4. Discussion
To the best of our knowledge, this is the first evaluation of the
effectiveness of a specialist adult ADHD service in relation to
improvements of functional impairment, pre- and post-titration onto ADHD
medication. The results indicate that overall, ADHD medication is
effective at reducing the functional impairment of adults with ADHD in
all domains of the WFIRS, which is consistent with similar research in
this area20. This evidence has contributed to longer
term commissioning of the service. However, the large proportion of
service users either disengaging from treatment (19.5% of the sample),
being assessed as not suitable for medication (12.4% of the sample) or
choosing not to have medication (2.7% of the sample), highlights a
significant service gap and the need to offer an alternative
intervention for the management of ADHD. This endorses NICE
guidelines11, which recommends non-pharmacological
treatment for adults with ADHD who have either made an informed choice
not to have medication, have difficulty adhering to medication; or found
medication to be ineffective/intolerable.
The present study also found that the level of functional impairment
reported by people that disengaged from the service did not
significantly differ to those that completed titration, suggesting that
this was not a factor in people disengaging from treatment. It is
possible that those who disengaged could have done so due to unmanaged
ADHD symptoms (e.g. the organisational skills needed to attend regular
appointments over several months). This further strengthens the need for
psychosocial support, as “CBT for adult ADHD aims to set up early
success experiences that help improve engagement in treatment and
hopefulness”21 (p.67). Further research into this
area is needed to understand the reasons for disengaging in treatment
and what the service could do or offer to help people to remain engaged
in treatment.
Disparity in the levels of disengagement between those that were
recently given an ADHD diagnosis (25.6%), compared to those diagnosed
prior to the present episode of care (15.7%) highlights a potential
avenue for exploring reasons for disengagement. Due to the relatively
small sample size used in this evaluation, caution is needed with
drawing conclusions from this finding. However, the psychological impact
of both the consequences of untreated ADHD across the life span, as well
as the emotional impact of receiving a diagnosis later in life, have
been well documented. Matheson et al.22 highlighted
that adult patients with a delayed diagnosis of ADHD have many unmet
needs regarding treatment. Young23 found the delay in
diagnosing ADHD until adulthood may contribute to a sense of feeling
misunderstood by others, uncertainty, and dissatisfaction because the
underlying cause of their problems went unidentified, misdiagnosed, and
untreated for so long. He suggested a six-stage model of psychological
acceptance of a diagnosis of ADHD: (a) relief and elation, (b) confusion
and emotional turmoil, (c) anger, (d) sadness and grief, (e) anxiety,
and (f) accommodation and acceptance. This indicates an important role
for psychological treatment, which should begin at the point of
diagnosis23. Comparison with a matched site that can
provide this level of support could offer valuable insight as to the
short- and long-term benefits and cost-effectiveness of offering this.
The present findings, along with the evidence discussed, highlights the
wide gap between NICE guideline policy in England and clinical practice,
in terms of the support that adults with ADHD receive. More investment
is needed to help people to not only deal with the symptoms of ADHD they
face, but to adjust to and accept a diagnosis. Having an adult
diagnostic service inherently brings about a responsibility to offer an
appropriate, comprehensive response to the needs of the population they
serve.