Challenges of adult ADHD

Many patients of psychiatrist John Sharp, MD, don’t realize that their inattentive and impulsive behaviors could be caused by attention-deficit/hyperactivity disorder until their children are diagnosed with the condition.

“Parents look at these symptoms [and realize] they are causing problems in their own lives,” said Dr. Sharp, a psychiatry professor at Harvard Medical School who treats patients in Boston and Los Angeles.

When those parents come to see him, they often say, “I think I have ADHD.”

Many times, they’re correct.

Although ADHD long has been considered a childhood developmental problem that wanes with age, physicians are noticing that more adults are inquiring about and being diagnosed with the illness.

Why so many cases?

Likely driving the uptick is greater awareness among doctors and the public about symptoms of the disorder and the importance of treating those symptoms, health professionals say. Also contributing to the rise is research showing that many children don’t outgrow the condition. That means if an ADHD diagnosis is missed in childhood, the individual might need treatment when he or she gets older.

Up to 60% of children with ADHD continue to show significant symptoms into adulthood, according to a 2005 Archives of Disease in Childhood report.

“Children might grow out of some of their physical hyperactivity [as they age]. But what’s going on in their heads, they don’t [often] grow out of that,” said North Carolina family physician Michael L. Coates, MD.

Health professionals estimate that 4.4% of adults have the illness, making it the second-most common mental health condition in adults after depressive disorders.

It’s unclear, however, how widespread ADHD is in U.S. adults, partly because of the difficulty in diagnosing it, physicians say. A key challenge is proving that some symptoms were present in the patient before age 7.

Complicating matters is that internists receive minimal training in identifying and treating the disorder, because it develops in childhood and tends to be considered a pediatric problem, said internist and pediatrician Steven M. Scofield, MD.

He estimates that an average internist has 20 to 80 adults with ADHD. Many of those probably are undiagnosed and receiving care for conditions such as depression, generalized anxiety disorder and substance abuse, said Dr. Scofield, an assistant professor in internal medicine and pediatrics at the University of Rochester Medical Center in New York.

Undertreatment of adult ADHD is a nationwide problem, research shows. Only 11% of adults with the illness receive treatment due to multiple factors, including failure to seek medical help and misdiagnosis, said a 2008 study in World Psychiatry.

Properly treating the disorder is critical, because ADHD can lead to trouble keeping a job and maintaining relationships due to inappropriate behavior, said Raphael Wald, PsyD, a clinical psychologist and neuropsychologist at Palm Beach Psychology Associates in Boca Raton, Fla.

This condition “can destroy marriages and careers,” he said. “It’s really important to address it if it’s present.”

Some skeptical of adult ADHD

Yet some health professionals and others question if adult ADHD is a real disorder. Dr. Scofield discussed that skepticism during his presentation on the illness at the American College of Physicians annual meeting in New Orleans in April.

“I think it’s a true diagnosis,” he said later in an interview. But he said the tendency of health professionals to sometimes overdiagnose the condition in children might have led some people to question whether adult ADHD is a real problem.

“The reality is [adult ADHD] is there,” said Dr. Coates, chair of the Dept. of Family and Community Medicine at Wake Forest School of Medicine in Winston-Salem, N.C. He is among the physicians who have noticed an increase in adults with the disorder during the past few years.

In New York City, internist Gary I. Rogg, MD, sees several young adult and middle-age patients every month who think they have ADHD. These are common ages for symptoms to emerge in individuals who weren’t diagnosed with the illness in childhood, health professionals say. During their 20s and 30s, some people experience increased stress related to college, family or work, and that can make coping with the disorder overwhelming.

Dr. Rogg’s first goal when seeing such patients is to rule out other health conditions, including anxiety and depression, which have symptoms that are similar to those of ADHD. He orders a full metabolic workup if he suspects an overactive thyroid, which can lead to inattention and restlessness.

But he mostly relies on a thorough history that includes questions about the person’s past to determine if the individual has ADHD. There is no reliable blood test or imaging procedure to identify the neurobehavioral disorder.

“We tell residents and medical students, ‘If you listen to your patients, they will always give you the answer,’ ” said Dr. Rogg, assistant professor and assistant director of the Dept. of Medicine at Montefiore Medical Center in New York. “In that way, the patient history is really crucially important” in diagnosing ADHD.

Dr. Rogg often starts by asking the patient when the problem began and when family members and friends started noticing symptoms. He also inquires about any life changes that might have occurred around that time, such as marriage, divorce or a new job, that could be causing the problem.

During such patient visits, Dr. Coates listens for signs that the individual is impulsive and has difficulty focusing or paying attention. Those are key symptoms of the three ADHD types.

Although there is no known definitive cause of the disorder, data show a genetic factor to the illness, said psychiatrist Victor Fornari, MD, director of the division of Child/Adolescent Psychiatry at North Shore-LIJ Health System in New Hyde Park, N.Y.

Head trauma, including a concussion, is another factor that might increase a person’s risk of developing the condition, Dr. Coates said. When taking the patient’s history, he asks about head injuries.

Most important for doctors to remember when diagnosing ADHD “is that it doesn’t appear overnight,” Dr. Coates said.

“If an adult says, ‘I lost focus over the last two years,’ I look for another problem. But when patients say they always had this difficulty going back to childhood,” he considers ADHD.

Asking about the past

To identify symptoms that started early in life, Harvard psychiatrist Dr. Sharp asks patients about trouble with friends in childhood and inquires about their grades in school and whether they had to repeat a year. He also asks about their school behavior, such as frequently staring out the window during class.

To help ensure that his diagnosis is accurate, he usually schedules a second appointment. For that visit, he often asks the patient to locate an old report card or school record. Such information can provide greater insight into the patient’s childhood behavior.

When possible, Dr. Sharp speaks with a parent or spouse about how the symptoms have affected the patient. Some ADHD symptoms have to cause impairment in at least two settings, such as home and work, says the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Although Dr. Sharp recognizes that such extensive questioning is time-consuming, he urges physicians not to diagnose a patient with ADHD and prescribe medication on the first visit.

“There are some people who are seeking medication and might not qualify for the diagnosis,” Dr. Sharp said. “You want to always get a good history and then set up another appointment to get more history before commencing treatment. Most drug-seekers won’t bother coming back another time.”

Fear of patients abusing stimulants used to treat ADHD is a significant barrier to internists wanting to treat adults with the condition, Dr. Scofield said.

In many cases, however, internists don’t have a choice in seeing these patients. Due to a nationwide shortage of mental health professionals, primary care physicians increasingly are caring for and managing mental health conditions, including ADHD.

When doctors diagnose the illness, Dr. Sharp recommends that the treatment extend beyond medication to behavioral changes. For example, he encourages patients to become more organized and to get sufficient sleep.

Dr. Coates takes a similar approach with his adult ADHD patients. He suggests that they stop drinking excessive amounts of alcohol, which can make them more scattered, and recommends intensive exercise every day, because it’s a natural stimulant.

When he prescribes medication, he assures patients that the drugs don’t make them become somebody else. The medication “allows you to be who you are,” he tells them.