Day 2 of the 10th Meeting of Minds kicked off with parallel sessions, allowing the audience to choose between insightful plenary presentations covering the management of either children/adolescents or adults with ADHD. In the afternoon, the latest interesting publications adding to the ADHD scientific literature were discussed by a team of experts who provided their insights on the implications for clinical practice. The meeting ended with a series of thought-provoking presentations focusing on the future of ADHD, predicting the key topics that will form the basis of future Meeting of Minds congresses.
Parallel session 1: Optimising the management of ADHD in a diverse group of patients
Moderator: Professor Duncan Manders
ADHD and co-occurring neurological disorders in children and adolescents
Professor David Dunn (Indiana University School of Medicine, IN, USA) began the first presentation of this parallel session by sharing the aim of his presentation, which was to increase awareness of comorbid ADHD and neurological disorders, and to discuss current recommendations for the treatment of individuals with ADHD and comorbid neurological conditions.
Beginning with epilepsy, Professor Dunn highlighted that children with ADHD have a higher incidence of epilepsy compared with those without ADHD (3.24 versus 0.78 per 1000 patient-years, respectively). The same is true for children with epilepsy, who have a higher incidence of ADHD compared with children without epilepsy (7.76 versus 3.22 per 1000 patient-years, respectively).1 Moving on to the treatment of patients with comorbid ADHD and epilepsy, Professor Dunn presented data from clinical studies suggesting that ADHD medications do not increase the risk of seizures.2,3
In the next section of the presentation, Professor Dunn discussed migraines, presenting data showing that children with ADHD have an increased risk of migraines versus those without ADHD.3
Professor Dunn then went on to discuss the treatment of comorbid ADHD and Tourette’s syndrome. In a study by the Tourette’s Syndrome Study Group, there was no evidence that the ADHD medications studied worsened tics; a finding that has been repeated in some other studies.4-6
Professor Dunn then discussed a number of other less studied neurological disorders that can be present in children with ADHD. For example, in children with mild traumatic brain injuries, approximately 25% also have ADHD, with the prevalence increasing with the severity of the brain injury.7-9 Developmental Co-ordination Disorder (DCD) is another example of an under-recognised psychiatric comorbidity, which is associated with increased rates of combined-type ADHD, increased developmental delays, increased school failure, more severe ADHD and more behavioural problems compared with ADHD alone.10 In individuals with comorbid ADHD and DCD, 58% report poor outcomes (e.g. criminal conviction or an alcohol or substance abuse disorder) at 22 years of age compared with 13% of individuals with ADHD alone.11 Professor Dunn then went on to highlight comorbid ADHD and neurocutaneous disorders, including neurofibromatosis type 1. Up to 60% of individuals with neurofibromatosis type 1 have comorbid ADHD, with inattention shown to be the more common presentation.12 Finally, Professor Dunn reported that approximately 50% of individuals with foetal alcohol syndrome have comorbid ADHD.13 In these children, there is often only a limited improvement in the symptoms of ADHD with treatment. This may be because of difficulties in differentiating between symptoms of ADHD and symptoms of alcohol-related neurodevelopmental disorder, with both exhibiting difficulty concentrating, disorganisation and hyperactivity.14,15
Professor Dunn’s conclusion was that a number of individuals have ADHD that is comorbid with a neurological condition. Professor Dunn emphasised that in children with neurological impairments, it is very difficult to distinguish symptoms of ADHD from internalising disorders, and clinicians must be aware of alternative disorders to ADHD that may be causing the symptoms. There is a need for further research to determine if ‘secondary’ ADHD has the same natural history as the classic definition of ADHD and to investigate treatment response in these children.
Professor Dunn: “Inattention, hyperactivity and impulsivity are common symptoms in multiple disorders. In children with neurological impairments, we should ask if we are distinguishing symptoms of ADHD from internalising disorders.”
Gender differences in ADHD in children and adolescents
In this presentation, Dr Ellen Littman (Clinical Psychologist, NY, USA) discussed the entrenched gender bias that is present in the diagnosis, treatment and clinical research of ADHD. Dr Littman began the presentation by emphasising the imbalance in the number of boys versus girls with ADHD, with this difference beginning to equalise in adulthood.15 This suggests that girls with ADHD are being overlooked somewhere in the system.
