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6 Challenges in Assessing ADHD in Adult Patients

6 Challenges in Assessing ADHD in Adult Patients


  • The clinical presentation and functional impacts of ADHD in adults vary greatly from their child and adolescent counterparts. Scroll through the slides to read more on this issue. View a PDF of this article.


  • It is often assumed that hyperactivity/impulsivity fade or resolve entirely in adults as they grow older. However, maturation results in a shift in this symptom cluster, and it evolves from behavioral to cognitive—adult patients feel restless as opposed to running around and being disruptive in school.

     


  • Inattention presents as difficulty in completing tasks, poor time management, difficulty in sustaining attention in work-related activities, distractibility and forgetfulness, and poor concentration.


  • Ultimately, this may result in frequent job changes, unemployment, failure to live up to one’s occupational potential, and lower salaries. Moreover, deficits in global performance in the adult patient’s life role, follow-through, and memory can have pervasive effects that extend to those who depend on him or her (eg, children, spouses, employers, friends).


  • There are a host of validated rating scales for assessing adult patients with suspected ADHD, such as the Adult Self-Report Scale (ASRS) and the Conners Self-Report Scale. One of the most significant limitations of self-report scales is that they are generally not sufficient independently to establish a diagnosis in the absence of more objective data or documentation.

  • Major challenges include a lack of validated diagnostic criteria; psychiatric comorbidity and symptom overlap; compensatory mechanisms; evidence of significant clinical impact; underdiagnosis vs overdiagnosis; and prescription drug abuse and drug-seeking behavior.

  • Because ADHD is considered a developmental disorder, the presence of current symptoms as well as a history of previous symptoms (in childhood) needs to be established. Even with DSM-5 criteria, practitioners need to make a retrospective evaluation of the presence of ADHD in childhood in order to establish a diagnosis in adulthood but many patients have problems recalling childhood symptoms or they have no documentation substantiating a childhood diagnosis. Patients with ADHD also have impaired short- and long-term memory; therefore, recall bias can affect the accuracy of assessments. The challenge is determining whether this was an established childhood diagnosis, a missed diagnosis in childhood, or a late-onset adult ADHD.

  • Determining whether ADHD is present alone or whether it is comorbid with another psychiatric disorder is critical—a mood or anxiety disorder may be responsible for the ADHD-like symptoms. Compared with patients who have a depressive disorder, those with ADHD tend to have more occupational or functional impairment, organizational deficits, and impulsivity issues. The distinction between ADHD and bipolar disorder can be especially challenging, since the manic and hypomanic features of bipolar disorder are similar to the hyperactive and impulsive symptoms associated with ADHD. In patients with ADHD, these symptoms tend to be constant, but in bipolar disorder there is a waxing and waning of manic symptoms interrupted with periods of depression. Patients with bipolar disorder tend to be goal-directed and are usually productive, while patients with ADHD are less able to complete tasks. Substance use disorders are also common in patients with ADHD.

  • Patients who are highly functioning with higher than average IQs tend to develop useful coping mechanisms to overcome symptoms or to hide them from others. Some patients become compulsive list makers or develop a highly structured daily routine in order to complete tasks and to minimize forgetting details or losing belongings. They may unknowingly rely on coworkers or family members to an inappropriate extent for reminders or assistance in completing tasks or fulfilling responsibilities. Although compensatory mechanisms are generally therapeutic for the patient, they may cloud the clinical picture particularly in cases where the patient does not self-suspect ADHD but rather a family member or the practitioner suspects ADHD.

  • Among the DSM criteria is an item that evaluates the degree of clinical impact of ADHD symptoms on life domains. For a diagnosis of ADHD, there must be clear evidence of significant clinical impact, which can be especially difficult to objectively assess. Failure to demonstrate significant clinical impact precludes a diagnosis of ADHD even if all other criteria are satisfied. Examples of true clinical impact include disciplinary action at work, risk of job loss, relationship discord, or frequent automobile accidents or accidents in the home.

  • Given the high degree of psychiatric symptom overlap, the realistic possibility of feigning ADHD symptoms, and a general fear of enabling drug addiction or diversion, the underdiagnosis versus overdiagnosis of ADHD in practice has been called into question. There are no available data to quantify this concern, and therefore no support can be lent to the argument of failure to recognize ADHD or misdiagnosis of ADHD. A psychiatric comorbidity and the point of entry into the health care system (primary care versus a psychiatrist) may influence whether ADHD is overdiagnosed or underdiagnosed.


  • The majority of adult patients who present with self-suspected ADHD are between the ages of 18 and 24; therefore, the unfortunate but realistic risk of drug seeking must be considered. A definitive statistic that quantifies the risk and rates of stimulant medication abuse is elusive owing to patient unwillingness to admit abuse or diversion.


  • For more on this topic, see Adult ADHD: A Review of the Clinical Presentation, Challenges, and Treatment Options, by Jennifer A. Reinhold, PharmD, BCPS, BCPP, on which this slideshow is based.

Comments

Addendum: I am also the Director of Behavioral Health at Memorial Medical Center, in Las Cruces, New Mexico.

