ADHD in general practice

This section covers:

• recognition
• prevalence
• ADHD in women and girls
• the neurodivergent spectrum
• comorbidities

Recognition

ADHD is a lifelong condition that typically originates in childhood (The Quality of Life of Adults with Attention Deficit Hyperactivity Disorder: A Systematic Review). Untreated ADHD severely disrupts daily life, hindering focus, organisation, and impulse control. Individuals struggle with chronic disorganisation, missed deadlines and impaired productivity. Relationships strain due to inattention and impulsive reactions. 

GPs play a crucial role in recognising ADHD for several reasons:

• Early identification and intervention. Timely recognition of ADHD by GPs allows for early intervention and appropriate management. Early identification enables individuals to access necessary support and treatment, potentially improving outcomes in academic, social, and occupational domains.
• Improved quality of life. Recognising ADHD allows for the development of personalised treatment plans that can significantly improve an individual's quality of life. Effective management can help in addressing symptoms and associated challenges, enhancing overall well-being and daily functioning.
• Preventing misdiagnosis or delayed diagnosis. ADHD can often be mistaken for other conditions due to overlapping symptoms, such as anxiety, depression, or learning disabilities. GPs with proper training and awareness are equipped to differentiate ADHD from other disorders, ensuring better diagnosis and appropriate treatment.
• Educating patients and families. GPs can play a pivotal role in educating patients and their families about ADHD, its characteristics, and available treatment options. Educated families are more likely to understand and support the individual with ADHD, contributing to a conducive environment for treatment and progress.
• Addressing comorbidities. ADHD often coexists with other conditions, such as depression, anxiety, or substance abuse. Recognising ADHD allows GPs to identify and manage these comorbidities effectively, addressing the complete spectrum of an individual's mental health.
• Promoting public awareness. GPs, being primary healthcare providers, can contribute to raising awareness about ADHD within the community. This awareness can reduce stigma and encourage individuals experiencing symptoms to seek help, ultimately benefitting the overall mental health of the population.
• Optimising healthcare resources. Proper recognition of ADHD by GPs helps in optimising healthcare resources by directing appropriate referrals, reducing unnecessary investigations, and ensuring efficient use of mental health services.

Prevalence

According to the National Institute for Health and Care Excellence (NICE)'s 2018 ADHD diagnosis and management (external PDF), the prevalence of ADHD in school-aged children in the UK is estimated to be between 2% and 5%. It is estimated that between 3% and 4% of adults in the UK have ADHD, with a male-to-female ratio of approximately 3:1.

The frequency of GPs encountering patients with ADHD can vary based on several factors, including geographical location, population demographics, awareness of ADHD, referral patterns, and overall healthcare infrastructure. GPs, as gatekeepers to secondary care, are currently referring most patients with possible ADHD to specialist services. Patients themselves are accessing private providers, either directly or via GPs to commissioned providers. 

However, ADHD is a common neurodevelopmental disorder, and GPs are likely to encounter patients with suspected or diagnosed ADHD regularly in their practice. Factors that may raise suspicion of ADHD in a patient during a GP encounter include:

• Observable symptoms like inattention, hyperactivity, impulsivity, restlessness, difficulty focusing, and organisational challenges, especially if these symptoms have been persistent and pervasive since childhood.
• Behavioural observations like fidgeting, difficulty staying seated, excessive talking, or impulsive actions during the consultation, suggesting hyperactivity and impulsivity.
• Patient or parental reports of concerns regarding difficulties in daily functioning, academic or occupational challenges, or issues in personal relationships.
• Educational or occupational issues such as academic or occupational underachievement, frequent job changes, or difficulties in job performance due to inattention, impulsivity, or hyperactivity.
• A history of ADHD or related conditions in the patient's family, which may increase the likelihood of an ADHD diagnosis.
• Co-existing conditions such as anxiety, depression, learning disabilities, or conduct disorders, which often accompany ADHD and may complicate the clinical picture.
• Evidence of significant functional impairment across multiple settings, such as home, school, work, and social situations.
• Emotional regulation challenges persist, causing additional stress. 

Overall, untreated ADHD significantly impedes functioning across personal, academic, and professional spheres, adversely affecting the quality of life. This emphasises the importance of comprehensive and timely intervention strategies.

ADHD in women and girls

ADHD is thought to be under-recognised in girls and women (Females with ADHD: An expert consensus statement). They are therefore less likely to be referred for assessment for ADHD by their GP. They may be more likely to have undiagnosed ADHD and to receive an incorrect diagnosis of another mental health or neurodevelopmental condition. 

