At the congress of the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Munich, ADHD was also a topic. To what extent are the guidelines accepted by physicians and implemented in practice? And what does care look like in adults and in preschool-aged children? Seemingly, patients must overcome various hurdles as they transition from childhood to adulthood, which can lead to gaps in care and problems in their social and professional lives.
To what extent are guidelines on attention deficit hyperactivity disorder (ADHD) actually considered in the care of children and adolescents? This question was addressed by a study presented at the congress. The hypothesis was that not only knowledge of such guidelines on the part of providers, but also attitudes toward them and the practicality of the guidelines play a central role in their implementation in everyday practice. These components were collected from a total of 1381 individual providers and 351 group providers (e.g., social pediatric centers or child and adolescent psychiatric outpatient clinics) nationwide in Germany via interviews conducted either by telephone or online. The response totaled 275 medical representatives. Of these, pediatric and adolescent medicine specialists formed the largest group at 37%, followed by child/adolescent psychiatrists (28%) and psychotherapists (25%). According to the physicians, the patients were mainly primary school students, and less frequently adolescents or preschool children.
A descriptive review of the data showed that diagnostic standards (e.g., exploration of symptomatology, comorbid symptoms, child development, and risk factors in pregnancy) were largely met. However, teacher involvement in the diagnostic process was limited, although all interviewees agreed that talking to the environment was key. In terms of treatment, psychotherapy was the method of first choice, pharmacotherapy less frequently, and, surprisingly, the combination of both methods was also rare. In general, the guidelines are widely accepted. Over 80% of respondents felt that experience alone was not enough and that guidelines were therefore needed. Only financial and time constraints or limitations in cooperation with other providers are barriers to implementation.
What happens after the 18th birthday?
The “Cologne Adaptive Multimodal Therapy Study” (KAMT) investigated the long-term effects of multimodal ADHD treatment. Originally, 75 children diagnosed with hyperkinetic disorder aged six to ten years were treated in an initial intensive phase lasting a maximum of six months with initial psychoeducation followed by either behavioral therapy (THOP) or counseling plus medication (psychostimulants). Depending on the success of the therapy, the treatments were continued alone or in combination in subsequent phases. A short-term analysis after completion of the intensive phase had shown good efficacy of both behavioral and combination treatment (medication plus behavioral therapy/psychoeducation). During follow-up, multimodal approaches were continued on an individual basis as needed. After eight years, the researchers recorded a stabilization of the results, which was due to the long-term treatment.
17.5 years later, it was now possible to evaluate data from 70 of the former patients, who were now young adults between the ages of 22 and 32. During the follow-up, the focus was, among other things, on career development (collected via interview), current ADHD symptoms (collected via questionnaires), comorbid symptoms, and life satisfaction (FLZ questionnaire).
Although the proportion of very problematic courses was low, just under a quarter (23%) of patients still fully met criteria for ADHD in young adulthood, mostly of the inattentive type. 59% were in partial remission (predominantly mixed type). 23.4% showed comorbid internalizing, 17% externalizing disorders. 8% of former patients did not have a high school diploma, which is not unusual compared to the general population. However, the proportion of secondary school dropouts, 45%, and the proportion of those without completed vocational training, 17%, were significantly higher in the ADHD population. This could actually be effects of ADHD. More often than their peers, 60% of the time, ADHD patients took manual jobs. The unemployment rate was in the normal range.
18% still needed psychotherapeutic or psychiatric support as adults, not least for psychosis and drug withdrawal. Substance abuse was higher than in the general population. 16.7% were taking psychotropic drugs, mostly neuroleptics and antiepileptics.
ADHD in adulthood
Another symposium was also devoted to ADHD in adulthood. Finally, according to the authors of the KAMT, more than one-third of former ADHD patients continue to need therapy. A 2012 survey of insured patients showed that after the 18th birthday, drug treatment was stopped in about 49% of patients. Approximately 20% of the 623 young adults (18-21 years of age) who had been in treatment (including stimulants) as children or adolescents reported difficulty obtaining further treatment after age 18. Only 12% were referred by their physician for further care. Psychotherapeutic measures were also continued only to a small extent, making this group of patients a highly burdened population that encounters gaps in care and has difficulty accessing the intensive therapeutic and medical services it actually needs.
From the (self-completed) questionnaires of the Insured Health Monitor, it can be inferred that 37% of the persons continue to have strong to very strong ADHD-typical problems. 34% consult their doctor or therapist at least once a year because of this, but the majority of patients with severe symptoms do not see a doctor.
One solution to facilitate the transition and change of care systems during the transition to adulthood is a specific consultation hour for young adults (18-25 years), in which the pediatric and adolescent clinic and the adult clinic for psychiatry and psychotherapy work together and jointly create therapeutic concepts. The life and professional situation of young adults are given special consideration. Such a pilot project is running with some success at the University Hospital of Cologne. Hyperkinetic disorders account for the largest proportion of treated conditions at approximately 50%.
Diagnostics and therapy in preschool age
At preschool age, ADHD symptoms are more difficult to distinguish from age-typical behavior, yet in Germany approximately 2.4% of boys and 0.6% of girls aged three to five years meet the diagnostic criteria for simple activity and attention disorder (ICD10 F90.0). Problems such as developmental delays, motor deficits, low frustration tolerance, frequent rule-breaking, risk-taking, and reduced stamina, as well as difficulty establishing stable relationships, may increase from the time the child stands on his or her own two feet.
It is now known that ADHD begins before the age of seven. In addition, comorbid problems are also often already present. Since the child’s behavior varies greatly and depends on the particular situation, diagnosis is not easy – but early diagnosis is central, especially for the prevention of secondary problems, to reduce the pressure of suffering and to protect development. However, one in two children who meet the criteria for simple attention deficit disorder in preschool no longer meet the ADHD diagnostic criteria by elementary school.
Psychoeducation and counseling can be considered as a treatment option at any age, as well as training for parents and educators, e.g. the Prevention Program for Expansive Problem Behavior (PEP). Pharmacotherapy is indicated only after the age of six years. Self-management methods do not yet work at this stage of development.
Source: DGKJP Congress, March 4-7, 2015, Munich, Germany
InFo NEUROLOGY & PSYCHIATRY 2015; 13(4): 16-17.
