Diagnostic Assessment & Treatment of Adult ADHD

Topics• Neurobiology of ADHD• Prevalence in adults• Clinical picture• Diagnostic assessment• Treatment

ADHD IS NOT OUTGROWN

Neurobiology of ADHD• Highly heritable (80% of variance explained bygenetic factors)• Neurobiological disorder:– brain 5% smaller and less active: dACC, globuspallidus, caudatus, dLPFC, cerebellum– 8 kandidate genes, esp. dopaminergic (DRD2,4,5,DAT1)– Inhibition deficit based on dopamine deficiency– Methylphenidate: dopamine agonist; acts as inhibitorof associations, moodswings, restlessness andimpulsivityThapar 1999; Faraone 2005; Castellanos 2002; Bush 2006Kessler 2006; Kooij 2005

ADHD symptom scores in twin studies:highly heritableBoomsma 2003Martin 2002Kuntsi 2001Coolidge 2000Thapar 2000Willcutt 2000Hudziak 2000Nadder 1998Levy 1997Sherman 1997Silberg 1996Gjone 1996Thapar 1995Schmitz 1995Stevenson 1992Edelbrock 1992Gillis 1992Goodman 1989Matheny 1980Willerman 19730 0.2 0.4 0.6 0.8 1Heritability

Developmental trajectoriesof brainvolumes(Castellanos et al., JAMA,2002)

Anterior Cingulate (Cognitive Division)Fails to Activate in ADHDMGH-NMR Center & Harvard- MIT CITP Bush et al., Biol. Psychiatry, 1999Normal ControlsADHDy = +21 mm1 x 10 -2 y = +21 mm1 x 10 -2-31 x 10 1 x 10-3

The brain in ADHDcompared to controls:Smaller,Less active&Impairedfunctioning

Clinical picture of ADHDLifetime symptoms of Attention-Deficit/Hyperactivity Disorder:• Inattention: distracted, chaotic, forgetful, late, difficultymaking decisions, organising and planning, no sense oftime, procrastination• Hyperactive: (inner) restlessness, tense, talkative, busy;coping by: excessive sporting/alcohol abuse/avoidingmeetings• Impulsive: acting before thinking, impatient, difficultyawaiting turn, jobhopping, binge eating, sensation seekingIn addition in 90% of adults, lifetime:• Moodswings (5x/day) and Anger outburstsAPA 1994; Kooij 2001; Conners 1996

Decrease of hyperactivityHyperactivity is adjusted, compensated for, or experienced as more‘inner restlessness’:• Avoiding meetings where you have to sit stil• Excessive sporting• Hectic job full of change• Cannabis / alcohol / tranquillisers against restlessness• Talkativeness, inner restlessnessThe decrease in marked outward visible hyperactivity has presumably beenthe reason why we mistakenly have thought that ADHD wasoutgrown

Inattention most invalidatingsymptom in adultsAdults need more attention than children:• Procrastination• Chaos• Difficulty organising• Being late• Difficulty reading and remembering• Forgetting things or appointments• Using no watch or agenda!

ADHD in DSM-IV• Attention-deficit/hyperactivity disorder• 18 criteria: 9 attention problems (A) and 9hyperactive/impulsive criteria (HI)• Diagnosis in childhood from 6/9 of one or bothdomains3 subtypes:• ADHD, inattentive type (also ADD) (10-15%)• ADHD, hyperactive/impulsive type (3%)• ADHD, combined type (85%)

Impairment in adult ADHDIn clinical as well as epidemiological samples compared to NCs:• Learning problems (60%)• Less graduated• Lower education• Lower income• Less employed, more sickness leave• More job changes (longest job 5 yrs)• More often arrested, divorced and more social problems• More driving accidents, teenage pregnancies, suicideattempts• Higher (mental) health care costsBiederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, in prep 2008

ADHD and preferred jobs• Nightshifts or irregular work (most adults with ADHD areeveningtypes)• Work outside, with animals, in (top)sports• On the road/ lot of variation (sales)• Try to avoid administrative tasks, unless with support oforganiser/secretary (topmanagers)• Short deadlines and external structure are helpful (journalists,musicians, stand-up comedians)• Long term projects are boring and won’t be finished(administrative, routine work)• 40% has only shorttime jobs and changes every few yearsKooij 2003

