Hero

Videos

Slideshows

Articles

Podcasts

Poll

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Somatic symptom and related disorders (SSRDs) are a set of psychiatric conditions characterized by physical symptoms that are inconsistent with physical disease and influenced by psychological factors. They are common in pediatric medicine, with prevalence rates ranging from 13% to 50% depending on the setting. Across all ages, SSRDs account for nearly 20% of health care spending annually.

 Additionally, a small subset of patients have multiple somatic complaints and tend to access crisis and emergency services and hospital services at higher rates. They also have high recidivism rates.

Despite the recognition of the impact of SSRDs on pediatric health care, clinicians and patients/families continue to be frustrated with the evaluation and management of these conditions.

 Without early incorporation of a broader biopsychosocial conceptualization, there can be an undue focus on disability, impairment, and somatic complaints. This leads to low-yield diagnostic testing and increased polypharmacy interventions that do not address the rehabilitative needs of the patient and family.

 In the absence of an explanatory model for symptoms, patients and families may feel they are being dismissed, creating a dynamic of mistrust between patients/families and the medical system. Ultimately, without a clear road map for evaluation and management, care can be inconsistent and misuse of health care resources may occur, which, in turn, can lead to poor outcomes.

As SSRDs most often present in nonpsychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or in a hospital setting. Therefore, psychiatric consultation should be considered as early as possible to foster the perception that consultation-liaison (CL) psychiatrists are an integral part of the multispecialty team.

SSRDs account for approximately 15% to 20% of psychiatric consults in the pediatric hospital setting and have been reported as the second most common reason for consultation after suicide assessments.

 As such, there is a growing effort to standardize the evaluation and management of pediatric SSRDs. Most recently, the 

American Academy of Child and Adolescent Psychiatry 

(AACAP) published a Clinical Consensus Pathway for SSRD Evaluation and Management.

Most SSRDs are seen in nonpsychiatric settings, with approximately 6% of hospitalized children relaying symptoms consistent with an SSRD.

 The most common complaints include neurologic symptoms, pain, gastrointestinal distress, and fatigue.

 SSRDs can present at any age, but they are more common and less problematic in prepubertal youth, with increasing impairment and pathology in adolescents.

 Prevalence rates are equal across sexes prior to puberty; after puberty, higher prevalence is seen in female sex.

 Although psychological trauma, particularly sexual trauma, is a well-associated risk factor for SSRDs in adults, it is not necessarily associated with SSRDs in youth.

 However, if present, trauma in youth with SSRDs often results in a more complicated treatment course, more severe symptoms, and increased risk for need of higher levels of psychiatric care.

The evaluation and management of youth experiencing an SSRD are predicated on early recognition of risk factors (

). The foundation of an SSRD evaluation is built on concurrent mental health and physical health evaluation, unified evidence-based language that is consistent across disciplines, and direct communication with the family regarding the multifactorial nature of SSRD presentation. Care of youth with SSRDs requires close interprofessional team support. This includes collaboration among the primary care physician (PCP), emergency physician, hospitalist physician, nursing, social work, child life, rehabilitative staff, subspecialty pediatricians, and CL psychiatrist/psychologist. Roles should be delineated early in the management course.

CL psychology/psychiatry should be consulted at the earliest suspicion of an SSRD to normalize psychiatric involvement in comprehensive care. Beyond assessment, CL psychology/psychiatry can aid with framing conversations with the patient and family, providing evidence-based interventions, and addressing psychiatric comorbidities. Although SSRDs do not necessarily accompany other discrete psychiatric conditions, anxiety disorders and mood disorders may be present in up to 50% of youth with SSRDs. These comorbidities should be incorporated in the case formulation for proper management of these conditions.

 Ultimately, this process is dynamic and highly interactive and should adapt to the needs of the patient and family.

Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the multiple biopsychosocial factors allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. Joint communication by all involved physicians and other clinicians using consistent DSM-5 language and clear discussions of a conceptual framework for symptom development, highlighting mind-body interactions, are crucial.

Once the evaluation is complete and the diagnosis of SSRD is confirmed, it is helpful to have an interprofessional care meeting with the patient family to share the diagnosis. Explaining a conceptualization of how symptoms formed, progressed, and continue to present—along with the related biopsychosocial factors influencing presentation—is the most critical part of this conversation. This is accomplished via joint physical health and mental health providers using consistent DSM language with the relationship of physical, environmental, psychological, social, and cognitive factors to symptom development. For the patient and family to invest in the diagnoses and partner in the ongoing management of SSRD, they must understand this conceptualization.

Importantly, clinicians should gauge the patient’s and family’s readiness to accept the information. As such, communication must be geared to the individual’s understanding, values, and readiness. It is often valuable to pair discussions with the use of motivational interviewing to enhance engagement and understand the patient’s or family member’s experience. Discussions may start with a more biological conceptualization, emphasizing concepts such as somatosensory amplification and visceral hypersensitivity; analogies may be used to highlight mind-body interactions. Some families may be able to appreciate and incorporate psychological constructs earlier in the discussion of this conceptual framework. It is important to validate emotions while shifting discussions to functionality. Patients may want to focus on their impairment; it is, therefore, important to pivot conversation to highlight strengths, abilities, and incremental improvements.

