<p class="first" id="d572035e239">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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