The Natural Course and Treatment of ADHD, and Its Place in Adulthood

The care of children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD) has repeatedly been the subject of criticism, guidelines, and key issues papers (1). These agree that further research is urgently needed into the causes of ADHD, ADHD progression, and the effects of prevention and of pharmaco- and psychotherapy, both in children and adolescents and in adults. The article by Banaschewski et al. in this issue of Deutsches Ärzteblatt International (2) provides an overview of the current knowledge concerning the pathophysiology, diagnosis, and treatment of ADHD. It is clear that there will be no litmus test for ADHD in the near future. It must therefore still be assumed that its causes are multifactorial, and that diagnosis must be comprehensive and painstaking. This fact must be highlighted again and again.

Persistence into adulthood

Although ADHD remains an illness of childhood and adolescence, it is no longer assumed that all patients “outgrow” it. It remains unclear what percentage of sufferers have symptoms persisting into adulthood and who is at particular risk of this. In contrast, it is clear that care for adults with ADHD is insufficient (3). A particular weak point is care during the transition from adolescence to adulthood. A recent position paper by psychiatric bodies indicates the high demand and great need for development in transition psychiatry (4).

In this context, the publications by Banaschewski et al. (2) and Bachmann et al. (5) address an important subject, and one that leads to a number of further questions. The critical debate by Francis (6) concerning the classification criteria for psychological disorders was not the first time the subject of ADHD overdiagnosis aroused the interest of the public. The issue had been raised in view of clear increases in prevalence rates and increased use of psychopharmacotherapy. In contrast, in a statement by the European Network Adult ADHD, Kooij et al. (7) indicate that they believe that prevalence among adults is underestimated, although in their view symptoms persist and lead to considerable burdens and limitations in social life more frequently. It is claimed that there are now well evaluated screening and diagnosis procedures, and thus Banaschewski et al. (2) also believe that care provision must be comprehensive, evidence-based, and suited to patients’ needs.

The empirical data

It is apparent that epidemiological studies have found no increase in prevalence in recent decades, despite improved diagnostic methods and recording tools (8, 9). In contrast, in the last 25 years there has been an increase in numbers of patients diagnosed with and treated for ADHD, as shown in a number of studies based on health insurers’ data (9). The authors conclude from this that efforts to close the gap between the number of people requiring ADHD treatment and those actually treated have clearly been more successful. Accordingly, Bachmann et al. (5) argue that the frequency of ADHD diagnosis in adults is lower than the prevalence recorded in epidemiological studies, “which indicates that a significant proportion of cases remain undiagnosed and highlights the need for further expansion of care for adult ADHD patients.”

The question therefore arises as to how many affected individuals continue to require psychopharmacotherapy and/or psychotherapy treatment in adulthood due to the severity of their symptoms. A second step should therefore clarify which individual therapeutic interventions are promising and necessary on the basis of evidence-based treatment programs, i.e. how an optimum treatment algorithm can be found (7).

However, reliable empirical data for this is still lacking, so the conclusion that care provision levels are too low is tentative. In addition, in adulthood there are multiple comorbidities that must be taken into account in the treatment plan.

The question remains as to how many patients in an epidemiological sample of ADHD patients actually require treatment, and what the differential treatment indications are. In this regard, one reason for the frequency of diagnosed ADHD being lower than the prevalence reported in epidemiological studies may be that not all affected individuals require treatment in the narrower sense; in particular, pharmacotherapy is sometimes unnecessary even when the criteria for ADHD diagnosis are met.

A burden persisting into adulthood

The findings of a study by the current authors on the care of ADHD patients during the transition from adolescence to adulthood also indicate this (10): more than one-third of those surveyed felt that they continued to suffer from symptoms and psychological problems typical of ADHD and requiring further specialized treatment. To what extent the other affected individuals continued to meet the diagnostic criteria for ADHD must remain an open question, as must the issue of whether this group continued to require treatment.

Nevertheless, this preliminary data shows that further research is needed to clarify both the necessity and time of transition and the need for further treatment.

Improving transition

As the findings of our investigation also showed, it certainly cannot be taken as given that those who are still substantially burdened as young adults receive treatment or are able to benefit from treatment that is available. This highlights once again the fact that in the future the psychiatric support system must be better oriented toward the particular needs of the transition from adolescence to adulthood and the problems associated with the prolongation of adolescence into individuals’ twenties (3).

Changes in frequency of diagnosis in adults and the prevalence of stimulant treatment should be further observed and critically discussed by specialists.