Management of an SSRD in youth is an iterative process that begins with setting clear goals and expectations. Misalignment of expectations is often a point of conflict. Patients and families may expect complete resolution of symptoms following initial encounters. Here, psychoeducation is key to the initial framing of the concept of somatization, discussing mind-body interactions, and describing joint medical and psychiatric management. Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD.

 CBT aids in greater awareness of how cognition, emotions, and other psychological processes impact physical sensations, and it empowers the patient with strategies to dampen somatic complaints. It focuses on improving functioning in small, achievable steps while shifting the focus away from impairment.

CBT psychotherapy can occur in tandem with delivery of rehabilitative services. As many as 50% of youth with an SSRD will have a comorbid depressive or anxiety disorder, making treatment of psychiatric comorbidities an important component of SSRD management.

 Close involvement with the PCP is necessary, including proactive, regularly scheduled brief visits. These visits should be used to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. PCPs should conduct judicious evaluations of new concerns, collaborating with psychiatry, psychology, and subspecialty pediatrics as needed. In this way, the propensity to seek care in crisis and pursue care in a disjointed fashion can be extinguished over time.

Care should be provided in the setting that best matches the patient’s needs and severity of illness. For youth with severe worsening of function without a clear diagnostic understanding, medical admission may be warranted for further evaluation and management. Youth with significant psychiatric comorbidity may benefit from inpatient or partial psychiatric hospitalization. Those patients with significant rehabilitative needs will benefit from intensive outpatient or inpatient rehabilitation. Most youth, however, can be successfully managed in the outpatient setting with regular PCP evaluations, ongoing psychotherapy, and psychiatric care, as well as additional rehabilitative and pediatric subspecialty follow-up.1 This approach, which aligns with national consensus, provides the best framework for youth to regain functioning, improve symptomatically, and succeed in the care of SSRD.

Care of youth with SSRDs highlights the important liaison role of CL psychiatry. CL psychiatrists aid in the dissemination of information and develop a shared understanding with the patient and family; they also support appropriate language use and incorporate psychological, social, psychiatric, familial, and cognitive factors in the overall assessment with the larger care team. This should include clearly defining care team roles, as well as setting expectations with patients and their families (

The CL psychiatrist should describe mind-body interactions using analogies that simplify understanding for the patient and family. For example, a computer analogy helps explain SSRDs, in which physical disease is more akin to a hardware problem and psychosocial and environmental factors are more akin to a software issue. Similarly, it can be helpful to describe SSRDs as the body’s alarm system being overactive or hypersensitive to somatosensory interactions, which can lead to identification of factors that can heighten or dampen normative reactions to bodily sensations. The goal is to aid patients and families in understanding the interplay of physiologic, psychological, social, and emotional factors that influence somatic symptoms.

Given the diverse and wide-ranging issues and the number of team members involved in effective SSRD care, the CL psychiatrist should also be at the forefront in aiding standardization of multidisciplinary, evidence-based interventions. This should be informed by existing consensus guidelines, such as those published by the AACAP in 2020, and local resources, systems of care, and practice experiences.

CL psychiatrists may be asked about the use of psychopharmacology in managing SSRDs. There is no evidence to demonstrate that psychopharmacology can directly ameliorate the symptoms of SSRDs, and this should be expressed clearly to patients and families as well as to the larger care team.14 At times, youth and families may become frustrated that psychopharmacology has not resulted in resolution of symptoms. Therefore, it is important to reiterate, early on, that management of SSRDs is predicated on a multidisciplinary approach that targets the factors fostering symptom-development and persistence. Here the focus is shifted to improvement in functioning and incremental rehabilitation of cognitive, emotional, and physical health factors.

Psychopharmacology can be helpful in addressing psychiatric comorbidities and may provide more immediate relief for other psychiatric factors resulting in acute distress. When provided, psychopharmacological options should have clear targets for management with clear expectations within the greater context of treatment. It is important to explore familial expectations and continue to set realistic expectations, emphasizing the importance of ongoing engagement with other care teams, including psychology and rehabilitative services.

CL psychiatry can also have an important role in informing longitudinal management of SSRDs, which may be accomplished through collaborative clinical models. Such models often have psychiatry and psychology providing integrated care in a primary care or subspecialty pediatric practice. Inpatient psychiatric care may be needed for young patients with severe psychiatric comorbidities, safety concerns related to suicidal ideation or behavior, or severe psychological trauma. Ultimately, disposition planning must account for the level of training, experience, resources, and standardization of practice that exists within different settings in a given health system.

 is a child and adolescent psychiatry fellow at the University of Michigan. Dr Biermann is clinical assistant professor in the Department of Psychiatry at the University of Michigan.

is a clinical instructor and associate medical director of the Nyman Family Unit in the Department of Psychiatry at the University of Michigan. 

is associate professor in the Departments of Psychiatry and Pediatrics at the University of Michigan.

