"...Since the recognition of ADHD in children was rare before the mid-1990's, there is a large population of people who went undiagnosed and untreated in childhood and present for the first time as adults."
National Institute for Health and Clinical Excellence (NICE): March 2009
ADHD consists of poor attention and concentration, impulsiveness, and bodily restlessness or hyperactivity. However, there is much variation between individuals, both in childhood and adulthood. Many adults and children do not have the hyperactivity which can make ADHD more obvious (hence "ADD" or "the inattentive subtype" rather than "ADHD").
NICE has now confirmed what developmental disorder specialists have believed for many years: "we would expect to find 0.6 - 1.2% of adults retaining the full diagnosis by age 25 years and a larger percentage (2 - 4%) with ADHD in partial remission." (NICE uses "ADHD" to refer to both ADD and ADHD, while I often prefer "ADD / ADHD", as above).
How Specialist Assessment Can Help
My assessment looks for features of ADD / ADHD in the context of past and present problems with academic study, employment and relationships. Some features of ADD / ADHD can be positive: I also aim to identify and understand these. A fuller picture might only emerge after more than one consultation.
Once the diagnosis is made, possible treatments are discussed. NICE have recommended wider use of medication in ADHD, as well as the development of other approaches, especially cognitive-behavioural psychotherapy. In my view the NICE guidelines are very good in many areas: for example, they stress the importance of specialist supervision of medication, which is largely unlicensed in the United Kingdom. However, I think the guidelines encourage the view that medication in adults is very well-established, when the evidence for effectiveness and safety in adults, although encouraging, comes from a relatively limited clinical and research base (see the summary, on the "News and Links" page, of my recent presentation on the NICE guidelines, at the 2009 ADDISS national conference: this topic is still under active discussion).
My own guidelines for treatment in adults are:
Severe ADD / ADHD: medication is usually the initial treatment, often enabling and enhancing other approaches later
Moderate ADD / ADHD: consider non-medication-based approaches, but medication is often a reasonable first option
Mild ADD / ADHD: a non-medication-based approach might be recommended first. Patients have often tried a form of psychotherapy in the past, in which case medication could be a reasonable option
I have links with several independent psychotherapists who have interests in the area of ADD / ADHD, some of whom are also based at 17 Wimpole Street. Problems which can be addressed in this way vary widely, from the well-known consequences arising out of poor impulse control and hyperactivity, which include substance misuse, eating disorders, and other addictive behaviours, through to all kinds of mood disorders (depression and anxiety) and other mental health disorders, as well as more subtle issues of personal identity and functioning.
It is important that any therapy or medication does not undermine personal strengths, so I encourage patients to take an active role in choosing and monitoring any interventions.
I am able to prescribe all the specific ADD / ADHD medications, including the long-acting stimulants which are recommended by NICE. At 17 Wimpole Street we have experience of prescribing the preparations, such as Adderall XR, which are not in the UK formulary. Of current interest is atomoxetine, which has been used widely for adult ADD / ADHD in the United States, but less in the UK. Atomoxetine is not a stimulant, and not a controlled drug, so there appear to be no concerns about misuse.
When ADD / ADHD medications are started for the first time, I now usually recommend face-to-face reviews at two and ten weeks, with two email feedbacks before the first review, and four further email feedbacks before the second review.
Fees for initiation and monitoring of ADD / ADHD medication are outlined on the Terms and Fees page.
