a series ofmanifestations, that do not lead to an adequate diagnosis,or if there is no longer adequate care or support, the child,parents and school can be under great pressure. Over time,separate measures can be taken to focus on isolatedproblems, such as: behavioral, anxiety and mood problemsor disadvantages in development and school performance,without the connection with ADHD. This usually does notimprove the child’s prognosis.

Group analysisIn a group analysis at a special education school, the FPwas used in 15 boys aged 13–17 years old, as the school wasconcerned about them and asked for advice. Eight of themshowed the following combination: attention problems,poor executive functions, learning problems, acting outand acting in and regulatory problems of emotions andaggression. All were not, or no longer, in care and theirbehaviour posed serious problems to the school. Althoughit was not possible to get them all to the outpatient clinicfor an adequate diagnosis and treatment, it was possibleto advise the teachers how to deal with each of them better,based on their own specific FP.

ConclusionProfiling and determining a child’s level of performance isuseful in the light of needs-based assessment and needs-based support. The FP is an ICT tool that gives a broadpicture of the current situation of a child or group ofchildren. It illustrates the concerns of one or more fillersabout a child, as well as the stimulating factors, in manyareas of functioning and interaction. The FP gives handlesfor making decisions on support at the youth care or schoolor workplace or home or sports club. This helps insystematising decisions about a child. It can be used as atool for pre-diagnosis, and it helps to prevent over-diagnosisand unnecessary medicalisation. The FP also helps toprevent missing a diagnosis. If ADHD is established, the FPcan provide advice to skilled and non-skilled people involvedin the child. With the ‘moving bubble’ technology, scenarioscan be made and tested for feasibility. Group analysisenables the evaluation of data on a larger scale ■

Declaration of interestThe author declares that there is no conflict of interest.

References1. American Psychiatric Association. Diagnostic and Statistical Manual of MentalDisorders, 5th edn. Washington, DC: American Psychiatric Association, 2013.2. Child Point. The Functioning Profile. www.functioneringsprofiel.nl (last accessed26/10/17)


S The Functioning Profile (FP) is a web-basedapplication that surveys the child’s current situation to contribute to organising supportfor children in youth care, at school and athome to avoid early medicalisation.

S The FP can also be used to track the child’sprogression and to ensure the supportrecommended is having the desired effect.

S The FP prevents missing a diagnosis as it can be used by professionals the childencounters in their every day situation, anddoes not rely on the child presenting in clinic.

Keypoints

BProfiling anddetermining

a child'slevel of

performanceis useful inthe light of

needs-basedassessmentand needs-

basedsupportC

To access the Functioning Profile website, please go towww.functioneringsprofiel.nl (available in Dutch only). The Functioning Profile is available in English and will soon be available in German. Please contact the helpdesk forinformation about the possibilities or for further information:[email protected]

aising a child with any disabilityis something that only parents

who have experienced it can reallyunderstand. That is not said lightly,nor is it intended to diminish thegenuinely serious task of parenting ingeneral, but it does add an extradimension. I have worked withchildren and young people with adiagnosis of attention deficithyperactivity disorder (ADHD) andtheir families for nearly 20 years, andtheir stress and exhaustion ispalpable. ‘Is it my fault?’, ‘Why me?’, ‘Imust be a bad parent.’ Add to that theexhaustion of actually raising a childwho generally cannot start a task, stayon task, finish a task, fidgets endlessly,zones out, forgets instructions(regardless of countless reminders) isusually late, cannot get up in themorning, loses books and sports kitand is often constantly on the go – ifnot physically, then mentally andverbally. The self-blame game goes onand on. Typically, up until a formaldiagnosis, advice will have beenarriving thick and fast from allquarters. As so many of our parentsfrom ADHD Richmond support grouptestify, everyone has an opinion abouttheir child: ‘Give it time,’ ‘She needs abetter routine’, ‘She’s hungry’, ‘She’sthirsty’, ‘She’s hot’, ‘She’s cold’, ‘He’sthe eldest’, ‘He’s the youngest’, ‘Wellhe’s the middle child’, and classically‘Ah, well, he’s a boy.’ Eventually, adiagnosis can come as a huge relief,but what next?

Experience of special needs and isolation Despite having a daughter with a chronicand complex medical condition, supportgroups were not for me. I was lodged firmlyin the medical model, believing only theoracles of Great Ormond Street, having beenlet down by local services who felt they couldnot cope with her complex needs. I feltisolated, sad and angry and eventuallytransformed this negative energy into apassionate determination to ensure shewould be well supported. I was fortunate

enough to be able togive up my career tohelp structure andencourage her andinform others abouthow to best help.Today, she is a thriving

and strong testimony to the willpower andresilience of those who come through suchadversity. My experience encouraged me toensure that other parents were not alone,and I started work at a local charity forchildren with special needs. It was there thatI came across ADHD and the parents whofelt victimised, blamed, stigmatised and thattheir children were misunderstood. I felt areal need, not only to support these families,but to represent their collective voice to localservice providers with the hope of effectingchange and greater understanding.

Support groups could play a pivotal role,not only in supporting families throughincredibly challenging times but also byforming a common voice for change. Myaim in this article, while accepting thatsupport groups are not for all, is tounderline the important role they play andthe unharnessed potential they possess.Whether it occurs immediately afterdiagnosis or at a critical point in a child’slife, a shared experience has significantbenefits. My aim is to highlight andgalvanise the huge potential and passion ofparents to make a bigger difference. To me,this latter part is missing in the nationalADHD context and I would like to establisha framework that allows support groupsaround the country to come togethertowards a common goal of challengingignorance and raising awareness.Supporting families, studying the condition,working with young people and workingwith service providers to bring aboutunderstanding and change has been myday-to-day mission ever since.