Manuel Mota-Castillo, MD

Manuel @

I like the format used to present this article because it is reader-friendly and direct to the point. On the other hand, I believe that the author (as the majority of clinicians do) falls into the trap of endorsing two DSM-supported fallacies:
1- “ADHD has a high degree of comorbidities”. The reality that I have found in the past 25 years is that ADHD is frequently considered a Dx of “inclusion” (based of symptoms) instead of one of exclusion. What I mean is that if a person has rapid changes in mood, is irritable or “super happy”, takes 2-3 hours to fall sleep, because of racing thoughts and his parents have spectrum bipolar disorders, OCD or another anxiety disorder, one should consider a Dx different to ADHD. If the conclusion is, for example, bipolar II disorder then there is no need to add a Dx of ADHD because the lack of attention, restlessness, impulsivity, etc., already have an explanation. Also without logical foundation is to label as “ADHD” a child with Autism Spectrum Disorder. We all know that Autism comes with obsessions and that those intrusive thoughts distract the person.
2- “It is difficult to differentiate bipolar spectrum disorder from ADHD”. In my entire career I have found one case that let me with doubts about the Dx but I opted for a trial with atomoxetine because that person also was “a nervous wreck” and the stimulants are contraindicated in the presence of anxiety. The patient responded well and both, the ADHD and the anxiety got better.
Another angle that I want to address is the comment about the potential for “doctor shopping” by pseudo-patients or people addicted to amphetamines. Here in New Mexico (and before in Florida and Arizona) there are doctors and Nurse Practitioners that truly believe that “anybody can benefit from an amphetamine”. Apart from the medical risk that amphetamines pose to the human body, it is the fact that patients with OCD, PTSD and other types of anxiety will get worse if given amphetamines (or even caffeine). Still, believe it or not, I have found patients with overt psychosis being prescribed psychostimulants.
Finally, I should say that I have a great respect for pharmacist doctors and I welcome their feedback and advice regarding medications but it is true that only physician must diagnose medical conditions. To rule out medical mimics of psychiatric illnesses you have to be a medical doctor. Nevertheless, in view of the American Psychiatric Association and the American Academic of Child and Adolescent Psychiatry lack of response to the dangerous practice of allowing teachers and school counselors to “diagnose” AHDH (using a behavioral scale that is not a diagnostic tool) and sending a child to a pediatrician to get a Rx for psychostimulant, I have not quarrel with a pharmacist writing about ADHD.
Dr. Manuel Mota-Castillo
Chief and
Residency Program Director
Department of Psychiatry
Burrell College of Osteopathic Medicine
3501 Arrowhead Drive
Las Cruces, NM 88003
Office: (575) 674-2334

Manuel @

I would like to suggest that before prescribing a stimulant to an adolescent, young adult or an adult, the clinician should perform a drug test (not just a screen) to assess the use of marijuana, stimulants and other substances.
Also, one MUST check the PDMP for your state. I have recently treated a professional who was getting prescriptions for amphetamine salts from 6 psychiatrists, 8 different pharmacies and apparently NO one had checked to see the on going doctor shopping.
If you feel you must diagnosis and treat with stimulants, adult ADD or ADHD, be a responsible prescriber. Do the right thing by your patients.
Susan

Susan @

Good advice Susan! It's the responsible thing to do. Thank goodness for PMP. Niw that we have it, let's use it!

Carol @

I'm afraid to say this: A decent medical publication should never accept clinical comments from someone who is not a physician, in this case, a pharmacist.
This is an insult to medical professions, that are: physicians, nurses, nurse assistants, physical therapists, if the author lacks a clinical experience, his or her comments have no more value than those of a reader's digest writer, of course, no comparison to a 'Meta-analysis' is possible.
A pharmacist claiming to have clinical experience is by definition incurse in the offense of 'Professional intrusion'.
Please, don't do this anymore!

Jose @

I disagree. Pharmacists must learn about and know far more than nurses about stimulent addiction and the law. I have a BSN, by the way.

Linda @

This arrogance and contempt for vital professions allied to medicine is breathtaking.

Please, don't do this anymore!

roger @

This is excellent information. I have found among job holding/school attending young people that they tend to be serious minded, truly distressed and definitely not the prototype of the drug seeker. Furthermore, they respond well to treatment. I agree the waters on the diagnostic criteria are murky at best and navigation can be a challenge. Good to keep the "big 3" in mind: actual work problems, relationship discord and accidents. I once had an attorney who presented telling me his paralegal was threatening to quit because he had hundreds of sticky notes all over the place! Just a clue!

Carol @

EEG biofeedback needs to the front line treatment for issues of this kind. The benefits are so strong, pervasive and enduring that careful diagnosis is less relevant.
See http://noviancounseling.wixsite.com/bibliography for a boat load of research on a variety of conditions.

Gary @

Not true at all! The evidence that suggests this is minimal to non-existent.

John @

ADHD in adult mostly experience like they are behind their age. Girls shows a ADHD symptoms like they are more shy, irritated, early morning depression, less eye contact, less active

Nadira @

Very good information, thank you. I also recommend http://www.drthomasebrown.com/ ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults

Alonso @

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