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) 

In This Article

How to Treat Adults with ADHD

Effective Treatments

The symptoms of ADHD can be treated effectively in both children and adults. The beneficial effects of stimulant medication and atomoxetine on the core symptoms of ADHD have been demonstrated in numerous studies in children. An increasing number of studies in adults demonstrate a similar clinical response to that seen in children.[32,236–239] Due to the demands and responsibilities of adult life, adults face many problems that are different from those faced by children and they therefore need a different range of psychosocial and psychological treatments tailored to both their developmental level and ADHD. Psychological treatments in the form of psychoeducation, cognitive behaviour therapy, supportive coaching or assistance with organising daily activities are all thought to be effective.[240–242] Further research is however needed as there is an insufficient evidence base to recommend their routine use in clinical practice.[32]

Impact of Non-treatment

Long-term follow-up, epidemiological and clinical studies have shown that adults with untreated ADHD, when compared to normal controls, experience higher rates of academic failure, low occupational status, increased risk of substance use disorders (tobacco, alcohol or drugs), accidents and delinquency, and have fewer social relationships or friends.[18,121,127,131,243,244] Patients diagnosed with ADHD in adulthood often complain that they did not receive treatment earlier in life and feel that their life would have been different if they had. Appropriate treatment could have prevented accidents and ongoing impairment at school, at work and in their peer and partner relationships. After decades of undiagnosed and unmet needs, the diagnosis offers an explanation for their problems which is valuable to a lot of patients and their family. Treatment of adult ADHD can influence psychosocial impairment that results as a consequence of 'core' ADHD symptoms, and may lead to improvements in associated features and comorbid disorders.[245–247] These include the following:

  • psychological functioning and self-confidence

  • family/relationship functioning

  • interpersonal (broader than family) functioning

  • professional/academic functioning

  • cognitive deficits

  • driving performance

  • risk of substance use disorders

Optimal Treatment Algorithm

Similar to the treatment of ADHD in children, a multimodal approach to treatment of adults with ADHD and associated co-morbid disorders should be taken.[248] Ideally, the treatment plan would also involve the adult's partner, family or close relationships. The multimodal approach includes:

  • psycho-education of ADHD and comorbid disorders

  • pharmacotherapy for ADHD and comorbid disorders

  • coaching

  • cognitive behaviour psychotherapy (individual and group)

  • family therapy

Treatment Focus in Co-morbid ADHD

Treatment should follow careful diagnostic assessment of ADHD and associated comorbid disorders. In the case of comorbidity, the integrated treatment plan should address both ADHD and the comorbid condition, the order of pharmacological treatment depending on the type and severity of comorbidity. Generally, severe mental health disorders should be treated first, such as in-patients with psychosis, major depression, mania or drug addiction; following which the diagnosis of ADHD and need for treatment can be reviewed. However, treatment of milder depressive and anxiety disorders may be deferred until after treatment of ADHD and often needs no further treatment as the comorbid symptoms may resolve following effective treatment of ADHD. Symptoms such as demoralisation and low self-esteem following a life with ADHD, and mood instability, improve with stimulant treatment alone.[234] It is up to the clinician to decide on what is the most important need for every patient with specialist advice being sort for more complex cases.

With respect to substance use disorders, ADHD is considered an important factor in its aetiology as the substances are often used for self-medication and may relieve symptoms like restlessness, inattention, impulsivity and sleep problems;[207,249–251] or may be taken as part of stimulus seeking (novelty seeking) traits that are also associated with ADHD. In such cases, treatment of ADHD may help patients to stop substance use for self-medication[252–254] or may reduce impulsive stimulus seeking behaviour. However, systematic research has not provided a strong evidence base for appreciable improvements in ADHD when treated in the presence of substance use disorders;[255,256] and drug or alcohol abuse disorders should always be targeted as a primary disorder. Treating ADHD in parallel with SUD can however be important in some cases, particularly where ADHD is severe or where there is good understanding and compliance for the treatment program.

