Updated European Consensus Statement on diagnosis and treatment of adult ADHD


Introduction

ADHD is a neurodevelopmental and heritable disorder with a lifespan perspective: starting in childhood, persisting in adulthood until old age, with significant psychosocial impairment, a high comorbidity rate and multi-morbidity. It is associated with high levels of personal distress, and a substantial economic burden for society if left unidentified and untreated. [Kooij et al., 2019]

Summary

This consensus statement reflects agreement on the state of ADHD, but by definition it is provisional. It does not negate the ongoing scientific debate in the field and the different opinions and hypotheses about adult ADHD among experts. Yet none of that undercuts the legitimacy or validity of the construct, or of the conclusions one can make about the current status of the consistency of the evidence.


Key points from this article

This covers the key points that the author(s) have highlighted in this publication.

Neurobiological and environmental background

  • High heritability (60-80%), environmental risk factors and their interaction, are involved in the majority of ADHD cases.
  • Abnormalities in grey matter, cortical thickness and white matter microstructure have been shown in ADHD compared to controls, indicating that structural deficits in ADHD involve interconnections among large scale brain networks.
  • Functional neuroimaging shows dysfunctions in several domain-specific fronto-striatal and fronto-cerebellar neural networks, as well as an enhanced activation of default mode regions. These findings, as well as the effectiveness of pharmacological treatments with dopamine agonists, support the neurobiological underpinnings of ADHD.

Diagnosis

  • The clinical diagnosis of ADHD depends on self-report during a structured diagnostic interview, whenever possible with collateral information about lifetime symptoms and impairment. It cannot be established using solely neuropsychological tests.
  • Recent research shows that besides inattention, hyperactivity and impulsivity, emotional dysregulation and excessive mind wandering are common symptoms associated with ADHD in adults.
  • The underdiagnosis of girls and women with ADHD may be due to a different expression of symptoms and comorbidities, to referral bias, and to interaction of hormones with the dopaminergic system. Further research is needed.
  • The concept of late-onset ADHD refers to an age of onset after 12 years, and needs further study concerning the overlap and differences with childhood onset ADHD.
  • High rates of psychiatric comorbidity, physical multi-morbidity, increased mortality and suicide rates, and criminality may ‘mask’ the underlying ADHD condition.
  • Stigma leads to misconceptions about ADHD and underdiagnosis.

DSM-5 criteria

Main changes in the DSM-5 criteria for ADHD are:

  • ADHD is placed in the chapter of Neurodevelopmental Disorders
  • The age of onset of symptoms is before age 12, instead of age 7
  • The cut off for current symptoms in adults is 5/9 instead of 6/9
  • A diagnosis of ADHD can now be combined with Autism Spectrum Disorder (ASD)

Prevalence

  • The mean prevalence of ADHD in adults across 20 countries is estimated at 2.8%. In people above age 60, a similar prevalence rate has been found.
  • The prevalence of ADHD in prisons is 25%, a 10-fold increase compared to the general population.

Transition

  • Two-thirds of children with ADHD continue to have ADHD symptoms associated with impairments in adulthood, therefore adjustments in the health care system to support the transition from child to adult services are needed.

Treatment

  • Psychoeducation for adults with ADHD and their significant others is recommended as a first treatment step.
  • Stimulants are the treatment of choice for adults with ADHD. Long-lasting, extended release formulations are preferred for reasons of adherence to treatment, for the protection against abuse, to avoid rebound symptoms, for safer driving, and to provide cover throughout the day without the need for multiple dosing.
  • Licensing of stimulants for adult ADHD is urgently needed in European countries and beyond.

Pharmacological treatment of special groups

  • The non-stimulant atomoxetine is recommended as a second line treatment. There is limited evidence in adults for guanfacine, bupropion, tricyclic antidepressants and reboxetine in controlled studies.
  • Cognitive Behavior Therapy reduces ADHD-core symptoms, associated symptoms such as emotion dysregulation, anxiety and depression, and functional impairments across different areas of daily living in adults. CBT is best used within a multi-modal treatment approach and as an adjunct to medication, as research does not fully support the efficacy of CBT as a sole treatment for adult ADHD.
  • In patients with ADHD and substance use disorder, to be effective, treatment with stimulants may use higher dosages than normal.
  • In patients with ADHD and bipolar disorder, the combined approach of a mood stabilizer with a stimulant has been shown to treat both disorders effectively without inducing (hypo)manic states.
  • During pregnancy stimulants are not advised, though large cohort data showed no increased risk for congenital malformations using stimulants during the first trimester. The risk for cardiac malformations using MPH however was slightly increased, while this was not the case for amphetamines.
  • Research on the wishes of older people with ADHD regarding treatment, and trials on the safety and efficacy of medicines are needed.
  • Based on data from large cohort studies, following treatment, the negative outcomes associated with ADHD significantly diminish, i.e. traffic accidents, mortality, criminality, depression and suicide, and substance abuse.

