Diagnosis & Treatment

MEDICAL DISCLAIMER

Information provided on this website is intended for your general knowledge and is not meant to be a substitute for professional medical advice and treatment. You should never disregard professional medical advice or delay in seeking an assessment or medical treatment because of something you may have read on this site. You should also not use the information on this web site or the information on links from this site to diagnose or treat ADHD and/or co-morbidities, in yourself or others, without consulting a qualified adult ADHD specialist.

Diagnosis and management of ADHD in adults

The following extracts (relevant for adults) have been taken from the shorter version of NICE Clinical Guideline 72 –  (recommendations for health professionals).

Person-centred care

Treatment and care should take into account people’s needs and preferences and in the case of children, those of their parents or carers. All people with ADHD, including children, should have the opportunity to be involved in decisions about their care and treatment in partnership with their healthcare professionals.

Good communication between healthcare professionals and people with ADHD is essential. It should be supported by evidence-based written information tailored to the person’s needs. Treatment and care, and the information people are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities and to people who do not speak or read English.

Information, consent, the law and support for people with ADHD and their carers

Many people with ADHD, and their parents or carers, experience stigma and other difficulties because of the symptoms and impairment associated with ADHD and current practice within healthcare and education. The following recommendations have been developed based on the experiences of people with ADHD and their families.

Healthcare professionals should develop a trusting relationship with people with ADHD and their families or carers by:

  • Respecting the person and their family’s knowledge and experience of ADHD
  • Being sensitive to stigma in relation to mental illness.

Healthcare professionals should provide people with ADHD and their families or carers with relevant, age-appropriate information (including written information) about ADHD at every stage of their care. The information should cover diagnosis and assessment, support and self-help, psychological treatment, and the use and possible side effects of drug treatment.

Adults with ADHD should be given written information about local and national support groups and voluntary organisations.

Healthcare professionals should ask families or carers about the impact of ADHD on themselves and other family members, and discuss any concerns they may have. Healthcare professionals should:

  • Offer family members or carers an assessment of their personal, social and mental health needs
  • Encourage participation in self-help and support groups where appropriate

Care pathway for the treatment and care of people with ADHD

Adults presenting with symptoms of ADHD in primary care or general adult psychiatric services, who do not have a childhood diagnosis of ADHD, should be referred for assessment by a mental health specialist trained in the diagnosis and treatment of ADHD, where there is evidence of typical manifestations of ADHD (hyperactivity/impulsivity and/or inattention) that:

  • Began during childhood and have persisted throughout life
  • Are not explained by other psychiatric diagnoses (although there may be other coexisting psychiatric conditions)
  • Have resulted in or are associated with moderate or severe psychological, social and/or educational or occupational impairment.

Adults who have previously been treated for ADHD as children or young people and present with symptoms suggestive of continuing ADHD should be referred to general adult psychiatric services for assessment. The symptoms should be associated with at least moderate or severe psychological and/or social or educational or occupational impairment.

Diagnosis of ADHD

ADHD is a valid clinical disorder that can be distinguished from coexisting conditions (although it is most commonly comorbid) and the normal spectrum. ADHD differs from the normal spectrum because there are high levels of hyperactivity/impulsivity and/or inattention that result in significant psychological, social and/or educational or occupational impairment that occurs across multiple domains and settings and persists over time.

A diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD, on the basis of:

  • A full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person’s everyday life, and
  • A full developmental and psychiatric history, and
  • Observer reports and assessment of the person’s mental state.

A diagnosis of ADHD should not be made solely on the basis of rating scale or observational data. However rating scales such as the Conners’ rating scales and the Strengths and Difficulties questionnaire are valuable adjuncts, and observations (for example, at school) are useful when there is doubt about symptoms.

For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:

  • Meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder),  and
  • Be associated with at least moderate psychological, social and/or educational or occupational impairment based on interview and/or direct observation in multiple settings, and
  • Be pervasive, occurring in two or more important settings including social, familial, educational and/or occupational settings.

As part of the diagnostic process, include an assessment of the person’s needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people, there should also be an assessment of their parents’ or carers’ mental health.

Assessment Tools

1. Diagnostic Interview for ADHD in adults (DIVA)

Transition to adult services

Young people with ADHD receiving treatment and care from CAMHS or paediatric services should normally be transferred to adult services if they continue to have significant symptoms of ADHD or other coexisting conditions that require treatment. Transition should be planned in advance by both referring and receiving services. If needs are severe and/or complex, use of the care programme approach should be considered.

A young person with ADHD receiving treatment and care from CAMHS or paediatric services should be reassessed at school-leaving age to establish the need for continuing treatment into adulthood. If treatment is necessary, arrangements should be made for a smooth transition to adult services with details of the anticipated treatment and services that the young person will require. Precise timing of arrangements may vary locally but should usually be completed by the time the young person is 18 years.