1. Malas N, Donohue L, Cook RJ, et al. Pediatric somatic symptom and related disorders: primary care provider perspectives. 

2. Kullgren KA, Shefler A, Malas N, et al. Taking the pain out of somatization: development and implementation of a hospital-based clinical practice guideline to address pediatric somatic symptom and related disorders. 

3. Ibeziako P, Brahmbhatt K, Chapman A, et al S. Developing a clinical pathway for somatic symptom and related disorders in pediatric hospital settings. 

4. Shaw RJ, Pao M, Holland JE, DeMaso DR. Practice patterns revisited in pediatric psychosomatic medicine. 

5. Bujoreanu S, White MT, Gerber B, Ibeziako P. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. 

6. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. 

7. Rask CU. Functional somatic symptoms in 5-7 year old children: assessment, prevalence and co-occurrence. 

8. Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? results from the 1958 British Birth Cohort Study. 

9. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Pediatric somatic symptom disorders. 

10. Plioplys S, Doss J, Siddarth P, et al. Risk factors for comorbid psychopathology in youth with psychogenic nonepileptic seizures. 

11. Thomson K, Randall E, Ibeziako P, Bujoreanu IS. Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics. 

12. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioral therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. 

13. Ibeziako P, Randall E, Vassilopoulos A, et al. Prevalence, patterns, and correlates of pain in medically hospitalized pediatric patients with somatic symptom and related disorders. 

14. Kleinstäuber M, Witthöft M, Steffanowski A, et al. Pharmacological interventions for somatoform disorders in adults. 

There is a growing effort to standardize the evaluation and management of pediatric SSRDs, which have been reported as the second most common reason for consultation after suicide assessments.

Care of Youth Hospitalized With Somatic Symptom and Related Disorders

Recent study results revealed that children with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) had a 

 in the incidence of later development of bipolar disorder (BD) compared with matched children without ADHD.

 is common, has a more severe course than either diagnosis alone, and is associated with greater risk of suicide attempts.

 Clinicians will have trouble determining which diagnosis best fits the patient, and it could be that the patient has both diagnoses. Often the patient (and/or prescriber) prefers the ADHD diagnosis and the stimulant medications used to treat it. They hope to avoid the BD diagnosis and medications used to treat it, because of the perceived stigma and complexity of treatment. The differential diagnosis is made by recognizing that bipolar (hypo)manias occur in discrete episodes of at least 4 to 7 days, whereas the hyperactivity and associated symptoms of ADHD are more or less constantly present as features of the individual’s temperament.

The comorbidity of ADHD and BD may involve overlapping genetics. In Sweden, 13,532 twin pairs (aged 9 to 12 years) were 

 using parent-rated instruments for ADHD and hypomanic episodes.

 Overlapping symptoms were removed to aid in the analysis. The twin pairs were reassessed when aged 15 years and again when aged 18 years (N = 3013 pairs). They found that genetic factors associated with hypomania explained 25% to 42% of the likelihood of ADHD’s hyperactive/impulsive symptoms. There was less effect on the inattentive symptoms of ADHD. Monozygotic twins had a stronger association of the 2 conditions than dizygotic twins. The rest of the variance was presumed to be associated with causes of ADHD that do not contribute to causing hypomania.

The bottom line of these data is that it is important to take the time to diagnose bipolar disorder accurately in patients with a history of ADHD or who are presenting with current ADHD. Mood-stabilizing medications such as lithium will usually be indicated for the bipolar condition.

Stimulant treatment of ADHD when there is comorbid BD has been controversial. However, an important 2016 study by 

 that may influence practice. This large observational study found that if patients are treated with methylphenidate for ADHD and their BD is not being treated with a mood stabilizer, the likelihood of manic switch over 3 to 6 months is multiplied by nearly 7-fold, compared with 

 not treated with methylphenidate. However, if patients are on a bipolar mood stabilizer, the addition of methylphenidate was associated with reduced odds of becoming manic, compared with the control patients with BD who were not given a stimulant, with a hazard ratio of 0.6 (ie, a 40% reduction). Thus, it seemed that methylphenidate can be safe and effective for ADHD symptoms if the patient is on a mood stabilizer to manage the BD. Note that amphetamine products were not evaluated in this Scandinavian study; many European countries have not approved these agents.

In summary, it is critically important to carefully evaluate whether patients with ADHD also have BD. If you miss the bipolar diagnosis and treat the ADHD with a stimulant, the potential for harm (ie, induction of mania) is considerable. However, if the bipolar disorder is under control with a mood stabilizer, the use of a stimulant (at least methylphenidate) need not be avoided. Indeed, it may be quite helpful.

is associate professor of psychiatry, Harvard Medical School, and co-lead psychiatrist, US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, MA. He is a member of the 

 Editorial Board. The author reports no conflicts of interest concerning the subject matter of this article.