To try and explain this imbalance, Dr Littman explored some of the challenges associated with diagnosing ADHD in girls. First, girls may show lower levels of hyperactivity compared with boys,15,16 meaning that a diagnosis of ADHD may not be considered. Second, girls with ADHD exhibit higher rates of anxiety,15 which may prevent clinicians looking further and considering a diagnosis of ADHD. Third, monthly fluctuations of oestrogen, progesterone and testosterone may negatively affect the symptoms of ADHD,15 with Dr Tannock hypothesising that this might explain why many girls do not struggle noticeably with the symptoms of ADHD until their early teens.
Dr Littman then went on to discuss some of the different challenges that girls with ADHD face compared with boys. Girls are faced with the feminine stereotype of being a good listener, showing empathy, co-operating, taking care of others and being able to multi-task. Girls with ADHD experience lower self-esteem compared with boys,15 which Dr Tannock thought might be related to girls experiencing greater pressure to conform to feminine stereotypes. Furthermore, many girls with ADHD are driven to mask their symptoms,15 which might be related to efforts to fit in with their peer group
The pattern of psychiatric comorbidity in girls and women with ADHD also differs to that of boys and men, with women showing a higher prevalence of anxiety and oppositional defiant disorder compared with men.15 These differences will have an important role in complicating the diagnosis of ADHD in women and will also affect the way in which patients are monitored and treated. Hormonal changes also have implications for the management of girls and women with ADHD, with evidence suggesting that when oestrogen levels drop as part of the menstrual cycle, the symptoms of ADHD can be increased.17 Existing studies aiming to increase the understanding of ADHD have not considered the role of fluctuating hormones in this condition, raising questions about how the effect of pharmacological treatments may vary throughout the menstrual cycle.
Dr Littman’s conclusion was that ADHD in girls and women is a public health issue requiring greater awareness. Earlier identification and treatment of girls with ADHD is required to try and prevent the negative outcomes associated with ADHD in later life. A greater understanding of gender differences in the presentation and trajectory of ADHD is required to ensure that girls and women with ADHD are being treated optimally.
Dr Littman: “Gender bias in ADHD is insidious and persistent, but not intentional.”
Dr Littman: “Why are these girls so hard to see and why is the impact of ADHD so different?”
Adapting management strategies to meet the changing needs of patients
This presentation, which was delivered by Dr Martin Gignac (Institut Philippe-Pinel de Montréal, Canada), covered the management of adolescents with ADHD and the reasons why management strategies must be adapted to effectively treat patients during this transition period in their lives.
Dr Gignac began by discussing factors that can promote resilience in individuals with ADHD as they grow up, including internal factors, family factors and social factors. Examples of internal factors include an ability to plan, feeling useful, high self-esteem, secure attachment, humour and creativity. Family factors promoting resilience include competent parents, adequate supervision and a good relationship with at least one parent. Social factors that promote resilience include a good support network, a stimulating school environment and participation in activities.
Dr Gignac highlighted that between 30% and 84% of children with ADHD will still show symptoms in adulthood.18 Dr Gignac then went on to discuss the neurobiology of adolescence. To exhibit self-control, individuals must inhibit their automatic impulse for instant gratification, and make choices based on their own values, those of their parents and those of society. How successfully an adolescent exhibits this self-control is determined by the functional development stage of their brain, and the variations in the structure and function of the frontoparietal and frontostriatal circuits that occur with increasing age.19 Increased motivational impulses for novelty combined with immature impulse-control systems predispose adolescents to risk-taking.20 Dr Gignac then discussed the influence of peers on risky behaviour in adolescents. Evidence suggests that adolescents show an equivalent degree of risk-taking compared with adults when they are alone. However, when adolescents are in the company of their peers, they exhibit a higher degree of risk-taking.21
Dr Gignac explained that intervention is also necessary to manage the risk of psychiatric comorbidities in adolescents with ADHD, with evidence showing that the presence of ADHD at the age of 4–6 years is associated with a higher risk of symptoms associated with major depression or dysthymia at 18 years (risk ratio 4.32) and a higher risk of attempted suicide (risk ratio 3.6).22
In his conclusion, Dr Gignac stated that intervention can and should begin early. It is important to consider the neurological explanations behind the risks associated with adolescence in individuals with ADHD, and to promote internal and external resilience to prevent negative outcomes.
