Is Attention Deficit Hyperactivity Disorder (ADHD) a legitimate diagnosis?
As a Psychiatrist who advocates for the appropriate diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults, I am frustrated by the many misconceptions that linger like flies at a neighborhood BBQ. Perhaps you will find the story and comments below relatable. And if not, that’s okay too…
A COMMON STORY
At some point in your life you came to the realization that something just wasn’t adding up. Throughout high school you struggled to stay organized and motivated. But on the rare occasion that you found the energy and courage to sit and start your weekend homework on a Saturday morning rather than Sunday at midnight you were probably discouraged yet again.
“How many times do I have to read this sentence before I understand what it means?”
“Why did I just read 20 pages of this book but couldn’t tell you one meaningful thing about it?”
“Screw it, I’m gonna play sports or video games instead.”
So you begin telling yourself that you’re just not smart enough, not good enough, not savvy enough to juggle life like everyone else. Eventually, your tank began overflowing with the incredibly helpful and encouraging “you just need to work harder. Stop being lazy. Do you even care about your future?” And your self esteem began sinking into the cold, dark abyss like the Titanic in 1912. Your energy, your life force, and your contagious positive spirit began dipping to dangerously low levels. If not already feeling like a failure, you sensed actual failure was imminent.
As time went on, you probably took one or a combination of paths. Either you said “fuck it” and started drinking and doing drugs out of anger and frustration or you continued to suffer in silence but pretended you were okay only to feel more drained and guilty about not telling the truth. Or maybe you developed coping skills and compensated by being overly obsessive and overly worried about everything because you’ve been told repeatedly that in order to achieve goal X you just needed to work harder. Then one day you heard someone talk about Attention Deficit Hyperactivity Disorder and you immediately felt something awaken inside you. You were so relieved to hear you weren’t the only one who relied on Sparknotes to pass English class–not because you were lazy but because there wasn’t enough time in the day to read the same page more than 3 times. After all, 20 pages of reading meant 60 pages for you.
So you debated whether to go to the doctor and be evaluated. You felt vulnerable and worried about opening up to someone you’ve never met. You’re started to worry that you might sound like a “drug seeker” or a “cheater.” Once you finally built the courage to share your story you were met with your worst nightmare–immediate invalidation. “We don’t prescribe those drugs in this clinic.” This is followed by urine drug testing and a referral for a $1,500 Neuropsychological test that only worsens your preexisting anxiety and obsessive thinking. So you go to the testing center and sit there in a quiet room clicking buttons and solving puzzles for hours. And now you’re waiting for the results…
There are many points to this story. Humans are complex and the brain is by far the most complicated machine in our universe. Neuropsychological tests are NOT something I routinely order and the reasoning is simple: How does sitting at a computer in a quiet exam room or solving boring puzzles for hours in a controlled environment confirm that my patient really is experiencing distress and dysfunction? How does a neuropsychology test with inconsistent validity help my patient who can clearly articulate how they are feeling and what they are experiencing?
SCIENCE IS TRUTH
Despite numerous attempts by uninformed opinionators to delegitimize the diagnosis of ADHD, the science speaks loud and clear: Attention Deficit Hyperactivity Disorder (ADHD) is a real disorder that can occur in children and adults.
It isn’t uncommon to hear people offer opinions such as “ADHD is an excuse to medicate misbehaving children to appease parents” or “everyone has ADHD and would benefit from psychostimulants.” When I hear these things, I take a deep breath and remind myself that these opinions are just what they are…opinions.
The belief that ADHD is an excuse to medicate misbehaving children or the notion that adults seek an ADHD diagnosis to obtain stimulants to “cheat the system” is not supported by any legitimate scientific evidence. Do people abuse prescription stimulants? Yes, they do. Are some children misdiagnosed with ADHD? Yes, some are. Do some adults “fake” the diagnosis to obtain stimulants? Yes, some do. But let’s leave the blanket statements and unsubstantiated beliefs in the box labeled “99% of political arguments” (the label included).
If anything, ADHD is not recognized nearly enough in adults. The possible reasons for this are beyond the scope of this post. But here is a review of the diagnosis and treatment of ADHD in adults based on an extensive review of the literature and a presentation I gave last year at a conference.
Oh, and in case you were wondering, the rumor that stimulants increase the risk of Parkinson’s disease later in life is a gross misreading of the literature (unless you “believe” that the illicit use of street methamphetamine has the same pharmacokinetic and pharmacodynamic long term effects as prescription stimulants used at therapeutic doses).
(A) A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by Inattention and/or Hyperactivity (see below)
Inattention: Six (or more) symptoms present for at least 6 months and are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (Age 17 and older), at least five symptoms are required.
- Inattention to detail, careless mistakes
- Often does not seem to listen when spoken to directly (e.g., mind seems to wander elsewhere).