However, in some countries, regulatory rules will not allow prescription of stimulants in patients with substance use disorders. Patients should be asked to register their drug/substance intake and be encouraged to stop their use. Despite concerns that pharmacotherapy with stimulant medication may be a risk factor for substance abuse, the literature supports the view that stimulant treatment for ADHD either has no impact in risk for substance abuse, or may even lower the risk of substance abuse by reducing the early onset of substance abuse in adolescents.[206,254,257–259]

Psycho-education

Psycho-education is the first step in the treatment plan and involves educating the patient and ideally also the partner or family about ADHD symptoms and impairment, the prevalence in children and adults, the frequent comorbidity, the heritability, the brain dysfunctions involved, as well as the treatment options. In many cases, simply providing the patient with this information may help the patient's understanding and bring him or her comfort. Often this process offers new insights into past difficulties. Relationship difficulties often decline after this sharing of information with family members. Feelings of guilt and remorse can be left behind, and the patient's social network may begin to be restored. This social network will prove invaluable to the patient during the treatment process. Informing the patient about the existence of self-help groups may be valuable, allowing him or her to join and share information and experiences, as well as to gain further comfort and understanding. There is a need to further develop structured psychoeducation programs with specific objectives.

Pharmacotherapy for Adult ADHD in Europe

Stimulants (methylphenidate and dexamphetamine) are first choice medication treatments for ADHD in children and adults, based on an extensive and still growing body of data concerning efficacy and safety.[32,260] Atomoxetine is usually considered the second line treatment, followed by other non-stimulants like bupropion, guanfacine, modafinil and tricyclic antidepressents, based on efficacy outcomes in controlled studies in different age groups.[239,261–264]

Stimulants are effective in about 70% of patients with ADHD in controlled studies[265–267] depending on the study design and maximum drug dosage. A recent European study of adults with ADHD showed the effectiveness of methylphenidate over a period of six months, in the longest double blind placebo controlled trial to date.[268] Stimulant treatment not only improves the symptoms and impairing behaviours associated with ADHD, but also improves related problems such as low self-esteem, anger outbursts, mood swings, cognitive problems and social and family function. Side-effects are usually mild and transitory, mainly consisting of headache, reduced appetite, palpitations, nervousness, difficulty falling asleep, and dry mouth.[148,269,270] Stimulants may increase blood pressure and heart rate, and decrease weight, therefore patients should be assessed regarding these issues prior to, and monitored during treatment. Stimulants are not advised during pregnancy or breastfeeding and are contraindicated in psychotic disorders up to now; although some specialists have treated ADHD successfully in stable patients with schizophrenia maintained on antipsychotics.[271] Relative contra-indications are hypertension, cardiac problems including angina, hypertrophic cardiomyopathy and arrhythmias, hyperthyroidism and glaucoma. For these disorders, first referral to and treatment by a specialist are needed before starting a stimulant. Stimulants may be used in autism with generally positive effects, although in some cases autistic features may worsen.[272–275] A recent meta-analysis indicated that treating ADHD in children with tic disorders is safe and effective.[276,277] Stimulants have little impact on seizure threshold and may be used in epilepsy.[278]

Although stimulants are by far the best studied and most effective treatment for ADHD, their use in some parts of Europe is still controversial in both children and adults. It is not yet common practice for doctors to prescribe stimulant medication to adults. As a result support services and expertise for treating ADHD in adults are not always available. As discussed earlier, the use of stimulants continues to be hampered by stigma and lack of up to date information in their use, with restricted access in many European countries.[279]

The hesitancy and uncertainty about the appropriate use stimulant medication by both the general public and many physicians may also be related to the history of abuse with amphetamines in the past. Health authorities have given methylphenidate the same drug classification as amphetamines and they both perform similar to each other in traditional assays of abuse.[280,281] Abuse potential has been studied by Nora Volkow (Director of the National Institute of Drug Abuse, USA) who showed that abuse potential relates to the route of administration, with rapid rise in dopamine levels following injection or snorting of stimulants. In contrast, during oral clinical use, methylphenidate elicits slow steady-state dopamine increases in the brain which mimic those of tonic neuron firing, rather than rapid dopamine changes associated with reinforcing drug-like effects.[257] In the Volkow study it was found that intravenous methylphenidate could not be distinguished from cocaine by cocaine addicts, whereas this was not the case for oral methylphenidate. Therefore the use of extended release medications that have a slow rate of serum rise, are preferable to reduce potential for abuse and diversion.

