European Consensus Statement on Diagnosis and Treatment of Adult ADHD: The European Network Adult ADHD

Sandra JJ Kooij; Susanne Bejerot; Andrew Blackwell; Herve Caci; Miquel Casas-Brugué; Pieter J Carpentier; Dan Edvinsson; John Fayyad; Karin Foeken; Michael Fitzgerald; Veronique Gaillac; Ylva Ginsberg; Chantal Henry; Johanna Krause; Michael B Lensing; Iris Manor; Helmut Niederhofer; Carlos Nunes-Filipe; Martin D Ohlmeier; Pierre Oswald; Stefano Pallanti; Artemios Pehlivanidis; Josep A Ramos-Quiroga; Maria Rastam; Doris Ryffel-Rawak; Steven Stes; Philip Asherson

Disclosures

BMC Psychiatry. 2010;10(69)

Review

The European Network Adult ADHD

The European Network Adult ADHD was founded in 2003 and includes 40 professionals from 18 countries across Europe with an interest in and experience of ADHD in adults https://www.adult-adhd.net. This independent expert panel was set up to help improve the diagnosis and management of ADHD in adults throughout Europe. It is the opinion of the panel that today, due to lack of recognition and misunderstanding about the disorder and the use of appropriate, stimulant or non-stimulant medication, to control symptoms of ADHD, many adults with ADHD are misdiagnosed and are often prevented from receiving effective treatments. This may lead to unnecessary suffering for individual patients, their families and work colleagues.

Objectives of Consensus Statement

The objectives of this consensus statement are to increase awareness of the following: (1) That ADHD often presents as an impairing lifelong condition in adults, yet is currently underdiagnosed and treated in many European countries; (2) That instruments for screening and diagnosis of ADHD in adults are available; (3) That appropriate treatments exist.

Three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?

Methodology

This document is the result of three meetings between 2003 and 2009 in which the need for communication and a consensus statement in Europe were identified. A formally prepared document with consensus statements agreed by experts within the group was reviewed and discussed. Following this process the final document was circulated for written approval by all members of the European Network. For the assembly of the document, reviews and randomised controlled trials in adults were identified from Medline, Embase and the Cochrane Database, as well as from reviews on ADHD in children and cross-referencing and identification by the participating experts. Details of the clinical presentation of adults with ADHD were further informed by clinical expertise. This consensus statement is written for specialists in psychiatry but is also intended to increase the understanding of the disorder and to facilitate referral for diagnosis, treatment and follow-up from primary health care physicians and other health care providers.

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Table 1. Summary of key points from the consensus statement
Neurobiological and environmental background	Anomalies in brain functioning identified in case control studies of cognitive, electrophysiological and neuroimaging studies, and the effectiveness of pharmacological treatments with dopamine agonists support the neurobiological underpinnings of ADHD. High heritability and associated environmental risk factors suggest a primary role for genetic influences that are moderated by environmental factors in the majority of cases.
Diagnosis	The gender differences in child and adult ADHD may be due to different expression of symptoms and co-morbidities, perception of impairments, and referral bias; and deserve further study. Age, gender, and IQ matched reference values are still lacking for diagnostic assessment of ADHD in adults. The age-of-onset criteria required for the retrospective diagnosis of ADHD in adults is less reliable and less important than the persistence of symptoms and impairment of ADHD during the lifespan. A cut off of 4/9 current DSM-IV criteria may be sufficient in adults with a childhood onset of symptoms, when accompanied by significant impairments. Age-appropriate presentations of ADHD symptoms should be taken into account when scoring the symptoms of ADHD in adults. The diagnosis of ADHD in adulthood should be based on self-report and in-depth evaluation, but collateral information is desirable. Various instruments are available for screening and assessment of ADHD, but validation studies are urgently needed. Neurobiological and neuropsychological tests are neither imperative nor sufficient for the diagnosis of ADHD but may document specific functional impairments.
Treatment	Non- treatment may deprive the patient of the chance to resolve functional and psychosocial impairments at personal, relationship and professional levels. The severity of ADHD and associated co-morbid disorders should be the first guide to select which disorder to treat first. Treatments can often be combined. Albeit local regulatory rules may dictate differently, in patients with ADHD and substance use disorder, ADHD treatment with stimulants should not be withheld, but rather postponed until problematic substance use is stopped and there is a commitment to the treatment process. Stimulants are the treatment of choice for adults with ADHD. Long-lasting, extended release formulations are preferred for reasons of adherence to treatment, for the protection against abuse, to avoid rebound symptoms, for safer driving, and to provide cover throughout the day without the need for multiple dosing. The non-stimulant atomoxetine can be a second line treatment. Others like modafinil, bupropion, guanfacine, and tricyclic antidepressants have shown efficacy in controlled studies. Psychotherapy targets the relief of co-morbidities and behavioural, social, cognitive or other functional impairments. The poor long-term prognosis in a substantial part of patients and the absence of a cure upon stopping medication underline the role of long-term management of the adult with ADHD. With appropriate diagnosis and treatment, morbidity may be low, health care use efficient, outcomes better and associated with lower economic burden. More research on ADHD throughout the lifespan until old age is needed.