Costs

  • The economic burden of ADHD is considerable and falls both on the individual and the state. Pharmacotherapy in children is cost effective compared to no treatment and behavioral therapy, but data in adults are still lacking.

Excerpts from the article

The information provided from here on is an excerpt of knowledge from this study. Please refer to the full publication for the full text version.


Heritability and environment

Family, twin and adoption studies from the last 20 years show that ADHD is a familial disorder with high heritability, indicating that a significant genetic component influences risk for the disorder [[4][5][6][7][8][9][10][11][12]]. Environmental factors such as severe institutional deprivation are also likely to play a role, either as main causal factors in a few cases [13] or by interaction with genetic risks. Family studies indicate a risk to first-degree relatives of 4–5 fold the population rate or higher, with prevalence rates around 20% among first degree relatives [14]. Data on ADHD in children and adolescents find average heritability of around 76% [12]. Studies in adult twins using self-rated ADHD symptoms consistently report lower estimates of heritability, around 30–40% [[15][16][17]]. One reason for lower heritability of adult self-reported ADHD symptoms may be from the use of self-ratings. These lead to lower estimates of heritability compared to informant ratings regardless of age, perhaps due to variable levels of awareness among individuals rating their own ADHD symptoms [18,19]. Studies combining data across informants [20], or using clinical diagnostic information [21] find heritability estimates for adult ADHD in the same range (70–80%) as for children [22].

Neurobiology

Structural brain scans of adults with ADHD showed grey matter abnormalities in several brain areas, including the right frontal and prefrontal areas [48,49], anterior cingulate [[50][51][52]], the basal ganglia and the cerebellum [[53][54][55][56]] with some preliminary research also showing abnormalities of the visual cortex [57]. Additionally, cortical thickness was found to be reduced in adult ADHD [56,58,59]. Some evidence suggests that grey matter abnormalities, in some subcortical regions, are more pronounced in children than adults. This might reflect the effects of age, medication, intrinsic heterogeneity of the ADHD syndrome, or a combination thereof [51,[60][61][62][63][64]].

Neuropsychology

As a group, individuals with ADHD are characterized by altered neuropsychological functioning across a variety of executive function (EF) measures. There is currently insufficient evidence to warrant the use of neuropsychological testing to determine the diagnosis of ADHD [82] or to predict impairment in major life domains [83].

ICD and DSM criteria for ADHD

There are two diagnostic manuals used to diagnose ADHD: The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD). As ADHD has been recognized as a disorder affecting individuals across the lifespan, the diagnostic criteria for adolescents and adults have been adjusted in the DSM-5, published in May 2013.

  1. ADHD is now in the chapter Neurodevelopmental Disorders, which includes conditions associated with factors affecting the brain development.
  2. Diagnostic criteria have been adapted by adding some examples describing how ADHD symptoms are expressed across the lifespan.
  3. The age of onset criteria has been changed requiring several symptoms to be present before age of 12 years, instead of some symptoms and impairment by age 7.
  4. The term “subtype” has been replaced by “presentation”, reflecting the variation of ADHD symptoms within the same individual during the lifespan.
  5. The symptom threshold required has been reduced to 5 symptoms instead of six for older adolescents and adults (>17 years) in either the inattention or hyperactive/impulsive domain.
  6. Criteria requiring significant impairment has been modified to “clear evidence that symptoms interfere with or reduce the quality of social, academic and occupational functioning”, with specifiers regarding severity level.
  7. The presence of Autism Spectrum Disorder (ASD) is no longer an exclusion criterion, consistent with evidence showing their frequent co-occurrence.
  8. ADHD Not Otherwise Specified (NOS) has been changed into Other Specified ADHD and Unspecified ADHD.