The hidden ADHD storyBoth anecdotally and from evidence-basedresearch, there is no doubt that ADHD isleads to conflict and poor cohesion withinthe family1 and significant depression,anxiety and stress for parents.2 Children andyoung people with ADHD may have a higher

frequency of behavioural and conductproblems than children without ADHD,leaving a larger than usual burden onfamilies to cope.3 In adolescent follow-upstudies of girls, persistent impairments werefound in multiple domains, such as peerrejection and academic achievement,4 andincreased risk for developing otherpsychopathologies, such as conduct disorderor depression, was evident.5 Girls withADHD are also more likely to be bullied thantheir peers without ADHD.6 These factorsimpact on young people’s mental health andtheir ability to manage the school day andmake and keep friends. The wider family isalso impacted, with friends and relationsstruggling to understand and support whatseems like a very difficult child or teen.

We also know that parents feelstigmatised by social groups, and that theeffects on social functioning may impactpersonal relationships with partners, so alltoo often family breakdowns occur.

The real ADHD – not just naughty kids?Anyone who has any solid workingknowledge about this neuro-developmentalcondition will roll their eyes at this overused,inaccurate and frankly insulting anecdotethat ADHD is just a way of describingnaughty kids – it is wrong and that is a fact.Parents and carers have had enough of beingstigmatised by poorly researched newspaperheadlines screeching about pharmaceuticalcompany profits without understanding thefacts. In the UK, the only way to get adiagnosis of ADHD is to see a trained expert– usually a consultant child and adolescentpsychiatrist – and reach a diagnosticthreshold over a number of nichedetermined criteria. ADHD has to beconsidered a life-changing disability thatadds serious and sustained impairment toeveryday activity. This is no disabilityfeatherweight, but a chronic and seriouscondition.

The complexity of a diagnosis means that one child is rarely like another,causing late diagnosis, confusion andmisunderstanding among professionals. In all the time I have worked alongsidefamilies and health and teaching

ADHD in practice | 2017; Vol 9 No 2 www.adhdinpractice.com | 27

Service provision

The role of support groups &Valerie IvensBA (Hons) Parent,Support GroupLead, ADHD Coachand Advisor 1

1 ADHD [email protected]

R

professionals, I can honestly say no twochildren have ever been alike in theirpresentation of ADHD or mix of difficulty.

Diagnosis and next steps A clear diagnosis of ADHD helps the personand the wider family too. Anecdotally, wehear there is less blame, a willingness tothink again about how they interact withtheir child and a change in attitude towardsothers once they have a clear understandingof what the diagnosis actually means.

A coffee and a chat – so yesterday?So what is the role of support groups, andhave they moved on from a shared chat overa coffee? Is there still a place for just meetingand talking in an age when everything isavailable through an online search? Well, Ifundamentally believe there is an absolutelycritical role for face-to-face contact.

A recent study examined what parentsof children with disabilities and specialneeds found helpful about belonging tomutual support groups.7 Quantitative data(based on 56 parents from six groups)indicated that members found the groups‘very helpful’ and were ‘very satisfied’ withthe support they received. They alsodescribed the groups as high in cohesion,expressiveness, task orientation and self-discovery. An analysis indicated that suchsupport was helpful in three broad areas:● the sociopolitical, which involved

developing a sense of control and agencyin the outside world

● the interpersonal, which involved a senseof belonging to a community

● the intra-individual, which involved self-change.

Key benefits were identified as a sharedsocial identity, learning from the experienceof others, personal growth (based onconfidence and self-esteem), empowermentand psychological health benefits. Studiesstrongly suggest that parents perceivebenefits from peer-support programmes ashighly effective, and this is sustained acrossvarious types of support and conditions.

Looking at the shared social identity,parents finally found a sense of belongingafter other parents had seemed tostigmatise and marginalise them. The storyof the cold shoulder at the school gate is afrequent one, as is children not beinginvited to parties or parents to class

gatherings. Yet the ability to share througha support group helped foster a sense ofbelonging, support and empowerment.This actually enabled parents to feel able tocope better and experience a reduced senseof isolation, loneliness and guilt.

These are very significant findings thatprovide evidence to back up the things thatparents have consistently told us over thelast 20 years.8,9

The joy of the support group ethos is itssense of continuity, to be dipped into and outof throughout a family’s journey. There willalways be critical times when parents wish toseek out others who have been through asimilar experience, and times when thingsfeel more stable. Typically, key times seem tobe school transition periods (primary tosecondary, puberty, transition to adulthoodand beyond school). On some occasions, itwas found to be helpful for parents to createsmaller groups meeting outside the mainsupport group forum, typically sharingexperiences more closely about topical issuesand expanding their social and supportnetworks. In general, and for the vastmajority of parents and carers, it is a sense ofcommunity and belonging that gives themthe security of knowing that support is athand, as and when it is needed.

The support group offerThe group with which I have workedprovides support in many forms. Perhaps

the most important form is an exchange ofuseful and practical information. Manystudies have found that the exchange ofuseful and practical information is animportant element of support, and manyparents also described learning from theexperience and knowledge of otherparents.10–13 Add to this the chance to justshare experiences with other parents on thesame journey and a handful of veryexperienced professionals covering law,education and coaching, and the value ofthe group cannot be overstated. In a settingin which parents have access to each otherand to knowledgeable experts – either asregular speakers or as the group’s supportnetwork – a self-confidence andreassurance starts to develop, empoweringthem in their conversations with thoseinteracting with their children.

Reports underline the criticalimportance of social identity – that thissharing fostered a sense of belonging,support and empowerment, and that carerswere better able to cope.11,14 Parent mentorsgive further support by drawing on theirown experiences to help other parents gainconfidence and offer reassurance.

This support allows parents to gainstrength and feel empowered as well ashelping them to develop new skills and feelmore motivated, affirming theirexperiences as parents.

Perhaps more importantly, belonging to


Service provision


■ For the vast majority of parentsand carers, there is asense of communityand belonging whichgives them security ofknowing that supportis at hand, as andwhen it is neededSTILLFX/SHUTTERSTOCK.COM

and sharing these experiences within agroup helps parents and carers feel moreconfident and in control and less alone anddepressed, and this in turn brought aboutan improved relationship with their child.8

With a disability that has challengingbehaviour and labile emotions at the centre,such a positive finding cannot be overstated.

