Adult ADHD & Early Intervention!!!!

I remember my first public humiliation in 2006 when I presented a study about Adult ADHD to the Research Ethics committee in Lincolnshire, one of the psychiatrists on the panel got up and after scornfully looking at me said, "Adult ADHD is a scam' it doesn't exist. I was utterly taken aback, and those thoughts ruminated in my head for years to come. 

Fast forward a few years, and I see myself in a Locum consultant role where I was offered to lead a team and pioneer service for Autism Spectrum disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) for adults. I have learnt one thing, and that is never to say No to a good opportunity, I accepted the job in an instant, and that was the turning point of my career.

It was as if someone had just introduced me to a completely different but fascinating world. There was so much learning, unlearning, unravelling and exploring. It changed my perception about mental health and helped me think beyond the familiar realms of psychosis, mood, anxiety and personality disorder. It was as if Universe wanted me to have a third eye or a 6th sense. It was an evolution, metamorphosis beyond anything that I had ever experienced. 

Working in Home Treatment teams has its perks; I have been in 5 different Home treatment teams Nationally; it suits my learning style, which is predominantly an Activist. It also provides me with the opportunity to see a diverse presentation of people with mental health issues, adding to my skillsets and help me develop extra facets both as a Leader and a doctor. I made use of my skillset and realised over a while that at least 1/4th  to a 1/3rd  of those cared by Home treatment teams are undiagnosed ADHD.

What's ironical is that it can only be diagnosed and treated by a specialist service, even if non-specialist service diagnoses the person, they cannot initiate the medication. What's more mind blogging is that some areas do not have a specialist Adult ADHD service, even if they have, the waiting time is such that those patients with undiagnosed ADHD fall through the net and are lost to the system. Waiting lists that start from 2 years can be as long as ten years. It's like not having a service at all, and the system doesn’t seem to be bothered about it. 

I remember sitting down for an interview for a Speciality doctor post in 2008 in Trafford, when they asked me my perspective about specialist services. My reply was that we unknowingly are deskilling the workforce by creating specialist hubs which should be part of a conventional secondary care mental health service. I did say that it will deskill the next crop of the psychiatrist in a lot of critical and significant areas. The interviewer later came to me and applauded me for my insight. I see that insight turning into reality now, every single day. 

In our communities, the prevalence of Schizophrenia is 1-1.2%, all the services prioritise psychotic disorders, including the Community mental health team(CMHTs). We have inpatients prioritising patients with a psychotic disorder and then have the specialist services like Early Intervention in Psychosis or previously disbanded services like assertive outreach team all prioritising the 1% of the population. On the other hand, ADHD has a global prevalence of 4-6%; guess how many services there are to cater to them, just one and that too, with a never-ending waiting list. A 4-6-fold burden of disease with very few  to understand them and look after them. 

There are rarely any transition services from CAMHS and mostly diagnosed ADHD CAMHS patients fall prey to the lack of transition services and come off ADHD medication. Multiple unfavourable outcomes mar the cohort; a big chunk of them start using recreational substances to cope, leading to criminality.

According to different studies done on the  Prison cohort, the estimate includes 30-40% undiagnosed cases of ADHD; besides, 10% of those with addiction issues are undiagnosed too. In the community, they are misdiagnosed with Anxiety disorders, Emotionally Unstable Personality disorders, Addiction issues, Anti-social Personality disorders, or labelled as feral youth.

What needs to be done?

Our CCGs, GPs, secondary mental health services and emergency medicine need to develop a skill set to help diagnose and manage these patients effectively. CMHTs should start to assess these patients, initiate the treatment and provide a follow up till they are stable, they should be able to differentiate between EUPD and ADHD to prevent misdiagnosis. 

There is a need for Early Intervention services for ADHD in adults; this service will prevent people from being lost to the system in a brief period. It will help organise their lives, prevent criminalities hence preventing the excessive use of resources like Police, Emergency department, Prison services, social services, Criminal Justice system and so forth.  

If we start thinking of an Early Intervention in ADHD, we will reap its long-term impact reducing the burden on the person, community and economy. However, this is unachievable unless we embark on an awareness drive in the community, in reaching the neighbourhood, schools, colleges, universities etc. 

It all should start at the grass-root, educating professionals especially from mental health services to spot, diagnosis and manage the condition. One important area is training to teach Psychiatric nursing and medical trainees of this disorder.

There is hardly any curriculum catering to these needs. How do we expect an efficient service without providing the workforce with the relevant toolkit? There is only a handful of professionals with the skillset, which they have developed on their own accord. 

Before concluding the blog, let me educate you about ADHD. It stands for Attention deficit hyperactivity disorder. The symptoms are categorised under a triad of hyperactivity, impulsivity and inattention. 

DIAGNOSTIC CRITERIA ACCORDING TO THE (DSM-5)

1.     Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level.

o   Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

o   Often has trouble holding attention on tasks or play activities.

o   Often does not seem to listen when spoken to directly.

o   Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

o   Often has trouble organising tasks and activities.

o   Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

o   Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

o   Is often easily distracted

o   Is often forgetful in daily activities.

2.     Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to the extent that is disruptive and inappropriate for the person's developmental level.

o   Often fidgets with or taps hands or feet, or squirms in seat.

o   Often leaves seat in situations when remaining seated is expected.

o   Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

o   Often unable to play or take part in leisure activities quietly.

o   Is often “on the go” acting as if “driven by a motor”.

o   Often talks excessively.

o   Often blurts out an answer before a question has been completed.

o   Often has trouble waiting their turn.

o   Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

·       Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

·       Several symptoms are present in two or more settings, (such as at home, school, or work; with friends or relatives; in other activities).

·       There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

·       The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of Schizophrenia or another psychotic disorder.

Based on the types of symptoms, three presentations of ADHD can occur:

·       Combined presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

·       Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

·       Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

ADHD and co-morbidities, it can co-exist with Emotionally Unstable Personality disorder (EUPD), Autism Spectrum disorder (ASD), Anxiety disorder, Depression, Psychotic disorder, addiction and Anti-social personality disorder.

One of the Red flags is a patient with multiple diagnosis in a short timeline, with none of the interventions offered (both pharmacological and non-pharmacological), providing any respite. 

There are screening tools like ASRS, Connors, which are commonly used and then there are diagnostic tools like DIVA 2.0, ACDS, BADDS.

The mainstay of management is predominantly medication.

-       Stimulants: Methylphenidate, modified amphetamines, Preparations are available as an immediate and slow-release

-       Non-stimulants: Atomoxetine, certain Tricyclic antidepressants (desipramine, amitriptyline), Bupropion, Venlafaxine too

•       Psychological therapy: Behavioral therapy, also dependent on co-morbidities

It is one Neurodevelopment disorder with an excellent prognosis; it changes a person’s life proving respite, however is dependent on the timeline of intervention, the earlier, the better. 

Please feel free to contact me if you have any queries…