This article was originally posted ahead of print on October 30, 2020 under the title ADHD in Bipolar Patients: Genetics, Diagnosis, and Treatment, and has since been updated. -Ed

1. Meier SM, Pavlova B, Dalsgaard S, et al. 

Attention-deficit hyperactivity disorder and anxiety disorders as precursors of bipolar disorder onset in adulthood

Comorbidity of ADHD and suicide attempts among adolescents and young adults with bipolar disorder: a nationwide longitudinal study

3. Hosang GM, Lichtenstein P, Ronald A, Lundström, Taylor MJ. 

Association of genetic and environmental risks for attention-deficit/hyperactivity disorder with hypomanic symptoms in youths

4. Viktorin A, Rydén E, Thase ME, et al. 

The risk of treatment-emergent mania with methylphenidate in bipolar disorder

Although clinicians and patients may wish otherwise, the comorbidity of ADHD and bipolar disorder needs to be considered.  

ADHD in Patients With Bipolar Disorder: Genetics, Diagnosis, and Treatment

In the midst of a nationwide opioid epidemic, there is a population that is largely being ignored. According to a large cohort study, only a small percentage of teens receive proper aftercare following near-fatal overdoses. 

 examined data from more than 4 million Medicaid enrollees (N = 4,039,216) and found that only 1 in 54 youths aged 13 to 22 years received evidence-based pharmacotherapy after an overdose. Unfortunately, it appears that proper care in this patient population is given in very few cases (

 invited lead author Rachel H. Alinsky, MD, MPH, to share insights from the study. Alinsky is an adolescent medicine and addiction medicine fellow at 

Johns Hopkins University School of Medicine

: Your research highlights the need for quality treatment, especially for younger patients. What insights can you provide about interventions and obstacles to treatment?

We need to find effective interventions that can link adolescents and young adults directly into treatment after an opioid overdose. We also need to evaluate the barriers to accessing care at the time of overdose (such as insurance restrictions, lack of community providers or treatment centers, and stigma), and find strategies to mitigate these barriers. System-level changes are necessary, such as targeting federal funding for research and treatment for youth, decreasing insurance barriers, and increasing the availability of youth-serving physicians and addiction treatment centers.

 In the study, you and your colleagues noted, “Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment.” Is that because these youths have hit rock bottom?

In the addiction treatment field, we do not abide by that old adage—that people have to hit rock bottom before they are ready to get treatment. That is somewhat of a myth. What we are trying to emphasize in our article is that overdose is a particularly crucial time when we can draw someone into treatment because they are presenting into the medical setting, seeing doctors, and we have this opportunity to interact with them and offer them treatment. Coming into the emergency department with an overdose may be the only time this person is sitting face-to-face with a doctor, and we want to capitalize on this opportunity to offer the best care we can to the patient.

Of course, that does not mean they did not want treatment a month ago or a week ago—they very well might have wanted treatment but did not know how to access it in our very difficult-to-navigate addiction treatment system. So when the patient is physically with us after an overdose, we have the chance to help them gain access to lifesaving treatment.

PT: What are the key takeaway points from the study?

Prior to this study, we knew that teens and young adults were about one-tenth as likely as adults to receive treatment for opioid use disorder in general.

 And while we knew that more than 4000 adolescents and young adults between the ages of 15 and 24 die from an 

 very little was known about health care use following nonfatal opioid overdose in youth. We were interested in figuring out the extent to which adolescents and young adults are receiving evidence-based treatment after a nonfatal opioid overdose.

We found that fewer than 1 in 50 adolescents and young adults who had an opioid overdose received the standard-of-care medication treatment that is recommended by the American Academy of Pediatrics.

 We also found that youths with opioid overdose have a 

; more than 8% of youths with heroin overdose experience another overdose within 3 months.

When an adolescent or young adult goes to the hospital with an emergency, you expect them to get the treatment they need. But here we see that less than 2% are getting that treatment, which would not be acceptable for any other medical condition. In pediatrics, it would be unacceptable if only 1 in 50 youths with asthma [received] the standard treatment when they came into the emergency department, or if 1 in 50 youths with diabetes [received] the standard treatment when they were hospitalized with diabetic ketoacidosis. Pediatricians would not find that treatment gap acceptable. Yet this is where we are now with the treatment for youths who have an opioid overdose—and we need to do better for them.

Additionally, with such high rates of recurrent overdose, it is even more important to get these youths into effective treatment as soon as possible, so we can try to prevent another overdose.

Finally, prescribing practices should be closely monitored in young people; they are a critically neglected patient population when it comes to addiction monitoring. As verified in an earlier study of 2,752,612 adolescents: “Safe opioid prescribing practices are critical to mitigate the risk of prescription opioid overdose in adolescents and young adults.”

PT: What are the key issues in recognizing opioid use disorder in youth?

The diagnosis of opioid use disorder is straightforward and is based on how many criteria an individual meets from a set of 11 criteria defined in DSM-5. In the case of youths who are presenting with opioid overdose, there is a chance that clinicians may view this as a standalone incident, and not recognize it as a manifestation of an adolescent’s underlying opioid use disorder. Thus, clinicians should be thinking about, and evaluating for, opioid use disorder in any youths that present with an overdose. Clinicians should probe for issues such as taking the opioid in larger amounts than intended, unsuccessful efforts to cut down use, cravings, recurrent use despite failure to fulfill obligations at school or home, or recurrent use in physically hazardous situations.

