Diagnosing Adult ADHD

Question:

"As a busy practitioner, I am seeing more and more patients saying, ‘I have adult ADHD.' I don't want to over-diagnose adult ADHD, but I also don't want to miss it if it's really present. What is the best way for me to approach these patients?"

Rakesh Jain, MD, MPH:  I will start out by quoting a patient of mine, a married school teacher with two young children:

"For years I have struggled. For years I knew something was wrong. For years I thought I was just stupid. Only in my late 30s, after I received a diagnosis of ADHD and the right treatment, do I feel I am truly part of life. It's such a relief to finally get the diagnosis. Oh what a difference it's made in my life."

This is an oft-heard tale in both specialty and primary care practices. You are quite right in pointing out that a large number of our patients are approaching us asking questions if they have adult attention-deficit/hyperactivity disorder (ADHD). Sometimes it's because they have a child or another family member who was recently diagnosed with it and they find themselves identifying with this family member's symptoms. ¹  Sometimes it's because they read something about adult ADHD in a magazine or newspaper or watched a program regarding ADHD on TV. No matter how they get to us, they are getting to us in large numbers, and many of us feel besieged by these presentations and seek guidance. ^2,3  I will do my best to offer you a quick look at the literature on this topic, as well as practical advice on it.

ADHD is indeed a disorder where the symptoms  begin  in childhood. In fact,  DSM-IV demands that at least some of the symptoms of ADHD be present before the age of 7. This is a crucial point – the symptoms have to begin before age 7, but  DSM-IV  does not mandate that the diagnosis be made before the age of 7. In fact, the majority of ADHD diagnosis is made after that age! Let's not be confused by the  DSM-IV 's need for the symptoms to start before age 7 and deny patients the appropriate diagnosis of ADHD because they were not diagnosed early in life with this condition.

It would behoove us to discuss some more points as background to our more in-depth conversation regarding adult ADHD that will follow shortly. ADHD, as defined by  DSM-IV , can present as one of three types: predominately inattentive subtype, predominately hyperactive-impulsive, and then the combined subtype. The most common in childhood is the latter, but in adult years I tend to see a number of patients with the inattentive subtype and the combined subtype. Hyperactivity is one set of symptoms that does diminish in most patients with age. Hence, don't be surprised if some of your patients report that they were quite hyperactive as children with significant diminishment of these symptoms in adulthood. Don't let this fool you into believing that the inattentive and/or the impulsivity symptoms have also abated! Please  proactively  check for this before you make a decision. ^4-6

I italicized the word proactively above with full intent to draw your attention to it. Because ADHD in adults can be present for decades and be missed by all involved (patients, their family, clinicians), we clinicians clearly have a responsibility in being proactive in screening for ADHD in our patients. But we first need to address an important question:  Why should we even screen for ADHD in either patients coming to see us for an evaluation for this condition, and others already in our practices but offering no complaints?

Here are five reasons why we clinicians should adopt a proactive stance:

1. ADHD can significantly reduce the quality of human life (in every way imaginable – with negative impact on personal, occupational, educational, parental, and social functioning). ^7,8
2. ADHD frequently hides in plain sight, often in patients with comorbid psychiatric conditions, such as depression, anxiety, alcohol and/or drug abuse, etc. ADHD, if not identified or treated, often leads to diminished treatment outcomes of other disorders. ⁹
3. ADHD is very chronic in nature and it's unreasonable to expect it to "just go away" with time in an adult patient. Clinical intervention is suggested in most clinically symptomatic patients.
4. There are many well-validated instruments available to us clinicians for screening purposes. They are readily available, have good psychometric properties, and are well accepted by patients. ¹⁰
5. ADHD, even in adults, is a treatable condition. This is the silver lining to this issue! Non-pharmacological treatments are first line and should be offered to every adult patient with ADHD. Medication treatments can be offered, and if offered judiciously and well monitored, many patients have significant benefit from them.