Dr Gignac: “It is important to keep track of the adolescent’s peer group – teenagers are more likely to show risky behaviour when they are with their friends.”
Parallel session 2: Optimising the management of ADHD in adults with co-occurring mental health disorders
Moderator: Dr Jakob Ørnberg
Clinical complexities of adults with ADHD and real patient cases
In this plenary session, moderated by Dr Jakob Ørnberg (Aarhus University Hospital, Denmark), Professor Philip Asherson (King’s College London and Maudsley Hospital, UK) opened with a presentation on the clinical complexities of adults with ADHD, which focused on ADHD and psychiatric comorbidities. He began by discussing the results from the National Comorbidity Study survey, which showed that there was an increased risk of psychiatric comorbidities, particularly mood disorders, anxiety disorders and substance-use disorders, in adults with ADHD.23 He then went on to describe the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM) criteria for adult ADHD diagnosis, and the common associated features of ADHD that support the diagnosis, such as emotional symptoms, developmental traits, education problems and cognitive deficits.24
Professor Asherson went on to present common symptoms in adult ADHD:25
- Emotional instability: anger, irritability, temper control, mood lability
- Initial insomnia
- Feeling restless (agitated when severe)
- Talking excessively or tangentially (severe ADHD)
- Low self-esteem
- Concentration difficulties
- Mind wandering and ceaseless mental activity.
However, ADHD and co-occurring mental health problems are common, and Professor Asherson described three main groups which should be considered:26
- Symptoms of ADHD mimicking other disorders, for example:Anxiety: excessive mind-wandering, worrying about performance deficits, feeling overwhelmed and restlessDepression: chronic low self-esteem, poor concentration, sleep disturbance
Personality disorder (e.g. borderline personality disorder): chronic trait-like psychopathology, behavioural problems, emotional instability
Bipolar disorder: restlessness and overactivity, sleep disturbance, mood instability and distractibility
- Overlapping neurodevelopmental traits and disorders which can develop alongside ADHD, such as autism spectrum disorder, and specific and general learning difficulties
- Development of co-occurring mental health disorders such as anxiety, depression, substance-use disorder etc.
Professor Asherson went on to describe the development of psychiatric comorbidities across the lifespan, beginning with ‘pre-comorbid’ conditions which may present before the appearance of ADHD symptoms, before discussing that ‘simultaneous comorbidities’ can often co-occur when ADHD symptoms reach a clinical significance level and that there are a number of ‘post-comorbidities’ that present in adolescence/adulthood.27
Professor Asherson continued by explaining that there are genetic correlations between ADHD and traits such as depression, diabetes, lung cancer, number of children, obesity and smoking.28
He continued his session by describing the results of a meta-analysis, which showed that stimulants appeared to be more effective than atomoxetine in reducing emotional instability in adult patients with ADHD;29 however, it was noted that the size of the effect differed depending on the scale used. Professor Asherson then went on to explain the risks of mania when treating ADHD and bipolar disorder with methylphenidate, noting that patients treated with methylphenidate with no mood stabiliser (n=718) had an increased risk of a manic episode; however, patients treated with methylphenidate and a mood stabiliser (n=1103) were at reduced risk of a manic episode.30 He then presented results from National Registry Studies investigating the impact of treatment on behavioural outcomes, with data showing reductions in violent re-offending, depression, substance abuse, childhood injuries and transport accidents.31-35
Professor Asherson continued by describing a four-question scale used for initial screening of adult ADHD, which asks the following questions:
1. Do you usually feel restless?
2. Do you usually act first and then think?
3. Do you usually have concentration problems?
If the patient answers ‘Yes’ to questions 1 and/or 2 and/or 3, ask:
4. Have you always had this?
If the answer to question 4 is ‘Yes’, it is important to consider further diagnostic assessment for ADHD.36,37 He noted, however, that emotional lability symptoms are missing from this scale.