Support for each other – is there more?Perhaps my main driver for writing thisarticle is because I see so much morepotential for these parent voices andpassions. There are no greater advocatesfor children and young people withdisabilities than their parents, regardless ofthe disability. We have seen over the past5–10 years a huge awareness campaign forautism and the very real need for a greaterunderstanding of the condition,culminating in the Autism Act, which haspaved the way for teacher training, earlier

identification and interventions. I stronglybelieve that ADHD, increasingly free fromits poor press and with brain scanningimages confirming the brain developmentdifferences, will receive the same nationalawareness afforded to autism within thenext five years. The results would becatalytic in supporting these vulnerablechildren through school and adolescence,when things can so easily go wrong. Thecost to society of a young adolescent routeddown a negative path, frequently known topolice and the criminal justice system, ishuge. The cost of awareness of ADHD andearly intervention is a fraction of this andcould reduce the amount spent on thecrimincal justice system in the long run. Soyes, this is a rallying call to all of thosesupport groups out there who would like tosee a national movement for change. And itwon’t be a moment too soon.

There is a strong motivation amongsupport group members to offer others

what they have received themselves. Justimagine that operating at a national level ■


References1. Biederman J, Faraone S, Milberger S et al. Predictors ofpersistence and remission of ADHD into adolescence: resultsfrom a four-year prospective follow-up study. J Am Acad ChildAdolesc Psychiatry 1996; 35: 343–51.2. Pimentel MJ, Vieira-Santos S, Santos V, Vale MC. Mothers ofchildren with attention deficit/hyperactivity disorder:relationship among parenting stress, parental practices andchild behaviour. Atten Defic Hyperact Disord 2011; 3: 61–8.3. Bagwell CL, Molina BS, Pelham WE Jr, Hoza B. Attention-deficit hyperactivity disorder and problems in peer relations:predictions from childhood to adolescence. J Am Acad ChildAdolesc Psychiatry 2001; 40: 1285–92.4. Hinshaw SP, Owens EB, Sami N, Fargeon S. Prospectivefollow-up of girls with attention-deficit/hyperactivity disorderinto adolescence: Evidence for continuing cross-domainimpairment. J Consult Clin Psychol 2006; 74: 489–499.5. Monuteaux MC, Faraone S, Gross LM, Biederman J.Predictors, clinical characteristics, and outcome of conductdisorder in girls with attention-deficit/hyperactivity disorder: alongitudinal study. Psychol Med 2007; 37: 1731–1741.6. Elkins IJ, Malone S, Keyes M, Iacono WG and McGue M. Theimpact of attention-deficit/hyperactivity disorder onpreadolescent adjustment may be greate for girls than forboys. J Clin Child Adolesc Psychol 2011; 40: 532–545. 7. Solomon M, Pistrang N and Barker C. The benefits of mutualsupport groups for parents of children with disabilities. Am JCommunity Psychol 2001; 29: 113–132.8. Brown LD. Towards defining interprofessional competenciesfor global health education: drawing on educationalframeworks and the experience of the UW-Madison GlobalHealth Institute. J Law Med Ethics 2014; 42: 32–37.9. Singer G, Janet M, Powers LK et al. A multi-site evaluation ofparent to parent proframs for parents of children withdisabilities. J Early Interv 1999; 22: 217–229.10. Bull L. The use of support groups by parent of children withdyslexia. Early Child Dev Care 2003; 173: 341-347 11. Kingsnorth S, Gall C, Beayni and Rigby P. Qualitativefindings from a pilot parent led peer support group. Child CareHealth Dev 2011; 37: 833–840.12. Rearick EM, Sullivan-Bolyai S, Bova C and Knafl KA.Parents of children with newly diagnosed type 1 diabetesexperiences with social support and family management.Diabetes Educ 2011; 37: 508–518. 13. Sullivan-Bolyai S, Lee MM Parent mentor perspectives onproviding social support to empower parents. Diabetes Educ2011; 37: 35–43. 14. Nicholas DB and Keilty K. An evaluation of dyadic peersupport for caregiving parents of children with chronic lungdisease requiring technical assistance. Soc Work Health Care2007; 44: 245–259.


Service provision

SKey benefits of support groups are a shared socialidentity, learning from the experience of others, personalgrowth, empowerment and psychological health benefits.

SSharing experiences within a group helps parents andcarers to feel more confident, in control and less aloneand depressed.

SSupport groups have a strong motivation to offer otherswhat they have received themselves.

Keypoints

ttention deficit hyperactivity disorder(ADHD) symptoms have been linked to the

risk of unintentional injury for decades, dating toat least the 1939 assertion by Dunbar andcolleagues 1 that hypothesised factors such as an‘urge to activity’ and ‘impulsivity’ might lead to therepeated fracture injuries that the authorsobserved in select adult industrial workers.

In contemporary epidemiological research, repeatedstudies indicate that children, adolescents and adults withADHD have an increased risk of unintentional physicalinjury. A recent meta analysis reported that effect sizes forthe relationship generally hover in the 2.0 range,indicating that individuals with ADHD have roughly twicethe risk of injury compared to healthy individuals.2 Thisrelation has been reported in large-scale cohort studies(such as Merrill and colleagues 3), instudies of risk-taking in simulatedenvironments (such as Stavrinos andcolleagues 4), and matched case-control studies (such as Shilon andcolleagues 5), and seems robust to childdevelopment, culture, injury causesand types and changes over time.

Almost all research identifying linksbetween ADHD and injury risk relieson correlational data, however, thecausal factors underlying the association remain unknown.Most experts agree that there may be multiple underlyingfactors that co-occur to increase the likelihood of injuryamong individuals with ADHD. Below, several of the causalfactors hypothesised to be the most relevant are outlined.

