Day 1 of the 10th Meeting of Minds was opened in a celebratory fashion by Professor David Coghill (Royal Children’s Hospital Melbourne, Australia) who reflected on the decade of advances in ADHD that have been captured at this globally recognised annual event. Professor Coghill fondly recalled the very first Meeting of Minds in 2008, and expressed his pleasure that the meeting has become such an important date in the calendar, informing the audience of the latest developments in science and clinical practice. Day 1 of the meeting provided engaging plenary presentations highlighting the recent advances in the field of ADHD, and an in-depth look at managing the transition between adolescence and adulthood. In addition, a panel discussion session treated the audience to an evaluation of recent developments in ADHD treatment guidelines.

Plenary 1: A decade of advancement in ADHD

Moderators: Professor David Coghill, Professor Joseph Sergeant

A decade of advancement in ADHD

Professor Joseph Sergeant (Vrije Universiteit, The Netherlands) opened this reflective plenary session with a whistle-stop tour of developments in ADHD over the past decade since the Meeting of Minds was initiated in 2008. Professor Sergeant touched upon some of the exciting milestones of discovery, including genetic biomarkers, the identification of the association between ADHD and premature mortality, the increasing interest and acceptance of adult ADHD, and the introduction of new pharmacological treatments.

On reflecting on the progress of the past 10 years, Professor Sergeant shared the sentiment that all of those present at the meeting should be proud of the achievements and advances in the care of patients with ADHD that have occurred over the decade-long journey. However, despite these improvements, Professor Sergeant acknowledged that there are a number of limitations in the treatment landscape that have persisted over the years. For example, the assumption that non-pharmacological treatments would be of significant benefit in patients with ADHD has not been definitively confirmed in clinical studies.

To conclude, Professor Sergeant looked forward to the next 10 years, calling for the ADHD community to continue striving towards new developments that will form the key areas of discovery in the future.

Professor Sergeant: “What we do next has to be guided by asking what we can do to help the patients and families in our care.”

How has our understanding of the causes of ADHD changed?

Continuing on the theme of reflection, this presentation delivered a snapshot from the personal clinical experiences of Professor Edmund Sonuga-Barke (King’s College London, UK). Professor Sonuga-Barke began by highlighting that over the past 10 years, we have realised that ADHD is more complex than previously thought.

As an example, Professor Sonuga-Barke pointed out that studies investigating the genetics and heritability of ADHD have opened up whole new areas of research requiring further elucidation. While the initial hope was that a few candidate genes would have a large effect on the risk of developing ADHD, it is now more likely that thousands of as yet unidentified genes are responsible for the genetic component of risk.1 Professor Sonuga-Barke went on to highlight the challenges of investigating the many gene variations implicated in the uncharacterised percentage of genetic risk.

Professor Sonuga-Barke then discussed how we have realised that the influence of environmental factors on the risk of developing ADHD is more complex than previously thought. Ten years ago, it was thought that environmental factors were directly implicated in the risk of developing ADHD; however, data from twin studies suggest that 70% of the variance in risk is due to shared genes and 0% is due to shared environment.2 Following on from this finding, there is now a hypothesis that studying the interplay between genes and environment may help to explain some of the uncharacterised components of genetic risk.3 However, with the exception of extreme adversity, environmental factors are now thought to have only a marginal role in determining the risk of developing ADHD.

Finally, Professor Sonuga-Barke described how we have gained a greater understanding of the complexities of the pathophysiology of ADHD in the past 10 years. While ADHD has previously been considered a single pathological entity, it is now thought that different patients may present with different pathophysiologies. It is unclear if these are subtypes of ADHD or a reflection of the complex brain systems involved in ADHD that result in varying manifestations of ADHD across different individuals.4

Professor Sonuga-Barke’s conclusion was that ADHD is now understood to be a heterogeneous and highly heritable disorder, with environmental factors unlikely to play a major role once gene–environment interactions are taken into account. Looking to the future, longitudinal studies will be required to further investigate the interactions between genes, environment, brain structure/function and cognition, symptoms and impairment.

Professor Sonuga-Barke: “Although we have made enormous advances, we still don’t feel any closer to the goal of science-driven therapy.”

Established risks and consequences of ADHD

This thought-provoking presentation delivered by Professor Henrik Larsson (Karolinska Institute and Ӧrebro University, Sweden) discussed some of the potentially serious negative outcomes associated with ADHD.

