Referral groups

There are three distinctive groups of referrals:

  • Graduates from child services. In the ADHD pathway only the severe and/or complicated cases will be seen by the Mental Health Services, most of children will be discharged from Children Mental Health Services and Community Paediatrics directly to their GP to continue effective treatment.
  • False graduates. Young adults who have stopped their treatment shortly after they were discharged from the child services and are experiencing difficulties and are willing to re- initiate a previous effective treatment. This group should be screened to clarify if their current difficulties are actually ADHD –related. It is vital to review former medical files to identify evidence supporting their claims, being previously diagnosed and receiving effective treatment - for instance some adults remember to be seeing a specialist when they were younger but they may be have a different diagnosis: Oppositional Defiant Disorder/ Conduct Disorder or (ODD/ CD), Specific Learning disorders such Dyslexia, Dyspraxia, Autism Spectrum Disorder.
  • New patients. The most heterogeneous and numerous group, age range from 16 to 80, there is a predominance of males (although the adult gender ratio is 1:1), most of them approach their GP after learning about the condition from radio/ TV program, newspaper articles, or having an acquaintance or relative recently diagnosed etc. Many have already done some reading online and may attend with a completed A-ADHD scale (downloaded from the net). Only half of this group will meet the diagnostic criteria. Ideally PMHS workers will identify the other half during the screening process, it is likely this half will present with long standing issues such recurrent depression, bipolar disorder,  personality disorders, Asperger’s and substance misuse.
Screening Process

It is vital to obtain collateral information from other sources. Ideally this will be a relative who has known the patient for a long time and can provide information about symptoms present during childhood (a fundamental feature of A-ADHD). A parent would be the best source but obviously this is not always possible for adult patients.

ADHD symptoms are dimensional not categorical and they need to put into context, e.g. fidgeting in a boring lecture maybe normal, everybody has lost something, mood swings are part of a normal human experience. Always enquire (and document in detail) how severe and how often the symptoms are troubling the patient or people around them, request specific examples.

 

Three essential criteria must be satisfied for diagnosis (taken from DSM IV, please see appendix 1 for further advice):

  • Symptoms must have been present before the age of 7 years i.e. not new problems starting during in adulthood (except in the case of a recent, severe brain injury i.e., traumatism, infection).
  • Be present in more than two or more settings (e.g. at leisure or work or at home) the use of stimulant in order to achieve professional goals is called cognitive enhancement.
  • There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. It is not enough to just report the symptoms; the patient should also explain the associated impairment(s).
Advice regarding co-morbid conditions

Advice regarding to co-morbid conditions:

  • Undiagnosed and untreated A-ADHD has a great likelihood of co-morbidity with other mental health difficulties (up to 70 %).
  • The most frequent are depression, anxiety, Asperger’s, bipolar and personality disorder (usually antisocial and emotionally unstable type and substance misuse).
  • North America is opting for multiple diagnoses whilst Europe/ UK is more conservatory, multiple diagnosis are exceptional cases.
  • Always prioritise the treatment of any co-morbid condition: since they also can mimic ADHD symptoms, treatment may clarify diagnostic doubt.
  • Positive response to stimulant medication is not a diagnostic test.
  • Stimulant medication can make co-morbid condition worse.
Differential Diagnosis
  • Co-morbid conditions can also be differential diagnosis. Please see appendix 3 for specific further advice for bipolar and emotional unstable personality disorder.
  • An anger issue in absence of other elements, inattention and hyperactivity, should not require a further assessment for ADHD.
  • Instrumental and planned violence is strong indicator of different psychopathology.
  • Typical ADHD patients may experience temper outburst usually provoked by frustration and extremely rare directed to people, the incident is very short-lived and usually followed by a feeling of embarrassment and apology. The absence of remorse may lead to explore different pathologies: autism, psychopathic disorder.
  • If a patient uses the word “respect” when he/ she explains a recent violent incident it may be an indicator of antisocial or even psychopathic personality.
  • The only forensic element has some evidence linked to ADHD is “false confession syndrome”, ADHD detainee may confess in order to leave the police cells as result of impulsive traits and poor tolerance to low stimulating environment.
  • This group may be seen by children services because ODD/CD diagnosis.
  • Patients with past and/ or current substance misuse disorder (SUD)
  • Chronic use of illicit substance will impair concentration and attentio
  • There is a current trend to assume there is a big number of undiagnosed UD patients with an underlying A-ADHD, it is been said that half of the attendees in SUD clinics
  • There is a consensus between different guidelines, treat SUD first and to re-evaluate ADHD after a period of abstinence, at least 6 months, only a minority of the initially suspected ADHD will met the formal diagnosis. NICE does not recommend the use of stimulant in this population
  • Some argue that without appropriate ADHD treatment some patients will never achieve abstinence hence the need to add ADHD treatment during the recovery period. At this stage evidence is sparse supporting that action and guidelines still recommend always treating the co- morbid condition firs
  • For the screening purposes, there is not any evidence supporting some patient’s claims that they may have self- medicated with illicit stimulants; this hypothesis is not supported by Pharmacodynamic laws. Interestingly there is one substance has been showed some strong links with ADHD, nicotine.

 

All the above is advice rather than absolute truths. Some patients’ presentations will not fit easily in any description so caution must be taken in order to avoid over and under-diagnoses.

Expand all