Importantly, both clinical studies and clinical experience support the view that the methylphenidate does not lead to stimulant or drug addictions. On the contrary, it has been shown to have a neutral or reducing impact on substance abuse and the risk of relapse.[206,253,254] Furthermore, stimulants are not addictive from the clinical perspective. Adolescents treated from childhood generally use less stimulant medication or stop, using instead of taking more. A common problem is poor compliance or cessation of treatment during the adolescent years. There is also no clear evidence of tolerance over time. Neither has stimulant use been associated with adverse effects on driving, but rather is associated with an improvement in the concentration of ADHD patients during driving.[127,282] The main potential problem associated with their use and reported in a number of studies from the US is the inappropriate diversion of stimulants, by parents self-treating themselves with their children's medication or as a cognitive enhancement medication for college students. This should not however detract from their specific use to reduce ADHD symptoms and associated impairments in people with ADHD.[283]

Continued research in adult patients and education about efficacy and safety may help to overcome these problems. The non stimulant atomoxetine may be an alternative to treatment with stimulants in substance abuse patients with ADHD, although studies showing superiority over stimulants in this difficult patient population are still lacking.[200,284–286]

Types of Stimulants

In the United States, more than ten different stimulant preparations have been developed for treatment of ADHD, the most recent being long acting formulations of oros-methylphenidate, mixed amphetamine salts, dexmethylphenidate and lis-dexamphetamine.[265,287,288] These improvements were necessary because of the very short half-life leading to relatively short duration of symptom control from immediate release methylphenidate (two to four hours) and dexamphetamine (three to five hours). The requirement for a longer duration of activity in adults, requires repetitive dosing with immediate release stimulants, of between three to four doses in most cases, and more often in others, to avoid rebound symptoms and for adequate control of ADHD symptoms during the day and evening.[148,270] Compliance to such frequent dosing regimens is however poor in ADHD patients due to forgetfulness, inattentiveness and self-organisation problems, leading to daily instability by frequent rebound symptoms and ineffective treatment.[148,289–291]

Extended release preparations of stimulants have durations of action between 6 to 14 hours, which may permit once-daily dosing, although an adult may still need twice daily dosing of medication for a 12–16 hour day. Currently, combinations of immediate and extended release preparations are often prescribed in adults with the aim of tailoring the dose regime to the individual requirement and medication response of each patient. Dosing schemes and maximum daily dose vary across Europe (from 0.3–1.5 mg of methylphenidate/kg/day). However, the panel recommends that the dose of stimulants in adults should be individually adjusted, based on response and tolerability. The short half life of the medications suggest that it is more practical to consider maximum dose in terms of the maximum taken at each time point, the length of the effect of each dose on the control of ADHD symptoms, and the number of doses required to provide symptom control throughout the day; rather than a maximum based only on mg/kg per day. Individual differences in the optimal dose response to stimulant medication means that the best approach is to titrate the dose for each individual, starting at a low dose and increasing to an effective dose, while keeping side effects to a minimum; and should not be determined on a mg/kg basis.

In Europe, limited and different products are registered in the various countries. Some countries still only have access to immediate release methylphenidate and may or may not have access to dexamphetamine, while increasingly the longer-acting extended release preparations are being introduced. In Switzerland Dexmethylphenidate XR was licensed for use in adults in 2009 and this has been reported as a safe and effective option.[292]

Second Line Pharmacotherapeutic Treatments

For adults with ADHD who do not respond to stimulant therapy or who have a condition in which a stimulant is contraindicated, the non-stimulant atomoxetine that is licensed for child and adult ADHD in the USA is an appropriate alternative.[247] Atomoxetine has an effect size of around 0.4 in adults,[32,293] a duration of action of 24 hours, and no abuse potential.[294] Atomoxetine may be indicated in patients with comorbid substance use disorders, emotional dysregulation or social anxiety.[295–297] Other choices comprise medications like long acting bupropion, modafinil and guanfacine, that have all been investigated in ADHD.[262,298–300] Tricyclic antidepressants like Desipramine, an imipramine metabolite, has been shown to be effective in adults with ADHD.[301] However, these medications must be considered fourth line agents due to their side effects, limited value in treating the symptoms of inattention and relatively low effect size compared to stimulants in the treatment of ADHD.[302]

