American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tips for recognizing and managing adult ADHD

Experts say awareness in primary care is key to proper diagnosis and treatment

From the September ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

The patient complained he'd felt distracted, had near-constant restlessness, and was unable to finish projects. He'd had these symptoms since childhood, but had found ways to compensate and never thought to seek help. But then his young son was diagnosed with Attention Deficit-Hyperactivity Disorder (ADHD), and he sought out an opinion on his own condition.

“After asking a number of questions about the history of his symptoms and learning that his wife also suspected that he had ADHD ... I agreed with the patient that he might have ADHD,” said Sarah Gustafson Thompson, ACP Member, an internist based in Radnor, Pa. Like many other internists, this was relatively new territory for her, so she referred him to a mental health professional.

"We learned nothing about this in training," she said, explaining why she isn't comfortable diagnosing and treating this condition.

Other physicians have been reluctant and sometimes even ambivalent about diagnosing and treating ADHD because the diagnosis has been so dependent on a patient’s self-referral, said Mitchell D. Feldman, ACP Member, professor of clinical medicine at the University of California, San Francisco. “Patients might be influenced by pharmaceutical advertising and the lay press, and some studies suggest that, while primary care physicians frequently overlook ADHD in their patients, adults who are convinced they have the condition often do not meet the diagnostic criteria outlined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),” he said.

But given the intensity of the consequences of untreated ADHD and the fact that only one-quarter of the 4.4% of adults who have ADHD are identified and treated, according to a preliminary report from the US National Comorbidity Survey Replication, experts are urging physicians to become more aware of the likelihood of adult ADHD and more knowledgeable about its symptoms.

Dr. Feldman noted that primary care physicians should learn to treat uncomplicated ADHD if the patient presents without multiple comorbidities, and although they may end up referring out complex cases, “they need to start recognizing this disorder, giving the symptoms more serious consideration and preparing to co-manage care with mental health professionals.”

“The majority of mental health services aren’t provided by psychiatrists,” said Russell Barkley, PhD, research professor of psychiatry and behavioral sciences at the State University of New York Upstate Medical University in Syracuse, N.Y. “People are much more likely to come to their primary care physician first, so it’s important for the primary care community to be aware of ADHD symptoms and be ready to treat or refer.”

“ADHD wasn’t thought of as an adult condition until around 1987,” said Lenard Adler, MD, director of the adult ADHD program at the New York University School of Medicine and the author of the forthcoming book "Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder." Until then, many used to believe that children outgrew it, he explained. Experts now know that up to 60% of the 4%-8% of children in the U.S. who have ADHD—the most common pediatric psychiatric disorder—end up with symptoms that persist into adulthood.

So even recognizing the potential problem is progress, Dr. Feldman said. "The primary care community has been slow to catch up with what’s going on as far as psychiatric issues,” he said. “There’s been some confusion, for instance, about whether ADHD is a syndrome or a cultural construct, but now we have irrefutable evidence from brain imaging, genetic studies and epidemiological studies that it is a biological condition.”

Diagnosing ADHD

Experts gave the following tips to help internists best screen and diagnose patients who either self-refer or present with symptoms that might point to ADHD:

  • Understand ADHD. ADHD has three subtypes: Inattentive, hyperactive/impulsive, and combined hyperactive/inattentive, which is the most prevalent among adults. “In adults with ADHD, hyperactivity and impulsivity diminish with time as adults learn how to control the outward signs,” said Andrew Adesman, MD, chief of developmental and behavioral pediatrics at Schneider Children’s Hospital in New Hyde Park, N.Y. “Motor activity, like the fiddling and fidgeting we associate with children with ADHD can diminish, but the sense of restlessness remains.”

  • Ask about current symptoms. "One of the most discriminating questions you can ask is, ‘Are you often distractible?’” said Dr. Barkley. “If the patient answers, 'yes,' there’s a 99% chance that he or she has some kind of mental disorder." The 18 DSM-IV criteria for ADHD also include forgetfulness, failure to stay organized, inability to complete tasks, feelings of restlessness, excessive talking, a tendency to lose items, and impulsivity.

  • Recognize other red flags. Patients might come in with other symptoms that don’t immediately point to ADHD, such as sleep problems, depression or anxiety, Dr. Feldman said. “About 75% of patients with ADHD have some kind of psychiatric comorbidity,” he said. “When you see these symptoms, you need to do a broad history and consider ADHD.” In addition, patients with ADHD often will repeatedly fail at self-change programs, Dr. Barkley said. "For example, they may try again and again to stop smoking,” he said.

  • Ask about impairment. Once you’ve discovered the symptoms, determine how bothersome they are. ADHD causes significant impairment in occupational, social or educational domains; impairment in at least two of these areas—e.g., unemployment, being arrested, more car accidents, or abusing alcohol and tobacco—is a tip-off.

  • ADHD has nothing to do with intelligence or success, noted Joel Young, MD, medical director and founder of the Rochester Center for Behavioral Medicine in Rochester Hills, Mich. “I treat many doctors, lawyers, CEOs and other high-functioning people. There’s even evidence to suggest that intelligent people with ADHD are diagnosed later in life because they find creative ways to compensate for their disability.”

    Note that patients can be successful in one area, but do poorly elsewhere, such as the executive whose marriage and other relationships are failing because he works longer hours than he needs to and can’t relax.