Which limitations at work?• Concentration problems, easily distracted, chaotic• Being late• Unstructured• Difficulty organising/ administrating/ overview over time• Underachievement in education and work (lower level,less productive, less days working, less promotion)• Being fired or quitting jobs• Social problems by not paying attention, not listening• Conflicts by impulsive blurting out, oppositionalbehaviour towards authorities, irritability

ADHD and drivingADHD is a danger on the road!• Adolescents with ADHD compared tonormal controls:– 5x more accidents– More speeding fines– More driving licenses suspended• Connection to ADHD symptoms:– No overview, distracted by every billboard– Sensation seeking: quickly and risky overtaking– Dare devils: speed generates arousal– Impatient– No anticipation, impulsive responseCox 2000; Barkley 1993, 1996

Comorbidity in adults with ADHDADHD comes seldom alone:• 75% at least one other disorder• 33% two or moreMean: 3 comorbid disordersBiederman 1993; Kooij 2001, 2004

Comorbidity in ADHD?• Depression (60% SAD) 20-55%• Bipolar Disorder (88% BP II) 10%• Anxiety Disorders 20-30%• SUD 25-45%• Smoking 40%• Cluster B Pers. Disorders 6-25%• Sleeping Problems (DSPS?) 75%• Muscle, joint, neck- and backpain ??Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij2001, 2004; van Veen 2010; Amons 2006

The other way round: ADHD is comorbidin 20% of psychiatric patients• SUD:• Anxiety disorders:• Bipolar II:• Borderline PD:20% (Trimbos Institute)20% (PsyQ)20% (PsyQ)35% (Radboud University)And in accordance to epidemiological data USA: 20%vd Glind 2005; Rops 2010 in prep; Roodbergen 2010 in prep;Fones 2004; van Dijk 2010 in prep; Kessler APA 2007; Fayyad2007

12 month comorbidity with ADHDin adults, epidemiological study USAOR% ADHD % comorbid Din comorbid D in ADHD_____________________________________________Mood Ds 3.8* 20.4 31.7Anxiety Ds 3.8* 17.1 51.1SUDs 2.8* 18.1 14.21 Disorder 3.0* 11.6 24.52 Disorders 3.9* 14.5 14.43+ Disorders 8.3* 26.5 26.6Any disorder 4.4* 15.9 66.3Kessler, APA 2007

OR for comorbidity in active ADHDcompared to ADHD, in remissionActive ADHDADHD in remission98,2*876,26OR54323,9*2,53,53,9*1,23,94,3*1,610Any MoodDDepr Panic/GAD BP I /II PTSDKessler, APA 2007

ConclusionsEpidemiological study Kessler• 1 in 5 mood disorders are comorbid with ADHD• Depression is comorbid in 30% of ADHD• ADHD has an earlier onset than mood, anxiety orSUDs• ADHD is a riskfactor for a range of comorbiddisorders• Treatment/remission of ADHD leads to loweroccurence of mood-, panic disorder, and PTSDKessler APA 2007

ADHD or Borderline?Overlap• Impulsivity is hallmark of both• Frequent moodswings & irritability in 90% of adults with ADHDDifferential diagnosis• Inattention and hyperactivity only in ADHD• ADHD starts in childhood, borderline in adolescence• Emptiness, manipulative behaviour, all good-all bad patternsspecific to borderline• History of neglect or sexual abuse typical in borderline, not ADHDComorbidity• 6-25% of adults with ADHD also have cluster B personality disorder• 35% of borderline patients also have ADHDKooij 2006; van Dijk in prep, 2009

Chance of addictionADHD vs controls%4035302520151050Controls With med. Without med.(n=45)Wilens, 2003

LikelyhoodSubstance Use Disorder:Age at onset in ADHD compared tocontrols1 ADHD0.9 Controls0.80.70.60.5p

ADHD and SUD• Medication treatment of ADHD does notincrease chance of SUD• Research suggest a protective effect ofstimulants against substance abuseWilens 2003

ADHD, circadian rhytm, sleep, mood andseasonADHD100%OverweightDSPSSAD75%30%BP II10%Goikolea 2007; Amons & Kooij,2006; Kooij 2001; Lewy 2006;van Veen 2010

Diagnostic Assessment• Screening instruments (ASRS, CAARS,ADHD-RS, BADDS, WURS)• ASRS online:www.hcp.med.harvard.edu/ncs/asrs.php• Structured Diagnostic Interviews based onDSM-IV (CAADID, DIVA)• DIVA is now translated into Danish!Conners 1999; Kooij 2003, 2007