Professor Asherson concluded his presentation by presenting a treatment algorithm developed by the UK Adult ADHD Network: in patients who screen positive for ADHD with no comorbidity or comorbid personality disorder, drug treatment for ADHD should be initiated; however, in those patients who screen positive for ADHD with significant depression, bipolar disorder or another condition, the comorbid psychiatric disorder should be treated first in most cases. In all patients, treatment should be reviewed and additional treatments such as other medications or non-pharmacological treatments should be considered.38
Dr Larry Klassen (Eden Mental Health Centre, University of Manitoba, Canada) utilised patient videos to discuss differential diagnoses, explaining that the symptoms of ADHD overlap with a number of other psychiatric disorders; taking borderline personality disorder, generalised anxiety disorder and depression as examples. Dr Klassen noted that there is currently no specific treatment for borderline personality disorder, and that more often than not patients are treated with mood stabilisers; however, outcomes are currently not optimal. When discussing the patient who presented with generalised anxiety disorder, Dr J Antoni Ramos-Quiroga (Vall d’Hebron University Hospital, Spain) emphasised the importance of asking questions about their childhood/adolescence and their IQ, as this could impact on patient outcomes.
The plenary session finished with the panel answering a selection of questions from the audience on whether diagnostic criteria are sensitive enough in adults with ADHD and whether studies could be translated into clinical practice.
Professor Katzman: “If you have a patient who makes a scene in your waiting room because you are behind in your clinic, and they hate waiting because they cannot turn off their inner anxiety … Think ADHD!”
Headlines in ADHD: review of selected publications from 2017/2018
In this quick-fire presentation delivered by a team of ADHD experts, a number of key publications in ADHD from the past 12 months were evaluated and presented.
First, Professor Marina Danckaerts (Universitair Psychiatrisch Centrum KU Leuven, Belgium) discussed a paper by Elkins et al., which examined the effects of childhood ADHD symptoms on smoking in male and female adolescents.39 Professor Danckaerts presented the key finding that adolescents with more severe ADHD symptoms in childhood were more likely to initiate smoking, and at a younger age. The association between ADHD symptoms and smoking, number of cigarettes per day and nicotine dependence was greater in females compared with males. In monozygotic female twins with greater attentional problems than their co-twins, there was greater nicotine involvement, suggesting a possible causal influence. Hyperactivity/impulsivity appeared to be primarily non-causal, potentially working indirectly through shared propensities for both ADHD and smoking. Professor Danckaerts discussed some of the reasons suggested by the authors to explain their findings. Possible explanations included inattentive symptoms in girls causing more internal stress compared with boys or an interaction between oestrogen and nicotine affecting the dopamine reward system that increases the pleasure of smoking at certain stages of the menstrual cycle, while increasing withdrawal at other points of the cycle.
Professor Danckaerts then went on to discuss a paper by Serati et al., which was a systematic review investigating the relationship between obstetric and neonatal complications and childhood ADHD.40 This review included 40 studies and found that several types of neonatal complication were associated with the development of ADHD, for example, low birth weight and preterm birth. However, Professor Danckaerts highlighted that there are many limitations to this review, including the fact that no meta-analysis was performed and some of the risk factors identified only had evidence from one or two studies to support the relationship with ADHD. As a result, Professor Danckaerts recommended that further research in this area would be required.
In the next presentation, Professor Edmund Sonuga-Barke (King’s College London, UK) discussed a study by Evans et al., which reviewed the literature on severe irritability in child and adolescent psychopathology.41 This paper asked if a standalone diagnostic category for mood disorders in children should exist in the next edition of the International Statistical Classification of Diseases and Related Health Problems. The authors rejected this suggestion, and instead advised that a subtype of oppositional defiant disorder with chronic irritability/anger would be more consistent with the available evidence on irritability. Professor Sonuga-Barke referred to this paper as a substantial and important work that will have implications for the assessment, treatment and further research of children with these symptoms.
The next paper was discussed by Professor Luis Rohde (Federal University of Rio Grande do Sul, Brazil), who presented on a study by Georgiopoulos et al., which screened 53 adult patients with cystic fibrosis for ADHD using the Adult ADHD Self-Report Scale v1.1.42 Elevated symptom scores were reported in 15% of individuals, with elevated symptom scores associated with poorer health-related quality of life. Professor Rohde outlined the limitations of this study, highlighting that a diagnostic assessment for ADHD was not performed and that six patients with elevated symptom scores had previously been evaluated for ADHD but did not have a current diagnosis of ADHD.
Professor Rohde then went on to discuss a study by Salem et al., which was a systematic review and meta-analysis investigating the association between ADHD and migraine.43 Professor Rohde explained that this study found a significant association between ADHD and migraine; however, a number of methodological limitations must be considered. For example, only 14 studies were included and the methodology did not follow the strict Cochrane guidelines for meta-analyses, with no assessment of heterogeneity. Furthermore, the majority of patients in this study reported psychiatric comorbidities and were receiving pharmacological treatment, factors that may play a role in determining the risk of migraine.
