Dr Rob Baskind provides top tips for the primary care management of adults with attention deficit hyperactivity disorder and advice on the referral process

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Read this article to learn more about:

  • symptoms that suggest a patient may have attention deficit hyperactivity disorder (ADHD)
  • when to refer a patient with suspected ADHD and what information to provide
  • who should prescribe drug treatment for ADHD.

Attention deficit hyperactivity disorder (ADHD) is a common, chronic, and treatable neurodevelopmental condition affecting attention, hyperactivity, and impulsivity. Two-thirds of children diagnosed with ADHD continue to experience symptoms into adulthood.1 Adults with ADHD may also experience functional impairment that affects their relationships, psychiatric health, and risk-taking behaviour and their educational, occupational, and financial status. The prevalence of adult ADHD is estimated at 2.5%;2 however, ADHD is significantly over-represented in offender populations with rates up to 25%,3 and it is also associated with higher rates of drug and alcohol misuse.4 Family history is a strong risk factor for ADHD as it is a highly heritable condition.5

1 Take ADHD seriously

Public and healthcare professionals’ concepts and awareness about ADHD are diverse and individuals continue to be stigmatised.6 Myths about ADHD cause barriers to assessment and access to effective interventions. Common misconceptions include the belief that ADHD does not exist in people with a high IQ or people who do not have overt hyperactivity (i.e. ignoring the inattentive type). These beliefs can lead to the exclusion of many people who may still have ADHD and who have symptoms that significantly interfere with their functioning.

Patients with ADHD often describe having always ‘felt different’ or describe feeling incompetent; harbour feelings of self-blame and self-doubt; or express frustration as they feel that no one ‘understands them’. It is, therefore, important to take the time to listen to their concerns and take ADHD seriously.

2 Patients may present at different stages of their journey

Patients with a past diagnosis of ADHD may ask to be reassessed for ADHD having dropped out of treatment.

Patients without a diagnosis of ADHD may present either:

  • requesting an assessment for ADHD following a ‘self-diagnosis’, possibly through their own self-assessment, or through recognising traits in themselves following the diagnosis of a family member, or
  • with little awareness that they may have ADHD. See tip 3 for further guidance on recognising ADHD in adults.

3 Look out for the presentation of ADHD in adults

Be vigilant about identifying possible indicators of underlying ADHD. Patients may present complaining of common ADHD symptoms such as poor concentration, organisational difficulties, and being restless. They may not directly complain about specific ADHD symptomatology but instead present with other symptoms and concerns caused by the impact ADHD has had on their mental health and functioning throughout their lives.

A common presentation is with low mood and/or anxiety at a time of significant distress such as loss of a job or relationship discord. Common presentations of ADHD in adults are listed in Box 1. These presentations should prompt the clinician to consider ADHD as a differential diagnosis.

Box 1: Clinical presentation of adult ADHD

Psychological indicators

  • Chronic low self-esteem, frustration, and feelings of failure or not living up to one’s potential
  • Feeling easily overwhelmed, especially when entering a new stage of life (e.g. new job, having children)
  • Mood fluctuations throughout the day (e.g. gets frustrated easily, loses temper, and then behaves as if nothing has happened 5 minutes later)
  • Recurrent depressive presentations that are unresponsive to treatment
  • Difficulty getting to sleep, and may complain of not being able to switch off.

Behavioural and lifestyle indicators

  • Disorganised (e.g. lack of forward planning, messy)
  • Forgetful (e.g. misses appointments, loses things)
  • Chronic procrastination (e.g. inefficient, works through the night to meet a deadline)
  • Poor time management
  • Starts things but gets distracted easily
  • Impulsive decision making (e.g. spending that leads to debt, walking out of jobs, ending relationships)
  • Frustration through chronic procrastination and/or distraction affecting education or work
  • Struggling to complete further education degrees requiring re-sits and extra years
  • Difficulty maintaining stable employment through underachievement and/or conflict with colleagues
  • Use of alcohol or substances to relax or calm the mind
  • Criminal offences.

ADHD=attention deficit hyperactivity disorder 

It is worthwhile taking note of a few initial simple screening questions, such as those listed in Box 2, which may help to explore the possibility of the need for a formal ADHD assessment.

Box 2: Possible screening questions indicating the need for further assessment 

A positive response to any of the following questions (in context of other indicators) suggests further assessment for ADHD may be required:

  • Do you feel that you get bored, restless, or impatient more easily than most people?
  • Are you more forgetful or more disorganised than the average person?
  • Do you feel you are consistently failing to achieve your own potential?
  • As a child, did you have problems with:
    • paying attention?
    • doing impulsive, dangerous, or disobedient things?

ADHD=attention deficit hyperactivity disorder

4 Consider other explanations for symptoms

Physical health and other mental health conditions can present with symptoms that may mimic ADHD symptoms. It is important to rule out other physical health conditions including thyroid disease, iron deficiency, or traumatic brain injury.

Table 1 illustrates some important differences between ADHD and other mental health conditions.

