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Adults with ADHD: ignored and under-treated

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The transition from child and adolescent mental health services (CAMHS) to adult psychiatric services can be difficult to negotiate, especially if the individual has a disorder that is under-recognised in adults. This often applies, for example, to attention deficit hyperactivity disorder (ADHD). There may even be a belief that those with ADHD in childhood automatically grow out of it when they reach adulthood. Indeed, some may assume that ADHD in adulthood is a manufactured diagnosis, indicative of a creeping medicalisation of everyday life, driven by drug marketing.1 Such attitudes undermine attempts to secure appropriate management for affected patients.

ADHD is characterised by inattention, impulsivity and hyperactivity. In guidelines published in 2008, the National Institute for Health and Clinical Excellence (NICE) concluded that ADHD represented the extreme of “dimensional traits” (similar, for example, to obesity and hypertension), and that making the diagnosis is therefore based on the severity of symptoms and associated impairments.2 ADHD symptoms are predictive of both current and future problems in social, academic, family, mental health and employment functioning. Crucially, the symptoms persist through to adulthood, with around 15% of those affected still meeting full, and 65% partial, criteria for ADHD at age 25 years.2 Although overt hyperactivity in adults is less common than in children, social and occupational problems are caused by difficulties in concentrating, paying attention to detail and completing tasks, together with impulsivity and an inability to plan ahead. Moreover, ADHD is commonly associated with mental health, addiction or behavioural problems.2,3

While the evidence for treatment of adults with ADHD is sparse, NICE concluded that the drug methylphenidate (unlicensed in the UK for use in adults) is the first-line therapy for those with moderate to severe impairment.2 Drug therapy needs to be part of a comprehensive treatment programme addressing psychological, behavioural and educational needs, delivered by practitioners trained in managing patients with ADHD.2

So, it is clear that there needs not only to be a seamless transition from CAMHS to adult psychiatric services, but that there is access to appropriate adult psychiatric services for the assessment and management of ADHD identified in adulthood. In reality, services for adult ADHD are extremely patchy, few areas have properly commissioned services, and treatment is usually offered piecemeal by individual clinicians with an interest in the disorder. This situation is a clear example of national guidance not being translated into routine practice. In defining the quality indicators for the new NHS Outcomes Framework, the NHS Commissioning Board must include provisions for adult ADHD within the new commissioning arrangements.

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