Core symptomsADHD is hallmarked by three behavioral patterns –inattention, impulsivity and hyperactivity – and each hasbeen hypothesised to play a role in risk of injury amongpeople with ADHD. Inattention incorporates behaviourssuch as failing to attend to details, sustain attention duringtasks, attend to and follow instruction and stay organised.Maintaining one’s physical safety may require such skills.As an example, research in computer-simulated virtualpedestrian environments suggests that children andadolescents with ADHD exhibit riskier street-crossingbehaviours than children without ADHD do, perhapsbecause they attend less carefully to the traffic environmentsthat they encounter.4,6 Similar observations are reported inreviews of how ADHD diagnoses influence driving safety.7

Impulsive behaviours associated with ADHD includepatterns of interrupting others, experiencing difficulty in

waiting and intruding into others’ activities. Suchbehaviours may also increase the risk of injury. Forexample, in case reviews of paediatric burn injuries,scholars ascribe a substantial portion of unintentionalburn injuries to children’s impulsive behaviours, includingplaying with fire and flammable liquids/aerosols andpulling pots with hot liquids onto themselves.8,9 Othershave approached links between ADHD-associatedimpulsivity and injury risk from a neurobiologicalperspective. They argue that executive function deficits,such as poor inhibitory control, may lead individuals withADHD to make dangerous, disinhibited or impulsivedecisions in injury–risk situations, such as while driving.7

Still others have approached the question from abehavioural perspective, discovering that boys withADHD, perhaps due to impulsive behaviour patterns, were

less likely to anticipate risk or personalharm when encountering hazardoussituations, and were also less apt orable to consider prevention strategies,therefore, leading to increased risk ofinjury.10

Individuals with ADHD may alsodisplay hyperactive behaviourpatterns, which include difficultysitting still, fidgeting, leaving one’s seatinappropriately and running and

climbing in situations when one should not. Although onthe surface hyperactive behaviour patterns might appearto be related to injury risk, scientific results linking the twoare not well-established. One can imagine proscribedsituations in which hyperactivity may result in injury –fidgeting in heights where fall injuries are plausible orclimbing unstable structures – but research-based linksbetween attentional deficits and injury, and betweenimpulsivity/disinhibition deficits and injury, are moreestablished than links between hyperactivity and injury.

Behavioural choicesIncreased risk for injury among individuals with ADHDmay not occur entirely through direct pathways, but alsothrough more frequent exposure to situations that mightcause injury to anyone. In other words, individuals withADHD may choose to engage in activities that expose themto higher injury risk, and the higher exposure rate leads tohigher injury rates. There is evidence, for example, thatchildren with ADHD choose to play on team sports morethan individual sports or other leisure activities.11 Suchengagement may lead to more frequent sports-relatedinjuries, risk that is amplified by evidence that children

Review


ADHD and unintentionalinjury risk

&David C SchwebelPhD UniversityProfessor ofPsychology andAssociate Dean1

1 University ofAlabama atBirmingham, USA

B... individuals with

ADHD may choose toengage in activities that expose them to higher injury risk ...

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■ Children with ADHD prefer to play on sports teams overindividual sports orother leisure activities.Such engagement maylead to more frequentsports-related injuries– an effect amplified byevidence that childrenwith ADHD engage inmore aggressive andillegal play during teamsport competitionsthan comparisongroups do

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with ADHD engage in more aggressive and illegal playduring team sport competitions than comparison groupsdo.11 Links between ADHD and selection of injury–risksituations probably continue throughout the lifespan.Among adolescents, there are associations between ADHDand substance use, which may lead to increased injury riskthrough falls, intoxicated driving and other mechanisms.12

It is unclear if adults with ADHD drive more often thanadults without ADHD, but there are established linksbetween adult ADHD and risky and reckless drivingbehaviour.13

Comorbid conditionsADHD frequently co-occurs with othermental health conditions, includingoppositional and conduct disorders.Symptoms from comorbid conditionsmay contribute to increased injury risk among individuals with ADHD.For example, oppositional defiantdisorder co-occurs in about one-thirdto half of children with ADHD andincludes symptoms of defiance anddisobedience against rules.14 Whenrules are present to ensure safety andare defied, injuries may occur.Similarly, conduct disorder co-occursfrequently with ADHD and includessymptoms of fighting, truancy and fire-setting that may be associated withinjury risk. One relevant study foundthat pre-schoolers diagnosed withoppositional defiant disorder (ODD),and followed for two years, had more injuries thandemographically matched controls, but that comorbidADHD did not contribute additional risk beyond the ODDdiagnoses.15 Some have proposed that oppositionality maybe particularly relevant for young children with ADHD, asyoung children with hyperactive and impulsive behaviourpatterns may be protected from injury by adultsupervisors, especially if comorbid oppositional behaviourpatterns are absent. Older children and adolescents, whomake many decisions about their safety independent ofadult influence, may be more influenced by impulsive orinattentive behaviour patterns.16

‘Reverse’causality: can injuries cause ADHD symptoms?The general consensus among scholars is that ADHDsymptoms might lead to increased injury risk, but a ‘reverse’hypothesis has emerged in the field proposing that injuriesmight sometimes cause ADHD. Severe head traumainjuries, in particular, can lead to ADHD symptoms andlead to ADHD diagnoses. Patients who experiencetraumatic brain injuries most dramatically display deficitsin inhibition that closely mimic ADHD symptoms,sometimes called ‘secondary ADHD’.17 Symptom changes

are sometimes temporary, but there isalso evidence of long-term changes infunctioning relevant to ADHDsymptoms and diagnoses, especiallyfollowing severe brain injuries.18

Implications for treatmentand preventionInjury scholars often cite an adage,‘injuries are not accidental’. In fact,there are a number of strategies thatcan be used to prevent injuries fromoccurring, including injuries toindividuals with ADHD.

From an injury preventionperspective, the same strategies usedto prevent injuries for the generalpopulation are likely to be effective forindividuals with ADHD. Children withADHD must be supervised by qualifiedand attentive adults, as those adultscan provide the impulse control and

attentional capacity required to keep children safe inpotentially dangerous environments. Adolescent and adultdrivers with ADHD will experience reduced risk if theyavoid driving while distracted, fatigued or intoxicated.Sports injuries can be prevented through judiciousrefereeing, and workplace injuries through adherence tooccupational safety guidelines and policies. Broad injuryprevention guidelines specific to particular age groups,environments and situations are available from multiplegovernment, non-profit and scholarly sources. From theperspective of treating ADHD, to state the obvious, itwould be expected that amelioration of symptoms


SADHD symptoms and diagnoses are associated with increased risk of unintentional physical injury.S The risk transcends age, human development, culture, geography and time. SCausality of the link between ADHD and injury risk is unknown and likely multifaceted,

but hypothesised factors include: the inattentive and impulsive traits associated with ADHD;behavioural choices that expose individuals with ADHD to higher injury risk; comorbid conditions(including oppositionality) and possibly ‘reverse causality,’ whereby traumatic brain injuries cause ADHD symptoms and diagnoses.

