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22 Sep 2017

Jain R et al. Prim Care Companion CNS Disord 2017; Epub ahead of print

This review was funded by Shire.

It is now recognised that ADHD may persist into adulthood, with 57% of individuals with a history of childhood ADHD presenting symptoms in adulthood. A recent World Health Organization World Mental Health report indicated a prevalence of ADHD in adults of 2.8% across the 18 countries surveyed. Although this report implied that ADHD in adulthood is a global health issue, it is often under-diagnosed. This review article covered the following: a description of the negative impact of ADHD in adulthood, updates to diagnostic guidelines, clinical features, the importance of screening tools and clinical interviews, and treatment options for adults with ADHD.

Studies have shown that ADHD in adulthood can affect interpersonal relationships, family life and sleeping patterns, and is frequently associated with occupational failure, self-esteem issues and injuries/accidents, emphasising the importance of diagnosing and treating ADHD in adults.

Diagnosis of ADHD in adults has been addressed in the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM) guidelines for the diagnosis of ADHD, which were published in 2013 and have been updated relative to the 4th edition to now incorporate guidance specifically relating to adults with ADHD: e.g. (1) an established diagnosis of ADHD in individuals >17 years old now requires fewer criteria; (2) the age of onset has been increased to 12 years, not 7 years; (3) there are more examples of behavioural manifestations of ADHD in adulthood to aid diagnosis for clinicians; and (4) indications of current disease state and severity have been included.

However, despite these updated guidelines, diagnosis of ADHD in adults remains complicated, in particular due to the high rate of psychiatric comorbidity. A National Comorbidity Survey Replication found that ADHD in adults is significantly associated with any mood disorder (odds ratio [OR]=5.0), any anxiety disorder (OR=3.7) and any substance-abuse disorder (OR=3.0). Overlapping symptoms between ADHD and comorbidities are likely to contribute to under-diagnosis and misdiagnosis of ADHD in adults.

Although screening tools are useful in the diagnosis of ADHD in adults, their use can be complicated by the presence of comorbid psychiatric disorders. However, tools such as the self-administered 6-question Adult ADHD Self-Report Scale version 1.1 and the ADHD Rating Scale version IV with adult prompts do have a use in allowing clinicians to identify potential cases of ADHD in adults for further diagnosis. In combination with comprehensive clinical interviews, including longitudinal and familial histories, rating scales can help clinicians to reach a diagnosis of ADHD.

Of those adults (aged 18–44 years) who do receive a diagnosis of ADHD, many remain untreated, with a US study reporting only 10.9% of adults with ADHD having received treatment in the previous 12 months. This is despite the availability of non-pharmacological and pharmacological treatments for adults with ADHD.

Adults with ADHD may benefit from an array of non-pharmacological treatments, e.g. cognitive behavioural therapy, dialectical behavioural therapy, physical exercise and mindfulness awareness practice. In addition, multiple pharmacological treatments, which can be either psychostimulants or non-stimulants, are currently approved by the US Food and Drug Administration for the treatment of ADHD in adults. Treatment choice for an individual patient should be influenced by a number of factors, e.g. efficacy profile, required duration of action, safety profile and comorbidities.

ADHD in adults is often left under-diagnosed and untreated, which can have a negative impact on well-being. The updated diagnostic criteria for ADHD now include symptoms specific to affected adults, and the use of screening and assessment instruments may aid clinical diagnosis of ADHD in the adult population. However, diagnosis of ADHD in adulthood may be confounded by the high prevalence of comorbidities, therefore it is important for clinicians to recognise symptomatic overlap between comorbid disorders. A variety of non-pharmacological and pharmacological treatments are available for adults with ADHD, with psychostimulants exhibiting well-established efficacy for treating the primary symptoms of ADHD.

Read more about diagnosing and treating ADHD in adults here

Jain R, Jain S, Montano CB. Addressing diagnosis and treatment gaps in adults with attention-deficit/hyperactivity disorder. Prim Care Companion CNS Disord 2017; Epub ahead of print.

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