During the transition to adult services, a formal meeting involving CAMHS and/or paediatrics and adult psychiatric services should be considered, and full information provided to the young person about adult services. For young people aged 16 years and older, the care programme approach (CPA) should be used as an aid to transfer between services. The young person, and when appropriate the parent or carer, should be involved in the planning.

After transition to adult services, adult healthcare professionals should carry out a comprehensive assessment of the person with ADHD that includes personal, educational, occupational and social functioning, and assessment of any coexisting conditions, especially drug misuse, personality disorders, emotional problems and learning difficulties.

Treatment of adults with ADHD

Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Methylphenidate is the first-line drug. Psychological interventions without medication may be effective for some adults with moderate impairment, but there are insufficient data to support this recommendation. If methylphenidate is ineffective or unacceptable, atomoxetine or dexamfetamine can be tried. If there is residual impairment despite some benefit from drug treatment, or there is no response to drug treatment, CBT may be considered. There is the potential for drug misuse and diversion in adults with ADHD, especially in some settings, such as prison, although there is no strong evidence that this is a significant problem.

For adults with ADHD, drug treatment should be the first-line treatment unless the person would prefer a psychological approach.

Drug treatment for adults with ADHD should be started only under the guidance of a psychiatrist, nurse prescriber specialising in ADHD, or other clinical prescriber with training in the diagnosis and management of ADHD.

Before starting drug treatment for adults with ADHD a full assessment should be completed, which should include:

  • Full mental health and social assessment
  • Full history and physical examination, including:
    • assessment of history of exercise syncope, undue breathlessness and other cardiovascular symptoms
    • heart rate and blood pressure (plotted on a centile chart)
    • weight
    • family history of cardiac disease and examination of the cardiovascular system
  • An ECG if there is past medical or family history of serious cardiac disease, a history of sudden death in young family members or abnormal findings on cardiac examination
  • Risk assessment for substance misuse and drug diversion.

Drug treatment for adults with ADHD should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational or occupational needs.

Following a decision to start drug treatment in adults with ADHD, methylphenidate should normally be tried first.

Atomoxetine or dexamfetamine should be considered in adults unresponsive or intolerant to an adequate trial of methylphenidate (this should usually be about 6 weeks)15. Caution should be exercised when prescribing dexamfetamine to those likely to be at risk of stimulant misuse or diversion.

When starting drug treatment, adults should be monitored for side effects. In particular, people treated with atomoxetine should be observed for agitation, irritability, suicidal thinking and self-harming behaviour, and unusual changes in behaviour, particularly during the initial months of treatment, or after a change in dose. They should also be warned of potential liver damage in rare cases (usually presenting as abdominal pain, unexplained nausea, malaise, darkening of the urine or jaundice). Younger adults aged 30 years or younger should also be warned of the potential of atomoxetine to increase agitation, anxiety, suicidal thinking and self-harming behaviour in some people, especially during the first few weeks of treatment.

For adults with ADHD stabilised on medication but with persisting functional impairment associated with the disorder, or where there has been no response to drug treatment, a course of either group or individual CBT to address the person’s functional impairment should be considered. Group therapy is recommended as the first-line psychological treatment because it is the most cost effective.

For adults with ADHD, CBT may be considered when:

  • The person has made an informed choice not to have drug treatment
  • Drug treatment has proved to be only partially effective or ineffective or the person is intolerant to it
  • People have difficulty accepting the diagnosis of ADHD and accepting and adhering to drug treatment
  • Symptoms are remitting and psychological treatment is considered sufficient to target residual (mild to moderate) functional impairment.

Where there may be concern about the potential for drug misuse and diversion (for example, in prison services), atomoxetine may be considered as the first-line drug treatment for ADHD in adults.

Drug treatment for adults with ADHD who also misuse substances should only be prescribed by an appropriately qualified healthcare professional with expertise in managing both ADHD and substance misuse. For adults with ADHD and drug or alcohol addiction disorders there should be close liaison between the professional treating the person’s ADHD and an addiction specialist.

Antipsychotics are not recommended for the treatment of ADHD in adults.

Initiation and titration of methylphenidate, atomoxetine and dexamfetamine in adults

In order to optimise drug treatment, the initial dose should be titrated against symptoms and side effects over 4–6 weeks.

During the titration phase, symptoms and side effects should be recorded at each dose change by the prescriber after discussion with the person with ADHD and, wherever possible, a carer (for example, a spouse, parent or close friend). Progress should be reviewed (for example, by weekly telephone contact and at each dose change) with a specialist clinician.

If using methylphenidate in adults with ADHD:

  • Initial treatment should begin with low doses (5 mg three times daily for immediate-release preparations; the equivalent dose for modified-release preparations)
  • The dose should be titrated against symptoms and side effects over 4–6 weeks
  • The dose should be increased according to response up to a maximum of 100 mg/day
  • Modified-release preparations should usually be given once daily and no more than twice daily
  • Modified-release preparations may be preferred to increase adherence and in circumstances where there are concerns about substance misuse or diversion
  • Immediate-release preparations should be given up to four times daily.

If using atomoxetine in adults with ADHD:

  • For people with ADHD weighing up to 70 kg, the initial total daily dose should be approximately 0.5 mg/kg; the dose should be increased after 7 days to approximately 1.2 mg/kg/day
  • For people with ADHD weighing more than 70 kg, the initial total daily dose should be 40 mg; the dose should be increased after 7 days up to a maintenance dose of 100 mg/day
  • The usual maintenance dose is either 80 or 100 mg, which may be taken in divided doses
  • A trial of 6 weeks on a maintenance dose should be allowed to evaluate the full effectiveness of atomoxetine.

If using dexamfetamine in adults with ADHD:

  • Initial treatment should begin with low doses (5 mg twice daily)
  • The dose should be titrated against symptoms and side effects over 4–6 weeks
  • Treatment should be given in divided doses
  • The dose should be increased according to response up to a maximum of 60 mg per day
  • The dose should usually be given between two and four times daily.

Monitoring side effects and the potential for misuse in children, young people and adults

Healthcare professionals should consider using standard symptom and side effect rating scales throughout the course of treatment as an adjunct to clinical assessment for people with ADHD.

In people taking methylphenidate, atomoxetine, or dexamfetamine:

  • weight should be measured 3 and 6 months after drug treatment has started and every 6 months thereafter in children, young people and adults

If there is evidence of weight loss associated with drug treatment in adults with ADHD, healthcare professionals should consider monitoring body mass index and changing the drug if weight loss persists.

In people with ADHD, heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3 months.

In young people and adults, sexual dysfunction (that is, erectile and ejaculatory dysfunction) and dysmenorrhoea should be monitored as potential side effects of atomoxetine.

For people taking methylphenidate, dexamfetamine or atomoxetine who have sustained resting tachycardia, arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should have their dose reduced and be referred to a paediatrician or adult physician.

If psychotic symptoms (for example, delusions and hallucinations) emerge in children, young people and adults after starting methylphenidate or dexamfetamine, the drug should be withdrawn and a full psychiatric assessment carried out. Atomoxetine should be considered as an alternative.

Anxiety symptoms, including panic, may be precipitated by stimulants, particularly in adults with a history of coexisting anxiety. Where this is an issue, lower doses of the stimulant and/or combined treatment with an antidepressant used to treat anxiety can be used; switching to atomoxetine may be effective.

Duration, discontinuation and continuity of treatment in adults

Following an adequate response, drug treatment for ADHD should be continued for as long as it is clinically effective. This should be reviewed annually. The review should include a comprehensive assessment of clinical need, benefits and side effects, taking into account the views of the person and those of a spouse, partner, parent, close friends or carers wherever possible, and how these accounts may differ. The effect of missed doses, planned dose reductions and brief periods of no treatment should be taken into account and the preferred pattern of use should also be reviewed. Coexisting conditions should be reviewed, and the person treated or referred if necessary. The need for psychological, social and occupational support for the person and their carers should be assessed.

An individual treatment approach is important for adults, and healthcare professionals should regularly review (at least annually) the need to adapt patterns of use, including the effect of drug treatment on coexisting conditions and mood changes.

Reference:

National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. CG72. London: National Institute for Health and Clinical Excellence.

A free electronic copy of the physician’s version of the guideline can be accessed from our library here

Medications

  • Methylphenidate is  a stimulant that increases the activity of dopamine and noradrenaline in the parts of the brain that control attention and behaviour.  There are four brands of methylphenidate available in the UK as follows:
    • Ritalin: more information from electronic Medicines Compendium (eMC) is available here
    • Concerta: more information from eMC  is available here
    • Equasym: more information from eMC is available here
    • Medikinet: more information from eMC is available here
  • Atomoxetine is a type of medicine called a selective noradrenaline re-uptake inhibitor, and is a non-stimulant medicine that is used to treat ADHD.  Strattera is the only brand available in the UK:  more information from eMC is available here
  • Dexamfetamine is a stimulant medication used for treating ADHD and it works by increasing the activity of dopamine and noradrenaline in parts of the brain that control attention and behaviour.  It is generally used for those people for whom methylphenidate does not work.  Dexedrine is currently the only brand available in the UK:  more information available from Scottish Drugs Forum here

If there is anything on this page you would like to discuss, or if you have any questions, please join us in our Forum here.

Review date: 08/05/2013

Next review due: 08/05/2014

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