S Treatment of ADHD should reduce injury risk, and injury prevention efforts should reduce risk for all individuals.

Keypoints

BSevere head traumainjuries, in particular,

can lead to ADHD symptoms and even to ADHD diagnoses.

Patients who experiencetraumatic brain injuries

most dramatically displaydeficits in inhibition that closely mimic ADHD symptoms,sometimes called ‘secondary ADHD’

C


associated with ADHD – and especially symptomsassociated with inattention and impulse control – mightreduce the risk of injury for those individuals with ADHD.There is some published evidence that pharmacologicaltreatment might reduce risk of injury.19

ConclusionADHD is associated with increased risk of unintentionalinjury. Research supports this association through lifespandevelopment, across cultures and across time. Thecausality of the relation is less established, although datasupport the hypothesis that the core symptoms of ADHD– especially inattention and impulsivity, as well ascomorbid symptoms from disorders such as ODD andbehavioural choices made by individuals with ADHD –contribute to the association. There is also some evidencethat traumatic brain injuries may create ADHD symptomsand diagnoses. Further research is needed to continue toanalyse the relationship, but we must simultaneously workto prevent injuries among individuals with ADHD, boththrough empirically supported injury-preventionstrategies and through empirically supported behaviouraland pharmacological treatment of ADHD ■


References1. Dunbar HF, Wolfe TP, Tauber ES et al. The psychic component of the diseaseprocess (including convalescence), in cardiac, diabetic, and fracture patients. PartII. Am J Psych 1939; 95: 1319–1342.2. Amiri S, Sadeghi–Bazargani H, Nazari S et al. Attention deficit/hyperactivitydisorder and risk of injuries: a systematic review and meta–analysis. J Inj Viol Res2017; 9: 95–105.3. Merrill RM, Lyon JL, Baker RK et al. Attention deficit hyperactivity disorder andincreased risk of injury. Adv Med Sciences 2009; 54: 20–26.4. Johnson RC, Rosen LA. Sports behavior of ADHD children. J Att Dis 2000; 4:150–160.5. Stavrinos D, Biasini FJ, Fine PR et al. Mediating factors associated with pedestrianinjury in children with attention-deficit/hyperactivity disorder. Pediatrics 2011; 128:296–302.6. Shilon Y, Pollak Y, Aran A et al. Accidental injuries are more common in childrenwith attention deficit hyperactivity disorder compared with their non–affectedsiblings. Child Care Health Dev 2012; 38: 366–370.7. Clancy TA, Rucklidge JJ, Owen D. Road-crossing safety in virtual reality:acomparison of adolescents with and without ADHD. J Clin Child Adolesc Psychol2006; 2: 203–215.8. Jerome L, Segal A, Habinski L. What we know about ADHD and driving risk: aliterature review, meta-analysis and critique. J Can Acad Child Adolesc Psych 2006;15: 105–125.9. Mangus RS, Bergman D, Zieger M et al. Burn injuries in children with attention-deficit/hyperactivity disorder. Burns 2004; 30: 148–150.10. Thomas CR, Ayoub M, Rosenberg L et al. Attention deficit hyperactivity disorder and pediatric burn injury: a preliminary retrospective study. Burns 2004;30: 221–223.11. Farmer JE, Peterson L. Injury risk factors in children with attention deficithyperactivity disorder. Health Psychol 1995; 14: 325–332.12. Whalen CK, Jammer LD, Henker B et al. The ADHD spectrum and everyday life:experience sampling of adolescent moods, activities, smoking, and drinking. ChildDev 2002; 73: 209–227.13. Barkley RA, Fischer M. The unique contribution of emotional impulsiveness toimpairment in major life activities in hyperactive children as adults. J Amer AcadChild Adolesc Psych 2010; 49: 503–513.14. Harvey EA, Breaux RP, Lugo–Candelas CI. Early development of comorbiditybetween symptoms of attention-deficit/hyperactivity disorder (ADHD) andoppositional defiant disorder (ODD). J Abn Psychol 2016; 125: 154–167.15. Schwebel DC, Speltz ML, Jones K et al. Unintentional injury in preschool boys with and without early onset of disruptive behavior. J Ped Psychol 2002; 27:727–737.16. Schwebel DC, Roth DL, Elliott MN et al. Association of externalizing behavior disorder symptoms and injury risk among fifth graders. Acad Ped 2011;11: 427–431.17. Gerring JP, Brady KD, Anitachen MS et al. Premorbid prevalence of ADHD anddevelopment of secondary ADHD after closed head injury. J Amer Acad Child AdolescPsych 1998; 37: 647–654.18. Max JE, Lansing AE, Koele SL et al. Attention deficit hyperactivity disorder inchildren and adolescents following traumatic brain injury. Dev Neuropsychol 2004;25: 159–177.19. Dalsgaard S, Leckman JF, Mortensen PB et al. Effect of drugs on the risk ofinjuries in children with attention deficit hyperactivity disorder: a prospective cohortstudy. Lancet Psych 2015; 2: 702–709.


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Abstract watch


elcome to this edition’s ‘Abstract watch’.Given the quest for biological markers of

ADHD, Wainstein et al make an interestingobservation. We explore Bauer et al’s novel use ofgroup attendance at ADHD clinics. Obioha et al’sstudy on social skills deficits raises an interestingobservation that is typically associated more withASD than ADHD. Finally, Naenen-Hernani et alexplore the use of informed consent in minimisingtreatment drop out.

Pupil Size Tracks AttentionalPerformance In Attention-Deficit/Hyperactivity DisorderWainstein G, Rojas-Líbano D, Crossley NA et al. Sci Rep 2017; 7: 8228.http://dx.doi.org/10.1038/s41598-017-08246-w

Pupil size serves are a promising marker of cognitivestates as they reflect the activity of an 'arousal'network. Pupil size from ADHD and control subjectswas monitored during a visuo-spatial workingmemory task. A sub group of children with ADHDperformed the task twice, with and withoutmethylphenidate. A decreased pupil diameter wasshown in off-medication patients and was no longerpresent when patients took their medication. Acorrelation was found with pupil size and thesubjects' performance and reaction time variabilityand this effect was modulated by medication. Theresults indicate that pupil size could serve as abiomarker in ADHD.

