14 responses to “Adult ADHD — Practice Tip”

  1. Can you elaborate on this? What references are there to support this? I’m under the impression that IR stimulants have mixed evidence for people with a history of addiction. I worry the language used in this article perpetuates stigma towards people who have a history of addiction (or, an active non-stimulant addiction) and can lead to clinicians withholding treatment unnecessarily.
    “historical problems with addiction of any kind or a family history of addictions, which would make IR forms dangerous to use.”

  2. I had not heard of the WURS scale before, and will find this helpful in diagnosing adults with ADHD who were not diagnosed in childhood (which is the most common scenario in my practice). I was previously following the CADDRA guidelines and using the WSRS and other forms which was time consuming to score and seemed repetitive. I like that this approach cuts down on the number of forms I need to gather.

  3. Hi Laura.
    Thanks for your comment.
    Please note that this statement “historical problems with addiction…” is a suggestion of what to write on the ADHD-specific Special Authority Form to obtain long acting stimulants for your patients who could otherwise not afford them. Explaining in this way assists Special Authority to understand the reason for the request. Using this statement actually serves to ensure your patient has access to treatment.
    Indeed, if you apply for ADHD-specific Special Authority indicating a personal or family history of addictions as suggested above, Special Authority often waives the IR medication requirement. EBH

  4. Good article, we need to think about adult ADHD. The fear is misuse of stimulants. Do your do diligence by following the above recommendations. ORT may help sort the potential higher risk. Use stimulants more difficult to tamper. Don’t forget the role of diet, exercise, and mindfulness.

  5. Thanks for this concise article and all the attached references and resources. One of my concerns is that UBC does not accept a Family Doctor’s diagnosis of ADHD, only that of a psychiatrist or psychologist. As you know, a private psychologist is often out of reach for a student, and psychiatrists have long waitlists. So even if we do feel comfortable making this diagnosis (and I agree, if you have known a person a long time you will not be surprised by your patients who have ADHD), and starting medication, we are “not qualified” enough for the institution that trained us to accept our learned and informed opinion on our patients’ needs. How can we advocate for our young adult patients who may be permanently discouraged from pursuing their goals by this kind of barrier?

  6. As a pediatrician who see many children with ADHD, this was helpful is guiding the parents in getting their own diagnosis. Parents often recognize themselves in their children, but don’t know where to start to get help for themselves. I will definitely look into some of the adult scales for them, but also for my older patients, 18-19 years old.

  7. Also ask about tobacco smoking in adolescence. The nicotine stimulates one component of the adrenergic nervous system, in a fairly addictive but short term fashion. I have seen this as an adaptive self-treatment scheme in patients and acquaintances.

  8. You provide references for executive function skill support training, are you able to provide any resources for non-pharmacologic treatment options (executive function skill support and/or CBT for ADHD) to which patients can be referred? Things like online or self-guided programs, books you would recommend, or psychologists to whom patients could be referred (or could self-refer)? Asking for a friend…

  9. I appreciate the brief nature of these articles but I believe the discussion is not complete with comment on de-prescribing. Not all patients will benefit and others may have intolerable or unsafe adverse effects. What de-prescribing strategy is recommended. Also, what is the expected duration of treatment? Life long?

  10. Dear Dr. Battershill
    Thank you for your comments. You raise several good points.
    It is beyond the scope of this article to discuss second line medications for ADHD.
    As a neurodevelopment condition, ADHD symptoms appear in context-specific settings throughout a person’s life. For example in a pandemic many patients have worsening symptoms, especially those not able to move back home to environments with high degrees of scaffolding.
    Depending on physical health, individuals with ADHD may have periods throughout their life when they require medications. When EF skills are well-developed, patients learn how to self-manage and are well-informed about when they might or may not benefit from medications in different situations.
    Patients tend to stop using their medication on their own, often with significant negative consequences such as problems in management of chronic medical conditions, accidents, upkeep of health-promoting behaviours, to name a few. It is a good idea to work closely with your patient to establish the lowest workable dose of medication, which often remains stable.
    There is a minimal literature on de-prescribing for patients with this diagnosis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093505 is an article which discusses adolescents and children. In adults, one would expect that since brain myelination, pruning and other neurodevelopment processes are further along, patients would be less likely to grow out of their symptoms.
    At this point the bottom line is that many of these patients are never diagnosed wth ADHD and would benefit greatly from the diagnosis and treatment.

