Adult ADHD — Practice Tip

By Elisabeth Baerg Hall, MD, CCFP, FRCPC (biography and disclosures)

Disclosures: Volunteer board member for CADDRA (Canadian ADHD Resource Alliance), no payments received.
Mitigating potential bias: Recommendations are consistent with current practice patterns. All available medications for ADHD are discussed or referenced. Generic names are provided.

What I have noticed

Although physicians are increasingly aware of ADHD in adults, there are ongoing barriers to diagnosing and treating these individuals. [1] The estimated prevalence of ADHD is 7% in children, with at least 60% experiencing impairment into adulthood. [2] ADHD prevalence in adults is approximately 4%. [3, 4]  It has been estimated that about 40% of children with ADHD receive this diagnosis. The number diagnosed is far less in adults.

Why are we missing ADHD in adults?

• We don’t screen family members for ADHD when a patient is diagnosed. This is a highly heritable condition. [5]
• We forget to consider that ADHD looks different in adults:
  • Hyperactivity becomes less obvious. The hyperactive/impulsive gradient can be seen in social media obsession, argumentativeness, gossiping, spending, sexuality, eating, and emotional dysregulation, to name a few.
  • The inattentive ADHD of childhood becomes noticeable for widespread functional impairment in work, school, family, and social settings. Patients may initially present with social anxiety having experienced multiple failures in relationships secondary to inattention.
• We don’t look at functional impairment in multiple domains. When our patients seem successful at work or school, we don’t consider the familial and psychological costs of that success. There is a misconception that individuals who have done well academically cannot have ADHD. In fact, intelligence is correlated with later age at ADHD diagnosis. [6] Intelligent individuals often cope well until contextual demands expose further challenges (e.g., when relationships end, under employment duress, during preparation for Ph.D. theses, residency exams, etc.)
• We don’t consider that ADHD will almost always co-occur with another mental health condition. We forget that after the original mental health disorder is treated, ADHD impairment persists.
• We worry that by treating ADHD we are increasing the likelihood of our patient becoming addicted to stimulants or other drugs. In fact, substance use is more likely when patients with ADHD are not treated, as they are more likely to self-medicate. [7]

Data that addresses these issues

ADHD is classified in the DSM 5 as a neurodevelopmental disorder. It is present before age 12, often persisting through adolescence and into adulthood. It is like cortical ‘background noise’, always present and variably symptomatic, depending on context. Inattentive symptoms of ADHD are often not identified in childhood but require a retrospective lens. During stressful times and transitions, symptoms may present for the first time.  With careful consideration however, some childhood symptoms can be identified retroactively.

Throughout the lifespan, ADHD causes functional problems in many domains such as academic achievement, financial and relationship instability, psychological instability including binge eating, impulsive suicidality, and physical issues such as STI’s, addictions, accidents, and even premature death. [8, 9, 10]

October is ADHD Awareness Month. Patients may be increasingly aware of ADHD, having heard about the associated functional impairment, and identifying with these stories. Often, they will not identify ADHD as the problem. Issues with insight are known neurobiologically-based executive dysfunctions.

Treatment for adults with ADHD is effective. For best results, treatment includes both medications and Executive Function Skills support. The combination of Cognitive Behaviour Therapy (CBT) for executive function skills and medications has an effect size of over 1.4 (Effect Size — quantitative measure of the magnitude of the experimental effect. The larger the effect size the stronger the relationship between two variables. > 0.8 is considered a strong effect size). [9] Psychostimulant medications alone are still very effective (effect sizes .8) in adults. [10]

Treatment for adults with ADHD is effective. Best practices include both medications and executive function skills support. Cognitive Behaviour Therapy (CBT) for ADHD has moderate to strong effect sizes. Stimulant medications in children have large standard mean differences (SMD) compared to placebo however, SMD is lower in adults. For example, SMD for methylphenidate is approximately .78 in children (95% CI: 0.62-0.93) to .49 for adults (CI 0.35-0.64) whereas amphetamines for adults, SMD is -0.79 (95%CI -0.99 to -0.58) compared to placebo. [11] Adults are noted to have more issues with side effects, however, they remain highly effective medications overall. [12]

Treatment with ADHD medications is associated with improved outcomes in many areas including decreased physical trauma and injuries, motor vehicle accidents, criminality, suicidality, substance use disorder, and depression. [13]

What I recommend

Diagnosing ADHD is well suited to the primary care setting. In the context of a longitudinal primary care relationship, a physician will readily be alerted to the presence of ADHD.

In multiple interactions over time, physicians will see patients who are perpetually late or no shows, miss precious specialist consultations, sleep poorly, seem frequently overwhelmed, smoke cigarettes (3 x’s more likely), and experience more than their fair share of misfortune such as job losses, relationship disintegration, loss of child custody battles, TA’s, motor vehicle accidents (MVAs), traumatic brain injury (TBI), emergency room visits, flat tires, etc.