Acceptability of Group Visits forAttention-Deficit Hyperactivity Disorder in Pediatric ClinicsBauer NS, Azer N, Sullivan PD et al. J Dev Behav Pediatr 2017; 38: 565–572.http://dx.doi.org/10.1097/DBP.0000000000000492

This study investigates the views of caregivers, childparticipants and facilitators on the acceptability ofADHD group visits in busy paediatric clinics. A totalof 34 caregivers, 41 children and 9 facilitatorsoffered feedback. The feedback received indicatedthat caregivers enjoyed the ‘support group’ aspectand learning new things from others. An improvedunderstanding of ADHD was also reported bycaregivers, and the group visits enabled positivechanges between parents and their child. The

majority of families and facilitators highlighted avariety of benefits of the use of a group visit modelfor ADHD care. Despite systems-level barriers toimplementation, families and facilitators felt thebenefits outweighed the challenges.

Decreased Faux Pas Recognition and Parental Underestimation of Social Deficits in ADHD Children: A Pilot StudyObioha O, Papaioannou H, Mendoza M and Milanaik RL. Res J of Clin Pediatr2017, 1: 2.

This study aimed to assess social deficits in 50children with ADHD (aged 7 to 17 years old) using FauxPas Recognition tests and the accuracy of theirparents’ predictions of their performance. Childrenwith ADHD performed worse on the ‘absence of fauxpas’ condition than children without ADHD did.Children with ADHD also performed significantly worseon Faux Pas Recognition testing, indicating childrenwith ADHD may have substantial difficulties evaluatingsocial situations. A large discrepancy was notedbetween subject’s Faux Pas Recognition scores andtheir parents’ predictions, prompting concerns as towhether parents of ADHD children appropriatelyanticipate their children’s social needs.

Influence of Written Informed Consentfor Methylphenidate on MedicinePersistence Rates in Children withAttention-Deficit Hyperactivity DisorderNaenen-Hernani K, Palazón-Bru A, Colomina-Climent F, Gil-Guillén VF; GAIPNA(Alicante Research Group in Child and Adolescent Psychiatry). J Dev BehavPediatr 2017; 38: 603–610.http://dx.doi.org/10.1097/DBP.0000000000000495

A cohort study of 141 children with ADHD wasundertaken to assess the influence of writteninformed consent on nonpersistence withmethylphenidate treatment. Two groups wereanalysed with and without written informed consent.To assess the influence of consent on nonpersistence,bootstrapping was used to determine relative riskreduction (RRR) and number needed to treat (NNT).The use of written informed consent yielded higherpersistence rates. Further studies are needed todetermine whether we can use this procedureroutinely in clinical practice ■

Biological markers, group visits,social deficits and consent

In this regular column we feature a collection of abstracts that highlight some of the new research in the field of attention deficit hyperactivity disorder (ADHD). Research in this field is diverse and rapidly expanding,and we will endeavour to give you a sample of new findings and trends.

&Nigel HumphreyBA(Hons) MSc ClinicalPsychologist, Childand AdolescentMental HealthService, Guernsey,Channel Islands

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eople with attention deficithyperactivity disorder (ADHD)

spend large amounts of time online,and researchers are increasinglyasking about how this interacts withtheir condition. Internet ‘memes’ areone medium through which peopleshare and broadcast their thoughtsand feelings online. For young peoplewith ADHD, internet memes providea quick and engaging means ofentertainment and self-expression.This article explores the messages

that people with ADHD share andreceive online, particularly withrespect to treatment decisions andbridging the gap betweenprofessionals and the world ofmemes.

The association between ADHD andproblematic internet use is well researched.People with ADHD use the internet forlonger periods of time than the generalpopulation;1 in fact, the symptomatology ofADHD is thought to overlap with internetaddiction 2 and, in particular, problematic


Investigation

Internet memes: whatprofessionals need to know&Nathan HodsonBSc BMBS DHMSAHonoraryFellow1 -and [Jobtitle?] 2

1 University ofLeicester

2 Leicester GeneralHospital, UniversityHospitals ofLeicester NHS Trust

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■ Internet memesprovide a quick andengaging means ofentertainment andself-expression foryoung people withADHD

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internet gaming.3 These behaviours resultin reduced sleep among people withADHD, exacerbating their symptoms.1 Asystematic review by Wang et al 4 foundthat internet use was associated with moresevere ADHD, leading to the authors’recommendation that family andprofessionals should monitor internet useamong people with ADHD closely.

On the other hand, internet use canalso be empowering. People with ADHDand their families frequently go online forinformation about the diagnosis of ADHD,5

although they generally prefer to receiveinformation from health professionals.6

Montoya et al 7 worked with healthprofessionals and parents to investigate thequality of online information about ADHD,and found its quality was ‘generally poor’.This is particularly problematic becauseinaccurate online information can createtension between professionals and familiesregarding the appropriateness ofdiagnosis.8 It is, therefore, essential thathealthcare professionals are aware of theinformation that people with ADHD arereceiving online.

What are ‘internet memes’?The term ‘meme’ originates from RichardDawkins’ The Selfish Gene. Drawing acomparison with genes – the units ofgenetic transmission – Dawkins coined theterm ‘meme’ to denote units of culturaltransmission. Internet jokes became knownas memes because they are easily sharedacross message boards and social media.

The memes being discussed here areusually images with simple captions. Otherpeople can change the image or the captionto create new jokes. Background images arenormally available online as clipart graphicsor as stock photos, but sometimes memesbuild upon references from popular culture.Morpheus, a character from the Matrixmovies, is famous for making profoundcomments. Many memes depict Morpheuswith the superimposed text ‘What if I toldyou’ before a comment or piece of advice, asif to suggest that it would change the waythe viewer saw the world. Figure 1 uses thisformula to share their positive experience ofpharmacotherapy for ADHD.