Ultrashort screening of adult ADHD1. Are you usually restless?2. Are you usually easily distracted or chaotic?3. Do you usually do things before thinking?If 1 of 3 answers = yes:4. Did you have this symptom all your life?If yes, further diagnostic assessmentof ADHDKooij 2006

NEW:DIVA 2.0Now available in Danish, Dutch,English, Norwegian, Spanishand SwedishTranslation in 16 languagesNext:. Hebrew. French. GreecDIVA 2.0 onlinefree of charge:www.divacenter.eu

NEW!DANISH DIVA 2.0(Back)translation supportedby MediceRevision by Klavs Nicholson,Henrik Bulskov, Mette Lűnell,Annet Bron and Sandra Kooij

ADHD is a clinical diagnosis• Interview patient and partner: lifetime symptomsand impairment of ADHD and comorbiddisorders• Schoolreports if available• If possible, parents/sibs about childhood onset• Patient is best informant, though tends tounderreport severity• No neuropsychological diagnostic test (battery)• No validated instruments in EuropeKooij 2003, 2008; Ferdinand 2004

Dilemmas using childhoodDSM-IV criteria in adults• Formulation not applicable to adults• Selfreport in stead of informant report (parent)• Cutoff may be lower in adults• Age of onset criterium (< age 7) never validated inchildren and unreliable in adults• Current criteria lead to under-identification of adults• Age referenced criteria have to be developed andvalidated• DSM-V will use broader age of onset (before age 12 or16) and probably different criteria for different agegroupsBarkley 2002; Kooij 2005; Faraone 2000, 2004, 2006;www.dsm5.org

Cutoff currentDSM-IV criteria in adults?Epidemiological study (n=1800): adults were significantly moreimpaired starting from 4/9 current ADHD criteria:• of inattention as well as hyperactivity/impulsivity• in both genders, and in young and old people• effect remained significant after controlling for impairment dueto comorbidity (GHQ)• ADHD proved to have its own contribution to impairment,independent of comorbidityC/ 6/9 symptoms in childhood and 4 or more current DSM-IVsymptoms may lead to diagnosis of ADHD in adulthoodKooij 2005

Outline Diagnostic Assessment• Early onset in life• Chronic persistent course• Chronic impairment or compensation/copingcausing secondary impairmentMainstay of ADHD diagnosis is:CHRONICITYThe period that ADHD symptoms are rememberedwill be longest in older adults

Treatment of ADHD andcomorbidity1. Psycho- education2. Discontinue alcohol/drugs3. Medication for ADHD and comorbidity4. Light Therapy5. Coaching6. Cognitive Behaviour Therapy7. Support or Advocacy GroupsSafren 2005, Weiss 2003; Kooij 2010

Medication Proven Effectivefor ADHD1. Stimulants- Methylphenidate (short and longacting)- Dex-amphetamine (short and longacting, combinationpreparations)2. Atomoxetine3. Bupropion XL4. Modiodal5. Tricyclic antidepressants

Available Methylphenidate (Mph)preparations in USA but by far not in EuropeShort Acting Mph preparation• Ritalin (2-4 hrs)Long Acting Mph preparations• Concerta (-12)• Equasym (-8)• Medikinet (-8)• Ritalin LA (-8)• Ritalin SR (-6)• Focalin en Focalin XR (d-isomer)(3-4/8-10)• Daytrana TM (Patch) (-12)Spencer 2006, Ashton, 2006, Blick 2007, Wilens 2007

Other ADHD medications USAShort Acting Amphetamine• Dexedrine (3-5)Long Acting Amphetamine preparations• Adderall (4-6) and Adderall XR (10-12)(combination of amphetamines)• Dexedrine spansule (dexamphetamine) (6-8)• Vyvanse (lisdexamphetamine:l-lysine en dexamphetamine)(12)Noradrenergic compound• Atomoxetine (24)Expected• Nicotinergic compounds (ABT-418, ABT-089)• Only for adults: triple-bead mixed amphetamine salts (SPD-465) (16)• Guanfacine ER (Alfa adrenergic)Spencer 2006, Ashton, 2006, Blick 2007, Wilens 2007

Place of medicationin treatment• Medication is very effective and comesfirst after psycho-education• ADHD patients have a short attention span• After 3 months they quit treatment ifmedication is not taken or ineffective• Coaching without medication is lesseffective due to inattentiveness, irritability,forgetting appointments and tasks, and noshow

