Professor Phillip Asherson
ADHD in adults: latest findings and update on progress
In the opening keynote talk, Professor Philip Asherson (King’s College London, London, UK) highlighted that despite the symptoms and impairments of ADHD being well recognised in adults, ADHD in adulthood continues to be undiagnosed and misdiagnosed. Professor Asherson emphasised that adult ADHD services in the UK are growing and changing, but highlighted that the waiting lists for ADHD specialist services are long. He also discussed the importance of recognising the heritability of ADHD and that there is cognitive overlap in affect lability and mind wandering between ADHD and other psychiatric disorders. Professor Asherson concluded that there should be more effort from clinicians to ensure continued treatment management and use of ongoing specialised support in adults with ADHD.
Professor Asherson: “There has been lots of progress in the field…over time, we will see a progression from general to specialised services.”
Dr Sandra Kooij
Transition from child to adult services
Dr James Kustow (Nightingale Hospital, London, UK) chaired the first session, which focused on transitioning children with ADHD to adult services. He introduced the session by emphasising that adolescents may present with increased demands and challenges as they progress into adulthood, and that this period of life is associated with increased autonomy, exploration and experimentation, which may lead adolescents to stop taking their ADHD medication.
Dr Astrid Janssens (University of Exeter, Exeter, UK) began her talk by explaining that most adolescents are not aware of what will happen to them when they outgrow childhood ADHD services, and that an adolescent’s perception of ADHD medication affects their experience of transition between services. Dr Janssens stated that the involvement of parents helps adolescents engage in ADHD services and enables successful transitioning into adult ADHD services. She also highlighted that the majority of adolescents feel unprepared when approaching or going through the transition process, but that taking ownership of their ADHD (e.g. by making decisions, engaging during consultations, taking charge of their treatment and managing their care) and understanding that ADHD can be a long-term condition ensures that adolescents are prepared for their transition into adult ADHD services.
In the next talk, Dr Sandra Kooij (PsyQ, psycho-medical programs; Program & Expertise Center Adult ADHD, The Hague, The Netherlands; Department of Psychiatry, VUMC, Amsterdam, The Netherlands) began by discussing the impairments that ADHD can cause in adolescence and outlining the predictors of medication cessation in adolescents (including a lack of referral to an adult psychiatrist and a reluctance of general practitioners [GPs] to prescribe ADHD medications to patients aged ≥18 years) as well as the consequences of non-adherence to medication in those who require it. Dr Kooij explained that parenting interventions are beneficial and therapeutic for both parents and individuals with ADHD. She also emphasised that specific counselling and behavioural intervention goals should include continued education, parent and peer support, and enhancement of treatment motivation and self-esteem. Dr Kooij explained that a lifestyle app called SuperBrain has been developed for individuals with ADHD in The Netherlands, which allows users with ADHD to receive digital coaching and support from a psychologist; it is hoped that this app will later be translated into English and will be available in more countries.
The final talk of this session was presented by Dr Kobus van Rensburg (Northamptonshire Healthcare NHS Foundation Trust, St Mary’s Hospital, Kettering, UK), who stated that the period of adolescence is particularly challenging but is made more difficult by symptoms of ADHD. He highlighted that many 16–18-year-olds disengage from ADHD treatment and/or services and that this can put them at risk of poor academic performance and psychiatric comorbidities, as well as problems with employment. Dr van Rensburg stated that there are few good joint-working practices between child and adult ADHD services, and when he questioned the audience on this point, only a small number of audience members had a transition service set up at their centre.
This session concluded with questions and discussion points from the audience, including the problems faced in integrating adolescents into services if they leave home to go to University. A member of the audience recommended that childhood ADHD psychiatrists could shadow adult ADHD services so they know what adult ADHD looks like. It was also highlighted that adolescents who transition well into adult ADHD services tend to be those whose parents are involved in the transition process, and the idea of a child-and-parent bootcamp to educate individuals with ADHD about their condition was discussed.
Dr Janssens: “When we think about transition, we might need to think about stepping away from the fundamentals of autonomy…as I’m not sure that’s appropriate for an 18-year-old with ADHD.”
Dr Kooij: “…lots of help is needed but less help is available.”
Dr van Rensburg: “We have to help those with ADHD get in their heads that they are not alone on their transition into adult services.”