The revision of ICD-10ICD-11 has been published in June 2018. ICD-11, developed by the World Health Organization now refers to ADHD as Attention Deficit Hyperactivity Disorder, instead of previously Hyperkinetic Disorder (HKD) [97]. It now uses similar requirements as the DSM-5 regarding age of onset, and the same 3 presentation types. In Europe, ICD codes are often used for statistics on mortality, morbidity and by insurance agencies for health-related reimbursements [98], whereas DSM is primarily used in clinical practice by licensed mental health care professionals [99].

Clinical picture

Inattention and hyperfocus

Patients with mainly inattention problems are often slow to think and formulate due to distractions. They may formulate things in a long-winded and tangential way, losing themselves in irrelevant details and having difficulty making decisions. A difficulty for the clinician is that this may hinder the diagnostic assessment. Patients may also over-concentrate or ‘hyperfocus’. This phenomenon most commonly occurs when engaged in activities that the patient finds very interesting and/or provide instant gratification, such as computer games or online chatting. For such activities, concentration may last for hours on end, in a very focused manner.

Hyperactivity

With respect to hyperactivity, adults do not present in the same way as children. Their hyperactivity usually manifests in a more subtle way. Clinicians need to assess their feelingsof restlessness. A first impression of mobility is not definitive; sitting calmly during the diagnostic assessment does not exclude any ADHD. Hyperactivity in adults often manifests itself as feelings of continuous inner restlessness or agitation, talking too much, ceaseless mental activity, not being able to relax properly or needing alcohol or drugs to relax and/or sleep. Hyperactivity and/or restlessness may be temporarily relieved by the patient engaging in excessive sport activities, and in such cases the person may suffer physical ailments as the body may have insufficient time to recover and/or due to sustained injuries.

Impulsivity

Impulsive behavior and associated interpersonal conflicts often have consequences for relationships with family, friends, colleagues and employers. It may also seriously impact on personal finance when impulsive spending causes debt. Impulsive binge behaviors may also be present (e.g. binge eating), often to combat restlessness or due to a need for immediate gratification. Closely related to impulsivity are ‘sensation seeking’ behaviors when patients may seek out excitement from novel and thrilling stimuli. These often involve risk taking behaviors such as playing with fire, reckless driving, sexual risks, and provocative behavior leading to fights.

Emotional dysregulation

Emotional dysregulation is listed by DSM-5 as a characteristic feature of ADHD, supporting the diagnosis [113]. The type of emotional dysregulation seen in ADHD has been characterized as deficient self-regulation of emotional symptoms such as irritability, frustration and anger [114], and low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability [115]. Emotional dysregulation in ADHD is different from episodic symptoms such as marked sustained irritability occurring within the context of altered mood states, such as an episode of depression or mania. In ADHD, emotional symptoms tend to reflect short lived exaggerated changes, often in response to daily events, with rapid return to baseline within a few hours [114]. Whether the type of emotional instability seen in ADHD is qualitatively different to that seen in other chronic conditions such as borderline personality disorder or post-traumatic stress remains unclear.

Excessive mind wandering

Another common feature of adult ADHD is excessive mind wandering, also referred to as mental restlessness [[116][117][118]]. In DSM-5 mind wandering is briefly mentioned as the occurrence of unrelated thoughts. Although mind wandering is a universal experience, some forms of mind wandering are detrimental because they interfere with task performance. Adults with ADHD frequently report a distractible mental state with multiple unrelated thoughts that are constantly on the go and jump from one topic to another [119,120]. Mind wandering is also a feature of other mental health disorders such as depressive or obsessive disorders. However, in ADHD mind wandering is characterized by unfocused, short lived distractible thoughts with no pattern of repeated thoughts or abnormality of content. Research found that excessive mind wandering was strongly correlated with ADHD symptoms, was a strong predictor of the diagnosis (sensitivity and specificity around 90% for case-control differences), co-varied with ADHD symptoms over a 6-month period, and was a better predictor of ADHD-related impairments than the inattentive and hyperactive-impulsive symptoms of ADHD [120]. In ADHD it can be measured using the Mind Excessively Wandering Scale [116,118,120] (Table 1).

