Misconceptions, Treatment of Adult ADHD

Timothy E. Wilens, MD, chief, Division of Child and Adolescent Psychiatry, Harvard Medical School, Boston, Massachusetts, answers questions about his Psych Congress 2021 session titled “What’s new in adult and pediatric ADHD: A 2021 psychopharmacology update.”

In this Q&A, Dr Wilens, who is also the co-director at the Center for Addiction Medicine, Massachusetts General Hospital, Boston, discusses the main developmental impacts of adults with untreated ADHD, stimulant side effects, new treatments, and common misconceptions.

Question: What are the main developmental impacts of untreated adult ADHD?

Answer: Adults with untreated ADHD have higher rates of substance problems, behavioral addictions, depression (including suicidality), motor vehicle accidents, injuries, interpersonal difficulties/separations, peer relationships, academic, and occupational problems.

Q: What side effects typically occur with stimulants, and how can these impact ongoing successful treatment?

A: Common side effects of stimulants in adults with ADHD include lower appetite, difficulty sleeping, edginess, anxiety, grinding teeth, elevated heart rate and blood pressure, and sometimes spaciness. It is very important to monitor for side effects and discuss potential anecdotes with the patient. The vast majority of stimulant side effects can be managed successfully.

Q: How does undiagnosed pediatric ADHD affect patients into adulthood?

A: The biggest "hit" I see to adults who are newly diagnosed is self-esteem and self-worth issues. While our medications and cognitive behavioral therapy (CBT) can really help reverse and manage symptoms, adults with ADHD commonly still feel different from others, feel as though they wasted some of their life struggling, and somewhat depressed. Support groups, psychotherapy, and proper treatment can help reverse many of these problems over time.

Q: Are there any new treatments available that clinicians should be aware of?

A: The 2 newest treatments include a nonstimulant, viloxazine XR and a new stimulant preparation serdexmethylphenidate/methylphenidate. Both of these agents add to the armamentarium of medications available and clinical experience with these medications over time will help us identify ideal patients for their use. Both of these medications appear safe and well-tolerated.

Q: Are there any misconceptions in this area that you would like to clear up?

A:

• Misconception: You cannot diagnose adults with ADHD.
  • Clinical diagnosis using the DSM criteria is sufficient and is both valid and reliable in the diagnosis. There are nonproprietary and proprietary screeners and rating scales online that can be very helpful to establish a diagnosis.
• Misconception: ADHD goes away in adolescence.
  • Data from multiple longitudinal studies do not support this supposition. In fact, at least 50% of children with ADHD will continue to have ADHD in adulthood.
• Misconception: ADHD rarely co-occurs with other psychiatric disorders. 
  • This is incorrect. In fact, ADHD is overrepresented in most psychiatric disorders (eg, mood, anxiety) as well as substance use disorders.
• Misconception: Stimulants are dangerous and addictive in adults. 
  • There have been multiple studies over the past 2 decades including FDA approval studies supporting the tolerability and efficacy of stimulants. Moreover, longer-term outcome studies fail to show deleterious cardiovascular or cerebrovascular or neurological disorders. There is no evidence to suggest that adults being treated with stimulants develop stimulant or any other substance use disorders (the signal is in the opposite direction).

Timothy E Wilens, MD, is the Chief of Child and Adolescent Psychiatry, and Co-Director of the Center for Addiction Medicine at the Massachusetts General Hospital, Boston. He is a Professor of Psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder