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 National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder: diagnosis and management (CG72). Please note: any underlining (for emphasis) has been added by AADD-UK. Other resources used by AADD-UK to expand upon the extract, when needed, are named and linked to in the relevant sections.

1. Responsibility

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

2. Prerequisites of treatment and care for all people with ADHD

People with ADHD require integrated care that addresses a wide range of personal, social, educational and occupational needs. Care should be provided by adequately trained healthcare and education professionals.

3. Information, 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

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

4. Training

Trusts should ensure that specialist ADHD teams for children, young people and adults jointly develop age-appropriate training programmes for the diagnosis and management of ADHD for mental health, paediatric, social care, education, forensic and primary care providers and other professionals who have contact with people with ADHD.

5. Identification and referral in adults with ADHD

a) 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

b) 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.

6. Diagnosis of ADHD

a) 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.

b) A diagnosis of ADHD should only be made by a specialist psychiatrist, 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

c) A diagnosis of ADHD should not be made solely on the basis of rating scale or observational data.

d) 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.

e) Please note: there are links to diagnostic assessment tools at the bottom of this page.

7. Transition to adult services

a) 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.

b) 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.

c) 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.

d) 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.

8. Treatment of adults with ADHD

a) 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.

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

c) 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.

d) 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:

(i) assessment of history of exercise syncope, undue breathlessness and other cardiovascular symptoms

(ii) heart rate and blood pressure (plotted on a centile chart)

(iii) weight

(iv) 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

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

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

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

h) 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.

i) 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.

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

9. Drug Treatment for Adults with ADHD & Substance Misuse

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.

10. How to use drugs for the treatment of ADHD

a) Good knowledge by clinicians of the drugs used in the treatment of ADHD and their different preparations is essential. It is important to start with low doses and titrate upwards, monitoring effects and side effects carefully. Higher doses may need to be prescribed to some adults. The recommendations on improving adherence in children and young people may also be of use in adults.

b) During the titration phase, doses should be gradually increased until there is no further clinical improvement in ADHD (that is, symptom reduction, behaviour change, improvements in education and/or relationships) and side effects are tolerable.

c) Following titration and dose stabilisation, prescribing and monitoring should be carried out under locally agreed shared care arrangements with primary care.

d) Side effects resulting from drug treatment for ADHD should be routinely monitored and documented in the person’s notes.

e) If side effects become troublesome in people receiving drug treatment for ADHD, a reduction in dose should be considered.

f) Healthcare professionals should be aware that dose titration should be slower if tics or seizures are present in people with ADHD.

11. Initiation and titration of methylphenidate, atomoxetine and dexamfetamine in adults

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

b) 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.

c) 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.

d) 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.

e) 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/day
• the dose should usually be given between two and four times daily

12. Monitoring side effects (including weight loss) and the potential for misuse

a) Weight should be measured 3 and 6 months after drug treatment has started and every 6 months thereafter in adults

b) 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.

c) Strategies to reduce weight loss include:

• taking medication either with or after food, rather than before meals
• taking additional meals or snacks early in the morning or late in the evening when the stimulant effects of the drug have worn off
• obtaining dietary advice
• consuming high-calorie foods of good nutritional value.

d) Heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3months.

e) For people taking methylphenidate, dexamfetamine and atomoxetine, routine blood tests and ECGs are not recommended unless there is a clinical indication.

f) Liver damage is a rare and idiosyncratic adverse effect of atomoxetine and routine liver function tests are not recommended.

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

h) 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 physician.

i) 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.

j) If tics emerge in people taking methylphenidate or dexamfetamine, healthcare professionals should consider whether:

• the tics are stimulant-related (tics naturally wax and wane)
• tic-related impairment outweighs the benefits of ADHD treatment.

k) If tics are stimulant-related, reduce the dose of methylphenidate or dexamfetamine, consider changing to atomoxetine, or stop drug treatment.

l) 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.

13. Duration, discontinuation and continuity of treatment in adults

a) 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.

b) 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.

14. Stimulant dose equivalents (mg) of immediate-release methylphenidate (IR-MPH) compared with brands of modified-release methylphenidate

• IR-MPH 10 mg is equivalent to Equasym XL 10 mg or Medikinet XL 10 mg;
• IR-MPH 15 mg is equivalent to Concerta XL 18 mg;
• IR-MPH 20 mg is equivalent to Equasym XL 20 mg or Medikinet XL 20 mg;
• IR-MPH 30 mg is equivalent to Concerta XL 36 mg, Equasym XL 30 mg or Medikinet XL 30 mg;
• IR-MPH 45 mg is equivalent to Concerta XL 54 mg;
• IR-MPH 60 mg is equivalent to Concerta XL 72 mg (licensed up to 54 mg) or Equasym XL 60 mg.