Behavioral self-regulation (executive function deficits)

ADHD has been described as a disorder of executive functions such as inhibition and working memory. These include problems organizing, prioritizing and initiating work; focusing, sustaining and shifting attention to tasks; regulating alertness, sustaining effort and processing speed; managing frustration and regulating emotions; utilizing working memory and accessing recall; and monitoring and self-regulation of behavior [121,122]. Although clinically these are good descriptions of the types of difficulties experienced by adults with ADHD, behavioral measures do not correlate well with cognitive or neuropsychological testsof executive control [[121][122][123]]. A distinction needs to be made between rating scalemeasures of behaviours reflecting self-regulation of behavior referred to as EF (behavioral) deficits, and the results of neurocognitive tests of EFs such as working memory and inhibition. Neuropsychological test scores reflecting executive functioning lack ecological validity in that they have no significant relationship to behavioural rating scale measures of EF [124]. The EF test scores also are very poor at predicting impairment in a variety of domains of major life activities, compared to EF behavioural rating scales [125].

 Burden of ADHD

The impairments associated with ADHD across the lifespan are impressive. ADHD is associated with learning difficultiesschool dropout, underachievement at work [126], frequent job changes [127], chronic fatigue [128], financial problems, gambling and internet use [129,130], home and traffic accidents leading to increased mortality rates [[131][132][133]], relationship difficulties and intimate partner violence [134,135], early onset of addiction [136], teenage pregnancies and sexual transmitted diseases [137,138], a two-fold increased smoking rate [139], an increased number of suicide attempts and self-harm in adolescents [140,141], and increased criminality [142,143]. Moreover, physical disorders and ailments may become chronic due to forgetfulness, health problems induced by a negative lifestyle, poor eating and sleeping habits, and lack of health care follow-up [[144][145][146][147]]. ADHD has further been associated with auto-immune diseases [148], obesity [149], and physical multi-morbidity. In one large study, individuals with more than 4 diseases had over more than 3-fold higher odds of possible ADHD [146]. The risk of diabetes, hypertension, cardiovascular disease and cancer, that are related to obesity, may be increased as well. An additional burden on family life may be the presence of one or more children with ADHD, which happens frequently due to the high familial risks of the disorder.

Clinicians should also be aware that high functioning adults with ADHD may not present with a typical pattern of functional impairments in their daily life. Adaptive or compensatory skills can develop that mask the more overt behavioral problems related to ADHD [150]. Some may find work that is well suited to their symptom profile. Furthermore, in ADHD neurocognitive performance and inattentive symptoms are sensitive to the salience of task activities [151,152]. Such people with ADHD may excel in certain aspects of their lives, but still be impaired in others, such as more routine and mundane tasks such as paying bills, looking after the house, or developing stable social relationships. Problems can include subjective distress from symptoms such as mental and physical restlessness, sleep problems, and emotional instability; and the use of drugs such as cannabis or alcohol to reduce these symptoms.

Prevalence of ADHD across the lifespan

In childhood, ADHD is among the most common psychiatric disorders with a prevalence rate of 3–5 % [153]. For this age group, well established diagnostic and treatment services are available throughout most of Europe. In the last four decades, a large body of evidence has accumulated, showing how in the majority of cases ADHD is a lifespan disorder, persisting as either the full blown disorder, or in ‘partial remission’ with persistence of some symptoms and continued clinical and psychosocial impairments [[154][155][156][157][158][159][160][161]]. The prevalence of ADHD in adults across twenty countries was recently estimated at 2.8%, with a range between 1.4 – 3.6% [3]. ADHD was also found in a Dutch population study to persist into old age (> 60 years) with a prevalence of 2.8–4.2% depending on cut-off (6 or 4 current symptoms respectively), and associated with impairment [[162][163][164][165][166]]. ADHD in older adults is accompanied by increased rates of mood and anxiety symptoms, general health problems, conflicts, divorce, loneliness, and a lower income, showing a similar pattern of problems as in younger age groups. Research exploring the needs for treatment of older adults with ADHD has commenced, and the first treatment protocol of older adults with ADHD has been published [167].

Sex issues

Sex differences in ADHD diagnosis are well documented, with girls being less likely to be diagnosed, and sex ratios ranging between 1:5 to 1:9 [168]. Such discrepancy is less evident in epidemiological research in children where the sex ratio is 1:3, suggesting under recognition of ADHD in girls in the clinic. In both epidemiological and clinical studies of adult ADHD the sex ratio is closer to 1:1 [169].