A series of longitudinal clinical studies and patient registries have demonstrated that ADHD is associated with an increased risk of suicidal behaviour, including suicide attempts and completed suicide.5-7 In this presentation, Professor Larsson discussed some of the research his group has published, which investigated the reasons behind this association using data from Swedish National Registries.

Based on results demonstrating that psychiatric comorbidities partly explain the increased risk of suicidal behaviour in individuals with ADHD, Professor Larsson explained that the detection and treatment of psychiatric comorbidities should be a key strategy to reduce the risk of suicidal behaviour.6 Professor Larsson then went on to discuss how shared familial factors also influence risk, hypothesising that pleiotropic effects reflecting genetic variants associated with impulsivity may play a particularly important role.8 Finally, Professor Larsson briefly touched on the available data on ADHD medication and the risk of suicidal behaviour, concluding that there is no evidence of a positive association, and that any protective effect from medication is probably mediated by the improvement of ADHD symptoms and, in particular, impulsivity.9

In the next section of the presentation, Professor Larsson dealt with the association between ADHD and risk-taking behaviours, including criminality, substance misuse, risky sexual behaviour and accidents or injuries.10-14 Professor Larsson hypothesised that these aspects of risk-taking behaviour may help to explain why individuals with ADHD have been found to have a two-fold increased risk of premature mortality compared with individuals without ADHD, a difference that is largely driven by unnatural causes.15 Psychiatric comorbidities were again highlighted as another important component of the increased risk, with oppositional defiant disorder, conduct disorder and substance-use disorder associated with increased risks of premature mortality.15

While the effect of ADHD medication on the risk of premature mortality in patients with ADHD has not been investigated directly, Professor Larsson explained that his research group has used data from Swedish National Registries to learn more about the relationship between ADHD medication and the risk of serious transport accidents in adults with ADHD.14 In crude and adjusted within-individual analyses, respectively, ADHD medication was associated with a 29% and 58% reduced rate of transport accidents in men with ADHD. Similar results have been found in other studies investigating outcomes such as injuries and trauma.16-18

Professor Larsson’s conclusion highlighted the importance of remembering that despite the increased risk of negative outcomes in individuals with ADHD versus the general population, the overall risk is still low. However, there is a clear need for further research to develop tools that can identify patients with ADHD who are at particular risk of these negative outcomes.

Professor Larsson: “There are reasons to hypothesise that the risky behaviours demonstrated in patients with ADHD are also factors that are likely to increase the risk of premature mortality.”

What have developmental studies taught us?

This presentation was delivered by Professor Scott Kollins (Duke University, NC, USA) and discussed some of the major findings that developmental studies have contributed to the ADHD landscape over the years.

Professor Kollins began with an overview of developmental studies, explaining that there have been many study cohorts established over the years, with some covering time periods as long as 30 years. Professor Kollins explained that these studies have been immensely useful in collecting longitudinal data from large numbers of patients, but acknowledged that these studies would benefit from recruiting more heterogeneous populations in regards to psychiatric comorbidities, ethnic backgrounds and socioeconomic status. With these limitations in mind, Professor Kollins went on to discuss some of the key findings.

First, developmental studies have demonstrated that ADHD is a persistent disorder, with up to 65% of children with ADHD still exhibiting symptoms in adulthood.19 However, Professor Kollins emphasised that there is currently no way to predict which patients will experience remission and which patients will show persistence.

Despite the finding that ADHD will persist in the majority of cases, Professor Kollins highlighted that ADHD is still not managed as a chronic condition, hypothesising that this attitude may be contributing to the negative outcomes observed in patients with ADHD in developmental studies.15,20-22 Consistently, these studies have reported that individuals with ADHD are more likely to suffer from outcomes including substance-use disorders, early pregnancy, poor academic performance, criminal convictions and premature mortality.

Professor Kollins then went on to discuss the impact of ADHD medications on these negative outcomes, explaining that while ADHD treatments have been reported to have an effect in short-term trials,23 results from longitudinal developmental studies have been more equivocal. To demonstrate this point, Professor Kollins discussed the evidence showing that for some patients, ADHD treatment does not appear to confer a benefit from baseline beyond 3 years.24 The explanation for this observation is unclear, and Professor Kollins hypothesised that poor adherence may be one factor, with evidence showing that half of the children in one study experienced a gap in medication adherence over a 1-year period.25

Professor Kollins concluded with his opinion that developmental studies demonstrate that more must be done to mitigate the risks of long-term negative outcomes in patients with ADHD. To facilitate this, there is a need to improve the management of patients with ADHD over the long-term by conceptualising ADHD as a chronic condition.

