Abstract
In this special issue on ADHD in Adults, the important take home points for any reader that stand out so far are as follows:
ADHD in adults is not an infrequent occurrence Most cases that are diagnosed with ADHD in adulthood have a childhood history of ADHD with varying levels of impairment; the level of impairment experienced during early years is determined by the amount of cognitive reserve, and the quality of structure, supports and scaffolding that was available Majority of undiagnosed cases presenting in adulthood are not diagnosed with ADHD in the initial psychiatric consultations, rather they are given an Axis 1 diagnosis depending on the presenting complaints, thus leading to either mis-diagnosis and/or delayed diagnosis. Anxiety disorders, depressive disorders, substance use disorders (SUDs), personality disorders can either be the possible differential diagnosis for ADHD in adults as well as co-morbid disorders. Thus, delineating disorders is of utmost importance. The medications helpful for managing ADHD in children are effective even in ADHD diagnosed in adulthood.
Putting into use the knowledge gained so far, it can be reliably said that ADHD in adults is a clinically significant but still under-recognised condition with important functional consequences. Two common clinical pathways illustrate this aspect.
Both scenarios underscore the harms of undetected/undertreated ADHD: lost educational and occupational opportunities, higher rates of comorbidity (depression, anxiety, SUD), accidents, and reduced quality of life. Another debatable suggestion in current times is that of ‘adult onset’ ADHD which adds yet another layer of complexity in the holistic understanding and management of ADHD in adults. All these issues add to the challenges of designing and organising services for the management of ADHD in adulthood. Closing this management gap requires clinical pathways that are present across the lifespan, providing accessible diagnosis and treatment, and with pragmatic workforce strategies—especially in resource-limited systems.
The question then arises, “Who should be responsible for providing care and services for individuals with ADHD and how should such care and services be delivered?” To arrive at an informed decision, let us first understand about what the international guidelines/recommendations/consensus statements say about this particular aspect.
These have been taken from various guidelines listed in the reference section1–4 at the end. The core recommendations shared across major guidelines are as follows:
Based upon the heterogeneity of ADHD symptoms and the way it may present in adulthood and taking lessons from international guidelines, we propose some practical, evidence informed, scalable steps which can be undertaken at the level of multiple stakeholders designed to fit in with the realities of low resource settings.
(i) Clinical Pathways
Pragmatic Clinical Pathway
Optimising Pre-Existing Services
Scaling Up of Services
It may be useful to recall the concepts of “scaling up” of services and “task sharing” which were advocated by Eaton et al (2011) 5 . “Scaling up” has been described by Lancet Global Mental Health Group (2007) 6 as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis.” On the other hand, ‘Task-shifting’ or ‘Task-sharing’ is one notable strategy that has emerged over the past two decades as a method for delivering healthcare in low- and middle-income countries (LMICs). WHO describes task-shifting as- ‘specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health’. 7 Additionally, Patel et al (2015) 8 have previously highlighted that basic mental health interventions can be provided through a brief training of the community members; successful implementation using these approaches in the community was evidenced through the community-based intervention for people with schizophrenia and their caregivers in India (COPSI) trial. 9
Using the above mentioned conceptual paradigm, we propose the long-term goal to be the following: taking the screening and preliminary assessment to the primary care level and then aligning and integrating the ADHD care pathway with the existing community mental health program.
This would require training primary care physicians to take a structured developmental history and simultaneous collateral history (wherever possible), use appropriate scales, and identify comorbidity that requires specialist referral.
Shared care protocol can be considered in situations where specialist access is available (but in a limited manner), i.e. specialist starts/titrates; primary care physician continues with monitoring and periodic review (this essentially reiterates the shared care principles listed by NICE).
Transitional Clinical Pathway
The aim of this pathway is to improve both continuity and transition of care for adolescents and young adults. Child and mental health professionals (CAMHPs) should create transition protocols well before the child with ADHD turns 18 years of age, and additionally identify adult services for handover. Where such services are unavailable, CAMHPs and general (adult) psychiatrists should come to an agreement for time limited continued care while adult capacity is concurrently built up. In our opinion, development of frameworks of such transition protocols and pathways are of essence (and probably the key component) to be developed by individual Child and Adolescent Mental Health Services (CAMHS) in both government and private mental healthcare.
(ii) Capacity Building:
The World Health Organization (WHO) developed and launched the Mental Health Gap Action Programme (mhGAP) in 2008 in order to reduce the treatment gap and to enhance the capacity of low- and middle-income countries (LMICs), and published initial recommendations in 2010 which have been regularly updated; most recently in 2025. 10 This guideline is targeted towards non-specialized health workers at primary- or secondary-level health- care facilities, or those working at the district level including basic inpatient and outpatient services; and additionally health workers in general health care and other programmes to support delivery of integrated care and services. 10
The 2025 mhGAP document advises under Module CAMH3 with moderate certainty of evidence that “Psychosocial interventions focused on social skills, cognitive and organizational skills training should be considered to improve development and functioning in children and adolescents with attention deficit hyperactivity disorder (ADHD)”. Hence it can be seen that ADHD is not only a disorder with significant treatment gap but it also occupies an important place for targeted intervention in LMICs (like a country as India) as per WHO even now.