Women with ADHD are particularly vulnerable to early adversities, health and mental health problems compared to controls [176]. A higher prevalence of insomnia, chronic painsuicidal ideationgeneralized anxiety disorder, depressive disorders, a greater vulnerability to nicotine dependence [176,177] and an increased likelihood of risky sexual behaviors [138] has been reported in women with ADHD in comparison with controls.

Late-onset ADHD?

Recent longitudinal studies have indicated that besides typical childhood onset ADHD, with the full diagnostic criteria being met before the age of 12 years, there may be later-onset cases with onset of the full diagnostic criteria beyond this age [104,189,190]. These findings have proven controversial due to severe methodological limitations [192,193], however the large majority of later onset cases appear to meet the DSM-5 age of onset criteria of several symptoms by the age of 12 [113]. Late onset of symptoms was evaluated in the control arm of the long-term follow-up of the Multimodal Treatment study of ADHD (MTA). In most cases, other factors were present that could discount the late onset of ADHD symptoms and exclude the diagnosis of ADHD [194], such as symptoms representing nonimpairing cognitive fluctuations, a comorbid disorder, or the cognitive effects of substance use [192]. 

However, there remained a very small sample of adolescent onset cases. Another population cohort study found that the majority of those with apparent late-onset ADHD had high ADHD scores at least one point in childhood, suggesting that they may have been misclassified on the basis of their score at age 12 years [195]. These cases with high score before the age of 12 years might not have met full criteria before the age of 12 years, but would meet the current DSM-5 criteria for several symptoms in childhood. One conclusion is that clinicians should be aware that subthreshold cases of ADHD during childhood might go on to meet the full diagnostic criteria as older adolescents. Clinicians should take care to fully assess impairment, psychiatric history, and substance use when diagnosing and treating cases with apparent later-onset ADHD [192].

Comorbidity

Adult diagnoses may be missed in clinical practice due to lack of knowledge about ADHD in adulthood among practitioners and due to the high frequency of comorbid psychiatric conditions [201]. The lifetime co-morbidity rate is 60–80%. Having three or more disorders was associated with a ten-fold increase of the chance of having ADHD in a population studyin 20 countries [3]. Before treatment start, all comorbidities must be established so that the best order of treatment can be determined together with the patient. In the study by Fayyad et al, data on ADHD and comorbidities was collected on 26,744 respondents [202]. In adults with ADHD having one comorbidity was found in 23% of cases, two in 14% of cases and three in 14% of cases. Rates were particulary high for any mood disorder (22%), any anxiety disorder (34%), substance use disorders (11%) and any behavioural disorder (15%).

Psychiatric comorbidity is thus a clinically important dimension of ADHD heterogeneity and a factor that contributes to the persistence of ADHD in adulthood [203,204]. It is important for the diagnosis of ADHD, as well as the correct targeting of treatments, to identify mood, anxiety, eating, sleep, somatic and substance use disorders, in addition to personality, ticand autistic spectrum disorders [205]. Because adults with ADHD often exhibit low self-esteem, low mood, mood lability and irritability, these symptoms may sometimes be confused with dysthymia, cyclothymia, bipolar disorder or borderline personality disorder. Furthermore, daily mood changes in ADHD are very common, and represent a poorly regulated but essentially normal range of moods, rather than the more severe extremes of depression and elation as seen in bipolar disorder. It has been argued that chronic mood instability should be considered part of the core syndrome of ADHD [206,207]. ADHD and borderline personality disorder share symptoms of impulsivity, mood instability, anger outbursts and feelings of boredom [158,208,209]. In the ADHD patient, impulsivity and anger are usually short-lived and thoughtless rather than driven. Conflicts in relationships, suicidal preoccupation, self-mutilation, identity disturbances and feelings of abandonment are usually less intense than in borderline personality disorder. However, the differences may not be clear-cut because these symptoms are chronic and trait-like in both conditions [210].

ADHD in children is also associated with increased rates of neurodevelopmental disorderslike autism spectrum disorder, dyslexia and impaired motor coordination which are thought to arise from overlapping genetic influences [211]. Such neurodevelopmental comorbidities are less well studied in adults, but they are commonly observed in clinical practice and may lead to continued impairments. As the order of treatment will depend on the presence and severity of comorbidities, evaluation of comorbid disorders is a key component of the ADHD assessment process, using appropriate clinical diagnostic approaches.

