Inattention, impulsivity, hyperactivity… These three symptoms can be signs of an attention deficit disorder with or without hyperactivity, or ADHD. Partly hereditary, it is linked to several susceptibility genes which combine and interact with different environmental factors (prematurity, maternal smoking, etc.). Globally, it affects approximately 5% of children and 2.5% of adults.
there seems to be a late form, ADHD is frequently spotted in adults, especially since they were not diagnosed earlier. However, it can turn the lives of those affected by it upside down.
Accidents, addictions, anxiety, depression…
This disorder has important repercussions: it disrupts studies, professional activity, but also family life and social relationships. Furthermore, ADHD adults have more license suspensions, accidents and arrests than the rest of the population (they account for 26% of the prison population). Finally, there is a three times greater risk of addiction among them, so much so that in addictology consultations, 23% of patients have this disorder. And we frequently find anxiety, depressive, bipolar, sleep and personality disorders: psychiatric comorbidities affect three out of four patients.
Some people therefore rely on cannabis to attend a meeting without moving, others paradoxically rely on cocaine to calm their hyperactivity and channel their ideas. Addiction to nicotine is particularly common and excessive. As for alcohol, it is often consumed with binge-drinking behavior. Behavioral addictions like pathological gambling are more frequent and severe. Finally, the search for thrills and risk-taking combined with impulsiveness push a large number of ADHD subjects towards the frequent and sometimes frantic experimentation of several synthetic products.
How to spot this disorder in adults? There is a self-assessment scale to which one can refer. But it is the interview with a doctor who will make the diagnosis of ADHD, after a certain amount of information has been confirmed by the family. It is based, among other things, on the examination of the school trajectory, because if the deficit of attention can be compensated by adaptation strategies, these lose their effectiveness as schooling progresses, when the capacities concentration to be mobilized increases. However, in practice, patients are rarely diagnosed. And if they are so lucky, because of the small number of doctors trained or interested in adult ADHD, they will have to wait for months to get a specialist consultation in the hospital and start treatment.
This treatment is based on knowledge of the brain circuits and the neurotransmitters involved: noradrenaline and dopamine. They are the target of methylphenidate, the main molecule available in France for ADHD in children. In France, however, this does not have marketing authorization for adults except for the extension of a treatment started before the age of 18, which is not the case. for 95% of adult patients, whose diagnosis was established after their majority. Its prescription is therefore subject to the patient’s consent, and must be done in light of the evidence reported in the literature and taking into account the benefit / risk ratio.
As for the other existing molecules for adults, only atomoxetine is authorized, with restrictions: it benefits from a temporary nominal authorization, a cumbersome procedure which benefits few patients.
Naturally, it is better to stabilize addictions before starting a treatment: if moderate consumption of sedative substances is not contraindicated, the abuse of stimulants such as cocaine or amphetamines poses a problem. In addition, and all the more so since there are other psychiatric disorders, the management of ADHD must always be accompanied by follow-up and psychotherapy (to learn how to organize, manage your time , his impulsiveness, his mood swings…). Finally, both to improve adherence to treatment and to assess the effect of drugs, it is essential to inform loved ones and involve them in a positive way. However, compared to most European countries, France is lagging behind in the management of ADHD in adults.
Legislation that causes discrimination
Ideological positions have in fact led to consider only the child’s disorder, giving priority to psychoeducational measures. For several decades, only child psychiatrists, pediatricians and neuropediatricians were trained on the subject, resulting in an insufficient diagnosis and a delay in the knowledge of the disorder in adults. What is more, the health authorities and a part of the medical profession have an a priori negative with regard to the drugs used, because of their relationship to amphetamines. To remedy these fears of misuse and a Mediator-type scandal, it is advisable to offer secure medication protocols with well-established diagnoses, but also to combine the treatments with rigorous cardiological monitoring.
Another pitfall specific to France: the renewal of treatment initiated at the hospital is entrusted to a city doctor chosen by the patient. However, as no molecule has Marketing Authorization in France for ADHD in adults, health insurance funds tend to apply pressure to prevent the prescription of the few available methylphenidate-based drugs, going as far as not reimbursing them. . The poorest are therefore forced to interrupt their treatment, with the risk that their situation will deteriorate.
In short, French regulations and the state of the care system lead to discrimination against adults with ADHD, with a lack of access to diagnosis, delays outside of standard access to treatment, and obstacles to care and reimbursement of care, the efficiency of which is recognized abroad. Prescribing physicians, on the other hand, are subject to continuous pressure from health insurance funds. With a control of the contents of the medical files, but also of the letters accusing them of putting the patients in danger, when the latter are clearly better. Obtaining the signature of a protocol for treatment for an exonerating condition (ALD), or maintaining reimbursement for treatment therefore requires a lot of persistence, firmness and availability on the part of doctors. And solidarity among colleagues is more than necessary.
The role of associations
In 2015, hospital and liberal practitioners, psychiatrists and addictologists from Alsace, joined forces to contain the threats exerted by health insurance. Their pressure group quickly found support from ADDICTOLIB (liberal addictologists) and the French Federation of Addictology, then from the ADHD working group of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN). Then these partners decided to merge their efforts within the National ADHD Adult Coordination.
Born in 2018, this initiative aims to improve access to diagnosis, treatment and quality of care for ADHD adults, through: raising awareness among authorities, mobilizing and training professional health, proposals for an organization of dedicated care channels, but also the adaptation of the French regulatory system. Today, it has grown and has more than 60 members from psychiatry, addictology, pharmacology and neurology, working in hospitals or in the private sector. And it opened up to patient associations.
The role of these associations is to speak out for patients, to make ADHD known to adults for the general public. It is a question of echoing the difficulties encountered, but also, through testimonials, giving hope, encouraging diagnosis and taking charge. It is also a question of combating the isolation and stigmatization of patients and their entourage, by encouraging exchanges and solidarity between the members of the association. Or, to allow patients and those around them to understand their symptoms and thereby better modulate the consequences. An association could also lend its moral identity, in the event of a procedure, and defend patients in difficulty in reimbursing treatment. The persistence of French inertia, despite everyone’s efforts, could, moreover, give the European Court of Human Rights something to grind…
ADHD not diagnosed before adulthood, these are years of wandering and suffering, family, social, professional difficulties … While a diagnosis and a well-managed treatment allow you to take charge of your life and improve quality. In the name of what could we persist in depriving patients of it?
This article was written in collaboration with Dr Étienne Kammerer, addictologist, president of ADDICTOLIB and associate vice-president of the French Federation of Addictology.
Oussama Kebir, Psychiatrist, Addictologist, Researcher in molecular psychiatry, Hospital Practitioner at GHU Psychiatrie & Neurosciences de Paris, Inserm
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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