That attention deficit and hyperactivity embedded in the acronym ADHD find a variability and mutability throughout life that still need to be explored. Generally, little attention is paid to adults affected by this neurodevelopmental disorder, whose first manifestations are evident as children and are consolidated by the age of 12. The Italian Association of ADHD Families Onlus (Aifa onlus) is well aware of this and for this reason has long been sending messages to the National Health Service, to national bodies and to the Regions, creating opportunities and initiatives to raise awareness and growth on the specific issue of adults. The last one was a web-based seminar, much followed by family members and people with ADHD, entitled “ADHD in adults: state of the art and future perspectives” and conducted by Marco Di Nicola, psychiatrist at the UOC of Clinical and Emergency Psychiatry of the “A. Gemelli ”IRCCS of Rome, and with the introduction of the indefatigable Patrizia Stacconi, president of Aifa onlus.
A million people
If a total of about one million people with ADHD are estimated in Italy, in the age group between 18 and 67 years, there is one aspect that leaps to the eye: the disorder evolves, changes and can undergo remissions. “The data show that the persistence rates of childhood disorder range between 40 and 60%, with a gender ratio (male / female) varying from about 2 to 1. In some cases the disorder can undergo total remission. , in others partial; certainly the characteristics with which it manifests itself change with age, generally with the attenuation of symptoms of hyperactivity. These changes would seem to correlate with changes in the brain structure in specific cortical areas, as detected by studies of neuroimaging, although the underlying mechanisms to date have not yet been fully clarified2, explains Di Nicola – But for young adults, even teenagers, and for their families the right to treatment, stigma, bureaucracy remain, with considerable suffering . There is even, still, denial “.
Although ADHD is included in the international classifications of mental disorders (DSM-5, ICD-11), although the Health Service and the Italian law provide specific routes for prescribing drugs for ADHD, it was mentioned during the seminar the recent case of a report by a Technical Consultant of the Court of Milan who still considers the existence of this specific pathology to be doubtful.
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The diagnosis
“It is a complex disorder – explains Di Nicola – with heterogeneous manifestations, complicated by medical and social problems, as well as by the onset of relevant psychiatric comorbidities. A correct diagnostic framework and the consequent multidisciplinary therapeutic path therefore become indispensable. in charge of the person as a whole, by the care services, is essential to favor a functional recovery in the scholastic-working and emotional-relational spheres “.
The stigma on drugs
For families it is becoming increasingly difficult to support young people, sometimes barely of age, suffering from ADHD in the continuation of treatments, pharmacological and not only. “Therapies that must be increasingly personalized, modulated in the dosages and times of administration, to give visible and concrete support to the patient – continues the psychiatrist -. The diagnostic recognition and evaluation of the indication to a pharmacological therapy, which supports the interventions psychological-rehabilitation, represent the first step in the path of treatment. It is also necessary to improve awareness of the disease and counter the stigma related to the use of drugs, in ADHD as in other mental disorders “.
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Children and mood disorders
In Italy, the debate, especially regarding therapies in childhood, is still alive in public opinion. Mood disorders (depression and bipolar disorder), alcohol / substance abuse and pathological gambling, sleep disturbances, obesity, metabolic, hormonal and thyroid disorders are associated with the hallmarks of impulsivity, difficulty in attention / concentration, and emotional dysregulation, intrusive and repetitive thoughts, reactions of anger and aggression, up to the appearance of risky, uninhibited behaviors, sometimes with legal repercussions. A “life made of troubles”, of irrational and dangerous choices, immersed in risks and self-harm, not surprisingly with a high percentage of road accidents. A deadly and heartbreaking cocktail for those who suffer from it and those around it.
Delays in services
Faced with this picture – President Stacconi represented it well in the seminar – we have a Health Service that still struggles to respond to the growing demands, especially in the context of adult ADHD. Without recognized guidelines or protocols, psychiatric services (CSM) and addiction services (SERD) that do not communicate, a cumbersome and bureaucratic system: from the method of recognition of specialized drug prescribing centers, to the online therapeutic plan that is intertwined with the paper prescription to tracing in triplicate by the family doctor.
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Adults left alone
“The presence of specialized centers for ADHD in adulthood is detected in a total of 10 Regions and 2 Autonomous Provinces. Only Emilia-Romagna has appointed a Center per province but access is not direct and takes place through the CSM (Centers of Mental Health) – explains the president of Aifa onlus – Patients are often forced to pay private consultations in freelance. Many are prescribed other inappropriate drugs for ADHD that prove to be ineffective or even harmful. The few adults who succeed to obtain a diagnosis of ADHD and a specific pharmacological prescription, when they are sent for taking charge at the local ASL service of residence, they do not find any specific support such as cognitive behavioral psychotherapists experienced in ADHD able to organize paths similar to coaching, interventions considered very useful in the international experience. The figure of the coach for ADHD is widespread abroad “.
Personalize therapies
If ADHD is a neurodevelopmental disorder with familiarity rates around 70% and with a genetic substrate, there is also significant evidence about the relevance of environmental and epigenetic factors related to the disorder. Di Nicola spoke about the possible causal factors, and then presented the therapeutic possibilities, underlining the need for a gradual and multidisciplinary approach that integrates medical and psychosocial interventions. Among the latter, psycho-education and cognitive-behavioral therapy present greater evidence of efficacy; encouraging results also emerge from mindfulness and neurofeedback techniques. But personalization in the management of therapy is fundamental for Di Nicola. And this is the recommendation that comes from the clinician, aware that “we are still in an initial phase of knowledge and research, also in terms of the guidelines and protocols currently approved and recognized”.
Self-esteem
At the seminar dozens and dozens of questions from patients and family members: René, Sara, Guido, Monica, Antonella, Cinzia, Vincenzo, Irene and we could continue. From drugs to how to convince young people to continue their therapies, from the need for rapid and tangible improvements to Internet searches, from driving licenses to miraculous expectations. Up to the topic of self-esteem, reported by a patient: “But we also have positive sides: why not force on this and almost always describe ourselves only in the negative?”.
Two studies
To confirm the difficulty of care, here is a study by the Lundbeck Foundation Initiative for Integrative Psychiatric Research – iPSYCH on 9,133 people diagnosed with ADHD in Denmark since 1995. About half of individuals with ADHD are comorbid with another mental disorder ((bipolar , anxiety, substance abuse) stop drug therapy with stimulants within two years, a percentage of which due to the appearance of undesirable effects (insomnia, nausea, loss of appetite, nervousness up, in rare cases, tics, paranoia, hallucinations .) The study, published in the American Journal of Psychiatry, will continue to examine 20,000 cases.
Physical and metabolic problems
On the Lancet Psychiatry, however, the research of the Swedish Karolinska Institute was published which, comparing siblings with and without ADHD followed from 1973 to 2013, highlights how adults with ADHD would be more exposed to developing physical problems, metabolic, respiratory, musculoskeletal and neurological.
The research was carried out on 4 million people, extracted from the registers from 1932 to 1995. The analysis covered 35 physical pathologies. Well the brothers (both carnal and consanguineous) with ADHD are significantly more problems, except for arthritis. The strongest diagnosis association is related to alcohol-related liver disease, sleep disturbance, chronic obstructive pulmonary disease (COPD), epilepsy, fatty liver disease, obesity. But also greater risk of cardiovascular disease, Parkinson’s disease and dementia. It would be especially the carnal brothers (compared to relatives) with ADHD to have greater risks
.