Order of treatment incomorbid ADHD• First treat most severe disorder, usuallydepression, anxiety, bipolar disorder, SUDs;then add stimulant for ADHD• In case of personality disorder: first treatADHD

Methylphenidate (Mph)• Best studied (> 250 RCTs)• 50 years of clinical experience• Response: 70% children, 50-70% adults• Effect size .9• Better executive functioning• Safe, little side effects• Effective 20 min. after ingestion• Not addictive when used orally (but short acting can be when injected orsnored)• Inhibits reuptake of DA / NA• Short acting: too difficult to use due to frequent dosing need and lowcompliance; risk of abuse• Long acting best adviceFaraone 2003, Volkow ea 2002, Pietrzak 2006

Compliance in adults with ADHD?Using shortacting Mph• ADHD patiënts: chaotic and forgetful• Need to dose 6-8x/day ON TIME• Forget tablets, timer, batteries, water bottle and ...• No one is able to do this properly for a longer time• Efficacy low due to bad compliance• Medication wearing off generates rebound severaltimes a day, ´roller coaster´ in stead of stability• Patiënts stop short acting Mph: ‘medication is worsethan disorder´Kooij 2005

Long Acting Mph in adults• More stable effect during the day• Less rebound• Less chance of abuse (gel or small particles hard tosnore or inject)• Safer in traffic• Dose Concerta between 36-108 mg/day• Usually after wearing off Concerta, evening dose neededat 5 pm of Mph of intermediate duration (6 hrs)• In case of earlier wearing off: 2 nd dose Concerta neededin afternoon (8 am and 3 pm)• Combinations of Concerta and Equasym/Medikinet• Still waiting for stimulant with 16 hour efficacy to betterserve adults …

Duration of effect and dosing frequencyof the methylphenidates• Ritalin: 2 - 4 hrs (6 - 8 x/day)• Equasym and Medikinet: 5 - 8 hrs (1 - 2 x/day)• Concerta:8 - 12 hrs (1 - 2 x/day)Combinations now possible:• C 72 at 8 am and C 36 at 3 pm• C 72 at 8 am and E or M 30 at 5 pm• C 90 at 8 am and R 10 at 8 pm

Combination treatmentthe rule in adult ADHD75% of adult ADHD patients has comorbiditymostly sleep problems, anxiety, depression orSUDsCombined treatment is the rulerather than the exception

Combined treatment• No RCT data, but clinical experiencesuggests that Mph can be safely andeffectively combined with SSRIs, Lithium,Depakote and anti-psychotics• Because plasmalevels of Tricyclics mayincrease when combined with Mph, thismust be evaluated

Light therapy and ADHD5 days – 30 min – 10.000 lux – 40 cm:• For seasonal affective disorder: in 30%• For delayed sleep phase syndrome: in 70%• For ADHD?• For overeating?Levitan 1999, 2002; Amons & Kooij 2006, Rybak 2006,2007

Psychological treatment‘Coaching’: practical, supportive and directive, similar tocognitive behaviour therapy interventions:• time management (watch, timer, agenda, mobilephone/PDA)• organising daily life (household, children, administration)• reorientation on education or work• planning time/intimacy with spouse• getting overview over finances• addressing process of acceptance of the disorder andneed for medication• learning social and organisational skills

Contra-indicationsfor coaching• Crisis or suicidality• Impossibility to build a therapeuticalrelationship with patient (severepersonality disorders)• Ongoing substance abuse• Untreated comorbidity• Unmotivated patient, not acceptingdiagnosis and impairment

Coaching andCognitive Behaviour Therapy• Coaching is practical / skills oriented (planning, usingwatch and agenda)• CBT is more cognitive oriented (selfesteem, negativethinking, impulscontrol)• Both share: transparency, here and now, structured andgoal directed• In ADHD patients too much homework or assignments(CBT) may induce feelings of failure, coaching is morepractical, decreasing difficulty of tasks as needed by thepatient• The coach is more equal to the patient, in CBT thetherapist is not

Coaching?• Active and practical quidance in order to resolvedaily problems• Educating• Supportive and motivating• Companionship with other patients in groups• Learning to achieve own goals, problem solvingskills• Structured• Themes

Who can coach?• Psychologists• Psychiatric nurses• Job coaches• Even docters

Planning of time• Problem• Purpose• MethodNo overview over time, badplanning, being lateOverview, good planningWeekschedule: overview of allregular and variable activitiesTargetschedule: realistic targets,small steps, evaluation perweekWatch and agenda: learn how touse themTimer: use for medication and othertime cues, to increase sense of time

Dealing with money• Problem• Purpose• MethodSpending money impulsively,gambling, debtsOverview over finances,reorganising debtsAsking help to get finances inorder, regular payments usingcollections, prevent gamblingby behaviour interventions etc.