In more complicated co-morbid cases, clinical experience indicates that treatment may be combined with antidepressants and mood stabilizers, although controlled studies are still lacking.[303] A recent review on drug interactions in the treatment of ADHD concluded that methylphenidate appears to be more implicated in pharmacokinetic interactions suggestive of possible metabolic inhibition, while amphetamine was more involved in pharmacodynamic interactions and could potentially be influenced by medications affecting cytochrome P450 (CYP2D6).[304] Only monoamine oxidase inhibitors (MAOIs) are contradicted with the concomitant use of stimulants. Other drugs such as antidepressants and antipsychotics can be given at the same time as stimulants but in a few cases some adjustment in the dose of either drug might be required. Finally, there is no consistent evidence from randomised control trials for the use of food supplements, such as omega-3 fatty acids ADHD.[305]

Coaching and Cognitive Behavioural Therapy

Pharmacotherapy alone is usually not sufficient to stabilise the many problems of adults with ADHD. Coaching provides a structured, supportive therapy, either individually or in group sessions. Coaching aims to teach problem-solving skills for identified practical problems. Due to a lifetime history of the impairment, adults with ADHD have typically not learnt practical organisational skills[306,307] and may have developed poor coping skills and inappropriate behaviours in response to the impairments associated with ADHD.

A coaching program may include:

  • acceptance of the disorder

  • learning to deal with time management

  • learning to limit activities to 'one goal at a time'

  • organising home, administration, finances

  • dealing with relationship and work difficulties

  • learning to initiate and complete tasks

  • understanding emotional responses associated with ADHD

These components of coaching are also addressed by cognitive behavioural therapy for adult ADHD.[241,308] According to the clinical experience of the panel, many adults may benefit from supportive and/or cognitive behavioural therapy in combination with pharmacotherapy. Other forms of psycho-social or family therapy may help with impairments associated with ADHD, such as relationship problems and low self-esteem.[309] Psychotherapy targets the adaptation of the ADHD patient to a lifelong debilitating disorder and it may relieve co-morbid symptoms.

Current research does not support the efficacy of psychotherapeutic treatments as sole treatment for adult ADHD; neither do they relieve the core symptoms of ADHD. They are however considered an import adjunctive treatment for people who prefer a psychological approach or where residual symptoms or comorbidities remain. CBT has a strong evidence base for the treatment of some of the comorbidities associated with ADHD yet there are few controlled trials in adults with ADHD. The findings in ADHD are reviewed by the Research Forum on Psychological Treatments for Adults with ADHD, who identified moderate to large effect sizes from five empirical studies. They concluded that psychological treatments may play a critical role in the management of adults with ADHD who are motivated and developmentally ready to acquire new skills as symptoms remit.[310] Safren and colleagues[241] compared CBT plus medication with medication treatment alone and found significantly greater improvements for ADHD symptoms and anxiety and depression scores in the combined treatment group. Similar findings were reported by Rostain and Ramsey,[247] while a further study reported added benefits from CBT and psychoeducation delivered in a brief intensive group format.[311] Alternative strategies have focused on strengthening cortical (executive) function with several studies indicating treatment effects in ADHD symptoms using techniques such as working memory training and neurofeedback and cognitive remediation therapy in children[312–316] and meta-cognitive training in adults.[317] A full review of psychological approaches for ADHD throughout the lifespan has recently be published by Young and colleagues [240]

Prognosis and Costs

ADHD in adults presents as a lifelong condition that started during childhood. The precise details of the clinical presentation may change with age and with the demands of adult life, but are broadly similar to those seen in children. As medication treatment for ADHD does not cure the disorder and some or all symptoms may return after discontinuation of medication, long-term pharmacological and psycho-social treatment may be necessary. The poor long term prognosis of untreated ADHD has implications for the costs of illness. In children, the economic burden of ADHD has been estimated to be approximately double those of normal controls, due to substantially more inpatient as well as outpatient hospitalisations and emergency department visits.[318] The economic burden of untreated adult ADHD has been increasingly studied and shows the same pattern as in children, with higher than normal costs of sickness leave, less productivity, more accidents and more health care costs.[141,319,320] Effective management of the patient with ADHD is justified from a health economic perspective since undiagnosed and untreated ADHD will lead to inefficient health care use, less satisfactory clinical outcomes, lower personal well-being and poorer social and professional interactions.

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