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Diagnosing ADHD in children and adults

Professor J Antoni Ramos-Quiroga (Universitat Autònoma de Barcelona, Spain) and Dr Larry Klassen (Eden Mental Health Centre, Canada) discussed key diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders – 5th edition (DSM-5TM) (Figure); highlighting the difference in number of symptoms required for children versus adults (six vs five, respectively).1

Key diagnostic criteria of the DSM-5TM for children (and adults)1

"Key

Professor Ramos-Quiroga and Dr Klassen acknowledged that symptoms of inattention tended to drive diagnosis of ADHD over the lifetime – supported by results of a logistic regression analysis of ADHD symptoms in male children (n=128) measured over time, which indicated that the prevalence of remission of inattentiveness was lower than hyperactivity or impulsivity.2

Furthermore, Professor Ramos-Quiroga and Dr Klassen noted how DSM-5TM criteria supported the view that symptoms of hyperactivity-impulsivity tend to visibly wane over time; for example:

  • Hyperactivity/impulsivity: often runs or climbs in situations where it is inappropriate (Note: in adolescents or adults, may be limited to feelings of restlessness).1

Personality profile of ADHD

Also discussed were the roles of executive function deficits,3 emotional lability,4 motivational deficit,5 and personality characteristics6 in the profile of ADHD. For example: the presenters discussed one study that assessed the personality profile of adults with ADHD (n=217) versus healthy controls (n=434) with reference to the Alternative Five Factor Model of personality (five scales: Neuroticism-Anxiety; Activity; Sociability; Impulsive Sensation Seeking; and Aggression-Hostility). Results of this study indicated that those with ADHD scored significantly higher for all five personality traits versus controls, aside from Sociability; with Neuroticism-Anxiety, Impulsive Sensation Seeking and Aggression-Hostility being the most powerful predictors of ADHD diagnosis.6

Optimising the treatment of adult ADHD across the lifespan

In the final scientific session of MoM VII, Professor Philip Asherson (King’s College London, UK) discussed the apparent gap between what is recommended in guidelines in terms of care for adults with ADHD, and what occurs in practice.

Current guidelines for the treatment of adult ADHD

Professor Asherson noted that there was generally good consensus between the various guidelines for the treatment of adult ADHD.7-9 Following a question to the audience regarding whether psychosocial treatment was recommended as first-line treatment for adults, the differences in the National Institute of Health and Care Excellence (NICE) guidelines for the first-line treatment of children/adolescents and adults with ADHD were clarified:9

NICE guidelines: first-line treatment for ADHD9
Children/adolescents Adults
  • ADHD with severe impairment: treat first with medication
  • ADHD with moderate impairment: consider psychological treatment as the first-line approach
  • First-line treatment is medication unless psychological intervention is preferred
  • Drug treatment should always form part of a comprehensive treatment programme that addresses psychological, behavioural and educational/occupational needs
  • In adults, limited evidence of effectiveness of psychological therapies alone; but they have an important role adjunct to medication

Despite the fact that first-line treatment for adults with ADHD is recommended to be pharmacological, it was noted that adolescents and younger adults (aged 15–21 years) may be likely to discontinue ADHD medication,10 with reasons for non-adherence including: side-effects, dislike of taking medication and a feeling of being able to cope without it.11

Impact of treatment: beyond core symptoms

Professor Asherson highlighted that it was important that ADHD treatments target all aspects of ADHD, including core symptoms (hyperactivity-impulsivity and inattention) and associated impairments. These impairments may be psychological (e.g. low self-esteem, emotional lability, sleep issues), psychosocial (e.g. problems with relationships), or academic (which may be related to specific learning difficulties).9,12 Support in these areas of impairment may be particularly useful during the transition from childhood to adulthood.13

ADHD management: service delivery

However, Professor Asherson highlighted that in practice, management of ADHD was challenging to implement. Results were presented from a qualitative study that administered semi-structured interviews with adults with ADHD (n=30) who reported various issues in their experience of ADHD management, for example:14

  • Delays and difficulties in receiving a diagnosis14
  • Challenges in the transition between child and adult services14
  • Lack of individualised treatment programmes.14

Professor Asherson concluded that the unmet needs of adults with ADHD are substantial, and that work is required to ensure that guidelines and policy are implemented successfully to ensure appropriate management of patients.15

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, 2013.
  2. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 2000; 157: 816-818.
  3. Carmona S, Hoekzema E, Ramos-Quiroga JA, et al. Response inhibition and reward anticipation in medication-naïve adults with attention-deficit/hyperactivity disorder: a within-subject case-control neuroimaging study. Hum Brain Mapp 2012; 33: 2350-2361.
  4. Vidal R, Valero S, Nogueira M, et al. Emotional lability: the discriminative value in the diagnosis of attention deficit/hyperactivity disorder in adults. Compr Psychiatr 2014; 55: 1712-1719.
  5. Volkow ND, Wang G-J, Newcorn JH, et al. Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Mol Psych 2011; 16: 1147-1154.
  6. Valero S, Ramos-Quiroga A, Gomà-i-Freixanet M, et al. Personality profile of adult ADHD: the alternative five factor model. Psych Res 2012; 198: 130-134.
  7. Kooij S, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psych 2010; 10: 67.
  8. Nutt DJ, Fone K, Asherson P, et al. Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology. J Psychopharm 2007; 21: 10-41.
  9. National Collaborating Centre for Mental Health. The NICE guideline on diagnosis and management of ADHD in children, young people and adults – National Clinical Practice Guideline Number 72. The British Psychological Society and The Royal College of Psychiatrists, 2008. Last modified March 2013.
  10. Zetterqvist J, Asherson P, Halldner L, et al. Stimulant and non-stimulant attention-deficit/hyperactivity disorder drug use: total population study of trends and discontinuation patterns 2006-2009. Acta Psychiatr Scand 2013; 128: 70-77.
  11. Wong ICK, Asherson P, Bilbow A, et al. Cessation of attention deficit hyperactivity disorder drugs in the young (CADDY) – a pharmacoepidemiological qualitative study. Health Tech Assess 2009; 13: iii-iv.
  12. Asherson P. Clinical assessment and treatment of attention deficit hyperactivity disorder. Exp Rev Neurother 2005; 5: 525-539.
  13. Young S, Murphy CM, Coghill D. Avoiding the ‘twilight zone’: recommendations for the transition of services from adolescence to adulthood for young people with ADHD. BMC Psychiatr 2011; 11: 174.
  14. Matheson L, Asherson P, Wong ICK, et al. Adult ADHD patient experiences of impairment, service provision and clinical management in England: a qualitative study. BMC Health Serv Res 2013; 13: 184.
  15. Asherson P. Presented at Meeting of Minds (MoM) VII, 29–30 June 2015, Stockholm, Sweden.
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