Dealing with chaos at home• Problem• Purpose• MethodPapers and rubbish all over theplace, sometimes filthinessOrder and overviewAsking help from home careorganisationCleaning and clearing, with helpThrowing things away by making choicesSmall stepsMaking a system or support to continueorder afterwards

Reorienting on education• Problem• Purpose• MethodFailed educations,underachievement andimpairment at workFunctioning at own level aftertreatmentTry reading / administrativetasks / organisation / studyDo not assume former failuresChallenge new perspectivesMaking choices and performthem

Reorienting on work• Problem• Purpose• MethodWork below educational level,chaotic workplace, too manyorders from too many people,no structureOptimal functioning, taking intoaccount strenghts andweaknessesTalk about wishes with boss orphysician; make choices for typeof work and workplace; decideabout telling boss or not

Dealing with ADHD in the family• Problem• Purpose• MethodConflicts in family, patient andchild have both ADHDHelp for every familymember,stability in familyRefer child for diagnosis andtreatment; educate parents onhow to prevent conflicts; treatthe patient, support thespouse

Dealing with feelings of loss• Problem• Purpose• MethodFeelings of grief and lossbecause of late diagnosis,missed chances, having notime to spare to make up for itAcceptance of facts of lifewithout despairAcknowledge grief and loss,educate and support patientand family that it takes time;slow down overcompensation

Coaching in groups– 6-8 participants, 2 therapists– Once a week - every 2 weeks– 2.5 hours including break– 6-8 weeks– Structured, with scenario, powerpoint and filmMethodPsycho-educationSupportiveContact with other patients with ADHDLearning to achieve own goalsNadeau, 1999; De Kruiff & Kooij, 2001; Kooij 2003

Coaching in groups• Target group: learning to attain personal goals• Skills group: learning organisational,administrative, time management skills• Women with ADHD: psycho-education andsupport group• Doctors/professionals with ADHD• Cognitive behaviour therapy group• Sleep education and intervention group• How to raise children when you are a parentwith ADHD?

Books on coaching• Mastering your adult ADHD Sprich & Safren• Survival guide for college students Nadeauwith ADHD or LD• Learning to slow down and pay Nadeauattention• ADD - the friendly way to organize Kolbergyour life

ADHD and impairmentaccording to SafrenLow selfesteemRelationship problemsMood problemsAngerADHD symptoms,Bad copingstrategies:procrastination,perfectionismdistracted, not listeningImpairmentUnderachievement,FailureSafren 2004, 2005, 2006, 2007

Psychotherapy• Cognitive behaviour therapy: addressingproblems with impulse-control, selfesteem• Interpersonal psychotherapy?• Mindfulness?• Relationship therapy: individual / group• Supportgroup for partners/parents• Supportgroup by experienced trainedpatients for new onesSafren 2005, 2006, 2007; Zylowska 2008;Schuijers & Kooij, 2007

Support groups• Danish patient organisation for adults with ADHD• Holland: patient organisation ImpulsInformation - Advice and information lineADHD cafe’s – MagazineWebsite: www.impulsdigitaal.nl• PsyQ support project: experienced patients aretrained to educate new ones, on how it is to be intreatmentSchuijers & Kooij 2007

Relationship and ADHD• First treat the patient• Spouse often exhausted• Psycho-education also for spouse, what to expectfrom treatment, duration etc• Involve spouse in treatment• Inventarise relationship problems• Support both patient and partner• Learning to negotiate• Supportgroup for spouses• Sometimes relationship therapy

Set up Program Adult ADHDand Dutch Network Adult ADHDDr. J.J. Sandra Kooij, MD PhDPsychiatrist,Head Program and Expertise Center Adult ADHDPsyQ, the Hague, the Netherlandswww.psyq.nl

Short history of Adult ADHD:1995, the Netherlands• ADHD in adults does not yet exist in NL, but does inthe USA• After succesful treatment of 1 female patient withADHD and review of the literature• More patients follow• Collegues ask for information and training• Patient organisation Balans refers nationally• After one year and 120 patients, a team is needed…

