Professor Samuele Cortese, child and adoelscent psychiatrist within Psychology and Medicine at the University of Southampton, UK. 

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Keynote speaker at the ESCAP Expert Day - Friday 25th June 2021

“Treatment of ADHD: from evidence base to practice” by professor Samuele Cortese

In recent years, the research in understanding the mechanisms and development of ADHD plus ways to treat the condition has advanced significantly. But how can this research reach the clinic and be implemented in the daily lives of patients with ADHD, their families and the doctors that treat them? Professor Samuele Cortese will speak at the ESCAP Expert Day in June on this topic and gave us a brief overview of what his talk will entail.

He continued to chat with us on other aspects of his work.

Are the current diagnostic criteria enough?

Professor Cortese continued to discuss about the changing needs of the current criteria for diagnosing ADHD. He explained that like with other conditions and disorders we see in children and mental health in general, there is continuous progress; the classification systems are constantly changing to reflect the evidence and needs. One of the main discussions is the type of criteria that should be used to diagnose ADHD. The ones from DSM-5 apply a kind of algorithm in terms of counting symptoms, which is the first part of the criteria. This is standard practice in research, but it is not always easy to implement this in clinical practice, as some colleagues cannot follow this approach due to time restrictions and workload. Therefore, they use a different approach based on their experience and idea of what a child with ADHD should present with, a more prototypic approach. So, the main discussion is to what extent the current criteria are helpful in clinical practice, and future versions of the ICD and DSM criteria need to reflect this need”.

Tell us about your interest in linking somatic conditions with neurodevelopmental or mental health issues?

As well as his focus on translating research into the clinic, he is passionate about the associations of somatic or physical conditions with mental health conditions. “It is already known that some associations exist between somatic conditions and certain mental health conditions and disorders, such as depression and schizophrenia, but less is known for ADHD. Ultimately, the goal of this line of research is to inform clinicians about different diagnostic procedures and treatment management strategies that incorporate these somatic conditions. We are still in a phase of better understanding the strength of the link, the extent to which the link is with the condition, as well as the cross-sectional link and longitudinal one. For example, does ADHD come before the disorder or is the somatic disorder a manifestation of ADHD?”.

In terms of the impact of the research, the assessment and management of these somatic comorbidities could have important implications. “Generally, practitioners that are trained in ADHD are aware of the common comorbidities that are associated with the disorder, so they usually screen for other disorders, such as oppositional disorder, anxiety, and depression, but they don’t necessarily screen for somatic disorders. This is important, as in some cases it may really speed up the diagnostic process and may allow the patient to receive more comprehensive and effective management. We should also think about merging pathways instead of having separate pathways e.g., psychiatric services, and other medical services. In terms of treatment, there are some initial data to show that these associations can have important treatment implications; for example, if you screen and treat ADHD when present in an individual with obesity, you may impact, in a positive way, the outcome of obesity. These patients often struggle to adhere to dietary regimens and practice physical exercise, and ADHD is a barrier for these. Therefore, if you treat ADHD symptoms, it can have a positive impact on obesity. And it is not the anorexigenic effects of the stimulants used to treat ADHD, as stimulants are known to decrease appetite. Actually, this isn’t the mechanism because in general the anorexigenic effect tends to vanish over time. Rather, ,by treating ADHD you can improve executive functions and other functions that are important to help these obese patients. Thus, this research is fascinating in its scientific point of view but also at a public health point of view, and its clinical implications”.

How is the pandemic affecting patients with ADHD?

Samuele also explained his concerns about the pandemic and the impact it has had on ADHD patients, and the ability of the treating psychiatrist to do their job. “We are still learning unfortunately, about the impact of COVID-19 on these patients. From the beginning, it was clear that the pandemic was impacting the behaviours these patients display, at least in some of them, due to the lack of routine and structure. On one side, there’s been a worsening in some patient’s behaviour, but on the other side, the restrictions relating to the pandemic have, of course, impacted the way we practice in terms of diagnostic assessment and providing treatment. This was our major concern and the rationale that drove us [the European ADHD guidelines group] to write the guidance on dealing with these patients during the pandemic. It aimed to provide practicians with support on how to manage ADHD during the pandemic. We were aware from our own experience as clinicians but also reports from other colleagues throughout Europe that there was a number of individuals with ADHD that were not receiving the appropriate care because of the restrictions. These colleagues had concerns about to what extent was it appropriate and safe to start an assessment, or to conduct a follow-up, or start or continue medication. We aimed to provide colleagues with some guidance to their concerns, which we know retrospectively thinking, as we published this practical guide at the beginning of the pandemic. It is nothing ground-breaking, but it was important at that time to have an official body, like the European ADHD Guidelines group, to clearly state some facts, such as it is ok to treat and prescribe remotely under these circumstances. It provided some reassurance to the treating practitioner, also in a way, it has helped shape local policies. In fact, we are conducting a survey (details can be found here) to gather feedback from colleagues in the UK and other European countries because we are aware from lessons learnt during the pandemic that these guidelines need updating and can be done so based on the feedback our European colleagues provide us”. 

Samuele Cortese will present at 9am CET on Friday 25th June as part of the ESCAP Expert Day – Changing Perspectives. Find out more.

Find out more about Samuele Cortese's publication on PubMed Cortese S - Search Results - PubMed (nih.gov), in particular: https://www.nejm.org/doi/full/10.1056/NEJMra1917069