Effective treatments

The treatment of adults with ADHD should follow a multimodal and multidisciplinary approach, which includes psychoeducation, pharmacotherapy, cognitive behavior therapy(CBT) and coaching for ADHD.

Treatment focus in comorbid ADHD

In the most recent report of 20 nationally or regionally representative World Mental Health surveys, data on ADHD and comorbidities was collected on 26,744 respondents [202]. In adults with ADHD having one comorbidity was found in 23% of cases, two in 14% of case and three in 14% of cases. Rates were particulary high for any mood disorder (22%), any anxiety disorder (34%), substance use disorders (11%) and any behavioural disorder (15%). Treatment of ADHD is therefore most often in the context of co-occuring disorders.

Before treatment starts, all comorbidities must be established so that the best order of treatment can be determined together with the patient. In general, the most severe disorder is prioritized. For instance, psychosis, bipolar disorder, substance abuse, severe depression and severe anxiety are usually treated first. Milder mood or anxiety disorders, and emotional instability, may respond to treatment of ADHD and can be treated at the same time as ADHD. Drug and alcohol abuse should be stabilized but can be treated at the same time as ADHD.

Pharmacotherapy for ADHD

The recent systematic review and network meta-analysis on the comparative efficacy and tolerability of medications for ADHD in children, adolescents and adults by Sam Cortese et al. showed, that the first pharmacological choice for ADHD in children and adolescents is methylphenidate, and amphetamines in adults [222]. In fact in adults, amphetamines were not only the most efficacious compounds, as rated by clinicians and by self-report, but also as well tolerated as methylphenidate and the only compounds with better acceptability than placebo.

Licensing of ADHD medications for adults is more diverse than in 2009 [1], reflecting greater understanding of ADHD, and efforts to market ADHD medications in Europe. In Denmark, Ireland, Norway, Sweden, Switzerland, the Netherlands and the United Kingdom, most ADHD medications can be prescribed, either with a full license (e.g. Medikinet®, Strattera®, Elvanse®) or transitional licenses (e.g. Concerta XL®) and off-label prescribing is endorsed by national guidelines and formularies. Dexmethylphenidate (Focalin XR®) is licensed in Switzerland only. In other countries, only a limited selection of medications is available for funding by the state sector, but off label prescribing is possible. In another group of countries (e.g. Greece, Slovenia, Poland), only very few ADHD medications are available, with off-label prescribing mostly in the private sector. The European Network on Adult ADHD (ENAA) and the Neurodevelopmental Disorders Across the Lifespan (NDAL) section at EPA strongly recommend that evidence-based treatments for adult ADHD are made more available and licensed across European countries.

Efficacy and adverse effects of stimulants

Meta-analyses of randomized controlled trials (RCTs) demonstrate the efficacy of stimulantsand ATX in the reduction of ADHD symptoms in adults [[223][224][225][226][227]]. Standardized mean differences (SMDs) range from 0.4 to 0.7, with stimulants showing greater efficacy than ATX [224]. The longest RCT in adults still found significant effects of MPH after one year [228]. National registry data also suggest long term benefits. Although these studies are not definitive due to lack of randomization and controls, they demonstrate ‘real-world’ societal benefits associated with the use of ADHD medications. These studies show that during periods of receiving medications for ADHD there are marked reductions in transport accidents and mortality rates [132,229], criminal convictions [230], suicidal behavior [231], violent reoffending [230], depression [232] and substance misuse [233]. Similar analyses with antidepressants find no effects, suggesting the effects are specific to ADHD medications.

The main adverse effects of stimulants are increased heart rate and blood pressure, and reduced appetite and sleep [[242][243][244][245]]. Heart rate, blood pressure, sleep problems and weight are therefore assessed before, and monitored at least twice a year during treatment. Serious cardiac complications are rare [243,246,247] with reported risks for myocardial infarctionsudden cardiac deathventricular arrhythmias or stroke no more than 0.2-0.4% higher in one study [248]. MPH might trigger arrhythmias in patients with congenital heart diseases [249]. The consensus is caution in patients with known cardiac defects, but risks are small.