In terms of treatment, psychiatrists and other providers should offer medication for opioid use disorder as first-line treatment, consistent with recommendations from the 

. These medications include buprenorphine, methadone, and naltrexone. Pharmacological interventions can be combined with behavioral health services such as therapy or counseling. The provider will need to determine the level of care that will best support the patient in their current stage of treatment—inpatient hospitalization, residential treatment, intensive outpatient, or outpatient treatment.

We know that medication is effective and lifesaving for opioid use disorder; large studies in adults have found that medication cuts the risk of death in half.6,7 We also know that youths who are on medication stay in treatment longer.8 Because so few youths actually ever receive this effective addiction treatment, an overdose can be an ideal opportunity to link someone into care who has not been able to access it previously.

How can clinicians advise their patients and families on finding the most appropriate care?

Patients and their parents can advocate for treatment by asking their doctors about treatment when they are in the emergency department with an overdose. Some emergency departments have programs where patients can immediately start on medication treatment; the programs can then link them to a provider in the community. These programs have been shown to be extremely effective, with much higher rates of individuals entering and staying in treatment than if someone is simply handed a phone number to call to set up treatment.9 If that sort of linkage is not available, families should ask to be referred so their teen or young adult can receive treatment in their community as soon as possible.

Clinicians or patients and families who want to find available treatment resources within their community can use the treatment locator provided by the Substance Abuse and Mental Health Services Administration (

). Here you can enter your zip code and find all the available addiction treatment centers, sorting by services offered. It is also possible to specifically look for buprenorphine prescribers or methadone programs from that web page.

1. Alinsky RH, Zima BT, Rodean J, et al. 

Receipt of addiction treatment after opioid overdose among Medicaid-enrolled adolescents and young adults

2. Chua KP, Brummett CM, Conti RM, Bohnert A. 

Association of opioid prescribing patterns with prescription opioid overdose in adolescents and young adults

3. Overdose death rates. National Institute on Drug Abuse. Updated March 10, 2020. Accessed November 30, 2020, 2020. 

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

4. Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. 

5. Feder KA, Krawczyk N, Saloner B. Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder.

6. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. 

7. Medications for Opioid Use Disorder Save Lives. The National Academies Press. Accessed November 30, 2020. 

http://www.nationalacademies.org/hmd/Reports/2019/medications-for-opioid-use-disorder-save-lives.aspx

8. Hadland SE, Bagley SM, Rodean J, et al. Receipt of timely addiction treatment and association of early medication treatment with retention in care among youths with opioid use disorder. 

9. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. 

With opioid use disorder, a tiny fraction of young patients are getting treatment, which would not be acceptable for any other medical condition. 

Improving Care in Teens With Opioid Use Disorder

Adolescence is a time of mental and physical fluctuation as well as a preparation for adulthood. The rapid changes that occur during this period may impact mental health, which could continue following the transition into being an adult. An investigation in 

 looks into whether social support during the teenaged years could lead to fewer mental health issues once an individual is an adult.

The investigation was a population-based cohort and used participants from the Quebec Longitudinal Study of Child Development. The participants in the cohort were given either yearly or biennial assessments beginning at age 5 months until age 20 years. They were asked to self-report their perceived social support when they were aged 19 years using the 10-item Social Provision Scale. Then, when each participant was aged 20 years, an assessment of mental health issues such as depressive symptoms and suicide ideation was administered.

A total of 1174 adolescents were included in the study, breaking down into 574 female participants and 600 male participants. The researchers found that young adults who reported higher levels of perceived social support when they were aged 19 years subsequently reported having fewer mental health problems a year later. This remained true even following adjustment for a number of mental health problems, such as depressive symptoms and suicide attempts, in adolescence at aged 15 and 17 years as well as family characteristics such as socioeconomic status. Additionally, higher perceived social support was linked with fewer symptoms of depression (β = −0.23; 95% CI, −0.26 to −0.18; P = <.001 and odds ratio [OR], 0.53; 95% CI, 0.42-0.66 for severe depression) and anxiety (β = −0.10; 95% CI, −0.15 to −0.04; P < .001 and OR, 0.78; 95% CI, 0.62-0.98 for severe anxiety). It was also tied to lower risks for outcomes related to suicide (for suicidal ideation: OR, 0.59 [95% CI, 0.50-0.70] and for suicide attempts: OR, 0.60 [95% CI, 0.46-0.79]).

The investigators concluded that perceived social support appears to help prevent the increase of mental health problems, at least over the course of a year. Providing social support during this transition period could help promote better health in the population.

1. Scardera S, Perret L, Ouellet-Morin I. Association of social support during adolescence with depression, anxiety, and suicidal ideation in young adults. 

Support in the tender younger years may lead to fewer mental health issues in the future, according to research. 

Social Support in Teen Years Could Improve Later Mental Health

7 Questions that Separate ADHD from Bipolar Disorder

What are they key differences between ADHD and bipolar disorder? How can they be identified? 

