12 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. 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.

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