Professor Kollins: “We need to reconceptualise the treatment of ADHD as a chronic condition and re-think it in the same way we consider diseases such as diabetes and asthma to be chronic conditions.”

Emergence of ADHD in adults

The increasingly important topic of ADHD in adults was discussed in a thought-provoking presentation delivered by Professor Philip Asherson (King’s College London and Maudsley Hospital, UK). Professor Asherson highlighted that the topic of adult ADHD has proven particularly controversial over the years and that there is still considerable disagreement on the topic.

Professor Asherson explained that some researchers believe that ADHD causes a developmental delay that disappears by adulthood, an opinion that is supported by evidence showing that the prevalence of ADHD does indeed decrease over the lifespan.26 However, other researchers hypothesise that ADHD is better described as a developmental deficit, where symptoms may reduce over the lifespan, but the functional impairment versus the general population remains.27

Professor Asherson then went on to discuss some of the difficulties associated with characterising ADHD across the lifespan. For example, the percentage of patients with persisting ADHD appears to differ depending on whether self-report or parent-report is utilised, with lower persistence observed with self-report (44% versus 79%).28 Professor Asherson emphasised that these results support the need to obtain multiple sources of information when assessing patients.

A further interesting observation highlighted by Professor Asherson regarded the prevalence of ADHD over the lifespan and how the ratio of men to women appears to equalise in adulthood.29 Professor Asherson said that it is currently unclear if this is related to boys with hyperactive symptoms being referred to services more often than inattentive girls, or if it is related to adult women being more likely to demonstrate health-seeking behaviours. To discuss this point further, Professor Asherson presented data from a population-based study conducted by Larsson et al., where boys demonstrated more hyperactivity/impulsivity than girls at age 8–9 years and 13–14 years, but by the age of 16–17 years, mean hyperactivity/impulsivity scores were similar in boys and girls.30

Finally, Professor Asherson discussed psychiatric comorbidities in patients with ADHD and described how his experiences from clinical practice demonstrate that the prevalence and nature of psychiatric comorbidities change throughout the lifespan. In early childhood, typical psychiatric comorbidities identified can include autism spectrum disorder, learning disorders and tic disorders. In later childhood and adolescence, emotional/mood dysregulation, oppositional defiant disorder and conduct disorder become more frequent. In adolescents and adults, anxiety and depression, substance-use disorders, bipolar disorder, personality disorder and antisocial behaviour are commonly identified psychiatric comorbidities to ADHD.

Professor Asherson’s conclusion was that ADHD persists into adulthood for many patients. Over the lifespan, the ratio of males to females decreases, which may be related to a diagnosis of ADHD being missed in patients who do not exhibit hyperactive/impulsive symptoms. Psychiatric comorbidities experienced by patients with ADHD also vary across the lifespan, demonstrating the need to adapt management to support patients as they transition through life.

Professor Asherson: “Psychiatric comorbidity is a key issue in ADHD that is complicated by the shift in symptoms and appearance of psychiatric comorbidities throughout the lifespan.”

Advances in treatment choice across the life-course

This presentation delivered by Professor Jeffrey Newcorn (Mount Sinai Medical Center, NY, USA) discussed some of the factors that can influence treatment choices in patients with ADHD across the lifespan.

Professor Newcorn began with an overview of the many pharmacological treatment choices available across the world for the treatment of ADHD, describing that medications are broadly classified as stimulants or non-stimulants. Professor Newcorn explained that, in addition to the introduction of new medications over the past 10 years, several other key developments have changed the pharmacological treatment of ADHD. For example, new formulations of existing medications have allowed the duration of action to be optimised, and a better understanding of titration and dose optimisation has also improved the ways in which medications are used. The use of medications in adults with ADHD is an area in which a particularly rapid increase in knowledge has occurred.