  • Determine childhood onset. According to DSM-IV criteria, some symptoms that cause impairment must have been present before age seven for an ADHD diagnosis. “Don’t assume, however, that a patient had to have been fully diagnosed as a child in order for you to suspect the condition in an adult,” Dr. Adler said. “Remember that childhood is a very structured time, and as structure decreases, and as cognitive load increases, certain symptoms might come to the forefront.”

  • Administer a screening test. The World Health Organization’s Adult Self-Report Scale (ASRS) v 1.1 is probably the most widely used screening test; studies estimate that between 70%-90% of individuals who screen positive on this six-question screener turn out to have ADHD. According to Dr. Feldman, "The ASRS ... seems to be the best tool we have in terms of sensitivity and adaptability to primary care settings. It will probably help you identify about two-thirds of your ADHD patients.”

    Because screening tools are easily available on the Internet (see sidebar), a patient might come in after already testing positive on a screener. “That’s a nice place to start,” Dr. Adler said. “It gets the conversation going.”

  • Consider comorbid conditions. Other comorbidities, such as depression or substance abuse, can sometimes be treated in conjunction with ADHD. Depending on the severity, however, they might have to be addressed beforehand.

    Plus, it can be difficult to distinguish between certain conditions or determine if one is causing the other. “Depression, for example, is one of the most common comorbid conditions, but a patient can also be depressed because of ADHD,” Dr. Young said. “One way to determine this might be to ask, ‘Are you frustrated because you feel you aren’t doing well or can’t focus, or are you depressed for reasons you can’t pinpoint?’”

  • Get collaborative data. A spouse or family member can often provide valuable insight, according to Dr. Young. “Speaking to family members [including] the adult patient’s parents can be very helpful in determining the severity of symptoms and establishing childhood onset. Even getting the patient's old report cards can help by seeing if their teachers used to describe them as ‘hyperactive’ or ‘not performing up to potential.’”

Treatment options

Experts agree that ADHD symptoms respond well to medication therapy as well as mental health care. Although many medications approved for children are used off-label in adults, “two out of three patients are helped with the first medication they take,” Dr. Adler said.

Methylphenidates (Ritalin, Concerta, Ritalin LA, Focalin, Focalin XR), and amphetamine compounds (Dexedrine, Adderall, Adderall XR) are the most common medications used to treat ADHD. Of these, only Focalin XR and Adderall XR have been FDA approved for use in adults (at up to 20 mg/day). Stimulants work quickly (often within a day), but the effects wear off quickly as well, and they can aggravate motor conditions such as tics and worsen agitation, sleep problems and substance abuse problems.

Atomoxetine (Strattera) has also been FDA approved for use in adults (at up to 60-80 mg/day). This non-stimulant medication has a longer titration period, but it also has more regular effects and less potential for abuse.

Less commonly used medications include antidepressants and antihypertensive agents. New approaches include using antinarcoleptic medications (such as Provigil). Also, this past April, the FDA approved a new methylphenidate transdermal patch, Daytrana, for use in children.

Physicians need to closely monitor patients no matter what kind of medication they’re on, experts say. There’s particular concern about potential cardiovascular risks following 27 reports of sudden deaths, and 26 reports of nonfatal cardiovascular and cerebrovascular effects in pediatric patients on ADHD medications and 28 reports of nonfatal cardiovascular and cerebrovascular events in adults.

This past February, the FDA’s Drug Safety and Risk Management Advisory Committee voted in favor of adding a black box warning to all ADHD drugs warning patients and physicians of these risks. The FDA’s Pediatric Advisory Committee later recommended that the medications should not carry black box warnings, but should use simpler language and include more information on the labels. What action the FDA will finally take remains to be seen.

Experts recommend performing a baseline cardiac exam and taking a thorough history for cardiovascular disease and following up with regular blood pressure monitoring, even if the physician refers out for psychiatric care. “Psychiatrists aren’t as vigilant as primary care physicians in monitoring blood pressure,” observed Dr. Thompson, who noted that she recently started treating a patient for high blood pressure who was on Adderall for many years and never knew that he was at risk.

Yet a multimodal approach can be particularly effective. “Medications are the first-line treatment, but cognitive behavioral therapy is also very useful and can target residual symptoms,” Dr. Adler said.

Physicians are already finding ways to get patients the care they need. Dr. Thompson, for example, has developed a referral list of psychiatrists who specialize in ADHD treatment. Dr. Barkley suggested that internists start developing a general awareness of ADHD and honing their diagnostic skills by attending continuing education courses or taking an online course (he offers one). That first step, experts say, can help you pinpoint local experts.

Experts emphasize that more pressure is coming to bear on physicians, despite their hesitations, when it comes to adult ADHD patients. Dr. Adler recently surveyed 400 primary care physicians who reported prescribing medications for a variety of mental health issues and found that although 92% were comfortable treating depression, only 35% were comfortable treating ADHD. That, some say, will have to change.

“With ADHD treatment, we primary care physicians are now at the point where we were 10 to 15 years ago with depression,” said Dr. Feldman. "As we become more comfortable recognizing ADHD and new treatments emerge, I expect that primary care physicians will become the locus of diagnosis and treatment.”

Yasmine Iqbal is a freelance writer specializing in health care.

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