Memes and ADHDFor this analysis, 202 memes related toADHD or Ritalin® were obtained by

searching eight major public memewebsites, along with Tumblr, GoogleImages, a public Facebook page dedicatedto ADHD memes and two subreddits. Allmemes were in the public domain, havingbeen posted on open webpages. Given the

association between ADHD and high levelsof internet use, we would expect there to bea lot of memes about ADHD.

There are several factors explainingwhy people with ADHD are particularlyinterested in internet memes. First, thecaptions attached to the graphics orpictures create attractive in-jokes. Memesare simple to make, blurring the distinctionbetween audience and producer. Thisengenders a feeling of belonging to a

community, an experience particularlyimportant to people who are strugglingsocially or educationally. This is an exampleof the link between ADHD, social skilldeficits and internet use.9

High levels of internet use areparticularly associated with inattentivesymptoms in ADHD.10 Memes are likely tobe attractive to people with high levels ofinattentiveness because they areimmediately engaging and rapidlystimulating. Similarly, although peoplewith ADHD are often perceived as witty,many experience social cognitionimpairments,11 which the structured formatof meme-based humour may help toovercome.

The public nature of memes means thatthey have the potential to helpprofessionals understand patients’ feelingson a different level as people will feel morecomfortable expressing themselves onlinecompared with being in a consulting room.Memes are used in interaction with otherindividuals and as a medium of broadcastacross larger online communities. Asmemes are simple to create, they are usefulfor people without the resources to createonline videos, blogs or podcasts. Therefore,memes democratise discourse, allowingmore voices to participate. It is this group


Investigation


BMemes are likely to be attractive to

people with high levels of inattentiveness because they are

immediately engaging and rapidly stimulating

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■ Figure 1. Morpheus ‘what if I told you’ meme which the creator uses alongside a comment or piece of advicethat it would change the way the viewer saw the world.

of voices that is represented in thefollowing analysis of online memes.

What do memes tell us about ADHD?People with ADHD use memes to expressthemselves anonymously in public forums.These messages offer an insight into theexperience of having ADHD.Encouragingly, many memes show thepositive role that stimulants can play withinthe management of ADHD. Figure 2celebrates the beneficial effects ofmethylphenidate using a popularbackground image known as ‘victory kid’.

This background indicates that events haveworked out better than expected. In thiscase, the creator expresses the view thatRitalin really has helped them to overcomeadversity, portraying it as a small butsignificant victory.

Memes not only help us understandhow people with ADHD feel about aspectsof their condition, such as treatment, theyalso affect other people with ADHD. Peoplewith ADHD who use memes to sharepositive messages about ADHD treatmentprovide a kind of peer support. People withADHD who see these messages areencouraged to persist with engagement.

People with ADHD who use memes toshare positive messages receive a kind ofpeer support. Those viewing thesemessages are encouraged to persist withadherence to treatment.

The element of peer support is alsopresent in memes in which people sharethe issues they have with treatment. Figure3 uses an image well known to meme usersas ‘first-world problems’, superimposedwith the text, ‘I need to refill my Adderallbut I keep forgetting’. This ironicalcomment emphasises the challenges ofpartially managed ADHD. The ‘first-worldproblems’ background image is commonly


Investigation

■ Figure 2. A ‘victory kid’ meme which the creator uses to indicate that events have worked out better than expected.


Investigation


used by people complaining aboutrelatively insignificant difficulties, so in thismeme it creates humour through self-awareness and self-deprecation. Thismeme is a reminder that people withADHD often struggle with medicationadherence, reflecting the argument byCutler and Mattingly 12 that oneresponsibility of professionals is tooptimise delivery in order to facilitatemedication adherence.

Many other memes reflect on thechallenges of using stimulant medication,whether commenting on adherence,adverse effects or stigma. When otherpeople with ADHD view these memes, theirown feelings about side effects are validatedand normalised, helping them accept theiroverall experience of psychopharmacology.This is particularly valuable given thestigma facing people with ADHD, whichcan also impact upon their prospects.13,14

Harmful messagesHowever, the messages shared online arenot always positive. In this analysis, onethird of memes about ADHD treatmentmade negative or potentially hurtfulcomments. These memes do not appear tohave been created by people with ADHDand betray a lack of understanding of thecondition.

One meme uses a ‘condescendingWonka’ image to sarcastically dismiss aperson using prescribed ADHDmedication: ‘You must have such badADD.’ Exposure to messaging thatundermines or queries the need fortreatment is harmful to people who havebeen prescribed medication by a doctor. Itis known that people who are uncertainabout the necessity of medication are atgreater risk of intentional non-adherence.15

Other memes are directed at the self-esteem of people living with ADHD. They

often describe people with ADHD asunintelligent – a further impediment toeducational achievement. Alternatively,they make a moral judgment about theperson with ADHD. This reinforces the

approach described as ‘internalisingpersonal responsibility through moral self-condemnation’ experienced by manypeople with ADHD.16 They are epitomisedin the many memes describing corporal

Box 1. Action points

● Ask people with ADHD what they are looking at online● Discuss messages about ADHD that people with ADHD have seen online● Facilitate self-expression and creativity among people with ADHD● Encourage participation in positive online forums

BThe management

of ADHD is affectedby cultural factors,including televisionand newspapers,

but also the internet. C

■ Figure 3. First-world problems meme the creator uses this image to communicate that the compliant is relatively insignificant and creates humour through self-awareness and self-deprecation.

■ Figure 4. The original ADHD treatment meme that demonstrates that messages online are not always positiveregarding the treatment of and that there is a lack of understanding about the condition.

punishment as ‘the original ADHDtreatment’, of which Figure 4 is oneexample.

Harmful messages spread throughmemes have been challenged by TheADHD Homestead blog,17 which points outthat negative memes made by peoplewithout ADHD delegitimise the experienceof people who are adhering to medicationand experiencing the benefits. The dailychallenges of ADHD often affect self-esteem, and this is only compounded bymalign misinformation online. Thisproblem is not unique to internet memes;an analysis of newspaper stories found thatADHD was represented particularlyharshly there too,18 but awareness of thisgroup of memes provides additionalcontext for professionals and supporters ofpeople with ADHD.