Table 1: Differentiating ADHD from other mental health conditions
Possible differential diagnosisMore likely to be ADHD if the patient exhibits:

Depression

  • Chronic mood instability
  • Trait-like depression rather than episodic state-like depression
  • An absence of somatic symptoms.

Bipolar disorder

  • A lack of distinct periods of abnormal and extreme mood states with corresponding periods of normal baseline functioning in between
  • Tiredness due to lack of sleep rather than a reduced need for sleep
  • A lack of grandiosity or psychotic features
  • Ceaseless unfocused thoughts rather than episodic thought disorder (e.g. flight of ideas).

Anxiety

  • Ceaseless unfocused thoughts, as opposed to focused anxious worrying
  • An absence of somatic symptoms
  • Situation avoidance due to frustration with own behaviours rather than phobic avoidance common to anxiety disorders
  • Forgetfulness rather than hypervigilance.

Personality disorder

  • An absence of psychological disturbances, such as feelings of abandonment and chronic feelings of emptiness
  • Chronic inattention symptoms.

ADHD=attention deficit hyperactivity disorder

5 Know your local referral procedures

NICE Clinical Guideline (CG) 72 on Attention deficit hyperactivity disorder: diagnosis and management states that an ADHD diagnosis can only be made by a specialist psychiatrist, paediatrician, or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD.4 The local procedure for referral should be followed—see tip 6 for advice on provision of information that will support the referral.

Over the last 10 years an increasing number of specialist ADHD services for adults have been commissioned in the UK. Healthcare professionals who work in an area without specialist ADHD services for adults should speak with the local secondary care mental health services and, if necessary, with the local commissioning group to request funding for an out-of-area assessment.

6 Provide sufficient information to support your referral

If you feel a patient may require a specialist assessment for adult ADHD, it is important to gather as much information as possible to support the referral. A suggested list of supplementary information is provided in Box 3.

Box 3: Information to supplement onward referral for ADHD specialist assessment

  • Some evidence of childhood problems, such as problems with concentration, organisation, forgetfulness, hyperactivity, or impulsive behaviours
  • Any correspondence including educational psychology assessments; information regarding any past diagnosis of ADHD or other mental disorder; treatments provided and reasons why these were stopped (if applicable)
  • Completion of self-assessment scales. Regularly used scales that are available online include:
  • Current mental state and any existing medication or treatments
  • Current blood pressure, heart rate, and details of any significant physical health history
  • Current substance and alcohol use.

ADHD=attention deficit hyperactivity disorder

7 Be aware of the classification and assessment process

Adult ADHD is characterised by a persistent pattern of symptoms of inattention, hyperactivity, and impulsivity since childhood. Most clinicians will refer to the classification in the Diagnostic and statistical manual of mental disordersfifth edition (DSM-5);7 ADHD is classified as predominantly inattentive, predominantly hyperactive–impulsive, or combined.

An adult ADHD assessment often takes place over more than one appointment; Box 4 lists the main features that should be included in the assessment. A diagnosis of ADHD requires that the patient meets all five essential diagnostic criteria listed in DSM-5. A diagnosis of ADHD should not be excluded in patients with autism spectrum disorders as it has been demonstrated that ADHD and autism commonly occur together.8

Box 4: Important elements of an adult ADHD assessment

  • Comprehensive developmental history
  • General mental health history and assessment
  • Use of a structured diagnostic interview such as the Diagnostic Interview for ADHD in Adults (DIVA)
  • Gathering of information from several sources including:
    • third parties (especially parent or relatives who have known the patient since childhood if possible)
    • past assessments from mental health services, educational psychologists, or other professionals
  • Use of validated scales measuring symptom and functional impairments.

ADHD=attention deficit hyperactivity disorder

Keep it in mind that medication can be very effective

NICE CG72 states that for adults with ADHD, drug treatment should be:4

  • the first-line treatment, unless the person would prefer a psychological approach
  • started only under the guidance of a psychiatrist, nurse prescriber specialising in ADHD, or other clinical prescriber with training in the diagnosis and management of ADHD.

Medication for ADHD can work quickly and be highly effective in both the reduction of symptoms and improvements in overall functioning.

Current medications available for the treatment of ADHD include:

  • psychostimulants—
    • methylphenidate
    • dexamphetamine
    • lisdexamphetamine
  • non-stimulants—
    • atomoxetine
    • guanfacine.

Note that despite being licensed in children, not all ADHD medications are licensed for use in adults, despite guidelines supporting their use in adults. Some of the medicines discussed in this article currently (October 2017) do not have UK marketing authorisation for the indications mentioned. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s guidance on Good practice in prescribing and managing medicines and devices9 for further information.

The psychostimulants methylphenidate and lisdexamphetamine are schedule 2 controlled drugs.10 NICE CG72 recommends methylphenidate as the first-line drug, with dexamphetamine or atomoxetine reserved as second-line options if methylphenidate is ineffective or unacceptable.4 Draft NICE guidance, due to be published in February 2018, recommends lisdexamphetamine as the first-line pharmacological treatment for adults with ADHD, and methylphenidate as a second-line option.11 Medication should be titrated against symptoms and side-effects over 4–6 weeks until an effective and tolerable dose is reached.