To make the diagnosis:

• ADHD is NOT a diagnosis that needs to be made urgently. Take your time. Schedule 3-4 visits after a screen is positive. Note ADHD  is included in the Mental Health Planning and Management Fees (14043).
• Screen patients with the ASRS (Adult ADHD Self-Report Scale V1.1). The ASRS is a World Health Organization (WHO) screening tool with high specificity (99.5%) and moderate sensitivity (68.7%) in general population surveys. [14]. While this tool will not rule out other conditions affecting executive function, it can alert the physician to a possible ADHD diagnosis which has the potential to significantly impact your patients’ life course (see form below in Resources, download).
• Get the history: Use the information garnered from ASRS to guide your clinical questions focusing on functional impairment. E.g. If they report misplacing items (ASRS #10) ask, “How much time do you spend looking for lost things each day?”
• Screen family members with an ASRS when a patient is diagnosed with ADHD. Get collateral (ASRS) from spouses, family, roommates, or friends.
• Patients with a childhood history of an ADHD diagnosis are considered to have ADHD. (The gold standard for an ADHD diagnosis is the presence of symptoms before the age of 12. If they were diagnosed in childhood, they met this standard!) These patients need only be assessed for current symptoms and comorbidity. Use the ASRS to assess current impairment.
• If there is no childhood ADHD diagnosis, use the Wender Utah Rating Scale (WURS) Short Form (see below in Resources, download). A score of 46 or above on this validated childhood self-report scale indicates a high likelihood of ADHD in childhood. Use the WURS questions to guide your clinical history about childhood impairment.
• Use the PHQ-9, GAD-7 to consider other conditions. Be aware of the overlap between ADHD symptoms and depression and anxiety. If all are high, spend time understanding the context of your patient’s depression or anxiety.
• If there is a family history of bipolar disorder and your patient has episodic bipolar-like symptoms, refer for consultation.
• If your patient has Cannabis Use Disorder, or Alcohol Use Disorder, work with their care team to establish if a childhood history of ADHD is present. These patients benefit greatly from having their ADHD medicated so they can properly attend to their treatment groups, etc. Refer as appropriate.
• If your patient has any other Substance Use Disorders (SUD), refer.
• Screen patients with the ASRS when the co-occurring condition is not resolving. E.g. mood, anxiety, SUD, personality. Consider referring.
• Elementary School report cards are not necessary in primary care.

For treatment:

• Ensure your patient is healthy from the cardiovascular and cerebrovascular perspective. Complete requisite labwork and investigations. ECG is helpful if there are concerns.  Refer for appropriate investigations.
• Treat the most impairing mental health condition first. If this is not ADHD, remember to come back to establishing ADHD treatment soon after there are signs the more problematic condition is responding to treatment. If psychotherapy is the sole approach used for other mental health conditions, consider starting pharmacotherapy for ADHD at a very low dose in LA form so that patient can properly engage with therapy.
• CADDRA (Canadian ADHD Resource Alliance) is a well-respected organization with treatment guidelines. There is an up-to-date pharmacology handout freely available without membership. See link below in Resources.
• See your patient frequently to socialize them to the importance of working on structure, sleep, exercise, etc. It seems so obvious, but these facets of health are the cornerstone of executive functioning for your patients with ADHD.
• Encourage your patient to develop routines for self-care. This is more challenging for ADHD patients due to neurobiological deficits.
• Make pharmacare special authority requests to obtain generic long-acting medications for your patients of any age. Complete the ADHD-specific form (link below in Resources) outlining the diagnosis and current symptoms of ADHD and any comorbid diagnoses such as SUD, anxiety, etc. Identify any problems noted in a short trial (one week) of reasonable doses of Dexedrine (for example, 10-15 mg spansules/day) or Methylphenidate (for example, 5 mg am, noon, and early afternoon). This may include issues with short-term memory, where the patient may forget to take their medications, too much anxiety with IR (immediate release) preparations, historical problems with addiction of any kind or a family history of addictions, which would make IR forms dangerous to use.
• Use the ASRS to monitor symptom improvement. Increase the dose of medications in small increments weekly. Monitor side effects (see form below in Resources, download).
• For Executive Function support, it’s the same concept. Teach SMART Goals. Increase goal targets slowly. Build on success. Reward small accomplishments. Build on motivation. Stay focused on the simple interventions when there is a loss of progress.
• Your patients will experience profound life changes when treated.