- Doesn’t follow directions
- Difficulty organizing tasks and activities
- Often avoids tasks requiring sustained mental effort
- Often loses things
- Often easily distracted
- Often forgetful in daily activities
- Often has difficulty sustaining attention in tasks or play activities
Hyperactivity/Impulsivity: Six (or more) symptoms present for at least 6 months and are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (Age 17 and older), at least five symptoms are required.
- Often fidgets or squirms in seat
- Often leaves seat in situations when remaining seated is expected
- Often runs about or climbs in situations where it is inappropriate
- Often unable to play or engage in leisure activities quietly
- Internal restlessness, always on the go
- Often talks excessively
- Often finishes sentences or blurts out answers
- Often has difficulty waiting his or her turn
- Often interrupts or intrudes on others
(B) Several symptoms present prior to age 12 years
(C) Several symptoms present in two or more settings (home, school, work, etc)
(D) Significant dysfunction
(E) Symptoms do not occur exclusively during the course of another mental disorder
- Combined Presentation (A1 + A2 for the past 6 months)
- Predominantly Inattentive presentation (A1 for the past 6 months)
- Predominantly hyperactive/impulsive presentation (A2 for the past 6 months)
- Attention is a cognitive function
- Attention describes the mechanism that weighs the importance of various stimuli and selects the one that will receive the brain’s focus.
- An important component of our level of consciousness
- Two major functions of attention:
- Selective/directed Attention (stroop task)
- Sustained Attention (n-back test)
- The capacity to concentrate and maintain one’s attention correlates with the ability to ignore extraneous stimuli.
- Continuous Performance Tests (CPTs) give an objective estimate of an individuals attention and impulsivity
- An individual’s ability to focus or stay attentive appears to increase with age (based on reduction in number of errors on a standardized attention task) until approximately age 50 (-ish)
Brain Areas Involved in Attention:
- Working memory describes what is actively being considered at any moment
- Working memory and attention are closely related and interdependent
- Working memory and attention are important components of executive functioning
- Executive function includes working memory, attention, and other higher-level cognitive skills such as organizing priorities and planning
Trauma to the Prefrontal Cortex impairs working memory
- Phineas Gage (PG)
- Famous case of a railroad worker who had a tampering iron explode through his frontal cortex
- PG went from being responsible and organized to impulsive and inattentive
1970s: Neuroscientists began measuring working memory in monkeys
- Implanted microelectrodes into individual neurons in the PFC
- Measured activity in these neurons while monkeys performed the delayed response task (DRT)
- Individual neurons responded differently during DRT
- Some neurons were active only during the cue/response part of the task while other neurons responded only during the delay period
DOPAMINE & NOREPINEPHRINE IN WORKING MEMORY
- Rat studies using a radial maze DRT demonstrated an inverse correlation between extracellular DA concentration in the PFC and the number of errors during the task
- The length of the delay period was also inversely correlated with extracellular DA concentration in PFC and the number of errors
- Implications for Vagal Nerve Stimulation in ADHD
- Controlling the impulse to take an immediate, smaller reward rather than waiting for the larger, delayed reward is essential for completing any project. People who cannot control these impulses perpetually fall behind.
Stanford Marshmallow Experiments (1970s)
- Led by Stanford psychologist Walter Mischel, PhD
- 4 year old children were given one marshmallow and told they could either eat the marshmallow now or wait until the research assistant returned from an errand and receive two marshmallows
- Children who were better at inhibiting the impulse to immediately eat the one marshmallow were
- More resilient, confident, and dependable as adolescents
- More successful students and scored higher on the SAT
Nucleus accumbens (NAc)
- Attention and impulsivity are partially controlled by DA in the NAc
- People are less distracted when pursuing activities they enjoy.
- Stimulant medications increase DA at the NAc and improve impulse control.
- Rats with damaged NAc become more impulsive (choose immediate reward)
Striatal Dopamine Transporter (DAT) density
- High DAT density is seen in younger individuals and patients with ADHD
- Higher striatal DAT density has been correlated with more impulsive behavior
- Drug-naïve patients with ADHD have a slightly higher density in DAT
Attention Deficit Hyperactivity Disorder
- Dysfunctions in the PFC and striatum are the most common abnormal brain findings reported for ADHD
- Judith Rapoport’s (NIMH) neuroimaging studies:
- Children w/ ADHD had smaller brain volumes by approx 5%
- Smaller volumes for all four cerebral lobes (including white/gray matter)
- Smaller cerebellum.
- The trajectory of brain volumes did not change as the children aged, nor was it affected by the use of stimulant medication.
