Adult ADHD - A Difficult Diagnosis

Main Category: ADHD
Article Date: 20 Jul 2003 - 0:00 PDT


Treating adult ADHD is fairly simple, but diagnosing it is difficult. Many adults realize they have ADHD when their children are diagnosed with it.

Getting good treatment for adults and children who have attention deficit hyperactivity disorder, or ADHD, is fairly simple compared with some other neuropsychiatric disorders. The real problem is getting a timely, precise diagnosis.

For children, the problem has improved. Schoolteachers are much better informed about symptoms.

'Teachers are much more aware of ADHD and make many referrals,' says Jerome Schultz, PhD, clinical associate professor and director of The Learning Lab at the University of Vermont College of Medicine.

'What they identify as being ADHD may actually be depression or anxiety or vice versa. But usually there is some merit to their observations, even if how they label symptoms isn't always accurate.'

For many adults, a diagnosis of ADHD comes via their children's problems in school.

'There is a heavy genetic role in ADHD,' says Schultz. 'So it isn't surprising that when parents are told about the kind of ADHD behaviors their child is showing in the classroom, one of the parents may recognize their own ADHD childhood behavior in their child and seek help themselves.'

How Treated ADHD Adults Fare

So what happens to the estimated 60% of kids who undergo treatment for ADHD and grow up to become adults in need of treatment?

'If you look at ADHD in treated and untreated populations, the risk of substance abuse, serious accidents, work problems, and family problems is much, much higher in nontreated people,' says Lenard Adler, MD, director of the Combined Departments of Psychiatry and Neurology Adult ADHD Program at New York University School of Medicine.

But few studies have tracked their progress into adulthood.

'We don't have many systematic evaluations of adults who have been in long-term treatment for ADHD,' says Adler. 'We don't have wonderful longitudinal studies, but there is more adult scientific literature coming out, and it's clear that medication works for both adults and children.'

One reason for the lack of studies is that until the 1970s, doctors thought ADHD was something children simply outgrew. Now, doctors know that hyperactivity may decrease even while inattention and impulsive behavior keep going strong.

In adults, ADHD behaviors fall into three key categories, says Adler: current symptoms of inattentiveness, impulsivity, or hyperactivity; impairment in at least two of three areas -- work, life at home, and in social interaction with peers; and childhood onset of symptoms.

Effective Drug Therapy

It's important to note that ADHD is highly treatable. Stimulants, such as Ritalin, and selective serotonin reuptake inhibitors, or SSRIs, are commonly prescribed.

'Studies have shown that drug therapy is a much better treatment than talk therapy alone,' says Adler. 'But combined drugs and cognitive behavioral therapy can show a modest improvement over drugs alone.'

For those who can't tolerate stimulant side effects, atomoxetine, the only FDA-approved ADHD drug for childhood and adult ADHD, is another option. Sold as Strattera, this nonstimulant medication appears to affect powerful brain chemicals involved in control of behavior.

'Unlike stimulants, it is not a controlled substance. It doesn't have the risk of tolerance you have with those drugs,' says Adler, who adds that the newer long-acting stimulant drugs are also an important advance. These preparations make it easier for patients to take their medicine and keep symptoms under control.

A Difficult Diagnosis

'Since it is common to have [overlapping] neuropsychiatric disorders, the best diagnosis is made by a multidisciplinary team,' says Schultz. 'That might include various clinicians, psychiatrists, pediatric psychologists, or other behavioral specialists. They can arrive at a differential diagnosis that makes useful distinctions between depression, anxiety, ADHD, and bipolar disorder.'

In June, Adler and his colleagues released a survey of how 400 primary care doctors rated their ability to diagnose adult ADHD: Nearly 50% of the doctors said they do not feel confident in diagnosing ADHD in adults.

Sixty-five percent said they defer to a specialist when diagnosing adult ADHD, compared with 2% for depression and 3% for generalized anxiety disorder. A full 85% said they would take a more active role in diagnosing and treating adult ADHD if they had an easy-to-use screening tool.

Working with the World Health Organization, Adler and his colleagues developed an ADHD screening test asking patients to answer six questions about their behavior. If they score high, they take a more precise, 18-item symptoms checklist test.

'The advantage of the self-test is that it is patient friendly and standardized,' says Adler. 'We hope this will take a great deal of guesswork out of diagnosis.'

The ADHD self-assessment test, which is copyrighted by the WHO, is available online at www.med.nyu.edu/Psych/training/adhd.html.

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