Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women.

BACKGROUND: There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD. METHODS: The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan. RESULTS: A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them. CONCLUSIONS: This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Seven steps to mapping health service provision: lessons learned from mapping services for adults with Attention-Deficit/Hyperactivity Disorder (ADHD) in the UK.

BACKGROUND: ADHD affects some individuals throughout their lifespan, yet service provision for adults in the United Kingdom (UK) is patchy. Current methods for mapping health service provision are resource intensive, do not map specialist ADHD teams separately from generic mental health services, and often fail to triangulate government data with accounts from service users and clinicians. Without a national audit that maps adult ADHD provision, it is difficult to quantify current gaps in provision and make the case for change. This paper describes the development of a seven step approach to map adult ADHD service provision in the UK. METHODS: A mapping method was piloted in 2016 and run definitively in 2018. A seven step method was developed: 1. Defining the target service 2. Identifying key informants 3. Designing the survey 4. Data collection 5. Data analysis 6. Communicating findings 7. Hosting/updating the service map. Patients and members of the public (including clinicians and commissioners) were involved with design, data collection and dissemination of findings. RESULTS: Using a broad definition of adult ADHD services resulted in an inclusive list of identified services, and allowed the definition to be narrowed to National Health Service (NHS) funded specialist ADHD services at data analysis, with confidence that few relevant services would be missed. Key informants included patients, carers, a range of health workers, and commissioners. A brief online survey, written using lay terms, appeared acceptable to informants. Emails sent using national organisations' mailing lists were the most effective way to access informants on a large scale. Adaptations to the methodology in 2018 were associated with 64% more responses (2371 vs 1446) collected in 83% less time (5 vs 30 weeks) than the pilot. The 2016 map of adult ADHD services was viewed 13,688 times in 17 weeks, indicating effective communication of findings. CONCLUSION: This seven step pragmatic method was effective for collating and communicating national service data about UK adult ADHD service provision. Patient and public involvement and engagement from partner organisations was crucial throughout. Lessons learned may be transferable to mapping service provision for other health conditions and in other locations.

Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement.

Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help. Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters. Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD. Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue.

Risk Assessment Workgroup report.

The Risk Assessment Work Group focused on six charge questions related to CHABS, cyanobacteria and their toxins. The charge questions covered the following topics: Research needed to reduce uncertainty in establishing health based guidelines. Research that minimize the cost and maximize the benefits of various regulatory approaches. Exposure pathways for receptors of concern. Data available to support the derivation of health-based guideline values for harmful cyanobacterial algal blooms. Ecological services that guidelines or regulations should protect? A framework for making risk management determinations that incorporates consideration of the characteristics of CHABs, the risk for human health, ecosystem viability, and the costs and benefits of CHABs detection and management? The Work Group concluded that there is a considerable amount of human case-study data and information from animal studies to demonstrate that cyanobacterial toxins pose a hazard to humans, domestic animals, wildlife, and the ecosystem. However, the data on dose-response are limited and confounded by a lack of sufficient pure toxin to conduct most of the toxicological studies that will be needed in order to answer remaining questions on risk, and to provide the data for quantitative dose-response analysis. The Work Group recommended that research on purification or synthesis of pure toxin must be accomplished before the large scale studies to establish dose-response relationships will be possible. As the necessary-pure toxins become available, the Work Group recommended that studies be prioritized by the impact that they will have on reducing the uncertainty in the risk assessment in order to minimize the research costs and maximize the risk assessment benefits. Use of quantitative structure activity relationships (QSAR) and toxicity equivalency factor studies are also recommended as approaches for filling dose-response data gaps. The Work Group recognized that CHABs rarely introduce single toxins into the water supply. Under CHAB conditions, affected water is likely to contain a variety of toxins in varying concentrations that may change over the duration of the bloom. Accordingly, research on cyanotoxin interactions is needed, along with the development of risk assessment approaches for CHAB mixtures. The development of simple, accurate analytical methods that can be utilized by most analytical laboratories or used in the field was recognized as a major data need for establishing exposure potential and monitoring bloom conditions. Most currently available methods are time-consuming and/or costly. Human exposure to cyanobacterial toxins can occur through ingestion of contaminated drinking water, plus dermal contact and/or inhalation of aerosols while bathing and showering in tap water. Treatment can reduce the concentrations of both the toxins and the bacteria in the treated water but there is still much to be learned about the effectiveness of most treatment technologies on cyanobacteria and toxin removal. Human exposure to cyanobacteria and their toxins also occurs through incidental ingestion, dermal contact, and inhalation of aerosols during recreational use of surface waters, ingestion of contaminated fish and other foods of aquatic origin, and/or BGAS supplements. Establishing intakes and duration parameters for these exposure scenarios will facilitate the application of risk assessment approaches to these situations.