- Regions of significantly greater activation in healthy subjects relative to the attention deficit hyperactivity disorder (ADHD) group during a target detection task included areas of the parietal lobe and frontal lobe
- A neurodevelopmental disorder characterized by inattention, impulsivity, and/or hyperactivity
- One of the most heritable psychiatric disorders
- Historically conceptualized as a disorder of childhood
- DSM IV first to recognize persistence into adulthood
- Clinicians presume adult ADHD is the “grown up” version affecting the same individuals with ADHD in childhood
- Moffit et al. (2015) challenged this assumption
In School-Aged Children/Adolescents:
- Prevalence estimates = 5-7%
- Combined type most common
- Male:Female = 3:1
- ~ 2/3 children diagnosed with ADHD experience impairing symptoms in adulthood
- Prevalence estimates = 2.5-5.2%
- Male:Female more equal
- Inattentive type most prevalent in adults (47% of cases)
- Demands for attention ability increase with age
- Decline in hyperactivity-impulsivity likely related to cortical and subcortical maturation
Common Gender Differences
Consequences of ADHD
- Young adults diagnosed with ADHD are less likely to enroll in college and/or graduate from college
- Students with ADHD are more likely to be on academic probation and have a lower grade point average
- Adults with ADHD experience difficulties in all aspects related to employment
- Employment problems include poor job performance, lower occupational status, increased absence days, more workplace accidents and job instability
- A World Health Organization survey estimated that 3.5% of all workers suffer from ADHD.
- Only a small minority of these workers received treatment
ADHD and Criminality
- Studies have estimated the prevalence of ADHD among male prison inmates to be around 40% (Rösler et al. 2004; Ginsberg et al. 2010).
- Other studies found that in the absence of comorbid conduct disorder, ADHD patients had no higher risk for later delinquency than adults with other childhood psychiatric disorders (Gjervan et al. 2012).
ADHD symptoms present differently in adulthood
- Inner restlessness
- Excessive fidgeting (lectures, movies, etc)
- Impatience – “acting/talking without thinking”
- Difficulty keeping a job
- Difficulty maintaining relationships
- Attention seeking behavior
- Feeling bored
- Easily distracted
Common complaints from adults with ADHD:
- Mood swings
- Difficulties dealing with stressful situations
- Frequent irritability and frustration
- Emotional excitability (anger over minor things)
- Relationship problems (short-lived, divorce)
- Coping with one or more children with ADHD
Consequences of ADHD:
- ~20% of parents of children with ADHD have themselves ADHD (Faraone et al. 2000).
- Risky behaviors (traffic tickets, MVAs, injuries)
- Substance use problems (earlier onset; greater severity)
Diagnostic Approach to ADHD in Adults
- ADHD is a Clinical Diagnosis!
The initial evaluation
- Discern patient’s motive/intentions for presenting
- Use reflective listening
- Work with patient to identify target symptoms
- Prioritize target symptoms/problems
- Observe patient’s behavior in the office
- Numerous Job Changes
- School Failure
- Many traffic tickets
- Marital Problems
- Psychiatric History
- Comorbidities and Mental Disorders with overlapping symptoms
- Family History
- Childhood History
- Jittery/difficulty sitting still
- Patient’s thoughts quickly jump from one subject to another
- Many things remind them of something else
- These thoughts are rational
- Difficulty with being on time
- Disorganized belongings
- Quick temper and low tolerance for frustration
- NOTE: Some pts may have compensated for their deficits
Time course of symptoms
- Evaluating the level of impulsivity, disorganization, distractibility, hyperactivity
- Assessing the degree of impairment/dysfunction
- Importance of collateral information and education/occupation history
Obtain a comprehensive history
Rule out medications/medical conditions associated with inattention/impulsivity/hyperactivity
- Anticholinergics, antihistamines, beta blockers, antipsychotics
- Illicit use of drugs (cocaine, methamphetamine)
- Anemia, B12 deficiency, thyroid disease, Lyme disease
- Electrolyte disturbances
- Parasomnias (OSA, RLS)
- Psychosocial History
- Substance abuse
ADHD Scales and Rating Systems
- Helpful but not necessary
- Helpful for differentiating subtypes of ADHD
- Not recommended but may be important in the future
ADHD and Substance Use
- Untreated adolescents with ADHD are at high risk for drug/EtOH abuse
- A large study at MGH found that stimulant treatment was protective against the later development of substance abuse (Faraone & Wilens 2003)
- Individuals with unmedicated ADHD are at 3-4 times the risk for developing substance use disorder as those who are medicated (Biederman 2003)
- Adolescents with both ADHD and substance use disorders have a higher risk of suicide (Kelly, Cornelius, & Clark 2004)
- Males > Females when it comes to substance use an ADHD
- Adults with untreated ADHD are at twice the risk of developing a substance use disorder compared to adults without ADHD (52% vs 27%; Biederman et al, 1995)
- Research has shown that in patients with past substance use disorders, stimulants do NOT prompt the patient to revert to past behaviors (Schubiner, 2005; Wilens, 2004).