Dr Joe Johnson
Innovation in service delivery for adults with ADHD
The second session of the UKAAN meeting was led by Professor Philip Asherson, who indicated that each speaker would have 10 minutes to provide their thoughts on primary care and general adult services and provide insight into how these services are managed in different countries.
Dr Joe Johnson (Adult ADHD Service, North West Boroughs Healthcare NHS Foundation Trust, Warrington, UK) indicated that from 2008 to 2018 there has been an increased demand for ADHD transition services, due to the increased awareness and acceptance of ADHD as a psychiatric disorder not just limited to childhood. Dr Johnson stated that the waiting list for some ADHD services could include >500 patients, depending on borough, and that many patients with a diagnosis of ADHD could be on a waiting list for 2 years before they receive treatment. Dr Johnson indicated that at the North West Boroughs Healthcare NHS Foundation Trust, he had worked on engaging GPs in regular training sessions on ADHD, and that patients with stable ADHD can be discharged back into primary care under a shared-care protocol. In Dr Johnson’s opinion, he hopes that this approach will increase the capacity in specialist services and reduce the waiting time for individuals newly referred to specialist ADHD services.
Dr Sanjay Jain (Sussex Partnership NHS Foundation Trust, Brighton, UK) agreed that although local specialist adult ADHD services are successful, they are facing mounting pressure with increased caseloads and long waiting lists, which would eventually become unsustainable. Dr Jain expressed his view that Community Mental Health Teams (CMHTs) could be assessing and managing adults with ADHD similarly to other psychiatric disorders, and that implementation of a shared-care protocol with GPs may help manage and diagnose individuals with ADHD. Dr Jain indicated that in his opinion, adult ADHD services within general CMHTs may be the way forward, as this system may be more cost-effective and sustainable.
Professor Toni Ramos-Quiroga (Vall d’Hebron University Hospital, Barcelona, Spain) provided an insight into ADHD in Spain and highlighted that 20 years ago, similarly to the UK, ADHD was not included in doctor and psychiatry training. Professor Ramos-Quiroga indicated that in Spain, there are >300 general psychiatrists with a general knowledge of adult ADHD, and that there is a big interest in adult ADHD from psychiatrists who are working on substance-use disorders (SUDs) and those working within prisons. He also highlighted that every year in Spain there are courses on adult ADHD and that the topic is present in every national psychiatry meeting. Professor Ramos-Quiroga explained that adult ADHD education is provided at University and during psychiatry training, and that new Spanish ADHD guidelines now also include adult ADHD. New technologies to assess individuals with ADHD were also touched on, and these included mind-tracking technology and virtual reality.
The idea of a lifespan ADHD clinic was presented by Dr Sandra Kooij in the next talk. She indicated that mental health care is not set up for individuals with a long-term disorder and that in general, some adult and geriatric psychiatry may be less familiar in ADHD. Dr Kooij suggested that a lifespan ADHD clinic could offer support and treatment to all age groups of individuals with ADHD, and could be a place to which patients return if they relapse or need to adjust their treatment. She also indicated that this would be an excellent resource for longitudinal studies of ADHD. Dr Kooij indicated that a lifespan ADHD clinic was set up in 2016 at PsyQ in The Hague, The Netherlands, and that in her opinion, although challenging to set up, this approach is feasible and is the best service for individuals with ADHD.
Similarly to the UK, Dr Iris Manor (ADHD Clinic, Geha Mental Health Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel) explained that ADHD in Israel has changed in the past 20 years from both a patient and clinician perspective. Dr Manor explained that in Israel, it is common for psychiatrists, neurologists and family physicians to treat individuals with ADHD, which has led, in her opinion, to a “mess of specialists”, but she emphasised that there are still not enough specialists to learn from. Dr Manor highlighted that in Israel, lifespan clinics are available and that some individuals with ADHD are referred to separate adult clinics by specialists. She also indicated that individuals with ADHD in Israel are faced with a unique situation in the form of a compulsory enrolment into the army, which has a separate medical system.
Dr Kobus van Rensburg concluded this session by providing an overview of the clinical-psychology–led neurodevelopmental service in Northamptonshire, which has been established for nearly 15 years, and highlighted that this service offers a wide range of follow-up treatment and support options, including individual consultations as well as 13 different groups, workshops and forums for adults with ADHD. He also emphasised that adult ADHD services require a large amount of psychoeducation, as many individuals with ADHD do not understand what ADHD means.
