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1 Sep 2019

Weibel S et al. Encéphale 2019; Epub ahead of print

Unlike many European countries, the identification and management of ADHD in adults is underdeveloped in France and remains a topic of controversy. This review contains practical and therapeutic considerations for French-speaking healthcare professionals who are involved in the detection and management of adults with ADHD.

ADHD from childhood to adulthood

ADHD is classified as a neurodevelopmental disorder and symptoms may be severe in childhood. The symptoms associated with ADHD tend to evolve in adolescence and frequently persist into adulthood. Although the presence of ADHD symptoms during childhood is necessary for diagnosis, a large proportion of adults are diagnosed after adolescence. Some adults may have presented major difficulties in childhood but were not diagnosed with ADHD, whereas for others, good coping abilities (e.g. due to higher intellectual level or family support) may have resulted in their difficulties being masked until demands increased (e.g. academic studies, professional promotion or arrival of children) or until coping strategies depleted. This raises the possibility that the complete clinical presentation of ADHD may emerge at different developmental stages in different individuals, and may contradict the concept of ADHD being a neurodevelopmental disorder.

ADHD clinical characteristics among adults

Similarly to childhood, the symptoms of ADHD in adulthood include inattention, hyperactivity and impulsivity. A combined presentation of these symptoms is the most common in adulthood; however, symptoms of hyperactivity (e.g. jostling ideas or excessive urge to move/do things) and impulsivity (e.g. tendency to interrupt or risk-prone behaviours) typically improve with age, whereas inattention (e.g. difficulty concentrating, procrastination, forgetfulness or excessive mind-wandering) may persist (Larsson et al. 2011). Deficits in executive functioning and emotional dysregulation are also associated with adult ADHD, which can make differential diagnosis challenging, particularly with respect to mood and personality disorders.

Diagnostic assessment for ADHD in adulthood

There are a number of assessment tools that have been translated and validated in French, thus providing a range of structured interviews and standardised self-report questionnaires (Adult ADHD Self-Report Scale v1.1 [ASRS v1.1] 18-item screener; Affective Lability Scale [ALS]; Weiss Functional Impairment Rating Scale [WFIRS]; and Wender Utah Rating Scale [WURS]) to evaluate the core and associated symptoms of ADHD, psychiatric comorbidities and functional impairment.

Psychiatric comorbidities in adult ADHD

Many adults with ADHD (~80% of cases) are diagnosed with comorbid psychiatric disorders, such as anxiety disorder, mood disorders (unipolar and bipolar), other neurodevelopmental disorders (e.g. autism spectrum disorder, dyslexia or dyspraxia) and personality disorders (e.g. borderline and antisocial personality disorder). Substance-use disorder or behavioural addictions (e.g. eating disorders) are also common in adults with ADHD. Additionally, sleep disorders such as excessive daytime sleepiness, hypersomnolence, insomnia, narcolepsy and restless leg syndrome have been linked to ADHD in adulthood. The authors suggested that a detailed patient history should be established by the clinician using standardised diagnostic tools to assess the chronology of the onset of ADHD symptoms and comorbid psychiatric disorders.

Management of ADHD in adults

In France, there are no expert recommendations for the diagnosis and management of adult ADHD; however, the French National Health Authority has issued recommendations for the detection of ADHD in children. The authors recommended that provision of care for adults with ADHD should be multimodal and based on non-pharmacological interventions and pharmacotherapy. The authors stated that clinicians should first aim to reduce functional impairment associated with ADHD and psychiatric comorbidities via psychoeducation, cognitive behavioural therapy, cognitive remediation and adaptive measures in school/at work. They also highlighted that both non-pharmacological and pharmacological treatment should aim to directly relieve symptoms of ADHD. Methylphenidate is the only available first-line stimulant for ADHD in France, and it is not licensed for use in adults except if it has been instated before the age of 18. As such, the prescription of methylphenidate, which is subject to the regulations on narcotics, for adults with ADHD is off-label in France. The non-stimulant atomoxetine can be used as a second-line therapy France (with temporary authorisation for use), as can clonidine; however, clonidine is not specifically indicated for ADHD. Psychiatric comorbidities associated with ADHD are also recommended to receive specific care as a priority, as this may lead to an improvement in ADHD symptoms and reduce functional impairment.

The authors acknowledged that progress has been made in the recognition, care trajectory and management of childhood ADHD; however, they feel that strong action is required in this area for adult ADHD in France. The authors advocated:

  • Improvement in the screening for and detection of ADHD via training and awareness-raising for primary care physicians and those working in the area of addiction and in prisons.
  • The emergence of specialised teams to evaluate and diagnose ADHD in adults to enable therapeutic decisions to be validated between colleagues.
  • Official recognition of ADHD and its associated functional impairments as a means to provide adults with ADHD with training courses and professional activities.
  • Appropriate treatment for adults with ADHD. Many healthcare professionals are not trained in non-pharmacological therapies for ADHD, despite this being the first-line approach to treatment in France. Instead, adults with ADHD are often treated with methylphenidate off-label in the absence of reimbursement, which can have a financial impact.
  • Close collaboration between ADHD specialists and adult psychiatric units, addiction centres or sleep disorder units, due to the prevalence of psychiatric comorbidities in adults with ADHD.

Read more about the practical considerations for adult ADHD in France here

Larsson H, Dilshad R, Lichtenstein P, et al. Developmental trajectories of DSM-IV symptoms of attention-deficit/hyperactivity disorder: genetic effects, family risk and associated psychopathology. J Child Psychol Psychiatry 2011; 52: 954-963.

Weibel S, Menard O, Ionita A, et al. Practical considerations for the evaluation and management of attention deficit hyperactivity disorder (ADHD) in adults. Encéphale 2019; Epub ahead of print.

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