The role of innovation has been gradually, yet consistently, filtering into the management methods of adult ADHD. Just what are these advances – and how can we equip ourselves with them to enhance daily life for our patients? Dr Louise Theodosiou, from the Royal College of Psychiatrists, weighs in.
INNOVATION THROUGH IDENTIFICATION
The phrase, ‘I just want to know what’s wrong’, is regularly uttered in healthcare settings. The NICE guidance for ADHD details a personal account of a parent with ADHD who moved from being frightened of her anger and struggling to control her drinking, to being an effective parent with a professional career and a long-term relationship. Therapeutic advances and greater neurological understanding are key components of innovation, but raising awareness about the concept of ADHD is of equal importance.
WHAT DO WE MEAN BY ADULT ADHD?
Adults with ADHD tend to have difficulties managing their impulses, difficulty concentrating, and often feel a sense of restlessness which is not always visible to the people around them. These symptoms can greatly impact on people’s lives.
WHY SHOULD THE TREATMENT OF ADULT ADHD BE A PRIORITY?
Adults with ADHD are known to have significant comorbid mental health problems, such as depression and anxiety. They are also known to have greater rates of physical health problems from cardiac disease through to dental decay.
If we accept that the symptoms of ADHD impact on an adult’s ability to maintain a job and a relationship and to parent children, then we can start to understand their increased vulnerability to mental and physical health problems. Adults with ADHD struggle with the activities of daily life and so may find the process of co-ordinating their physical and mental health needs very difficult. Given this struggle, treating ADHD could lead to increased engagement with other healthcare services and reduce the economic impact of missed appointments.
INNOVATION THROUGH ACCEPTANCE?
Initial NICE guidance on treating ADHD only applied to children. There is now compelling evidence that ADHD continues into adulthood, yet the diagnosis remains controversial; as recently as 2010 the British Medical Journal published a debate entitled ‘Is ADHD a valid diagnosis in adults?’. Why does this diagnosis cause such polarity? Perhaps we need a further debate, possibly with the involvement of adults and families with ADHD.
INNOVATION THROUGH MAINSTREAM PRACTICE
The Cochrane collaboration is an independent, not-for-profit organisation of patients, professionals, researchers and carers, who have undertaken a large number of systematic reviews.
The collaboration withdrew their review of methylphenidate use in adults with ADHD after significant criticism, and one of the recurring concerns was the small sample size. It is widely acknowledge that there is a lack of adult ADHD clinics, and that adolescents wishing to transition into adult services often encounter difficulties.
Anecdotally, one of the ways that practitioners learn to understand ADHD, and the importance of treating this condition, is through direct clinical contact. A research paper / book by Rao and Place notes that in general adult psychiatry outpatient clinics, it’s possible to diagnose 22 per cent of the sample with ADHD. Within Child and Adolescent Mental Health Services, the same clinicians will often treat affective disorders, ADHD and autistic spectrum disorders. New models of 18 to 25 services are starting to be developed. Such services offer the opportunity for clinicians from child and adult mental health services to work collaboratively, sharing skills and training. If these services offer treatment of all mental health needs, then there is ample opportunity for clinicians to learn to identify and treat ADHD alongside comorbidity.
WHO ARE THE ADULTS WITH ADHD?
Broadly speaking there are three groups; diagnosed and receiving treatment, diagnosed and untreated, and those never diagnosed.
HOW DO WE ASSESS FOR ADULT ADHD?
The Maudsley adult ADHD clinic notes the need for an assessment of the whole lifetime of symptoms and impairment alongside a full psychosocial and clinical assessment with corroborating history from family, partners or carers. Objective assessment tools for ADHD are now increasingly used, for example, the QbTest.
This test combines a continuous performance task and tracking analysis and compares results against a control group to produce a report which can assist in the diagnosis of ADHD.
WHAT TREATMENT IS AVAILABLE?
The updated full NICE guidance is that first-line treatment for adults with ADHD should be medication, unless the patient requests a psychological approach.
Methylphenidate remains the recommended first-line treatment for adults with ADHD, followed by dexamphetamine or atomoxetine. Guanfacine prolonged release is now available for children with ADHD, but is not licenced in adults. Where medication alone is not working, or is not the patient choice, CBT is recommended. Coaching courses which allow patients to practice newly-learned skills have not yet been fully evaluated, but are starting to be used.
In conclusion, there is a need for more dialogue and awareness raising about this important condition. Adult ADHD has an impact on people’s lives, and we can work together to reduce this.