7 Questions That Separate ADHD From Bipolar Disorder

Diagnostic and Statistical Manual of Mental Disorders

, 5th edition (DSM-5) classifies attention-deficit/hyperactivity disorder (ADHD) as a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

 There is growing evidence that symptoms of ADHD can persist into adulthood and can cause significant impairments in social, academic, and occupational functioning. In addition, there is emerging evidence for the existence of a different variant of adult ADHD (aADHD) where ADHD symptoms emerge for the first time in young adulthood without any symptoms being 

 In this article we review various aspects of adult ADHD (aADHD) and suggest possible treatments.

The prevalence of ADHD in childhood is between 

 Emerging evidence indicates that ADHD symptoms may persist into adulthood in approximately 

 to suggest that adult ADHD (aADHD) is not just a continuation of childhood onset ADHD (cADHD), as many individuals do not have a history of this 

 It is postulated that there may be 2 distinct subtypes of aADHD: the first with childhood onset and the other with onset exclusively in adulthood. A meta-analysis evaluating the risk markers that predicted the persistence of ADHD from childhood into adulthood found that the severity of ADHD (odds ratio (OR) = 2.33, 

 < 0.001), treatment for ADHD (OR = 2.09, 

 = 0.037), comorbid conduct disorder (OR = 1.85, 

 = 0.030), and comorbid major depressive disorder (OR = 1.8, 

 = 0.019) emerged as predictors for childhood ADHD persisting into adulthood.

A meta-analysis by Simon et al, found the conservative pooled prevalence rate for adult ADHD (aADHD) to be 

 This study also found that the proportion of individuals with ADHD decreases with age, and the prevalence rates were equal among men and women. This data is in contrast to cADHD, where boys had 3 to 10 times greater prevalence rates when compared to girls. The authors also opined that the true prevalence rate of adult ADHD may be an underestimate, as some children with ADHD do not outgrow the disorder but outgrow the current diagnostic criteria (

Adult ADHD results in significant impairments in the individual’s personal, social, and professional life.

 Individuals with aADHD tend to have poor self-esteem and reduced quality of interpersonal and professional relationships. These individuals are twice as likely to be divorced, when compared to age-matched controls. They also have significant educational difficulties with lower grades, greater rates of academic suspension and dropout rates, and are less likely to graduate than students without ADHD. Individuals with aADHD have greater rates of traffic violations and motor vehicle accidents, and higher rates of emergency room visits and hospital admissions. They also have lower life expectancies and higher risk for death, including accidental deaths. Individuals with aADHD are more likely to be unemployed and have a greater likelihood of being involved in criminal behaviors. The overall national annual incremental costs of ADHD ranges from $143 to $266 billion.

 Most of these costs were incurred by adults ($105 billion to $194 billion) compared to children ($38 to $72 billion), and the largest cost category in this group was productivity and income losses of $87 billion to $138 billion. 

Approximately 80% of aADHD cases present with at least 1 lifetime psychiatric comorbidity.

 The National Comorbidity Survey found that aADHD was significantly comorbid with mood disorders (OR = 2.7 to 7.5), anxiety disorders (OR = 1.5 to 5.5), substance use disorders (SUDs, OR = 1.5 to 7.9), and intermittent explosive disorder (OR = 3.7).

 aADHD was also associated with greater disability in both basic functioning (self-care, mobility, and cognition) and instrumental functioning (days out of role), productive role functioning and also on social role functioning). Only 10.9% of these individuals with aADHD received treatment for ADHD in the preceding 12 months.

Available evidence from family, twin, and adoption studies indicates that ADHD tends to run in families, with a high heritability rate of 74%.

 In addition, a third of ADHD’s heritability is due to a polygenic component, indicating many common variants with each having small effects. The heritability of aADHD and cADHD appear to be very similar, although family studies indicate that there may be an increased familial liability for aADHD when compared with cADHD.

 Twin studies that are based on self-rated symptoms among a sample of adult population show a moderate heritability rate at 30% to 40%.

Current evidence indicates that some of the same genes that may be involved in cADHD may also be involved in aADHD.

 Linkage studies have identified LPHN3 and CDH13 as novel genes associated with ADHD across the lifespan. In a systematic review and meta-analysis of candidate gene association studies, pharmacogenetic and biochemical (metabolomics) studies performed among individuals with aADHD found an association between aADHD and the gene brain-specific angiogenesis inhibitor 1-associated protein 2.

 They also found lower serum docosahexaenoic acid (DHA) levels among aADHD individuals.

There is evidence from neuroimaging studies that among individuals with ADHD there is a dysfunction of dopamine pathways that are involved in attention, executive function, and motivation and reward.

 Additionally, dysfunctions are also noted in noradrenergic pathways, especially those projecting into the prefrontal cortex, the central region for executive function.

A simultaneous electroencephalography and functional magnetic resonance imaging (fMRI) study found that aADHD individuals had increased medial/lateral frontal and parietal activity during the voluntary selection task on fMRI.

