Understanding Primary and Associated Symptoms in Adult ADHD

Adults in the United States are seeking assessment, diagnosis, and treatment for attention-deficit/hyperactivity disorder (ADHD) at unprecedented rates.

Psych Congress Network sat down with Lenard A. Adler, MD, director of the Adult ADHD Program at NYU Langone Health, on site at the 2024 APA Annual Meeting to dive deep into the particular ways that ADHD can manifest in adults through not just inattention, hyperactivity, and impulsivity, but also executive function deficits, emotional dysregulation, and sluggish cognitive tempo. Dr Adler also offers some thoughts on why now more than ever, US adults are questioning whether or not they may have ADHD.

Don't miss Part 2 of this interview, "Helping Patients Navigate the Stimulant Shortage and Other Challenges in Adult ADHD"--find it here!

For more news and insights from the 2024 APA Annual Meeting, visit our newsroom right here on Psych Congress Network.

Psych Congress Network: Given the evolving understanding of ADHD beyond the core symptoms of inattention and hyperactivity/impulsivity, how do you recommend clinicians integrate assessments of associated symptoms like Executive Function Deficits, Emotional Dysregulation, and Sluggish Cognitive Tempo into their diagnostic process? Are there specific assessment tools or strategies you find particularly useful?

Lenard A. Adler, MD: The first step for clinicians is to get the diagnosis of adult ADHD correct, and that is accomplished by following the DSM criteria, which involve 4 critical steps. Then, they should go ahead and assess for associated symptoms, but you have to get the core diagnosis correct first. So, those 4 critical elements are sufficient current symptoms of significant inattention and /or hyperactivity impulsivity--that's 5 out of 9 significant inattention and /or 5 out of 9 significant hyperactivity/impulsivity in the last 6 months.

Significant impairment in 2 out of 3 domains in the individual's life, be it at home or work in social settings. Significant symptom onset in more than 1 setting in childhood—you don't have to be fully diagnosed with ADHD in childhood, either retrospectively or in childhood, but you do have to have significant symptom onset. The last thing is, and nothing replaces taking a careful history, is being sure that the signs and symptoms and impairments that you're noting are from ADHD and not something else, because other mental health disorders commonly co-travel with ADHD one-half to three-quarters of the time.

But once you've done that and made that diagnosis, it's important to then go look and see if some of these associated symptoms are co-traveled, because we know that executive function deficits—which are higher level cognitive processes involved in organization, planning, prioritization, working memory, keeping things in mind—occur equally common as the inattentive symptoms in adults with ADHD. They occur in about three-quarters of adults with ADHD according to some of the work we've done in the National Comorbidity Survey with Ron Kessler from the Harper School of Public Health. As for emotional dysregulation symptoms, it’s not a mood disorder, it's a moodiness, a changeability of mood, a lability of mood, easy bruising of mood, inability to express anger appropriately; those symptoms occur in about 45 % of adults with ADHD, which is slightly less common but almost equally as common is the hyperactive and pulse of symptoms.

So, those 2 symptom sets are actually fairly common and quite impairing, and if you don't ask about them, you're not going to be able to recognize them. Sometimes, those are the symptoms that aren't getting better with traditional medications—more on that later.

The third co-traveling symptom set that's important are the symptoms of sluggish cognitive tempos, and those are symptoms like slugishness, daydreaming, slow to move. There are 9 of them, and they also commonly travel with ADHD. The importance of identifying them is that if an individual has ADHD and sluggish-cognitive tempo from some of the data from Russ Barkley and from us and adults with ADHD, those individuals are much more likely to be impaired, and if you don't identify them, you're going to miss those symptoms and you have to bring those under the treatment umbrella.

So, why are all these co-traveling symptoms important? You have to try to understand them. The symptoms of executive function deficits are quite difficult to treat. They tend to respond at about half effect size as we get with the standard ADHD effect size, so they respond but not as robustly, and the symptoms of emotional dysregulation even less so.

Often, using cognitive behavioral therapy can be quite helpful if medications are not bringing about a full treatment response.

Psych Congress Network: Adult ADHD diagnoses have risen sharply over the last decade—why do you think more adults are coming forward to seek assessment and treatment? Could increased access to treatment, social media, or a combination of the two be playing a role here?

Dr Adler: I don't think we fully understand the reasons why more adults are coming forward to treatment.

I think it's multifactorial—the latest surveys have shown that primary care physicians still remain uncomfortable treating ADHD, and that does create tension in the market. They're much more comfortable, according to some of the surveys that we've done, treating anxiety disorders and depressive disorders as compared to ADHD. So, there’s still work to be done in terms of education.

Social media may play a role. We've had screeners out there for a long period of time, some of which I've helped design. They may help in terms of improving identifying individuals at risk for the disorder.

The take-home message is that if individuals are concerned that they might have ADHD, because we have good treatments available, it's appropriate to come in and get an evaluation. Getting evaluated doesn't mean you have the diagnosis.

Lenard A. Adler MD, completed his residency and chief residency in Psychiatry at the NYU Grossman School of Medicine, where he has remained on staff since 1986. Dr Adler is a professor of psychiatry and child and adolescent psychiatry. His research and clinical interests center on attention-deficit/hyperactivity disorder (ADHD) in adults, mainly focusing on new assessments and treatments. He serves as vice chair for education in the Department of Psychiatry and director of the Adult ADHD program.  He has published over 150 peer reviewed manuscripts and served previously as the President of American Professional Society of ADHD and Related Disorders.