Learning from memesThe management of ADHD is affected bycultural factors, including television andnewspapers, but also the internet. Previousresearch into stigmatising representationsin the media is mirrored in internet memeculture. Professionals caring for peoplewith ADHD benefit from an awareness ofthese influences and of the self-expressionof people with ADHD (see Box 1 for furtherpractical steps). People with ADHDcreating and viewing memes online areexposed to many potentially harmfulattitudes to ADHD therapy. However, mostmemes provide an outlet for frustrations,developing community and camaraderiethrough normalising and validating theexperiences of people with ADHD ■


References1. Weinstein A, Yaacov Y, Manning M, Danon P, Weizman A.Internet addiction and attention deficit hyperactivity disorderamong schoolchildren. Isr Med Assoc J 2015; 17: 731–734.2. So R, Makino K, Fujiwara M et al. The prevalence ofinternet addiction among a japanese adolescent psychiatricclinic sample with autism spectrum disorder and/or attention-deficit hyperactivity disorder: a cross-sectional study. J AutismDev Disord 2017; 47: 2217–2224. 3. Cho YU, Lee D, Lee JE, Kim KH, Lee DY, Jung YC.Exploratory metabolomics of biomarker identification for theinternet gaming disorder in young Korean males. JChromatogr B Analyt Technol Biomed Life Sci 2017; 1057:24–31. 4. Wang BQ, Yao NQ, Zhou X, Liu J, Lv ZT. The associationbetween attention deficit/hyperactivity disorder and internetaddiction: a systematic review and meta-analysis. BMCPsychiatry 2017; 17: 260.5. Sage A, Carpenter D, Sayner R et al. Online information-seeking behaviors of parents of children with ADHD. ClinPediatr (Phila) 2017: [Epub ahead of print]6. Bussing R, Zima BT, Mason DM et al. ADHD knowledge,perceptions, and information sources: perspectives from acommunity sample of adolescents and their parents. JAdolesc Health 2012; 51: 593–600. 7. Montoya A, Hernández S, Massana MP et al. Evaluatinginternet information on attention-deficit/hyperactivity disorder(ADHD) treatment: parent and expert perspectives. EducHealth (Abingdon). 2013; 26: 48–53. 8. Terbeck S, Chesterman LP. Parents, ADHD and theinternet. Atten Defic Hyperact Disord. 2012; 4: 159–166.9. Chou WJ, Huang MF, Chang YP et al. Social skills deficitsand their association with Internet addiction and activities inadolescents with attention-deficit/hyperactivity disorder. JBehav Addict 2017; 6: 42–50. 10. Yılmaz S, Hergüner S, Bilgiç A, Işık Ü. Internet addiction isrelated to attention deficit but not hyperactivity in a sample ofhigh school students. Int J Psychiatry Clin Pract 2015; 19:18–23. 11. Uekermann J, Kraemer M, Abdel-Hamid M et al. Socialcognition in attention-deficit hyperactivity disorder (ADHD).Neurosci Biobehav Rev 2010; 34: 734–43.12. Cutler AJ, Mattingly GW. Beyond the pill: new medicationdelivery options for ADHD. CNS Spectr 2017; 7: 1–12. 13. Thompson AC, Lefler EK. ADHD stigma among collegestudents. Atten Defic Hyperact Disord 2016; 8: 45–52. 14. Foy SL. Challenges from and beyond symptomatology:stereotype threat in young adults with ADHD. J Atten Disord2015; [Epub ahead of print]15. Emilsson M, Gustafsson PA, Öhnström G, Marteinsdottir I.Beliefs regarding medication and side effects influencetreatment adherence in adolescents with attention deficithyperactivity disorder. Eur Child Adolesc Psychiatry 2017; 26:559–571. 16. Honkasilta J, Vehmas S, Vehkakoski T. Self-pathologizing,self-condemning, self-liberating: Youths’ accounts of theirADHD-related behavior. Soc Sci Med 2016; 150: 248–255. 17. ADHD Homestead Blog. Bad ADHD memes, & my realreason for taking stimulants. http://adhdhomestead.net/adhd-memes/ (last accessed 25/10/17)18. Baeyens D, Moniquet A, Danckaerts M, van der Oord S. Acomparative study of the structural stigmatisation of ADHDand autism spectrum disorder in Flemish newspapers.Tijdschr Psychiatr 2017; 59: 269–277.


S Internet ‘memes’ provide young people with ADHD with a medium in which to broadcast their thoughts andfeelings and provide a quick and engaging means ofentertainment and self-expression.

SMemes are of interest to people with ADHD as thecaptions attached to the graphics or pictures createattractive in-jokes, they are simple to make and it givespeople with ADHD a feeling of belonging to a community.

SMemes have the potential to help professionalsunderstand their patients’ feelings.

SExposure to memes that undermine or query the need for ADHD treatment is harmful to people who have beenprescribed medication because people who are uncertainabout the need for medication are at greater risk ofintentional non-adherence.

Keypoints

DIARY DATES

12–14th January 2018The American ProfessionalSociety of ADHD and RelatedDisorders 2017 Annual MeetingWashington D.C., USAThe American Professional Society of ADHD and Related Disorders■ [email protected]■ https://apsard.org/meetings/

2018-meeting

3rd–6th March 201826th European Congress of PsychiatryNice, FranceKenes International Organizers of Congresses■ www.epa-congress.org

24–31th March 2018CADDRA presents ADHD 2018 –Exploring the Horizons Cruise ports of call: Miami, USA; Key West, USA; Costa Maya, Mexico; Cozumel, Mexico; George Town, Grand Cayman Canadian ADHD Resource Alliance(CADDRA)■ https://goo.gl/jKdMzZ

25–27th

April 2018Royal College ofPsychiatrists Facultyof Medical Psychotherapy Annual Conference 2018Cardiff, UKRoyal College of Psychiatrists■ [email protected]■ https://goo.gl/IuSRQo

25–28th April 20197th World Congress on ADHDLisbon, PortugalWorld Federation of ADHD■ www.adhd-congress.org

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