When prescribing methylphenidate, healthcare professionals should continue with the brand initiated by the specialist as different brands vary in their formulation (immediate release or modified release) and are not bioequivalent. For specific information about formulation, dose, duration of efficacy, licensing, and side-effects, healthcare professionals should refer to the individual summary of product characteristics. Further information about the treatment of ADHD is available in the British National Formulary.

Despite concerns regarding diversion and misuse of psychostimulants, there is little evidence that patients become addicted or dependent. Therapeutic stimulants, especially long-acting formulations, are not very effective at producing a ‘buzz’ and as a result have little street value. However, in cases of current substance misuse, healthcare professionals should be cautious and consider joint management with drug and alcohol services.12

Non-stimulants may be used if the patient chooses not to take psychostimulants, psychostimulants are not tolerated or effective, or there is a history of significant substance misuse. Effects can take a few weeks to become apparent.

9 Be aware of the local shared-care arrangements

NICE CG72 recommends that following titration and dose stabilisation, prescribing and monitoring should be carried out under locally agreed shared-care arrangements with primary care.4 Typical shared-care arrangements and required monitoring are shown in Table 2.

Table 2: Typical shared-care arrangements
Responsibilities of specialistResponsibilities of GP
  • Establish or confirm ADHD diagnosis
  • Conduct baseline monitoring of blood pressure, heart rate, and weight
  • Initiate and stabilise treatment
  • Counsel the patient about off-licence prescribing and discuss the benefits and side-effects
  • Confirm with GP whether they are willing to participate in shared care
  • Provide a review of the patient’s condition and treatment if there are any concerns or changes
  • Provide, as a minimum, an annual review
  • Advise GP of any changes in dosage and if medication is to be discontinued
  • Reply to shared-care request as soon as possible
  • Prescribe the stable dose of medication as recommended by a specialist
  • When prescribing methylphenidate continue with the brand initiated by the specialist as different formulations vary in the proportion of IR and MR and are not bioequivalent
  • Report to, and seek advice from, specialist regarding any concerns about care and treatment
  • Monitor blood pressure and heart rate every 3 months and weight every 6 months
  • Advise the specialist if the patient’s condition deteriorates or non-compliance is suspected
  • Check for drug interactions when prescribing new, or stopping existing, medication

ADHD=attention deficit hyperactivity disorder; IR=immediate release; MR=modified release

10 Advise the patient about non-pharmacological interventions

Lifestyle changes can help people to manage their symptoms of ADHD more effectively. Advise patients that they should:

  • get regular exercise4
  • eat a balanced, healthy diet4
  • minimise alcohol use and avoid recreational drugs.12

Psychoeducation about ADHD can help patients make sense of the diagnosis and learn to cope and live with the condition. This will often be provided by specialist services although it is useful for GPs to be aware of local and national charities and support groups, including:

References

  1. Faraone S, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006; 36 (2): 159–165.
  2. Simon V, Czobor P, Bálint S et al. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry 2009; 194: 204–211.
  3. Young S, Moss D, Sedgwick O et al. A meta-analysis of the prevalence of attention-deficit hyperactivity in incarcerated populations. Psychol Med 2015; 45 (2): 247–248.
  4. NICE. Attention deficit hyperactivity disorder: diagnosis and management. NICE Clinical Guideline 72. NICE, 2008. Available at: nice.org.uk/cg72
  5. Faraone S, Perlis R, Doyle A et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry 2005; 57 (11): 1313–1323.
  6. Mueller A, Fuermaier A, Koerts J, Tucha L. Stigma in attention deficit hyperactivity disorder. Atten Defic Hyperact Disord 2012; 4 (3): 101–114.
  7. Kupfer D, Regier D, Narrow W et al, the DSM-5 task force. Neurodevelopmental disorders. In: Diagnostic and statistical manual of mental disorders fifth edition—DSM-5. Arlington: American Psychiatric Association, 2013.
  8. Antshel K, Zhang-James Y, Wagner K et al. An update on the comorbidity of ADHD and ASD: a focus on clinical management. Expert Rev Neurother 2016; 16 (3): 279–293.
  9. General Medical Council. Good practice in prescribing and managing medicines and devices. GMC, 2013. Available at: www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf
  10. Home Office. List of most commonly encountered drugs currently controlled under the misuse of drugs legislation. Home Office, 2017. Available at: www.gov.uk/government/publications/controlled-drugs-list–2/list-of-most-commonly-encountered-drugs-currently-controlled-under-the-misuse-of-drugs-legislation
  11. NICE. Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline: short version—draft for consultation. NICE, September 2017. Available at: www.nice.org.uk/guidance/gid-cgwave0798/documents/short-version-of-draft-guideline
  12. Bolea-Alamañac B, Nutt D, Adamou M et al. Evidence-based guidelines for pharmacological management of attention-deficit/hyperactivity disorder: update on the recommendations from the British Association for Psychopharmacology. J Psychopharm 2014; 28 (3): 10–41.