Professor Newcorn emphasised some of the special considerations that are relevant to treating adults with ADHD. For example, inattention and mood dysregulation tend to predominate in adults with ADHD,31 meaning that the objectives of treatment will differ to those in children with ADHD, where hyperactivity and impulsivity are more common. Furthermore, adults will often also require a longer duration of action of medication compared with children, because the typical working day lasts longer than the school day.31 It is also important to be aware that the licensed doses of medication might differ in adults versus children. Professor Newcorn also highlighted that the presence of other health conditions, including cardiovascular conditions, should be considered carefully before initiating treatment in adults, particularly in older adults.31,32

Professor Newcorn then went on to highlight that although the above factors can help to guide treatment choice in adults with ADHD, it is also important to remember that the response to a given medication will vary between individuals. Professor Newcorn presented data from a study investigating differential response to extended-release methylphenidate and extended-release mixed amfetamine salts, demonstrating that patients who do not respond to a given medication may respond to a different one, and among patients who respond to multiple medications, it is possible that they will show differential responses.33,34

Professor Newcorn also discussed the role of behavioural interventions in the treatment of adult ADHD, highlighting that although there is considerable interest in these modalities, there is mixed evidence to support their use.35-37 New perspectives currently under investigation include meta-cognitive training in adults and organisational skills training in children.37,38 Professor Newcorn highlighted that continuity of treatment is likely to be required for success with behavioural therapies to ensure that any beneficial effects persist, with regular booster sessions required.

Professor Newcorn concluded that pharmacological treatments remain the best option for reducing the symptoms of ADHD. Treatment choice will vary between individual patients depending on a number of factors, but appropriate titration and dose optimisation are required for all patients. Finally, Professor Newcorn emphasised that it is important to focus on improving impairments in patients with ADHD: although medications can reduce the symptoms of ADHD, it is ultimately the functional impairments that have a daily impact on patients with ADHD.

Professor Newcorn: “Titrating medication to the optimal dose has developed increasing traction in the treatment of ADHD in the past decade.”

Plenary 2: Clinical guidelines for the diagnosis and management of ADHD in children, adolescents and adults: updates, similarities and differences

Moderator: Professor Duncan Manders

This timely panel discussion session aimed to increase awareness of the different ADHD guidelines within the context of several guideline updates published immediately prior to the 10th Meeting of Minds. The panel, comprising Professor Philip Asherson, Professor Tobias Banaschewski (Central Institute of Mental Health, Germany), Professor David Coghill, Dr Martin Gignac (Institut Philippe-Pinel de Montréal, Canada), Professor Luis Rohde (Federal University of Rio Grande do Sul, Brazil), Professor Patrick Bolton (King’s College London, and South London and Maudsley NHS Foundation Trust, UK), Professor David Daley (University of Nottingham, UK) and Dr Bruno Nazar (Federal University of Rio de Janeiro, Brazil), discussed the current recommendations for the pharmacological and non-pharmacological treatment of ADHD and highlighted the recent updates in guidance.

Professor Coghill opened the discussion with a brief overview of the history of ADHD guidelines, which were originally introduced with the first European Society for Child and Adolescent Psychiatry (ESCAP) guideline in 1998 with the aim of improving the diagnosis, treatment and management of ADHD.39 These guidelines paved the way for several other clinical guidelines, including those published by the Scottish Intercollegiate Guidelines Network (SIGN),40 the National Institute for Health and Care Excellence (NICE),41 the updated ESCAP guidelines,42 the European Network Adult ADHD Consensus statement43 and the Canadian ADHD Resource Alliance (CADDRA).44

The multi-national panel then went on to briefly summarise some of the key points regarding ADHD guidelines across the world. First, Dr Gignac highlighted the resource-based nature of the most recent 4th edition of the CADDRA guideline, which was published in 2018 just prior to the 10th Meeting of Minds.44 Dr Gignac emphasised that the CADDRA guideline provides clinicians with a toolkit that can be adapted to use with both simple and complex cases of ADHD. Of note, in the most recent update of the CADDRA guideline, there is an increased focus on the management of patients with ADHD and comorbid psychiatric conditions to reflect the high burden of psychiatric comorbidity that clinicians observe in practice.

Professor Asherson then discussed the UK’s NICE guideline, which was also recently updated in 2018.41 Professor Asherson highlighted the stringent methodology used to develop the evidence-based NICE guideline, and emphasised that the development process is well-documented and transparent. In addition, the guideline was reviewed by a broad range of stakeholders who were given the opportunity to comment on the guideline before it was finally published. Professor Asherson discussed how the latest version of the NICE guideline provides recommendations across the patient lifespan, with different recommendations made for each age group of children aged under 5 years, children aged over 5 years/young people and adults.

Next, Professor Banaschewski briefly discussed the soon-to-be published German Association for Psychiatry, Psychotherapy and Psychosomatic (DGPPN) ADHD guidelines, which were developed collaboratively by academic medical societies. Professor Banaschewski described these guidelines as evidence-based and consensus-oriented, with all relevant professional societies involved and required to come to an agreement for a recommendation to be included.