Adult ADHD is new in psychiatryand no knowledge availableAdults with ADHD need treatment by aMulti disciplinairy team:• To develop a comprehensive treatment program• To offer continuity of patient care• To facilitate research• To train professionals

A separate department for anon-existing disorder?• Oh no, that is too much!• The hospital is too small …• We cannot invest in such an experiment• Therefore …

2002 - Start Program Adult ADHDat Parnassia (later PsyQ)You need support of your boss! If not, go find another one!Team members:• 1 physician• 1 nurse• 0.5 psychologist• 1 secretary• 1 psychiatrist/manager• 1 general manager• 100 patients• ongoing research• start Expertise Center AdultADHD

6 months later …

April 200415 full time employees400 patientsCertificate KEMA/HKZMoving to other building

2005-2006: 800 patients34 fte 34 fteMoving again

Team Program Adult ADHD, 20091300 patients, 42 fte

PsyQ National ADHD-Day, October 2009: 140 Fte at 25 locations in the Netherlands

What did this team do?• Develop standardised diagnostic assessment and treatmentprotocols• Structured Diagnostic Interview for ADHD (DIVA 2.0): onlineavailable at www.divancenter.eu• Develop treatment protocols for coaching in groups• Evaluate and improve treatment• Audits and certification as treatment program• Training of collegues• Educating patients• Development of leaflet, films, E-newsletters for patients• Website www.adhdbijvolwassenen.nl• Online ADHD selftest and 5 films for education• Research• Top Mental Health Acknowledgement 2008 by theminister of Health

Specialised team Adult ADHD• As comorbidity is the rule in adultADHD, a specialised program isnever dull• General psychiatric treatment ofanxiety, mood and sleep disordersis the rule in Program Adult ADHD• Referral to other specialised teamsonly in very complex cases

Diagnostic Assessment• 3 hour interview with patient, spouse andfamily (DIVA)• Childhood onset and lifetime ADHDsymptoms and impairment• Comorbidity• Order and content of proposed treatment

InstrumentsDiagnostic Assessment• Screening questionnaire ADHD-RatingScale (ADHD-RS)• Structured Diagnostic Interview forADHD (DIVA)• Special form for standardised check oncomorbidity• Every diagnostic assessment is weeklysupervised by experienced professional

Treatment Program Adult ADHDSix Treatment Paths:meaning treatment• for a special group of patients• for a certain period• in a specified intensityBased on comorbidity and social/workimpairment

6 Treatment Paths1. Motivation (5 visits, then decide about further treatment)2. Short (6 months)3. Practical (1-2 yrs)4. Insight (1-2 yrs)5. Intensive (1-3 yrs)6. Relapse prevention (after treatment)• Evaluation every 6 months, then treatment stops, continuesor the patient is referred, based on predetermined criteria• Strict rules for no-show

Content Treatment PathsAll consist of similar basic elements:– Diagnostic Assessment– Treatment advice + psycho-education– Medication– Coaching/cognitive behaviour therapy:individual and group– Partner/familygroup

All kinds of groups /workshops possible• Introduction (4x in one month)• Target group• Cognitive training• Women• Professionals• Students• ADHD and work• Impulse control• Self esteem• Anger control• How to raise a child as parent with ADHD• Sleep education

Adults want helpPsyQ, in the Hague and in the Netherlands:• 1300 patients in the Hague, only local referrals• Mean age 38 yrs• Males: females = 1.5 : 1• PsyQ currently has now 30 locations and teams around thecountry• Most referrals at new locations are for adult ADHD (40-50%): unmet need …• Rapid increase in expertise and availability of patient carefor adult ADHD in the Netherlands• Next step: annual training adult ADHD for residentsthroughout the country (Dutch Network Adult ADHD)

Conclusions• Treatment of ADHD requires a lot of effort, no one cando it alone• ADHD treatment needs a specialised multidisciplinaryteam• After spreading the word to the media and patientorganisations,• The unmet need will lead to a rapid increase of requestsfor diagnosis and treatment• Start educating young professionals from the beginning• Cooperate and support each other nationally, i.e.:• Start your own Danish ADHD Network!• Dedication (not money) is the most important factor forsuccess

Adult ADHDDiagnostic Assessment and TreatmentIncluding DIVA 2.0JJS Kooij, 2010Pearson Assessment and InformationBV AmsterdamOrder only at: bestelling-nl@pearson.com

On MEDICATION (incl. melatonine)for patients with ADHD

European Network - UKAANSymposium, London, Sept 22-23, 2011‘ADHD: a lifespan condition’