Research indicates that girls with ADHD may display internalised symptoms, making it less evident compared to the more overt externalised symptoms often seen in boys (The female side of pharmacotherapy for ADHD – A systematic literature review). This discrepancy in symptom manifestation can result in inadequate support and intervention. Understanding these gender-specific nuances is crucial for accurate identification and appropriate management of ADHD by the GP, especially in populations where it may be under-recognised.

Neurodivergent spectrum

ADHD falls within the neurodiversity spectrum, which includes Autism, Developmental Language Disorder, Developmental Coordination Disorder, Specific Learning Disorders (dyslexia, dyscalculia), and Tourette's syndrome. Co-occurrence within this spectrum is common. Hence, encountering one neurodivergent condition should prompt consideration of possible comorbidity (see below) with others. This awareness and nuanced understanding are essential during the evaluation and diagnosis process.

A significant proportion of the general population identify as neurodivergent (with estimates of up to 20%), constituting a notable proportion of patients seen in general practice. Those with ADHD can often strain primary care resources due to issues like missed appointments, medication adherence challenges, and less effective consultations. ADHD is highly treatable, and proactive, targeted interventions can significantly mitigate these resource strains and enhance patient outcomes.

Comorbidity

ADHD often co-exists with other psychiatric conditions regularly managed within primary care; a phenomenon known as comorbidity. Common comorbidities include anxiety, depression, substance misuse, and addiction, although ADHD is not a diagnosis of exclusion. 66% of adults diagnosed with ADHD have an existing comorbidity, predominantly substance use disorders (32.9%), anxiety disorders (23%) and mood disorders (18.1%) (Pineiro-Dieguez B et al. Psychiatric comorbidity at the time of diagnosis in adults with ADHD: the CAT study. J Atten Disord 2016; 20: 1066-1075). 

Accurate assessment and a thorough evaluation should consider comorbidities, allowing an accurate diagnosis and effective management of ADHD as well as the comorbidities. It is worth noting that secondary care is rarely commissioned to do this.

The extended role of a GPwER ADHD involves an enhanced and specialised approach to the recognition, assessment, diagnosis, treatment, and ongoing care of individuals with ADHD. This expanded role enables GPs to provide more comprehensive and tailored support to individuals with ADHD and their families by various means.

The GPwER ADHD undertakes training focused on ADHD, including updated diagnostic criteria, treatment modalities, and best practices in managing ADHD across the lifespan. They conduct thorough assessments for ADHD, using standardised tools and evaluations to accurately diagnose ADHD and identify any comorbid conditions.

This role falls within the guidelines set out by the National Institute for Health and Care Excellence, which state that “a diagnosis of ADHD should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD, on the basis of:

• a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person's everyday life, and
• a full developmental and psychiatric history, and
• observer reports and assessment of the person's mental state."

The GPwER ADHD is familiar with the administration of the relevant diagnostic classification systems for ADHD as follows.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR.). American Psychiatric Publishing.)

Published by the American Psychiatric Association, this outlines the criteria for diagnosing ADHD based on symptoms categorised into two main types: inattention and/or hyperactivity/impulsivity. The DSM-5 provides specific criteria for diagnosing ADHD in children, adolescents, and adults and defines ADHD as:

• A persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development, as characterised by inattention and/or hyperactivity/impulsivity. For children and adolescents at least six symptoms will have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic or occupational activities. 
• For adults (aged 17 years and older) at least five symptoms are required.
• Note: The symptoms should not be solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions.
• Several inattentive or Hyperactive-impulsive symptoms should be present prior to age 12 years.
• Several inattentive or Hyperactive-impulsive symptoms are present in two or more settings for example: at home, school, work, with friends or relatives and in other activities.
• There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
• The symptoms do not occur exclusively during the course of Schizophrenia or another psychotic disorder and are not better explained by another mental disorder (for example: Mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

The International Classification of Diseases (ICD-10 and ICD-11)

is maintained by the World Health Organization (WHO). The ICD-10 includes diagnostic criteria for Hyperkinetic disorder while the updated version, ICD-11, provides criteria and coding for a diagnosis of ADHD. The International Classification of Diseases (ICD-11) defines the following criteria for ADHD.

A persistent pattern (for example, at least 6 months) of inattention symptoms and/or a combination of hyperactivity and impulsivity symptoms that is outside the limits of normal variation expected for age and level of intellectual development. Symptoms vary according to chronological age and disorder severity.

