With more than one million South Africans between the ages of 20 and 50 affected by adult ADHD, there is a need for a comprehensive guideline.
Drs Renata Schoeman and Rykie Liebenberg of the South African Society of Psychiatrists (SASOP) Special Interest Group (SIG) for adult ADHD, have complied the guidelines that include assessment procedures, drug treatment options and a treatment plan for long-term health.
Schoeman said, despite the known efficacy of treatment and the substantial costs of untreated attention-deficit/hyperactivity disorder (ADHD), access to healthcare and treatment is not a given for many patients in South Africa.
“Comprehensive assessment is not possible during the average 15 minute general practitioner consultation, and it is therefore strongly advised that the diagnosis of adult ADHD and treatment initiation should be made by a psychiatrist well versed in the complexities of ADHD and the comorbidity thereof.”
“In SA, there is poor identification and treatment of common mental disorders at primary healthcare level and limited access to specialist resources with a service delivery and treatment gap of up to 75%. Medication options are also often limited in emerging markets and in SA psychiatrists, and patients do not have access to the medication armamentarium available in established markets. Furthermore, the majority of South Africans currently utilise the public healthcare sector and may not have access to treatment options referred to in these guidelines,” state the authors.
According to Schoeman et al, ’Mental restlessness’ was first described by Sir Alexander Crichton in 1798, while ‘Fidgety Philip’ (a popular storybook character and now also an allegory for children with attention-deficit/hyperactivity disorder [ADHD]) was created by Heinrich Hoffmann in 1844.
According to the authors of the guidelines, the belief that ADHD is a childhood disorder prevailed until the 1990s. “Rigorous research, including longitudinal studies, and public awareness highlighted the presence of on-going symptoms in 65% of adult patients.”
This has lead to the idea that adult ADHD is now a recognised problem.
“Associated symptoms of ADHD include behavioural, cognitive, emotional and social problems. Problems with planning, task initiation, task completion, impatience and impulsivity can cause numerous work-related and interpersonal problems,” states the guidelines.
“ADHD is the most common psychiatric disorder in children, affecting 2% to 16% of the school-age population. The population prevalence for ADHD is estimated as 3% to 5%,” said the authors.
It is projected that between 60% and 70% of patients’ symptoms persist into adulthood, with the estimate of the occurrence of adult ADHD between 2.5% and 4.3%.
“ADHD is more frequent in men than in women in the general population, with a ratio of approximately 1.6:1 in adults. Women are more likely than men to present primarily with inattentive features. The increased diagnosis of ADHD over the past decade seems to reflect improved criteria for the identification of ADHD in adults and female patients,” explains Schoeman et al.
The specific prevalence of ADHD in SA is unknown. The South African Stress and Health study, a nationally representative household survey of 4351 adults, conducted between 2002 and 2004, investigated the prevalence and treatment access and use for mental health disorders.
“Unfortunately, results were grouped as anxiety disorders, mood disorders, substance use disorders (SUD), and ‘any other disorder’. ADHD would be included within the last group, with a prevalence of 30.3%,” said the authors.
“In the first South African study exploring the situation with regard to the prevalence and treatment of adult ADHD, extrapolating the known prevalence information to the South African context, the expected number of adults between the age of 20 and 50 years affected by ADHD was calculated to be between 771264 (3%) and 1285 439 (5%),” states Schoeman et al.
“In this triangulated study, lack of knowledge of adult ADHD and lack of funding for the treatment thereof were identified as the two main barriers to diagnosis and treatment. It is therefore possible that these prevalence rates are underestimating the true prevalence of adult ADHD in SA.”
Diagnosis and clinical characteristics
According to the guidelines, the core triad of ADHD is a persistent pattern of inattention or hyperactivity–impulsivity that interferes with functioning. This is accompanied by associated behavioural, cognitive, emotional and social problems, which can lead to work-related and interpersonal difficulties.
“These core symptoms should be evident since childhood, with evidence of several symptoms being present since before the age of 12. Also, substantial symptoms causing significant impairment should be present in more than one setting (e.g. home, school and work). Some of the impairments related to adult ADHD include job failure or under-employment, complications such as drug dependence, driving accidents, unwanted pregnancies and sexually transmitted diseases, and even a life of perpetual failure” said the authors.
“A field trial in a representative large sample (N = 4000) of 18–19-year-old adults indicated a 27% increase (from 2.8% to 3.55%) in the expected prevalence of ADHD when comparing DSM-IV to DSM-5 criteria. However, the study supported lowering the symptomatic threshold for diagnosing ADHD in adults, with the best symptomatic cut-off in the number of symptoms for predicting impairment being five symptoms of inattention and four symptoms of hyperactivity-impulsivity.”
Based on these criteria, three types of ADHD are identified:
- ADHD combined type: If both criteria 1A and 1B are met for the past six months
- ADHD predominantly inattentive type: If criterion 1A is met, but criterion 1B is not met for the past six months
- ADHD predominantly hyperactive-impulsive type: If criterion 1B is met, but criterion 1A is not met for the past six months.
Further distinctions are made with regard to severity:
- Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
- Moderate: Symptoms or functional impairment between ‘mild’ and ‘severe’ are present.
- Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe are present, or the symptoms result in marked impairment in social or occupational functioning.
“ADHD is a clinical diagnosis, which should only be made by a specialist psychiatrist, paediatrician or other healthcare professionals with training and expertise in the diagnosis of ADHD,” states Schoeman.