  11. Thanks for the article. I had a question regarding pharmacotherapy. I have inherited many patients with a long history of anxiety and depression that may be on SSRI/SNRI and Bupropion that now question if they have had ADHD all along. What is your approach to pharmacotherapy and adding stimulants if already on a few agents?

  12. As a 52-yo recently diagnosed with ADHD following diagnosis in 4 of our 6 children, I can only attest to most of the points presented in this very good, concise and helpful article. I self-administered the WURS and scored relatively low (35): I haven’t red the original paper and its methodology but I wonder if an adapted version exist tailored to older adolescents & young adults, as I think my symptoms mostly started after high school, when one would think that more “noisy” symptoms have recessed in most patients.
    Furthermore, I can attest that ADHD does not preclude a quite successful career (in medicine and medical research for me), but I do recall that I had a very hard time to get organized during my rounds until my fellowship. And decided not to embrace a career in surgery or intensive care medicine as I felt I did not have the rapid decision-making capacities needed to exert in these fast-paced specialties. Conversely, I think the volume of learning that a medical student has to digest, often going from one topic to another in short burst of studies, certainly kept my brain firing. But executive functioning and memory retention have always been a challenge, increasing with age and professional responsibilities, which I hope medication and CBT will rapidly improve. Finally, I am curious to know the incidence of ADHD in the medical profession, and if epidemiological research is underway, I’d be happy to volunteer. Thanks again.

  13. Very helpful article particularly with respect to the tips for requesting Special Authority, and all of the links to the various screening tools. I was not previously aware of the WURS for retrospectively screening for childhood ADHD. I plan to make use of this tool now, as I think it will be a helpful aid in clarifying the diagnosis in certain patients of mine.

  14. I do have a few questions/concerns about the article:
    – basing a diagnosis on the ASRS (which seems to be the trend in new ADHD clinics) is problematic – it is meant to be used as a screening tool, and it makes the diagnosis entirely subjective. Patients seeking a specific prescription can easily manipulate this questionnaire to get a diagnosis. Furthermore, I am not sure what the validity is for using a scale for symptom monitoring as well as diagnosis/screening?
    – the WURS is also a subjective measure, and in addition, introduces recall bias into the problem of diagnosis. Furthermore, it is not obvious to me why people with a childhood history of ADHD should be considered (automatically) to have ADHD as adults (“Gold standard”)? Perhaps the wording here is the problem?
    – diagnosis of ADHD should entail some objective (functional) impairment, and this should be assessed in multiple domains – how many domains should a normal person expect to perform well in simultaneously? it is not clear to me what role external cultural norms and expectations (within the family, the particular work/school context), as well as real financial or socio-economic pressures (eg, need to work multiple jobs to pay rent, bills, single parenting, etc) play in creating these “failures”. Are we aware of the impact of the ‘attention economy’ on our brains? At what point are people having abnormal responses to abnormal circumstances (hence having normal behaviour)?
    – following from this, do we know what the incidence of adult ADHD is? why are prescriptions for stimulants (esp. Vyvanse) exploding in BC? Does this correlate with diagnoses? why is this increase so rapid? is there really a biological explanation for this?
    – we know stimulants cause rapid rises in brain levels of dopamine, and can give immediate rewards and concomitant pleasure – what evidence is there for objective improvements in performance with stimulants?
    – there is little (if any) evidence to show that there are actual pharmacokinetic differences between long and short acting stimulants. If there is an addiction risk with IR forms, then it should it also not be considered for long acting forms as well? should we worry about a rhetoric (since it isn’t evidence) that long acting forms are less addictive? haven’t we heard such a rhetoric before (opioids)?
    – what data do we about that stimulant diversion/misuse? the current struggle to contain the opioid epidemic has lead to increases in polysubstance use and deaths due to stimulant use in particular – shouldn’t we be concerned about a possible connection between increases in prescribing and increases in stimulant use in vulnerable populations? Have we not learned anything from history?

    I appreciate the arguments put forth in the article. I look forward to more discussion

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