Inattention

Several symptoms of inattention that are persistent, and sufficiently severe that they have a direct negative impact on academic, occupational, or social functioning. Symptoms are typically from the following clusters:

• Difficulty sustaining attention to tasks that do not provide a high level of stimulation or reward or require sustained mental effort; lacking attention to detail; making careless mistakes in school or work assignments; not completing tasks.
• Easily distracted by extraneous stimuli or thoughts not related to the task at hand; often does not seem to listen when spoken to directly; frequently appears to be daydreaming or to have mind elsewhere.
• Loses things; is forgetful in daily activities; has difficulty remembering to complete upcoming daily tasks or activities; difficulty planning, managing, and organising schoolwork, tasks and other activities.
• Note: Inattention may not be evident when the individual is engaged in activities that provide intense stimulation and frequent rewards.

Hyperactivity/impulsivity

Several symptoms of hyperactivity/impulsivity that are persistent, and sufficiently severe that they have a direct negative impact on academic, occupational, or social functioning. These tend to be most evident in structured situations that require behavioural self-control. Symptoms are typically from the following clusters:

• Excessive motor activity: leaves seat when expected to sit still; often runs about; has difficulty sitting still without fidgeting (younger children); feelings of physical restlessness, a sense of discomfort with being quiet or sitting still (adolescents and adults).
• Difficulty engaging in activities quietly; talks too much.
• Blurts out answers in school, comments at work; difficulty waiting turn in conversation, games, or activities; interrupts or intrudes on others’ conversations or games.
• A tendency to act in response to immediate stimuli without deliberation or consideration of risks and consequences (for example, engaging in behaviours with potential for physical injury; impulsive decisions; reckless driving).

Evidence of significant inattention and/or hyperactivity/impulsivity symptoms prior to age 12, though some individuals may first come to clinical attention later in adolescence or as adults, often when demands exceed the individual’s capacity to compensate for limitations.

Manifestations of inattention and/or hyperactivity/impulsivity must be evident across multiple situations or settings (for example, home, school, work, with friends or relatives), but are likely to vary according to the structure and demands of the setting.

Symptoms are not better accounted for by another mental disorder (for example, an Anxiety or Fear-Related Disorder, or a Neurocognitive disorder such as delirium).

Symptoms are not due to the effects of a substance (for example, cocaine) or medication (for example, bronchodilators, thyroid replacement medication) on the central nervous system, including withdrawal effects, and are not caused by a disease of the nervous system.

Work of the GPwER ADHD

The GPwER ADHD:

• gathers comprehensive medical and behavioural histories to better understand the individual's symptoms and challenges.
• develops personalised, evidence-based treatment plans that may include a combination of behavioural interventions, psychoeducation, counselling, and medication management.
• works closely with the individual and their family to tailor the treatment plan to their specific needs, preferences, and circumstances.
• The GPwER ADHD prescribes and manages ADHD medications in collaboration with the individual, monitoring their effectiveness and addressing any side effects.
• The GPwER ADHD adjusts medication based on regular assessments of the individual's response and progress.
• The GPwER ADHD provides behavioural strategies and lifestyle recommendations to manage ADHD symptoms effectively, including advice on organisation, time management, sleep hygiene, and the benefits of exercise.
• The GPwER ADHD collaborates with other mental health professionals to support behavioural interventions, cognitive-behavioural therapy, or coaching to address ADHD-related challenges.
• The GPwER ADHD facilitates communication and collaboration among the various professionals involved in the individual's care.
• The GPwER ADHD acts as a central coordinator of care, liaising with specialists such as psychologists, psychiatrists, occupational therapists and educators to ensure a holistic approach to ADHD management.
• The GPwER ADHD conducts regular follow-up appointments to assess the individual's progress, make adjustments to the treatment plan as needed, and address any concerns or questions.
• monitors the impact of ADHD on academic, occupational, and social functioning, providing guidance to enhance overall wellbeing and performance.

In summary, the GPwER ADHD plays a crucial role in providing timely and tailored interventions to mitigate the adverse functional effects of ADHD on multiple life domains, including education, work, relationships, and overall wellbeing. The role can vary, encompassing tasks ranging from screening to prescribing and monitoring treatments, as well as conducting assessments and diagnoses for ADHD. 

Describing the comprehensive scope of the GPwER ADHD enables practitioners to concentrate their experience and further training on specific relevant aspects, ensuring they operate within their realm of knowledge and expertise. This role aims to improve overall healthcare outcomes for patients by promoting early identification and intervention.