Now that we have briefly reviewed pertinent background information, let's directly tackle your question: How should we approach a patient who comes in and says,  "Doctor, I think I have ADHD, help me."

Here are my specific recommendations:

• Take all such complaints seriously. While there is always a chance of a patient malingering and offering symptoms in order to obtain medications without good cause, in my experience this is uncommon. Take such a complaint seriously and deal with the patient respectfully. I make the recommendation regarding "respectfully" as many patients report that some clinicians have poo-pooed their ADHD concerns and made the patient feel as if they were "making up the symptoms" or it was "all in their head."
• Ask for a full description of both symptoms and impairment from them. Remember, symptoms don't make a diagnosis by themselves.  DSM-IV  demands that there must be impairment present as a result of these symptoms before a diagnosis can be made!
• Ask for childhood history. Questions to ask might be: "Do you remember or does anyone else report you had similar problems with inattention/hyperactivity/impulsivity before you were 7 years old?"
• Take a good longitudinal history. This is key to both understanding and treating ADHD.
• Age is no barrier to having ADHD. The oldest patient I ever made a first-time diagnosis of ADHD was 52. This was 20 years ago. Treatment did wonders to him and his life. So, be careful not to discriminate on the basis of a person's age!
• Don't feel rushed into a diagnosis! Take your time. In fact, I personally almost never make a diagnosis of ADHD in an adult patient without talking to or obtaining a report from a spouse, significant other, parents, siblings, old school records, etc. Historical information is the life-blood of making an accurate diagnosis of ADHD in any age group. Don't starve your clinical interview of this vital life force!
• Know the symptoms of ADHD. It's best to have ready access to the  DSM-IV-TR  ADHD criteria:  www.cdc.gov/ncbddd/adhd/diagnosis.html .
• Always consider the use of a screening instrument. Ask not just the patient to fill it out, ask a family member (or multiple family members) to fill it out. This can be hugely helpful. My two favorite instruments for this purpose are the  Adult ADHD Self-Report Scale  (ASRS) and  ADHD Rating Scale  (ADHD-RS).
• Don't forget to look for comorbidities, and don't be surprised if you find them! ^11,12 Remember, not all patients who report having ADHD symptoms have ADHD. Another condition might explain these symptoms entirely. ¹³  Hence, making sure you have a well-validated diagnosis of ADHD is critical. Don't be afraid, if the situation so calls for, to make more than one diagnosis. Data clearly shows that comorbidities are indeed the rule, and not the exception in adult ADHD. ^14,15
• As you consider treatment for such a patient, don't automatically assume all patients need medication treatment.
• First, consider offering non-pharmacological treatment. Data supports the use of cognitive-behavioral therapy for ADHD in adults, especially if time management skills and organizational skills are discussed during the therapy sessions. ^16,17
• If medication treatment is needed, certainly offer it to the patients. If you are unsure of your treatment plan, refer to someone who specializes in this condition. There are a wide array of medication options available, and it's best to think of the patient's individual needs and risk factors when you do decide to make a recommendation. There is good database on the effectiveness of both stimulant and non-stimulant medications.18,19
• No matter what medication treatment is offered, please make sure it's safe for the patient to take it (especially that their cardiovascular profile is healthy enough for such treatment), and that you conduct a thorough risk-benefit conversation with the patient (and if possible, with family present). ^18-20  Also, don't forget to document this conversation and the patient's consent in your chart.
• Finally, monitor the patient's progress regularly. Prescribing mediation is not the last step in the treatment process. Careful, regular, and thorough monitoring is indicated. ²¹

ADHD in adults is common and commonly missed, and this is a tragedy for the patient. I have not just had patients who suffer from adult ADHD, but close friends and a couple of family members. I have personally and with my own eyes seen the tragedy of undiagnosed adult ADHD. Your question and the opportunity to respond to it are both deeply appreciated by me.

—Rakesh Jain, MD, MPH

References

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