Based on this evidence and recommendation (as per WHO) we strongly propose that “capacity building” is one of the major strategies that needs to be adopted for ADHD in adulthood, not only at the grass-root level but by policy makers too. 10
Short modular training programs for general psychiatrists, psychiatry trainees and primary care doctors on adult ADHD assessment and management including diagnostic exercise, use of ASRS, psychoeducation, non-pharmacological and pharmacological interventions with decreasing degree of complexity should be planned. Training of psychiatric nurses can be undertaken for monitoring (i.e. adherence with prescription, side effects, workplace accommodations) of adults with ADHD. Online/tele-monitoring can be utilized to support remote clinicians and upskill district providers.
(iii) Low-cost Psychosocial Interventions:
Based on the previously discussed concept of ‘task-sharing’ and ‘scaling up’, group psychoeducation & skills training sessions (either offline or online depending on patient and/or clinician preference) for teaching organisational skills, time management, planning, sleep hygiene, problem solving can be introduced. Psychiatric nurses, clinical psychologists, psychiatric social workers can be roped in to develop and deliver these sessions after training and with continued and regular supervision. Digital interventions like online/digital cognitive behaviour therapy or even simple WhatsApp based messages can complement pharmacotherapy and help with adherence. Workplace/college liaison can be established for brief structured advice to employers/colleges on reasonable adjustments like extra time in examination, structured tasks for adults with ADHD.
(iv) Utilising existing National Programs & WHO mhGAP:
Adult ADHD training for screening & referral should be integrated with existing community mental health programs. The importance and relevance of 2025 WHO mhGAP has already been alluded to earlier, and its identified strands need to be integrated and adapted with the needs identified at both national and local level.
(v) Build Public Awareness:
Awareness campaigns targeting employers, teachers, families and primary care to recalibrate expectations and improve help seeking emphasising that ADHD persists into adulthood and is treatable.
(vi) Guidelines and Research:
Adaptation of international guidelines in the Indian context OR development of guidelines unique to the Indian setting should be undertaken and formal evaluation of management models like the telemedicine-based services, task sharing and shared care model should be undertaken in order to evaluate for their fidelity, quality assurance and ensuring adherence to clinical governance.
Where to Start??
Given below are a few practical points that can be implemented by a clinician or a service without any impediment for improving the recognition of Adults with ADHD and timely referral to appropriate services.
Hold preferably one-day training workshops for psychiatry trainees and general/adult psychiatrists.
Develop and run brief training courses for general physicians/primary care physicians, psychologists, mental health nurses and PSWs on screening (e.g. use of ASRS), assessing for adult ADHD, 6 practical CBT strategies for adults, and monitoring of treatment/interventions.
Add the 6-item ASRS screener to adult psychiatry intake/assessment proforma.
Create a one-page shared-care template: who starts medications, what baseline checks to do (BP, heart rate, substance use screen), titration schedule, red-flag reasons to refer back.
Set up a fortnightly tele-case review with an ADHD-experienced psychiatrist for clinicians working in remote areas.
Start a group psychoeducation class (6 sessions) for adults with ADHD and measure attendance and self-reported functioning.
The above mentioned points are by no means an exhaustive list. But as mentioned earlier, they serve as a template for improving the recognition of Adults with ADHD and timely referral to appropriate services.
Take Home Message
First and foremostly, ADHD in adults is not an infrequent occurrence. Most cases that are diagnosed with ADHD in adulthood have a childhood history of ADHD with varying levels of impairment. ADHD in adults is associated with a high degree of comorbidity. Unfortunately, majority of undiagnosed cases presenting in adulthood are not diagnosed with ADHD in the initial psychiatric consultations, rather they are given an Axis 1 diagnosis depending on the presenting complaints, thus leading to either mis-diagnosis and/or delayed diagnosis.
Secondly, International and National guidelines (NICE, European consensus, WHO and professional bodies i.e. IPS) support specialist diagnosis, combined pharmacological and psychosocial treatment for adults, structured monitoring, and planned transition from child to adult services.
Although this is the scenario existing across the world, but in India absence of the second scenario tends to compound matters surrounding identification and management of “Adults with ADHD”. In our considered opinion, in a vast yet rapidly developing country like India, closing the care gap for “Adults with ADHD” is feasible by developing transition protocols and utilizing the well-established concepts of scaling up, task-sharing, stepped care/shared-care protocols, tele-support, and targeted training, to ensure accessible, affordable, safe, and quality assurance delivery and continuity of care.
Footnotes
Acknowledgements
None.
Conflict of Interest
None.
Disclaimer
This article expresses the opinion exclusively of the authors, and not necessarily of the Journal.
Financial Disclosure
Nil.