 A meta-analysis found that right globus pallidus, the right putamen, and the nucleus caudatus are structurally affected in cADHD.

 Additionally, these changes and alterations in limbic regions like anterior cingulate cortex and amygdala were more pronounced among non-treated individuals and these appeared to diminish over time from childhood to adulthood.

In a study that sought to delineate the neural correlates of component-specific inhibitory deficits in aADHD using fMRI, brain activation was assessed during 3 stages of behavioral inhibition, ie interference inhibition (Simon task), action withholding (Go/no-go task), and action cancelation (Stop-signal task).

 Individuals with ADHD were impaired in all tasks. It was noted that impaired interference inhibition was associated with hypoactivation in parietal and medial frontal regions. During action withholding and cancelation, individuals with ADHD displayed hypoactivation in a fronto-striatal network. These findings indicate that at least 2 disturbed neural circuits in aADHD differentially associated with deficits in separate inhibitory subcomponents. Frontal brain responses were reduced among individuals with aADHD when compared to controls during free responses, whereas parietal brain functions seemed to be unaffected. These results appear to indicate that selection processes are related to dysfunctions, predominantly in frontal brain regions among individuals with ADHD. 

A study that investigated neural and behavioral correlates of visual encoding during a working memory (WM) task among young adults with aADHD found that there was ineffective allocation of attentional resources involved in encoding of information in WM.

 It has been noted that individuals with aADHD have significantly lower sensory gating than controls, suggesting an impaired ability to filter incoming information.

 Additionally, increased connectivity between the default mode network and a region within left lateral prefrontal cortex (PFC) has been noted. Furthermore, greater levels of resting state activity within that area of PFC was noted to be associated with reduced performance on attentional tasks.

 A common reason for this under-diagnosis is the nature of the illness, as it shares many clinical characteristics with common psychiatric disorders. These disorders include major depression, bipolar disorder, anxiety disorders, SUDs, and personality disorders. Given this overlap in symptomatology, it is recommended that aADHD should be evaluated using a dimensional rather than a categorical approach.

 Katzman et al recommend asking about long-standing and consistent problems with attention and distractibility. Additionally, inquire about complaints from the last 10 to 20 years, conceptualizing how the individual would have been as a child in a classroom. Early diagnosis and treatment of comorbid disorders appear to improve the outcomes among individuals with aADHD. 

It is also recommended that the focus of the evaluation in an adult presenting with symptoms of ADHD should be on the individual’s mental state, as it adds immediate and greater clinical value than the use of cognitive or neuroimaging information.

 Additionally, certain symptoms like physically restless, emotional dysregulation, excessive mental wandering, and sleep-onset insomnia may suggest a diagnosis of aADHD. It is also prudent to exercise caution when evaluating individuals with aADHD, as some individuals may feign ADHD symptoms in order to obtain stimulant medications for diversion to non-medical use.

To meet the DSM-5 diagnostic criteria for ADHD among adults, the individual needs to have 5 or more of the 9 symptoms of inattention and/or of hyperactivity and impulsivity.

 These symptoms need to also have persisted for at least 6 months. In addition, several inattentive or hyperactive–impulsive symptoms should have been present prior to the age of 12 years. These symptoms should be present in 2 or more settings, including home, school, or work; with friends or relatives; in other activities. Furthermore, there should be clear impairment with/or reduced quality of social, academic, or occupational functioning. These symptoms should not occur due to another psychiatric disorder, especially due to psychotic, mood, or anxiety disorders; or due to substance intoxication or withdrawal. The DSM-5 also defines 3 clinical presentations of ADHD based on symptom profile: predominantly inattentive, predominantly hyperactive/impulsive, and a combined (inattentive and hyperactive and impulsive) presentation. The DSM-5 recommends that collateral information should be obtained, as adult recall of childhood symptoms tend to be unreliable.

As there is significant co-occurrence of many common psychiatric disorders with aADHD, these disorders should ideally be diagnosed and treated first.

 This will ensure that the best treatment can be chosen for the core aADHD symptoms. If that is not possible, co-treating these disorders may also be beneficial among individuals with aADHD.

Pharmacological agents are considered first line interventions for the treatment of aADHD.

 The medications that are approved for the treatment of adult ADHD include stimulants, such as amphetamines (amphetamine, dextroamphetamine, and lisdexamfetamine) and methylphenidate (methylphenidate and dexmethylphenidate); and non-stimulants (atomoxetine).

 Other medications that are used off-label include modafinil, guanfacine, venlafaxine, bupropion, and desipramine.

Both amphetamines and methylphenidate are available as immediate release preparations requiring multiple dosing each day and sustained release preparations for once or twice daily dosing.

 The amphetamines and methylphenidate have been found equally efficacious in the treatment of aADHD, with approximately 70% of individuals reporting immediate improvement in core symptoms within 1 hour after administration of the drug. The common adverse effects of these drugs include insomnia, dry mouth, decreased appetite, weight loss, headaches, depression, and anxiety. They are contraindicated among individuals with hypertension, psychosis, or tics, as the medications may worsen these conditions. These medications need to be used with caution among individuals with serious heart disease. Stimulant medications are classified by the Drug Enforcement Agency as Schedule II substances, as they have a potential for abuse especially among individuals with SUDs.

