Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults,Considérations pratiques pour l’évaluation et la prise en charge du trouble déficit de l’attention/hyperactivité (TDAH) chez l’adulte
L'Encéphale. 2019-10-01; :
DOI: 10.1016/j.encep.2019.06.005
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Weibel S(1), Menard O(2), Ionita A(3), Boumendjel M(4), Cabelguen C(5), Kraemer C(6), Micoulaud-Franchi JA(7), Bioulac S(7), Perroud N(8), Sauvaget A(9), Carton L(10), Gachet M(11), Lopez R(12).
Author information:
(1)Service de psychiatrie 2, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; Inserm U1114, Strasbourg, France; Fédération de Médecine
Translationnelle de Strasbourg (FMTS), 67000 Strasbourg, France. Electronic address: .
(2)Service d’addictologie, Hôpital Fontan 2, CHRU de Lille, 59000 Lille, France.
(3)Clinique du château, Nightingale hospitals Paris, 92380 Garches, France.
(4)Équipe de liaison et de soins en addictologie (ELSA), service de psychiatrie et d’addictologie, centre de soin de prévention et d’accompagnement en
addictologie (CSAPA), Hôpital André Mignot, 78000 Versailles, France.
(5)Unité de neuromodulation et de psychiatrie de liaison, centre ambulatoire
pluridisciplinaire de psychiatrie et d’addictologie, Centre Hospitalier Universitaire de Nantes, 44000 Nantes, France.
(6)Service de psychiatrie 2, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France.
(7)Service d’explorations fonctionnelles du système nerveux, clinique du sommeil, CHU de Bordeaux, 33000 Bordeaux, France; CNRS, SANPSY, USR 3413, SANPSY, Université de Bordeaux, 33000 Bordeaux, France.
(8)Service des spécialités psychiatrique, département de santé mentale et de psychiatrie, Hôpitaux Universitaires de Genève, 1201 Genève, Switzerland.
(9)Addictologie and psychiatrie de liaison, CHU de Nantes, 44000 Nantes, France; Laboratoire “mouvement, interactions, performance” (EA 4334), Faculté Sciences du sport, Université de Nantes, 44000 Nantes, France.
(10)Inserm U1171 “Troubles cognitifs dégénératifs et vasculaires”, Université de Lille, 59000 Lille, France; Département de pharmacologie médicale, CHRU de Lille, 59000 Lille, France.
(11)Service d’urgence et post-urgence psychiatrique, hôpital Lapeyronie, 34000 Montpellier, France.
(12)Consultation spécialisée TDAH adulte, centre national de référence narcolepsie hypersomnies rares, département de neurologie, Hôpital Gui-De-Chauliac, 34000 Montpellier, France; Inserm U1061, 34000 Montpellier, France. Electronic address: .
Attention deficit with or without hyperactivity disorder (ADHD) is one of the
most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast
with many European countries, the identification and management of adult ADHD
remains underdeveloped in France, and a subject of controversy. This review
provides a practical update on current knowledge about ADHD in adults for
French-speaking professionals who have to detect or manage adult patients with
ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of
the international diagnostic classification. While symptoms and impairment due to
ADHD are frequently severe during childhood, they often evolve as children grow
older, with frequent persistent disabilities in adulthood. In adulthood, the
clinical presentation, as in childhood, involves the symptom triad of
inattention, hyperactivity and impulsivity. However, differences are noted:
hyperactivity is more often internalized, symptoms of inattention may be masked
by anxiety symptoms or obsessive-like compensation strategies. ADHD is often
diagnosed during childhood, but it is not rare for the diagnosis to be made
later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively
well-developed compensation factors could be two underlying reasons for the long
delay until diagnosis. Other symptoms, such as emotional deregulation or
executive function-related symptoms are also usually observed in adults. In
addition, in adults, ADHD is often associated with other psychiatric disorders
(in 80% of cases); this makes the diagnosis even more difficult. These disorders
encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety
disorders, and other neurodevelopmental disorders and personality disorders,
especially borderline and antisocial personality disorder. Substance-use
disorders are very common, either as a consequence of impulsivity and emotional
dysregulation or as an attempt at self-treatment. Sleep disorders, especially
restless leg syndrome and hypersomnolence, could share common pathophysiological
mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for
serious functional impairment, in various domains, leading to academic, social,
vocational, and familial consequences. The impact on other psychiatric disorders
as an aggravating factor should also be considered. The considerable disability
and the poorer quality of life among adults with ADHD warrant optimal evaluation
and management. The diagnostic procedure for ADHD among adults should be
systematic. Once the positive diagnosis is made, the evaluation enables
characterisation of the levels of severity and impairment at individual level. A
full examination should also assess medical conditions associated with ADHD, to
provide personalized care. In recent years, a growing number of assessment tools
have been translated and validated in French providing a wide range of structured
interviews and standardized self-report questionnaires for the evaluation of core
and associated ADHD symptoms, comorbidities and functional impairment. The
treatment of ADHD in adults is multimodal, and aims to relieve the symptoms,
limit the burden of the disease, and manage comorbidities. The most relevant and
validated psychological approaches are psycho-education, cognitive-behavioural
therapy and “third wave therapies” with a specific focus on emotional regulation.
Cognitive remediation and neurofeedback are promising strategies still under
evaluation. Medications, especially psychostimulants, are effective for
alleviating ADHD symptoms with a large effect size. Their safety and tolerance
are satisfactory, although their long-term clinical benefit is still under
discussion. In France, methylphenidate is the only stimulant available for the
treatment of ADHD. Unfortunately, there is no authorization for its use among
adults except in continuation after adolescence. Hence the prescription, which is
subject to the regulations on narcotics, is off-label in France. This article
aims to provide practical considerations for the management of ADHD and
associated disorders in adults, in this particular French context.
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