The panel then went on to discuss some of the realities of employing ADHD guidelines in practice. The panel agreed that guidelines help to guide practice, improve patient outcomes and increase the efficiency of the healthcare system. In particular, the panel welcomed the increasing focus on psychiatric comorbidity. Professor Bolton used the example of autism spectrum disorder, which has its own clinical guidelines, to demonstrate that clinicians can be unsure of what guidelines to follow in patients with comorbid ADHD and autism spectrum disorder, and explained that covering this topic in ADHD guidelines is a big step forward. Dr Nazar made a similar point, highlighting that in Brazil there are nine guidelines for eating disorders; however, none of them mention ADHD, raising questions about how to treat patients with an eating disorder and comorbid ADHD. As ADHD guidelines begin to acknowledge and advise on the treatment of patients with ADHD and psychiatric comorbid conditions, clinicians will find it easier to apply guidelines to the patients they see in practice.

The panel did acknowledge that guidelines are limited by the need to consider patient preference and choice when making treatment decisions. They highlighted that there is also a risk that clinicians can become over-focused on the recommendations, when there is also a need to consider how the patient feels in addition to how their symptoms are responding to treatment. Lack of resources was also highlighted as a reason why clinicians might struggle to apply clinical guidelines in practice, and as a key reason why it is important to have different guidelines for different regions that are written based on the healthcare system and treatments available in a given area.

In their conclusion, the panel agreed that ADHD guidelines should be utilised to help improve the care of patients with ADHD, and that future guidelines should continue to increase the focus on psychiatric comorbidities and the transition of care throughout the lifespan.

Professor Coghill: “Often we ask how we can ensure people follow guidelines. A better question would ask how we can facilitate people in engaging in evidence-based practice.”

Plenary 3: Current challenges: the transition years

Moderator: Professor Duncan Manders

Emotional impulsivity and self-harm in adolescence

Professor David Daley began the first presentation of the afternoon plenary session by describing the prevalence of self-harm in adolescents. The problem of self-harm appears to be underestimated because it tends not to be seen in clinical care unless the patient subsequently attempts suicide or if they are already presenting to clinical services.45 A community-based study in the UK showed that 13.2% of adolescents aged 13–18 years reported a lifetime incidence of self-harm.46

This is important for clinicians treating ADHD because impulsivity has been identified as a risk factor for self-harm.47,48 Professor Daley described two models that help to explain this link: the affect-regulation function of self-harm, where individuals self-harm to regulate their emotions, and the urgency theory, which suggests that some individuals in the presence of heightened negative affect are more likely to act impulsively.49,50 Negative urgency, described as a tendency to engage in risky impulsive behaviour as a response to negative emotional states, is one of the five facets of impulsivity as identified in the Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency (UPPS-P) Impulsive Behaviour Scale,51 and Professor Daley hypothesised that negative urgency might bridge the gap between intentions and actions.

Professor Daley went on to highlight the gaps in the current knowledge surrounding self-harm in individuals with ADHD. In particular, reviews have predominantly focused on non-suicidal self-injury and have not included community-based samples. In addition, there has been an over-reliance on cross-sectional studies, and the influence of covariates across studies has been inconsistent.

Professor Daley then discussed a number of examples from the literature, first dealing with a systematic review by Lockwood et al., which aimed to examine the relationship between self-harm and non-suicidal self-injury and impulsivity in a community-based sample of young people.52 The method of measuring impulsivity appeared to influence the relationship between impulsivity and self-harm, with all studies using the full UPPS-P scale finding a significant association between at least one impulsivity subscale and a self-harm outcome.52 The examined relationships were retained in the presence of depression and anxiety, affective lability and self-control, alcohol use, gender, negative affect, child maltreatment and self-esteem.

When considering the initiation of self-harm versus the maintenance, a study by Taylor et al.,53 which used the UPPS-P scale to examine if facets were differentially implicated when considering current versus past behaviour. This study found that undergraduates who self-harmed were different from controls on negative urgency, but there was no difference in these variables among those reporting current versus historical self-injury. The authors hypothesised that impulsivity may be implicated in the initiation of self-harm, but not the maintenance.

The pathway between self-harm ideation and action was then discussed, with Professor Daley describing two studies that both found that individuals who thought about self-harm, but did not report an episode, had significantly lower impulsivity than those who had acted on their thoughts.54,55

Professor Daley’s conclusion was that impulsivity does appear to be associated with self-harm in adolescence, although the relationship has varied between studies. Further research utilising a more clear definition of self-harm is required to understand this relationship further. In clinical practice, there is a need to consider the urgency to identify individuals who may be at risk of initiating self-harm.