“Adults with suspected ADHD whom have previously been diagnosed with ADHD during childhood with symptoms suggestive to on-going ADHD can consult general adult psychiatric service for confirmation of diagnosis and on-going treatment.”
It is important to consider the history of presenting complaints, but also to use (semi-) structured interviews, rating scales, school- or work-related assessments, social functioning assessments and collateral information in the diagnosis of the disorder.
The guidelines endorses the following rating scales for screening adult ADHD:
- The World Health Organisation Adult ADHD Self-Report Scale (ASRS) Symptom Checklist
- The Barkley adult ADHD rating scale
- The Brown ADD Scale Diagnostic Form (BADDS)
- The ADHD Rating Scale
- The Conner’s Adult ADHD Rating Scale (CAARS) (DSM–IV)
- The Wender Utah Rating Scale (WURS)
- The Wender-Reimherr Adult Attention Deficit Disorder Scale.
“The clinical interview is one of the cornerstones of the assessment process in diagnosing adult ADHD. Although various standardised, structured interviews and rating scales are available, these cannot replace the clinical assessment, but can add some rigor, standardisation and a quantifiable dimension to the areas being evaluated,” the authors explained.
For the main diagnostic assessment, the use of the following structured diagnostic interviews may be considered:
- The Brown Adult ADHD Diagnostic Interview
- The Conners Adults ADHD Diagnostic Interview for DSM-IV (CAADID)
- The Diagnostic Interview for ADHD in adults (DIVA).
A systematic interview is needed; the symptoms need to be presented, as well as the functionality across all spheres of the patient’s life.
“The Barkley Functional Impairment Scale for adults and the Weiss Functional Impairment Rating Scales (WFIRS) are useful measures to assess the impact of symptoms on clinically relevant domains of functioning,” said the authors.
According to the WHO, mental health is ‘a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’.
“The initial goal of any intervention is therefore symptoms relief, followed by on-going alleviation of symptoms accompanied by decreasing functional impairment and working towards optimal functioning” said Schoeman.
General aspects of treatment
As highlighted by the British Association for Psychopharmacology (BAP) guidelines, Maudsley guidelines and Schoeman, a comprehensive assessment and diagnostic certainty prior to initiating pharmacological treatment is crucial and treatment should be initiated at specialist level.
“Pharmacotherapy remains the cornerstone of treatment. Contrary to the treatment of ADHD in children, pharmacological interventions are always first line in adults – based on the lack of efficacy of non-drug intervention in the absence of medical treatment.
“Drug treatment should be continued as long as clinically effective and should be reviewed at least annually. Effects of missed doses, planned dose reductions and periods of non-treatment should also be evaluated.
Although pharmacotherapy plays a primary role in the treatment of ADHD, psychosocial interventions are also important as an essential part of the management approach for adult ADHD.
A multi-modal approach is also encapsulated in international guidelines (e.g. BAP and National Institute for Health and Care Excellence (NICE)), which recommend psychosocial treatments as complementary to psychopharmacological interventions.
“The first evidence for the effectiveness of stimulants in the treatment of ADHD dates back to 1937, when Bradley conducted a trial with Benzedrine in children with ADHD.
The first double-blind placebo controlled trial in ADHD examining the efficacy of Dexedrine was done in 1967.
Subsequently, many studies have been conducted and established the efficacy of both stimulant- and non-stimulant medications in the treatment of ADHD in children and adolescents, and more recently also in adults. “Consistent with the catecholamine hypotheses of ADHD, the drugs that effectively treat the disorder are known to modulate catecholamine pathways,” said the authors.
Medications used in the treatment of ADHD include:
- Psychostimulants [e.g. methylphenidate (MPH) and amphetamines]
- Non-stimulants [e.g. atomoxetine, alpha2-adrenoceptor agonists (clonidine and guanfacine)
- Tricyclic antidepressants (TCAs)
- Bupropion, modafinil and venlafaxine.
“Enhancement of dopaminergic and noradrenergic neurotransmission in the prefrontal cortex is probable critical to the therapeutic efficacy of ADHD medication,”
The authors stress that many drugs that are mentioned in international guidelines as third-line options for the treatment of adult ADHD, are used off-label in SA.
“Although other drugs such as clonidine, guanfacine, TCAs, modafanil and venlafaxine are mentioned, none of these are registered and use will be off-label – at the discretion of the treating physician.”
According to Schoeman et al, “Although pharmacotherapy plays a primary role in the treatment of ADHD, psychosocial interventions [psycho-education, cognitive behavioural therapy (CBT), supportive coaching or assistance with daily activities] are an integral part of management. Discussions on clinical efficacy are limited by the lack of head-to-head studies with adequate and unbiased methodology. In general, dopaminergic and noradrenergic agents can reduce the core symptomatology, though specific effects and side effects may vary between agents. Treatment choice would, therefore, also depend on factors such as:
- Patient preference and comorbid conditions
- Abuse potential
- Side effect profile
- Toxicity in overdose.”
Schoeman R, Liebenberg R. The South African Society of Psychiatrists/Psychiatry
Management Group management guidelines for adult attention-deficit/ hyperactivity disorder. S Afr J Psychiat. 2017;23(0), a1060. https://doi.org/10.4102/ sajpsychiatry.v23i0.1060