Screening, Diagnosing, and Treating Adult ADHD
Although adult attention-deficit hyperactivity disorder (ADHD) is common in the United States, few primary care providers receive adequate training, according to David W. Goodman, MD, who spoke about this topic during his presentation at the Practical Updates in Primary Care 2020 this afternoon.
Dr Goodman is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine and director of the Adult Attention Deficit Disorder Center of Maryland in Baltimore.
How Prevalent Is ADHD in Adults?
ADHD is highly prevalent in both children and adults, so it is important to screen regardless of age, Dr Goodman said.
“ADHD in adults, at 4.4%, is the second-most prevalent psychiatric condition in the United States,” Dr Goodman said. “I know you weren’t trained on this. You got mental health training, and they never mentioned adult ADHD, which means that ADHD should be part of every single mental health evaluation, at least through some screening questions.”
He said that childhood ADHD is typically diagnosed at age 7 years when symptoms present and are accompanied by impairments. However, if impairments do not accompany symptoms in childhood, the diagnosis may not be made until later in life.
How Can I Accurately Diagnose ADHD in Adults?
Dr Goodman said that diagnostic accuracy is enhanced by considering the presenting symptoms, the age of onset, longitudinal course (ie, chronic, pervasive, or impairment), and the family psychiatric history.
“Family history, which is not included in the diagnostic criteria, is very important because we know that ADHD is highly heritable—75% to 80% of cases are caused by genetic factors,” Dr Goodman said.
He also recommends using symptom checklists at baseline to target symptoms and throughout the course of disease to track any changes treatment may cause.
Diagnostic criteria for adults, according to the Diagnostic and Statistical Manual of Mental Disorders 5, include being aged 17 years or older, having a symptom threshold of 5 or more, and having a “presentation” category designation. Also, ADHD can now be diagnosed in adults with or without autism spectrum disorder, Dr Goodman said.
How Can I Identify Comorbid Psychiatric Disorders?
“Comorbidity is very high,” Dr Goodman said. “If you have 100 patients with ADHD in adulthood, 40 of them are going to have a mood disorder.” Bipolar disorder (19.4%), major depression (18.6%), and dysthymia (12.8%) are the most common mood disorders, Dr Goodman said.
Anxiety disorders are also common among adults with ADHD, including social phobia (29.3%), post-traumatic stress disorder (11.9%), panic disorder (8.9%), generalized anxiety disorder (8.0%), agoraphobia (4.0%), and obsessive-compulsive disorder (2.7%).
“How do you determine which disorder gets treated first, second, or third?” Dr Goodman asked. “The object is to treat one condition without worsening the other, untreated disorders.”
He said the recommended treatment prioritization is:
- Alcohol and substance abuse,
- Mood disorders,
- Anxiety disorders, and
- ADHD.
What Treatment Options Are Currently Available?
Dr Goodman then discussed therapeutic options for adults and children with ADHD. He said, “Education of ADHD, medication, behavioral changes, and cognitive therapies are all effective.”
“Do not make a diagnosis based on medication,” Dr Goodman urged. “In fact, 30% of adults with ADD do not have a beneficial response to the first stimulant. They may respond to an alternative stimulant.”
Six compounds are currently approved by the US Food and Drug Administration for adults with ADHD: methylphenidate, D-methylphenidate, amphetamine, mixed amphetamine salts, methamphetamine, and D-amphetamine. Adverse effects include insomnia, gastrointestinal upset, decreased appetite, weight loss, headaches, dry mouth, constipation, hand tremors, and jitteriness, Dr Goodman said.
Nonstimulant medications include atomoxetine for adults and children, guanfacine extended release for children and adolescents, and clonidine extended release for children and adolescents. Some additional medications are often used off-label, including bupropion for adults, desipramine for adults, and modafinil for children, Dr Goodman said.
Psychotherapy is also effective for treating symptoms related to adult ADHD.
“If you treat these patients, it is remarkably satisfying for you and for the patient,” Dr Goodman concluded. “They evolve. They morph into the person they had hoped and believed they could be unencumbered by their ADHD.”
—Amanda Balbi
Reference:
Goodman DW. Improving outcomes in adult ADHD. Talk presented at: Practical Updates in Primary Care 2020 Virtual Series; October 9-10, 2020; virtual.