The next presentation was delivered by Professor Jeffrey Newcorn (Mount Sinai Medical Center, NY, USA), who discussed a study by Molina et al.44 This paper reported findings from the Multimodal Treatment of ADHD study investigating substance use throughout adolescence into adulthood in individuals with ADHD. This longitudinal study, which included 547 individuals with ADHD and 258 individuals without, found that individuals with ADHD (mean age 24.67 years) had increased weekly marijuana use versus the comparison group (32.8% versus 21.3%, respectively) and increased daily cigarette smoking (35.9% versus 17.5%, respectively). Individuals with ADHD showed younger first use of alcohol, cigarettes, marijuana and illicit drugs, and faster escalation of alcohol and illicit drug use versus controls. Professor Newcorn said that these results are interesting and that more research is required to investigate why individuals with ADHD appear to be drawn towards marijuana use.
In the final presentation, Dr Rosemary Tannock (University of Toronto, Canada) discussed a study by Kofler et al., which investigated problems with working memory and organisational skills in 103 children with and without ADHD.45 Dr Tannock presented the key finding of this study that working memory predicted organisational problems, with approximately 38–57% of the effect conveyed by the relationship between working memory and inattention. Dr Tannock said that these results are interesting because they raise questions about whether working memory or organisational skills should be the primary target for intervention or if both deficits should be targeted. Dr Tannock concluded by calling for more research into the causal relationships between working memory and organisational problems, and highlighted that it is important to remember that there are cognitive challenges underlying disorganisation that must be addressed.
Dr Tannock: “The results of this study remind us that disorganisation in individuals with ADHD is unintentional, and it is important to emphasise this point to parents and teachers.”
Plenary 4: What does the future hold in ADHD?
Moderator: Professor David Coghill
In the first presentation of the afternoon, Professor Jan Buitelaar (Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior and Karakter Child and Adolescent Psychiatry University Center, The Netherlands) discussed the possibilities and challenges of personalised medication in ADHD.
Professor Buitelaar began with a brief description of personalised medicine, defining it as a broad and rapidly advancing field of healthcare that is informed by each individual person’s unique clinical, genetic and environmental data.46 However, Professor Buitelaar explained that he prefers the term ‘precision’ medicine, because it reflects the intent to subtype or stratify patients to deliver optimised and customised care to each individual patient, rather than to truly deliver a unique treatment to every patient.
Professor Buitelaar highlighted that personalised medicine is still some distance away in ADHD, although some success has been seen in other conditions, including certain types of cancer, human immunodeficiency virus (HIV) and cystic fibrosis.47 For example, in HIV, genetic testing can predict if a patient is likely to experience a serious hypersensitivity reaction in response to abacavir. Furthermore, in colorectal and breast cancers, physicians can test patients for proteins from specific genes that can predict the efficacy of certain pharmacological treatments.48,49
Professor Buitelaar described how the utility of personalised medicine may not be limited to treatment choice. It may also be able to predict outcomes, prognosis or psychiatric comorbidity.47 Furthermore, it is possible that preventative treatment could be initiated to prevent a condition developing in patients who are identified to have a heightened genetic risk. Advice regarding diet and lifestyle could also be tailored to the patient depending on their personal genetic profile.
In the next section of the presentation, Professor Buitelaar highlighted dopamine-β-hydroxylase and catechol-O-methyltransferase, which have been identified as putative, minor genetic biomarkers for ADHD.50 Professor Buitelaar also discussed research investigating the pharmacological modification of the glutaminergic neurotransmitter system in 30 adolescents with ADHD. In this study, differential treatment effects were observed in patients depending on the mutation status of their metabotropic glutamate receptor network genes.51 These results suggest that personalised treatment in ADHD could be possible in the future.
Professor Buitelaar concluded that personalised medicine can only become a reality if researchers and clinicians collaborate to conduct well-designed studies in large cohorts of patients. These trials will require a great deal of investment and it remains to be seen if personalised medicine will deliver the hoped-for benefits.
Professor Buitelaar: “Personalised medicine can only become a reality if there is stronger collaboration between researchers and clinicians to design proper trials of clinical relevance in large cohorts.”
ADHD in primary care
This presentation was delivered by Dr James Kingsland (National Association of Primary Care, UK) and provided a different perspective on the management of ADHD. Dr Kingsland began with an overview of the Primary Care Home (PCH) initiative, which is a new model of care shaping the delivery of community-based care services in parts of the UK. As part of the PCH, Dr Kingsland suggested that primary care could have an integral role in the management of patients with ADHD based on evidence suggesting that primary care physicians have a greater role in improving population health inequalities compared with specialists.
Dr Kingsland went on to describe some of the reasons he believes that primary care could have a central role in ADHD management. First, ADHD is now understood to be a chronic lifelong condition that will need to be managed throughout the lifetime. Therefore, once patients have been optimised on treatment, it is reasonable to argue that a patient’s primary care practitioner could then be involved in the management of ADHD, similar to other chronic conditions such as asthma and diabetes. Second, this population of patients may respond better to local and familiar settings, and seeing a doctor that they have already established a relationship with. Patients value available and accessible services, which can be delivered by primary care.
In the next section of the presentation, Dr Kingsland discussed some of the practical aspects that would be involved in the transfer of ADHD management to primary care. There would be a need to re-evaluate patient flow through the healthcare system and to include a more developed role for primary care in this model. A primary care service would need to be designed using input from a number of different partners and agencies involved in patient care and service development, and would need to take into consideration the requirements of the population being served. Communication with housing agencies, social care, addition services, prison services and tertiary care would be essential to delivering a multidisciplinary service.
Dr Kingsland then presented some of his experiences from practice in areas where patients’ 6-month and 12-month ADHD reviews are now performed by their primary care physician. In these areas, this shift has provided a 70% uplift in the overall healthcare capacity available to the ADHD community and has required minimal additional funding. Patients have provided excellent feedback, and appreciate receiving treatment closer to their homes. In addition, the feedback from primary care physicians has been positive, and primary care and specialist care providers are managing to work together.
To end the presentation, Dr Kingsland shared his opinion that in 10 years, primary care could be helping to deliver a fully integrated ADHD service with focused specialist care provided where required. This will lead to reduced waiting lists and increased convenience for patients, with reduced costs and more effective and efficient care. Transforming mental health care is integral to future models of care and provides an opportunity to strive for the best services possible.
Dr Kingsland: “Trying harder at what is failing is not going to work.”
Dr Kingsland: “Primary care shouldn’t just be acting as a triage system and shifting work to other sectors. Primary care should be able to deliver complete care.”
Emerging directions for ADHD
In this presentation, Professor Jeffrey Newcorn (Mount Sinai Medical Center, NY, USA) discussed a number of emerging topics in ADHD that may form the key areas of research and discovery in the future.
Professor Newcorn began by highlighting how the understanding of ADHD itself is changing, with an increasing focus on functional impairments and the importance of reducing these impairments in addition to the core symptoms of ADHD.52 There is also some debate regarding mind-wandering and its role in ADHD, with questions about whether it is a part of inattention, executive dysfunction or an entirely separate entity.53,54 There is also increasing interest surrounding emotional dysregulation and if it merits consideration as a core feature of ADHD.55
In addition to increasing complexities in the concept of ADHD itself, the current understanding of psychiatric comorbidities in individuals with ADHD has also been shifting.56 There has been particular interest surrounding the relationships between ADHD and disorders of low motivation and altered sensitivity to reward (e.g. depression, substance misuse and conduct disorder), and disorders of arousal (e.g. sleep disorders, binge eating, personality disorders and impulse-control disorders). For example, there is a need for a greater understanding of how persistent ADHD affects the risk of developing certain psychiatric comorbidities, the effect of early psychiatric comorbidity on the risk of adverse outcomes in ADHD and the ways in which psychiatric comorbidities can reflect incremental impairment in individuals with ADHD.57 A greater understanding of these relationships will help improve differential diagnosis and treatment in individuals with more complex presentations of ADHD.56
The next topic discussed by Professor Newcorn was the expansion of ADHD research into a broader range of age groups. As an example, Professor Newcorn highlighted that older adults have not been studied in clinical trials, which have more typically focused on children, adolescents and young adults. As a result, there is a lack of data supporting and guiding clinicians involved in the management of older adults with ADHD. Key unanswered questions in this age group include the benefits and risks of ADHD treatment as the risk of cardiovascular disease increases with age, and how to distinguish the symptoms of ADHD from mild cognitive impairment.58 Professor Newcorn then highlighted the need for further research in peri- and post-menopausal women, based on initial investigations of treating ADHD in this population of patients and evidence suggesting that the symptoms of menopause can overlap with the symptoms of ADHD.59,60
Professor Newcorn then went on to discuss some of his predictions regarding future developments in the treatment of ADHD. Professor Newcorn hypothesised that future treatments will aim to overcome some of the current issues surrounding duration of treatment and the public perception of the abuse potential of current ADHD medications. Professor Newcorn also explained that treatment is likely to become more selective for the individual patient, targeting the specific symptoms and functional impairments as necessary. Professor Newcorn also touched upon personalised treatment and how this may become a key theme in the future once more research is available. It is also possible that combined or multimodal treatments will become more common and that dose modification may take a more central role. Increased evidence surrounding non-pharmacological treatments may also help to determine how these treatments should be included in ADHD treatment plans. Finally, Professor Newcorn highlighted that a key problem in the current treatment landscape is poor adherence to treatment among children and adolescents.61 In the future, there is a need to research and develop new devices and new techniques to help patients remain on treatment.