15. Stimulants and Drugs used for ADHD in the UK

a)  The British National Formulary (BNF)  The British National Formulary (BNF) lists the following as stimulants and drugs used for ADHD: methylphenidate hydrochloride, dexamfetamine sulfate, atomoxetine, lisdexamfetamine mesilate, guanfacine, and modafinil.

b) Methylphenidate, dexamfetamine, lisdexamfetamine, and modafinil are stimulants but atomoxetine and guanfacine are not.

c) The BNF also states the following: Drug treatment of ADHD should be part of a comprehensive treatment programme. The choice of medication should take into consideration co-morbid conditions (such as tic disorders, Tourette syndrome, and epilepsy), the adverse effect profile, potential for drug misuse, tolerance and dependance; and preferences of the patient and carers. Methylphenidate and atomoxetine are used for the management of ADHD; dexamfetamine and lisdexamfetamine are an alternative in children who do not respond to these drugs. Pulse, blood pressure, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter. Guanfacine, a non-stimulant alpha₂-adrenoceptor agonist, can be used in children for whom stimulants are not suitable, not tolerated, or ineffective. Therapeutic response to guanfacine should be evaluated every 3 months for the first year and then at least yearly, when prescribed for extended periods.

d) The need to continue drug treatment for ADHD should be reviewed at least annually. This may involve suspending treatment. (Accessed 10/05/2017)

16. Medication: Patient Information Leaflets (PIL) and Summary of Product Characteristics (SPC)

The PILs and SPCs for each medication can be downloaded from the eMC website  which is kept up to date with current medical knowledge.  The documents published on the eMC are as regulated by the Medicines and Healthcare products Regulatory Agency (MHRA).  The eMC website is not, however, intended to be a substitute for professional medical advice and treatment. If you have questions about your medication, you should seek advice from your ADHD specialist.

17. Psychoeducation and Cognitive Behavioural Therapy (CBT) for ADHD

a) Psychoeducation can help people make sense of being diagnosed with ADHD and can help them to cope and live with the condition. NICE in Appendix E of CG123: Common mental health problems: identification and pathways to care [2011] defines psychoeducation thus: the provision of information and advice about a disorder and its treatment. It usually involves an explanatory model of the symptoms and advice on how to cope with or overcome the difficulties a person may experience. It is usually of brief duration, instigated by a healthcare professional, and supported by the use of written materials (accessed 10/05/2017).

b) 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.

c) 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.

d) An explanation of face-to-face CBT can be found on the NHS Choices website and here is a sampling: During the sessions, you’ll work with your therapist to break down your problems into their separate parts – such as your thoughts, physical feelings and actions. You and your therapist will analyse these areas to work out if they’re unrealistic or unhelpful and to determine the effect they have on each other and on you. Your therapist will then be able to help you work out how to change unhelpful thoughts and behaviours. After working out what you can change, your therapist will ask you to practise these changes in your daily life and you’ll discuss how you got on during the next session. The eventual aim of therapy is to teach you to apply the skills you’ve learnt during treatment to your daily life. This should help you manage your problems and stop them having a negative impact on your life – even after your course of treatment finishes (accessed 10/05/2017).

e) In addition to the NHS Choices website, the site for the Royal College of Psychiatrists has a leaflet describing CBT (accessed 10/05/2017).

f) NICE in Appendix E of CG123: Common mental health problems: identification and pathways to care [2011] defines computerised CBT thus: a form of cognitive behavioural therapy that is provided via a stand-alone computer-based or web-based programme. It should include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes. It should be supported by a trained practitioner who typically provides limited facilitation of the programme and reviews progress and outcome. The intervention typically takes place over 9 to 12 weeks, including follow-up (accessed 10/05/2015).

18. Assessment Tools/Information for ADHD specialists & other qualified medical professionals

a)  Diagnostic Interview for ADHD in adults (DIVA) 2.0 

The DIVA 2.0 is a publication of the DIVA Foundation, The Hague, The Netherlands, August 2010 and copies are also available in 18 other languages.  These and further information are available from the Diva Foundation (accessed 9/5/2017).

b) ACEPLUS The ACE+ is a semi-structured interview which is built on the ADHD Child Evaluation (ACE) both developed by Professor Susan Young.  The ACE+ supports  healthcare practitioners in the assessment and diagnosis of adults with ADHD.  ACE+ is in English, French and Turkish and is free to download and distribute from Psychology Services Limited

c)  The ADHD Lifespan Functioning Interview (ALFI), the B-BAARS ADHD screen for offenders, the Blame Attribution Inventory, various rating scales and other useful information and strategies are also available from Psychology Services Limited (accessed 10/05/2017).

d)  The UK Adult ADHD Network (UKAAN) website has a useful list of Clinicians Resources including, but not limited to, information about the DSM5, the ADHD Star, as well as a copy of a “shared care agreement,” various articles and screening tools (accessed 10/05/2017).

 

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Review date: 10/05/2017

Next review due: 11/05/2020