Authors and Disclosures

Sandra JJ Kooij^1*, Susanne Bejerot², Andrew Blackwell³, Herve Caci⁴, Miquel Casas-Brugué⁵, Pieter J Carpentier⁶, Dan Edvinsson⁷, John Fayyad⁸, Karin Foeken⁹, Michael Fitzgerald¹⁰, Veronique Gaillac¹¹, Ylva Ginsberg¹², Chantal Henry¹³, Johanna Krause¹⁴, Michael B Lensing¹⁵, Iris Manor¹⁶, Helmut Niederhofer¹⁷, Carlos Nunes-Filipe¹⁸, Martin D Ohlmeier¹⁹, Pierre Oswald²⁰, Stefano Pallanti²¹, Artemios Pehlivanidis²², Josep A Ramos-Quiroga²³, Maria Rastam²⁴, Doris Ryffel-Rawak²⁵, Steven Stes²⁶ and Philip Asherson²⁷

¹PsyQ, psycho medische programma's, Department Adult ADHD, Carel Reinierszkade 197, Den Haag, The Netherlands. ²Department of Clinical Neuroscience, Karolinksa Institutet, Section Psychiatry, St. Goran, Stockholm, Sweden. ³University Department of Psychiatry, Addenbrookes Hospital, Cambridge, UK. ⁴Pediatric Department, Hôpitaux Pédiatriques CHU-Lenval, 06200 Nice, France. ⁵Servicio de Psiquiatria, Hospital Universitari Vall d' Hebron, Universidad Autonoma de Barcelona, Barcelona, Spain. ⁶Reinier van Arkel Groep, Postbus 70058, 5201 DZ 's-Hertogenbosch, The Netherlands. ⁷Department of Neuroscience/Psychiatri Ulleråker, MK 75, S-750 17 Uppsala, Sweden. ⁸Institute of Development, Research, Advocacy and Applied Care (IDRAAC), Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Centre, Balamand University, Beirut, Lebanon. ⁹Centre des Consultations, Institut A Tzanck, Mougins, France. ¹⁰Department of Psychiatry, Trinity College Dublin (TCD), Dublin 2, Ireland. ¹¹Clinique des Maladies Mentales et de l'Encéphale (CMME), Sainte Anne Hospital Paris, France. ¹²Affektiva mottagningen, M 59, Psykiatri Sydväst, 141 86 Stockholm, Sweden. ¹³Département de Psychiatrie Adulte, Unité Lescure, CH Charles Perrens, Bordeaux, France. ¹⁴Private clinic for psychiatry and psychotherapy, 11a Schillerstrasse, Ottobrunn, Germany. ¹⁵Department of Child Neurology, Oslo University Hospital, Ullevaal, Oslo, Norway. ¹⁶Geha Mental Health Center, Petach-Tiqva, Sackler Faculty of Medicine, Tel-Aviv University, Israel. ¹⁷Department of Child Psychiatry, Regional Hospital of Bolzano, Via Guncina, Bolzano, Italy. ¹⁸Faculty of Medical Sciences, New University of Lisbon, Campo dos Mártires da Pátria, 1169-056 Lisboa, Portugal. ¹⁹Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Germany. ²⁰Department of Psychiatry, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium. ²¹Department of Neurosciences, Florence University, Florence, Italy. ²²Department of Psychiatry, National and Kapodistrian University of Athens Medical School, Eginition Hospital, Athens, Greece. ²³Programa Integral del Déficit de Atención en el Adulto (P.I.D.A.A), Servei de Psiquiatria, Hospital Universitari Vall d'Hebron, Barcelona, Spain. ²⁴Department of Clinical Sciences, Lund, Child and Adolescent Psychiatry, Lund University, Sweden. ²⁵Johanniterstraße 1, CH-3047 Bremgarten, Bern, Switzerland. ²⁶ADHD Program, University Psychiatric Center, Catholic University Leuven, Kortenberg, Belgium. ²⁷MRC Social Genetic and Developmental Psychiatry, Institute of Psychiatry, Kings College London, London, UK

^* Correspondence
s.kooij@psyq.nl

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