Professor Daley: “Impulsivity may increase vulnerability to maladaptive behaviours, bridging a gap between intention and behaviour.”

Different aspects of transition in patients with ADHD, from 15 to 25 years old

In this comprehensive presentation, Dr Rosemary Tannock (University of Toronto, Canada) discussed the transition period between the ages of 15 and 25 years in individuals with ADHD. Dr Tannock began by highlighting the increasing demands that are experienced by individuals with ADHD as they become older and more independent. Environmental demands become more challenging in many areas of life, including academic, occupational, financial and social demands. To meet these demands, individuals require internal resources, such as self-management, and external resources, which can include parents or friends, as well as objects such as alarm clocks and electronic reminders.56 However, resources often decrease as individuals transition into adulthood, resulting in an imbalance between demands and resources.

Dr Tannock then went on to explain how the symptoms of ADHD can manifest as this shift in demand and resources occurs. Symptoms of inattention can lead to poor organisation,57 poor time management57 and poor reading comprehension, while impulsivity in adolescents and young adults58 may put individuals at risk of accidents and antisocial behaviour. Dr Tannock shared her observations from clinical practice that these problems can lead to poor academic attainment, impaired relationships, risky behaviour, substance abuse, poor occupational outcomes, and a risk of anxiety and depression.

In the next section of the presentation, Dr Tannock focused more specifically on the transition between school and post-secondary education in individuals with ADHD. Dr Tannock began by describing some of the differences between the two academic settings. Compared with school, post-secondary education requires more independent and unmonitored work with a less structured schedule, which requires a greater amount of self-management. In addition, individuals may no longer be living at home and will be more influenced by the expectations of their peers, rather than those of their parents. Living away from home also means that parents will no longer be advocating for the individual.

A further challenge faced by individuals during this transition period involves taking responsibility for managing their own care. Individuals may suddenly find themselves in charge of managing their ADHD, having to re-order their medication and organise appointments themselves.56,59 Individuals with ADHD are particularly likely to discontinue their medication during this period, with a study of 51 undergraduates with ADHD aged 17 to 21 years finding that medication adherence was lower mid-transition, although it appeared to increase again post-transition.60

Dr Tannock highlighted that the transition to adulthood must be managed carefully, requiring proactive, co-ordinated and integrated plans involving the young person, their family or carers, and education and healthcare agencies. To demonstrate this point, Dr Tannock discussed some of the recommendations within the NICE 2018 guideline,41 where it is advised that planning for the transition into adulthood should begin early, with Dr Tannock advising that it should be introduced by age 13 or 14 years at the latest. As well as focusing on deficits, management plans must also focus on strengths and achievements, should be developmentally appropriate and should consider the goals of the patient. Regular review is important, and it should be ascertained regularly how much involvement from parents and carers the individual wants. Dr Tannock emphasised the importance of building independence in individuals with ADHD so they can manage their condition effectively when they transition towards independence.

Schaefer et al. have also provided guidance on the self-management of ADHD during the transition to college.59 Again, the importance of early preparation is highlighted.59 For example, in early adolescence (12–14 years), individuals should be able to explain their ADHD and how it affects their daily life. They should be able to describe their medication, be able to manage their medication at school and know their doctor’s name. By mid-adolescence (14–17 years), individuals should have a good knowledge of their medical history, and understand the risks of non-adherence and drug and alcohol use. The individual should be able to arrange their own prescriptions and be able to see the doctor alone for health check-ups. By young adulthood (17–25 years), the individual should be managing their own care independently. Dr Tannock also briefly mentioned the East Tennessee State University tool for monitoring transition readiness for medical self-management in adult healthcare, which is in the public domain and can help to assess what stage of readiness the individual has reached.61

In concluding, Dr Tannock reiterated that the transition from young adolescence to young adulthood in individuals with ADHD is a multi-dimensional and multi-step process that spans several years. This period is a time of increased vulnerability for the individual, where they are faced with increasing demands and diminishing external resources to help them cope. Early and clear transition planning involving the individual, their parents, their teachers and mental health services can help to facilitate the transition, facilitating self-management and self-advocacy.

Dr Tannock: “Successful transition requires proactive, co-ordinated, integrated plans involving the young person, carers, education and healthcare agencies.”

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