Thread by @psycheureka

ADHD has an ~80% chance of a comorbidity.

It is often missed or misdiagnosed, leading to delayed care or inappropriate treatment.

ADHD is not a checklist, it is a longitudinal diagnosis requiring developmental history, functional impact, and contextual formulation.

Here are 10 essential points to guide diagnosis and management. 🧠👇

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#1 ADHD is a Heterogeneous Condition

An individualised approach is critical; there is no one-size-fits-all solution.

Focus on specific domains, not just the label.

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#2 Six Domains to Consider in ADHD Diagnosis & Management

● Cognition
● Reward learning
● Behavioural inhibition
● Fight-flight response
● Activity
● Behavioural activation

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#3 The Prefrontal Cortex & the Goldilocks Effect

Optimal prefrontal cortex functioning requires a balanced level of dopamine and noradrenaline.

Too much or too little can impair cognition and other domains.

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#4 High Comorbidity

ADHD often co-occurs with:

● Sleep disorders
● Trauma
● Autism spectrum disorders
● Bipolar disorder
● Depression

Comorbidity is the rule, not the exception, with up to 80% comorbidity.

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#5 Recognise the Complexity of ADHD – The Iceberg Model

ADHD is paradoxically a complex condition. Multiple factors can influence ADHD, including organic, psychological, social, dietary, and lifestyle aspects.

A comprehensive evaluation is essential for effective management.

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#6 The FRAME of ADHD Treatment

ADHD treatment should prioritise long-term outcomes and functionality.

A lifespan approach is key due to prefrontal and striatal circuit changes over the lifespan.

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#7 Not Just Stimulants

ADHD pharmacology requires a thorough evaluation of key functions and foreseeability.

Recognise the key role of non-stimulants in optimisation.

Consider non-pharmacological approaches alongside medication.

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#8 Understanding the Difference between Phasic vs Tonic Dopamine

Phasic dopamine = brief, high-intensity spikes

Tonic dopamine = steady and sustained

Proper balance is crucial for optimal ADHD treatment.

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#9 Avoid Sensitisation & Desensitisation Cycles

Long-term phasic dopamine activity can lead to sensitisation and desensitisation cycles.

This may cause a diminished sense of reward over time.

These cycles are associated with side effects, tolerance, and non-adherence.

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#10 Optimal Functioning & Mesolimbic Pathways

Successful ADHD management requires balanced modulation of mesolimbic pathways (arousal and stress) and tonic dopamine receptors in the dorsal striatum (goal-directed actions and habits).

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Want to put these principles into practice?

Refine your clinical skills and gain a deeper framework for assessment and management in ADHD by visiting our course, “Adult ADHD Clinical Training Program | 6-Course Series for Psychiatrists & GPs” on The Academy:



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