- Stimulant-treated patients with ADHD, when properly dosed, rarely require escalating doses over time and rarely fit the description of a “substance abuser”
- A recent meta-analysis and systematic review have substantiated the availability, use, and misuse of prescription stimulants has risen sharply among college students without the disorder (Benson et al., 2015; Weyandt et al., 2013).
- Recently reported prevalence rate of stimulant misuse was estimated to range between 13 – 23%, (Benson et al., 2015).
- Misuse is distinguished from Substance use disorders
- Misuse was found to be inversely correlated with academic performance (Benson et al., 2015; Rabiner et al., 2009; Weyandt, et al. 2013)
- Risks for misuse: Caucasian, Males, Fraternity/Sorority life, Low GPA
Overview of Adult ADHD Treatment
- An Integrated/Multi-modal Approach
- Multiple studies have demonstrated the beneficial effects of pharmacotherapies for the core symptoms of ADHD in adults
- Similar clinical response to that seen in youth
- Attentional deficits and motor restlessness are best controlled with pharmacotherapy
- Treatment should then focus on behavioral interventions, involvement of close relationships, and Psychoeducation
- Much more difficult in adults
- Treat residual symptoms and mild co-morbidities last
Methylphenidate and Amphetamines
- Both AMPH and MPH target the DA and NE systems
- Increase the concentration of these neurotransmitters in the synaptic cleft
- AMPH has additional properties of promoting release
- More effective than nonstimulants in treating core symptoms
- Prescription stimulants do not pose significant health risks to individuals when used as prescribed (Findling & Dogin, 1998).
- Side effects of prescription stimulants are dose-dependent (Solanto, 2001, Weyandt et al., 2014)
- Psychosis, seizures, and cardiac events such as tachycardia, hypertension, myocardial infarction, and sudden death are rarely reported in individuals taking therapeutic oral doses of prescription stimulants (Greenhill et al. 2002; Graham & Coghill 2008).
- Potent NE Reuptake inhibitor
- Effective in adults and for long-term use
- Particularly useful in comorbid SUDs
- High discontinuation rate (side effects)
Modafinil (Provigil) and Armodafinil (Nuvigil)
- Weak DA reuptake inhibitor
- Modulates histamine and orexin release
- Very few studies supporting use in Adult ADHD
- Alpha-2 agonists
- Very few studies supporting use in Adult ADHD
Minimizing Abuse Potential
- Use nonstimulants
- Use extended release formulations
- Use contracts
- Random urine drug screening
- Pill counting
- Utilize the CURES database
Misconceptions & Stigma
- “Everyone has ADHD”
- “Most children grow out of ADHD”
- “ADHD is limited to males”
- “ADHD medications increase the risk of substance abuse”
- “Adults seeking treatment for ADHD are probably drug seeking”
- “Long term use of stimulants increases the risk of developing Parkinson Disease”
- “Stimulant medications commonly precipitate psychosis and mania in patients with co-morbid bipolar disorder or primary psychotic disorders”
- “Study drugs = cheating”
- “ADHD medications are damaging to the brain”
- Pharmacy issues – treated like a “drug seeker”
- Insurance issues – strict on when to fill medications
- Pressures to sell or give away medications
- Many clinicians feel uncomfortable dx/tx ADHD compared to other disorders
- Liability concerns
- Diversion and abuse of medications
Overgeneralization of research findings and unsubstantiated conclusions mislead clinicians and the lay public!
- Young, Joel. ADHD Grown Up: A Guide to Adolescent and Adult ADHD .(2007)
- Gil Zalsman & Tal Shilton (2016) Adult ADHD: A new disease?, International Journal of Psychiatry in Clinical Practice, 20:2, 70-76, DOI: 10.3109/13651501.2016.1149197
- Stewart, T. D., & Reed, M. B. (2015). Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States. The American journal of drug and alcohol abuse, 41(5), 458–464. doi:10.3109/00952990.2015.1060242
- Psychiatric Times. 7 Evidence-Based Insights About ADHD. https://www.psychiatrictimes.com/adhd/7-evidence-based-insights-about-adhd
- Higgins, E.S. & George, M.S. The Neuroscience of Clinical Psychiatry: The Pathophysiology of Behavior and Mental Illness. 3rd Edition. 2018.
- Blumenfeld, Hal., MD, PhD. Neuroanatomy Through Clinical Cases. 2nd Edition. 2010.
- Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
- Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
- Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013
- Schatzberg & Nemeroff. The American Psychiatric Association Publishing Textbook of Psychopharmacology. 5th Edition. 2017.