Resources:

1. ADHD Diagnostic and Treatment Information for Physicians:
   • Canadian ADHD Resource Alliance (CADDRA). Practice Guidelines 2020 Update. Free online access/pdf download or charge for USB/Print Edition (View). Accessed Oct 18, 2021.
2. Medication Algorithms:
   • CADDRA Guide to ADHD Pharmacological Treatments in Canada. January 2020. (View) Accessed Oct 18, 2021.
   • GPSC General Practice Services Committee: Child & Youth PSP Module (Doctors of BC) https://www.pspexchangebc.ca/
3. Rating Scales:
   • Canadian ADHD Resource Alliance (CADDRA). Practice Guidelines 2020 Update. Free online access/pdf download or charge for USB/Print Edition. (View) Accessed Oct 18, 2021.
     • ASRS (Adult Self-Report Rating Scale V 1.1 WHO)
   • Adult Retrospective Childhood Rating Scales.
     • Wender Utah Rating Scale Short Form (>46 highly suggestive of childhood ADHD) adult retrospective rating scale for ADHD in Childhood (Download)
     • ASRS (Adult Self-Report Rating Scale V 1.1 WHO) Scoring Key is on greyed questionnaire. This form can be used for diagnosis, collateral (e.g. spouse completes) and medication efficacy. (Download)
4. Medication Side Effects Questionnaire – VCH Adult ADHD Clinic (Download)
5. ADHD Information for Patients:
   • Canadian ADHD Resource Alliance (CADDRA). https://www.caddra.ca. This site has many other links which are recommended. Accessed Oct 18, 2021.
   • CADDAC – Canadian ADD Advocacy Coalition. https://caddac.ca/?s=adhd Accessed Oct 18, 2021.
6. Executive Function Skills Training. Inquiries for Executive Function Skills Provincial training updates to ADHDGMVTraining@gmail.com. University Student Health EF Group Medical Visit Training November 22, 2021 funded by the Shared Care Committee, Doctors of BC. Student Health physicians can send inquiries to ADHDGMVTraining@gmail.com.
7. Special Authority Pharmacare ADHD Forms:
   • ADHD-Specific: (download from gov.bc.ca) Accessed Oct 18, 2021.
   • General Form (download from gov.bc.ca) Accessed Oct 18, 2021.

References:

1. Hines JL, King TS, & Curry WJ. The adult ADHD self-report scale for screening for adult attention deficit-hyperactivity disorder (ADHD). J Am Board of Fam Med. 2012; 25(6), 847–853. DOI: 10.3122/jabfm.2012.06.120065. (View).
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. 2013. DOI: 10.1176/appi.books.9780890425596. (View with CPSBC or UBC).
3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006;36(2),159-165. DOI: 10.1017/S003329170500471X. (Request from CPSBC or view with UBC).
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. DOI: 10.1192/bjp.bp.106.034389. (View with CPSBC or UBC).
   
5. Faraone S, Asherson P, Banaschewski T, et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 2015;1:15020. DOI: 10.1038/nrdp.2015.20. (Request from CPSBC or find with Worldcat).
6. Rommelse N, Kruijs M, Damhuis J, et al. An evidenced-based perspective on the validity of attention-deficit/hyperactivity disorder in the context of high intelligence. Neurosci Biobehav Rev. 2016;71,21–47. DOI:10.1016/j.neubiorev.2016.08.032. (View with CPSBC or UBC).
7. Mariani JJ, Khantzian EJ, Levin FR. The self-medication hypothesis and psychostimulant treatment of cocaine dependence: an update. Am J Addict. 2014;23(2):189–193. DOI: 10.1111/j.1521-0391.2013.12086.x. (View).
8. Dalsgaard S, Øtergaard SD, Leckman JF, et al. Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet. 2015; 385(9983):2190-2196. DOI: 10.1016/S0140-6736(14)61684-6. (View with CPSBC or UBC).
9. Cortese S, Bernardina BD, Mouren M. Attention-Deficit/Hyperactivity Disorder (Adhd) and Binge Eating. Nutr Rev. 2007; 65(9): 401-411. DOI: 10.1301/nr.2007.sept.404-411. (View with CPSBC or UBC).
10. Gjervan B, Torgersen T, Nordahl HM, Rasmussen K. Functional Impairment and Occupational Outcome in Adults With ADHD. J Atten Disord. 2012;16(7): 544–552. DOI: 10.1177/1087054708329777. (Request with CPSBC or view with UBC).
11. Faraone SV. Interpreting estimates of treatment effects: implications for managed care. P T. 2008;33(12):700-711. PMID: 19750051; PMCID: PMC2730804. (View).
12. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry. 2018 ;5(9):727-738. DOI: 10.1016/S2215-0366(18)30269-4. PMID: 30097390; PMCID: PMC6109107. (View).
13. Quinn PD, Chang Z, Gibbons RD et al. ADHD Medication and Substance-Related Problems. Am J Psychiatry. 2017;174(9, 877-885. DOI: https://doi.org/10.1176/appi.ajp.2017.16060686. (View).
14. Kessler R, 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(2), 245-256. DOI:10.1017/S0033291704002892. (Request from CPSBC or view with UBC).
15. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: An aid in the retrospective diagnosis of childhood Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 1993;150(6):885-890. DOI: 10.1176/ajp.150.6.885. (Request from CPSBC or view with UBC).

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