In his concluding remarks, Professor Newcorn emphasised that although ADHD is a very well-established and validated disorder, it is likely that a number of shifts in understanding will continue to occur over the coming years. In particular, our understanding regarding the conceptualisation and boundaries of ADHD, and the relationship between ADHD and other disorders, is likely to shift further. Increased research in previously unstudied populations of patients should help to inform and improve treatment in these individuals, and advances in treatment should help to deliver more individualised treatment plans that promote adherence.
Professor Newcorn: “The treatment that, on average, shows the largest improvement in symptoms, may not be the best choice for any given patient.”
Advancing patient empowerment
In the final presentation of the meeting, Dr Ari Tuckman (Clinical Psychologist, PA, USA) began by expanding on one of the key themes of the meeting: that a number of patients with ADHD are remaining unidentified and undiagnosed. Dr Tuckman highlighted that several subpopulations of individuals are at particular risk of remaining undiagnosed, including adults, girls and women, individuals with predominantly inattentive symptoms, individuals with psychiatric comorbidities, individuals from under-represented socioeconomic, racial or ethnic backgrounds and individuals involved in the legal system. Dr Tuckman argued that these individuals are experiencing negative outcomes as a result of remaining undiagnosed and that more work must be put in to identify and treat these populations.
To identify these patients, a number of changes must take place. First, the stigma associated with ADHD must be reduced by utilising multiple methods of dissemination to target clinicians and members of the public with educational materials. Advocacy is important, and information about ADHD should be delivered to new audiences, focusing on populations that are likely to include patients at risk of remaining undiagnosed. Ideally, education on ADHD should be delivered by individuals who are known to the community or are part of the community. It is also important to direct individuals to good-quality online resources to prevent propagation of misconceptions.
Technology can also have a role in empowering patients with ADHD in their daily lives. Use of auto-fill features, cloud-based data, electronic reminders and calendars, and online impulse blockers that limit use of certain websites can all be utilised by patients to help them overcome functional impairments. It is important for clinicians to guide patients to effective technologies and help to vet any product claims regarding the use of particular electronic tools in ADHD.
Dr Tuckman then discussed the treatment of ADHD and asked that clinicians evaluate whether they are considering their patients’ suggestions where appropriate, thinking comprehensively about treatment options and addressing interacting psychiatric comorbidities. In particular, clinicians should ask themselves whether they are thinking about the impairments experienced by the patient, rather than focusing on the symptoms that may not be considered important by the patient. Dr Tuckman highlighted that although symptoms are easy to treat, over-focusing on symptoms can lead to missed opportunities for intervention in areas of need.
In his conclusion, Dr Tuckman delivered the message that ADHD should be considered as a chronic condition that can be managed, rather than a cause of suffering. For this to be achieved, under-diagnosis must be addressed and more targeted effective treatments should be provided to help empower patients to live better lives.
Dr Tuckman: “There are way too many adults with ADHD who are not being diagnosed and are ending up in bad places as a result.”
Dr Tuckman: “The ‘having’ part of ADHD persists, the suffering is optional.”
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