Finally, this session concluded with the speakers engaging in a debate with the audience, where there was a positive response to the idea of lifespan ADHD clinics. It was highlighted again that all psychiatrists should be trained in ADHD and that ADHD “should be everybody’s problem,” and that with engagement from GPs, nurses and pharmacists, this will help create a sustainable service that can manage referrals within reasonable timescales.
Dr Johnson: “…the demand for services outweighs the capacity.”
Dr Jain: “It is unsafe to have long waiting times…it is very important that patients get help quickly.”
Professor Ramos-Quiroga: “One of the most important topics is to have sustainable services…and include new technology.”
Dr Kooij: “A lifespan clinic is yet the best service to patients with ADHD.”
Dr Manor: “…symptoms are changeable, you can’t rely on them.”
Dr van Rensburg: “We cannot underestimate the importance of psychoeducation.”
Dr Mary Solanto
CBT for adult ADHD: why environmental modification is insufficient
The second keynote talk of the UKAAN meeting was led by Dr Mary Solanto (Developmental and Behavioral Pediatrics, Cohen Children’s Medical Center, New York City, NY, USA; Hofstra Northwell School of Medicine, Long Island, NY, USA), who presented her experience of using a novel cognitive behavioural therapy (CBT) programme for adults with ADHD. Dr Solanto explained how she has incorporated the following into the CBT programme: guided self-instruction; positive reinforcement; exercises to enhance accurate time-estimation; and dispelling irrational emotional self-statements. The use of planners and ideas to minimise procrastination and “distractors” were also presented, and the benefit of home exercises and group sessions was highlighted. Dr Solanto received many positive questions from the audience, and was asked for advice on how to implement some of her techniques into a CBT programme in other clinics.
Patient: “The medication helps me focus but the CBT tells me what I need to focus on.”
Dr Solanto: “Encourage patients via positive reinforcement until they become autonomous.”
Dr Cleo Crunelle
Adult ADHD and comorbidity
The final session of the day was chaired by Professor Toni Ramos-Quiroga and was opened by Professor Philip Asherson, who explained the overlapping clinical features between ADHD and borderline personality disorder, such as emotional instability, impulsive behaviour and unstable personal relationships.1 Professor Asherson presented currently unpublished data, which investigated these clinical features in more detail, as well as the excessive mind wandering in the two conditions.
The next talk was presented by Professor Andreas Reif (Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt am Main, Germany), who presented evidence for the relationship between ADHD and bipolar disorder. Professor Reif emphasised that there is a shared genetic risk between the two disorders,2 and stated that treating ADHD and bipolar disorder is therefore complex but clinically relevant and that different treatment strategies should be implemented.
The final session was concluded by Dr Cleo Crunelle (Department of Psychiatry, University Hospital Brussels, Brussels, Belgium; University of Antwerp, Antwerp, Belgium), who discussed treatment guidelines for individuals with ADHD and SUDs. Dr Crunelle highlighted that, in her opinion, there are several screening tools available to validate this population and that the treatment of both disorders should be integrated using combination pharmacotherapy and psychotherapy. She also indicated that psychoeducation and individual and/or group CBT could be implemented to treat individuals with ADHD and SUDs.
Professor Asherson: “Mind wandering is such an ADHD symptom.”
Professor Reif: “Paediatric bipolar disorder has an extremely high comorbidity with ADHD…should we have a new term for this disorder?”
Dr Crunelle: “ADHD and SUDs co-occur very often so this is a very important population that require [treatment] guidelines.”
Discussion – future directions
The UKAAN meeting concluded with questions and interaction from the audience, with further emphasis on the benefits of psychoeducation and CBT in individuals with ADHD and comorbid psychiatric conditions.
Disclaimer: The views expressed here are the views of the presenting physician and not those of Shire
- Kooij SJJ, Huss M, Asherson P, et al. Distinguishing comorbidity and successful management of adult ADHD. J Atten Disord 2012; 16(5 Suppl): 3S-19S.
- van Hulzen KJE, Scholz CJ, Franke B, et al. Genetic overlap between attention-deficit/hyperactivity disorder and bipolar disorder: evidence from genome-wide association study meta-analysis. Biol Psychiatry 2017; 82: 634-641.