The only non-stimulant medication that is approved for the treatment of aADHD is atomoxetine.

 It appears to have lower potential for abuse than stimulant medications. It is also preferred for use among individuals with ADHD and comorbid substance use disorders, tics, anxiety, or psychosis. However, atomoxetine appears to be less effective than stimulant drugs in reducing core ADHD symptoms and requires 1 to 2 weeks of treatment to achieve full benefit.

Additionally, there is no convincing evidence that atomoxetineis safer than stimulants, and it needs to be used cautiously among individuals with cardiovascular and cerebrovascular disease. The common side effects of atomoxetine include dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido, dizziness, and sweating.

 Other non-stimulant medications that can be used off-label among individuals with aADHD include modafinil, guanfacine, venlafaxine, bupropion, and desipramine, but the evidence for their use is limited to a few small controlled studies of short duration.

In a meta-analysis that included data from 19 trials and studied 13 different drugs, the investigators found that although both stimulant and non-stimulant medications are effective treatments for aADHD, stimulant medications show greater efficacy for the short durations of treatment when compared to placebo.

 However, there were no significant differences noted between short- and long-acting stimulant medications.

A systematic review of 18 published studies found that that cognitive behavioral therapy (CBT) was the most effective psychological treatment for aADHD and the comorbid symptoms of anxiety and depression.

The National Institute for Health and Care Excellence recommends prescribing medications to adults with ADHD if their ADHD symptoms are causing a significant impairment in at least 1 

, after environmental modifications have been implemented.

 The guideline recommends using lisdexamfetamine or methylphenidate as first-line pharmacological agents for the management of aADHD.

Another recommendation is switching between the 2 medications for adults who have had a 6‑week trial of 1 medication at an adequate dose without significant benefit. Atomoxetine was recommended if the individual cannot tolerate lisdexamfetamine or methylphenidate or their symptoms have not responded to separate 6‑week trials with either medication. The guideline recommends using non-pharmacological treatments among individuals with aADHD who have made a choice not to use medications, had difficulty adhering to medications, or found medications to be ineffective or intolerable. The guideline also recommended considering non-pharmacological treatment in combination with medication for individuals with aADHD who have benefited from medications, but whose symptoms are still causing a significant impairment in at least 1 domain. The recommendation involves elements of or a full course of CBT.

In a meta-analysis that evaluated psychostimulants (methylphenidate, dexamphetamine, mixed amphetamine salts, and lisdexamfetamine) and non-psychostimulants (such as atomoxetine) for the treatment of aADHD, the investigators found that pharmacological treatments were significantly more efficacious than placebo (standardized mean difference = 0.45) but less well accepted (odds ratio (OR) = 1.18) and tolerated (OR = 2.29).

 The effects of pharmacological treatments for individuals with co-occurring ADHD and substance use disorder remains uncertain. The evidence for the effectiveness of non-pharmacological treatments for aADHD as well as the combination of pharmacological and non-pharmacological strategies was found to be preliminary.

Emerging evidence indicates that there may be 2 distinct subtypes of aADHD: the first that arises in childhood and persists into adulthood and the other that occurs only in adulthood. Individuals with aADHD have significant educational, social, and occupational impairments in addition to greater rates of morbidity and mortality. There also appears to be a genetic preponderance for aADHD with moderate heritability. Available evidence indicates both neurochemical and neurofunctional impairments among individuals with aADHD involving the dopaminergic and noradrenergic systems and the frontal and parietal cortices. Unfortunately, aADHD is often underdiagnosed as this condition shares many clinical characteristics with common psychiatric illnesses including mood and anxiety disorders. Stimulant medications are the treatment of choice among individuals with aADHD with similar efficacy noted for the amphetamine and methylphenidate group of drugs. Atomoxetine is the only non-stimulant medication that is approved for the treatment of aADHD. CBT has the best evidence among non-pharmacological treatments and is beneficial for those individuals who decline pharmacotherapy, are intolerant to medications, or have residual symptoms despite adequate pharmacotherapeutic trials.

Although normally associated with children, attention-deficit/hyperactivity disorder can also persist in adulthood, presenting challenges to both patients and clinicians. 

Child & Adolescent Psychiatry

Care of Youth Hospitalized With Somatic Symptom and Related Disorders

ADHD in Patients With Bipolar Disorder: Genetics, Diagnosis, and Treatment

Improving Care in Teens With Opioid Use Disorder

Social Support in Teen Years Could Improve Later Mental Health

7 Questions That Separate ADHD From Bipolar Disorder

Adult Attention-deficit/Hyperactivity Disorder (aADHD)

The Need for LGBTQ and Gender-Affirming Spaces

How 4 Hours Can Make a Big Difference: A Successful High School During the Pandemic

Helping Young People Diagnosed With Psychosis Develop Identities

Collaborative Care Models and the State of Child Psychiatry