Australian psychiatrists have called for more public sector assessment and treatment for adults with the condition.
Trainee psychiatrists need more education in assessing and managing ADHD in adults and treatment should move further into the public sector, say Australian experts.
In an editorial published in the Australian & New Zealand Journal of Psychiatry, lead author, University of Queensland psychiatrist Associate Professor Shuichi Suetani and colleagues said the diagnosis of ADHD was challenging in adults.
“There are several reasons for this,” they wrote. “First, because the current diagnostic conceptualisation requires symptom onset in childhood, new diagnoses of ADHD in adults are always retrospective. This increases the risk of recall biases, particularly in those aligned with the diagnosis. Second, factors such as negative public views, negative attitudes of parents/teachers and poor awareness of ADHD in the education system decades ago may mean that collaborative information may not be reliable.
“Furthermore, the current diagnostic criteria for ADHD are based on the characteristics of the condition in childhood, and they do not consider the age- and gender-specific issues.”
In addition, ADHD was often associated with multiple psychiatric comorbidities, especially other neurodevelopmental disorders, and the number of comorbidities was likely to increase as ADHD persisted – especially if untreated – into adulthood.
“Finally, perhaps most importantly, diagnosing ADHD in adults is hard because we are never trained on how to diagnose ADHD in adults,” they wrote.
“At face value, we, psychiatrists, are uniquely situated to be able to assess and manage adult ADHD. To do so, however, we must put the cart?behind?the horse.”
As trainees, psychiatrists were taught that ADHD was characterised by the core symptoms of inattention, hyperactivity or impulsivity, the authors wrote.
“We were also told that ADHD is a childhood condition,” they wrote.
“Accordingly, the teaching around ADHD typically occurs within the mandatory child and adolescent rotation. Almost as an afterthought, we learnt that although the symptoms usually appear first in childhood, ADHD is often a lifelong condition with its impact and presentation changing over time.”
ADHD diagnosis is associated with a range of physical health, such as obesity, asthma and epilepsy, as well as social issues like accidental injuries and premature mortality.
“We also know that pharmacological treatment for ADHD is particularly effective for younger people,” the authors wrote.
A recent population-based study in Australia found that ADHD medication use was the highest among males aged 6–17 years (around 6%), but the rate declined rapidly with age, reducing to around 0.3–0.5% for those aged 25 years and over.
“This means only one in five adults with ADHD are being pharmacologically managed in Australia,” the authors wrote.
“Given the demonstrated efficacy of pharmacological treatment, why are 80% of adults with ADHD untreated?”
While they conceded that there were many systemic issues at play contributing to these difficulties, the authors highlighted the fact that there were very few specific program or services within the Australian public mental health system that provide ADHD assessment and treatment for adults.
Instead, the demand for these services seemed to be escalating in the private psychiatry sector. This had major implications, according to the authors. It contributed to high demand and long waiting lists for private practices and was problematic for young people with ADHD transitioning from paediatric and adolescent mental health services.
There were also challenges in providing psychiatry trainees with educational and clinical exposure to adults with ADHD.
“Currently, there is a limited evidence base for models of care with established evidence of effectiveness for adults with ADHD,” the authors wrote.
“Because almost all the care for adults with ADHD occurs in the private sector in Australia, we do not know what works and what does not empirically.”
However, there is hope, the authors said. Last year the Australian ADHD Professionals Association published an Australian guideline?and the Royal Australian and New Zealand College of Psychiatrists also has an ADHD network with an active membership and a focus on adult ADHD.
“But we need to do more,” they wrote. “We need a clear definition of what ‘adult ADHD’ means and develop training resources. Right now, adult ADHD mean different things to different people.”
This could include people with persisting ADHD from childhood, people whose ADHD was missed in childhood and people who have new onset ADHD symptoms in adulthood.
“To progress, we need to understand and agree on a consistent conceptualisation that considers a life span approach,” the authors wrote.
“We also need to train trainees in assessing (and this includes?excluding) and managing ADHD in adults.”
Critical to building this capacity would be to move adult ADHD into the public sector, which would provide educational consistency and clinical support. Another potential solution to expand the ADHD treatment capacity without adversely impacting on other patient groups may include increased training of a parallel workforce, such as mental health nurses, pharmacy practitioners and general practitioners. This may be done via the consultation and liaison model where psychiatrists focus on the assessment and diagnosis, and the long-term management is led by other health professionals.?
“More innovative solutions are required to meet the increasing demand for ADHD assessment and management in adults,” the authors concluded.
“Most of us spend five?years in psychiatry training without ever assessing or managing an adult with ADHD. How can we justify our professional competency in a condition we are never trained for?
“If we do not put the cart behind the horse, we will continue to face the criticism of under- or over-diagnosing ADHD among certain specific populations. This is not good enough for our profession. This is not good enough for our patients.”
Australian and New Zealand Journal of Psychiatry 2023, online 25 April
