Working adeptly to diagnose and treat adult ADHD

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Behavioral Health

Working adeptly to diagnose and treat adult ADHD

J Fam Pract. 2020 April;69(3):145-149

By

Jay A. Brieler, MD

Alison Matsunaga, MD

Jennifer Gafford, PhD

Rely on DSM-5 criteria and an appropriate rating scale to assess how an individual’s inattention, hyperactivity, and impulsivity interfere with functioning in different settings.

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References

1. Neurodevelopmental disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013:59-65.

2. Moreno-Alcázar A, Ramos-Quiroga JA, Radua J, et al. Brain abnormalities in adults with Attention Deficit Hyperactivity Disorder revealed by voxel-based morphometry. Psychiatry Res Neuroimaging. 2016;254:41-47.

3. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9:490-499.

4. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402-409.

5. Kessler R, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716-723.

6. Klein RG, Mannuzza S, Olazagasti MA, et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Arch Gen Psychiatry. 2012;69:1295-1303.

7. Asherson P, Young AH, Eich-Hochli D, et al. Differential diagnosis, comorbidity, and treatment of ADHD in relation to bipolar disorder or borderline personality disorder in adults. Curr Med Res Opin. 2014;30:1657-1672.

8. Grogan K, Gormley CI, Rooney B, et al. Differential diagnosis and co-morbidity of ADHD and anxiety in adults. Br J Clin Psychol. 2018;57:99-115.

9. Ilbegi S, Groenman AP, Schellekens A, et al. Substance use and nicotine dependence in persistent, remittent, and late-onset ADHD: a 10-year longitudinal study from childhood to young adulthood. J Neurodev Disord. 2018;10:42.

10. Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000:78-84.

11. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self‐Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35:245‐256.

12. Ustun B, Adler LA, Rudin C, et al. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry. 2017;74:520-527.

13. Ramos-Quiroga JA, Nasillo V, Richarte V, et al. Criteria and concurrent validity of DIVA 2.0: a semi-structured diagnostic interview for adult ADHD. J Atten Disord. 2019;23:1126-1135.

14. Pettersson R, Söderström S, Nilsson KW. Diagnosing ADHD in adults: an examination of the discriminative validity of neuropsychological tests and diagnostic assessment instruments. J Atten Disord. 2018;22:1019-1031.

15. Parikh AR, Baker SA. Adult ADHD: pharmacologic treatment in the DSM-5 era. Curr Psychiatry. 2016;15:18-25.

16. Searight HR, Gafford J, Evans SL. Attention Deficit Hyperactivity Disorder. In: Smith MA, Shimp LA, Schrager S, eds. Family Medicine: Ambulatory Care and Prevention. 6th ed. New York, NY: McGraw-Hill; 2014:829-846.

THE CASE

Emily L* is a 20-year-old woman who, on the advice of her college counselor, has made an office appointment to discuss her difficulty in keeping up with college classes. She achieved good grades in high school but is now struggling to deal with the quantity of reading in her courses. She was often able to complete assignments the night before the due date in high school, but this strategy is no longer working. She is having some doubt about her abilities, and is feeling overwhelmed, but is able to enjoy activities with friends. Her college counselor suggested she see her doctor for an assessment of her attention problems.

Ms. L’s family physician interviewed her and, aided by parental input, was able to identify a pattern of disorganized and impulsive behavior that was present even in grade school. Mood disorders and substance abuse were ruled out from the interview and lab testing, and cognitive ability was confirmed through a review of school testing.

● HOW WOULD YOU PROCEED WITH THIS PATIENT?

* The patient’s name has been changed to protect her identity.

Attention-deficit/hyperactivity disorder (ADHD) is classified as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), its hallmarks being inattentive, hyperactive, or impulsive behaviors that affect functioning or development.¹ Historically, it was thought that ADHD was a disorder of children and adolescents, and that patients “grew out” of their behaviors once adulthood was reached. It is now estimated that 50% of children with ADHD will carry the diagnosis into adulthood,² resulting in a prevalence of 5.9% to 7.1% for children³ and 3.4% for adults.⁴ There are 3 presentations of ADHD, known as ADHD-I (inattentive), ADHD-HI (hyperactive-impulsive), and ADHD-C (combined). The inattentive type accounts for 47% of adult cases, and adult ADHD disproportionately affects males compared with females.²

ADHD is a powerful risk factor for future substance use.

An overall pattern of underachievement and variable performance is common throughout life in patients with ADHD. Adults are much more likely to report subtle impairments in higher executive functions such as organization, time management, and modulating emotions. Consequences include poor performance at work, attendance issues, difficulty with social interactions, and an increased likelihood of unemployment.⁵ Among those employed, there is a large disparity in income compared with counterparts without ADHD.⁶ Increased risk of substance use, injury, and traffic accidents also has been reported.¹

Disorders that can mimic or coexist with ADHD

The differential diagnosis for ADHD is wide, and comorbidity with other disorders is common.

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