Long-term safety concerns

Currently there is no evidence of significant long-term risks using stimulants. Tomographyscans find higher striatal dopamine transporter availability in ADHD patients treated with stimulants [271]. The clinical implications of this up-regulation are not clear. Potential toxicity on heart valves of medications with an agonist effect on 5-HT2B receptors have been discussed [272], including MPH and guanfacine. Some argue that echocardiography should be routinely performed prior to treatment with potential valvulopathic drugs [273]. This risk is not however established, and we and others do not recommend routine echocardiograms [184,252,274], except in older adults (> age 50) [167].

Combined psychopharmacology

The high rate of psychiatric comorbidity in adult ADHD frequently necessitates combined psychopharmacology [275]. Accordingly, the risk of possible drug-drug interactions when treating adults with ADHD must be considered.

Cognitive behavior therapy (CBT) and coaching for ADHD

Although pharmacological treatment of ADHD is very effective, many patients continue to experience significant symptoms and functional impairment in daily living. Empirical evidence from numerous uncontrolled studies, more than ten randomized controlled trials (RCTs) and a meta-analysis has shown that in group or individual settings, cognitive behavioral therapy (CBT) reduces ADHD-core symptoms, associated symptoms such as emotion dysregulation, anxiety and depression, and functional impairments across different areas of daily living in adults [228,[313][314][315]]. CBT is best used within a multi-modal treatment approach and as an adjunct to medication as current research does not fully support the efficacy of CBT as a sole treatment for adult ADHD [274,[316][317][318]].

Stigma surrounding ADHD

Substantial stigmatization and myths continue to surround ADHD [345]. A recent study on negative coverage of ADHD and autism in Flemish newspapers found a 2-fold more negative than neutral or positive coverage of ADHD than of autism [346]. Stigma arises from lack of awareness, of prejudice about symptom etiology (e.g. poor parenting, lack of moral), incompetence (e.g. laziness) and perceived dangerousness (e.g. unpredictable and potentially violent behavior) [347]. Other variables contributing to stigma are doubts about the validity and reliability of an ADHD diagnosis, along with age, gender, ethnicity and the public’s skepticism toward ADHD medication. Also, the restricted regulatory status for ADHD medications in many countries adds to the stigma within the mental health profession and the media. Public stigmatization of ADHD, and the following self-stigma and courtesy stigma are underestimated risk factors for treatment adherence, treatment efficacy, symptom aggravation, life satisfaction, and mental well-being of individuals affected by ADHD [348].

Self-stigma has been studied in children and adolescents and is characterized by a sense of feeling different from peers, and negative self-evaluation as a consequence of that perception. However, some young people were prepared to challenge the stigma by self-disclosure and openness about their condition [349]. Lower stigma in teachers towards adult ADHD seems to relate to greater knowledge about the condition [350]. Among general practitioners (GPs) from the UK, Europe and Australia, there is mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributes to the presentation [351]. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for people with ADHD, there needs to be a focused and collaborative approach to training [351].

Conclusions

This consensus statement reflects agreement on the state of ADHD, but by definition it is provisional. It does not negate the ongoing scientific debate in the field and the different opinions and hypotheses about adult ADHD among experts. Yet none of that undercuts the legitimacy or validity of the construct, or of the conclusions one can make about the current status of the consistency of the evidence. ADHD is a neurodevelopmental and heritable disorder with a lifespan perspective: starting in childhood, persisting in adulthood until old age, with significant psychosocial impairment, a high comorbidity rate and multi-morbidity. It is associated with high levels of personal distress, and a substantial economic burden for society if left unidentified and untreated. DSM-5 has changed some of the criteria that facilitate the diagnosis in adolescents and adults. Assessment should include a detailed account of the developmental history, of both current and retrospective ADHD symptoms and impairment, and associated comorbidities. To prevent under-reporting of symptoms, external validation is desirable by collateral information. Multimodal treatment is required, comprising of psychoeducation, pharmacotherapy, and cognitive behavior therapy and/or coaching. Psychoeducational European programs to combat stigma and to inform the public and (mental) health professionals about new knowledge on the lifespan perspective of ADHD are needed to improve and increase diagnostic and treatment services for adult ADHD. Research on the different presentation of ADHD in women, and on treatment of ADHD in old age should be further developed in order to improve their treatment options.


References

Kooij, J. J. S., et al. (2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry56, 14–34. https://doi.org/10.1016/J.EURPSY.2018.11.001



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