Adult ADHD and the DSM-V

David W. Goodman, MD; Anthony L. Rostain, MD; Richard H. Weisler, MD.

David W. Goodman, MD: Hello, I'm Dr. David Goodman, director of the Adult
Attention Deficit Disorder Center of Maryland, and Assistant Professor of
Psychiatry and Behavioral Sciences at the John's Hopkin's School of Medicine.
I'd like to welcome you today to this Spotlight presentation entitled "Adult
ADHD [attention-deficit/hyperactivity disorder] and the DSM-V," a special
program designed to educate both psychiatrists and primary care providers about
the complexities of ADHD in adult patients. Today, we will talk specifically
about diagnosing adults with ADHD, why it's important, what the research shows
are key differences between adult and childhood ADHD, and why the diagnosis is
sometimes evasive.

Our learning objectives for today's spotlight are to identify key aspects and
symptoms that distinguish adult ADHD from childhood ADHD, and discuss the
contributions that the formal diagnostic criteria will make in recognizing adult
ADHD in the future.

I'm joined today by 2 colleagues and friends, Dr. Anthony Rostain, who is
Professor of Psychiatry and Pediatrics and the Director of the Adult ADHD
Treatment and Research Program at the University of Pennsylvania in
Philadelphia, and Dr. Richard Weisler, who is Adjunct Professor of Psychiatry at
the University of North Carolina, Chapel Hill, and Adjunct Associate Professor
of Psychiatry at Duke University in Durham, North Carolina.

Historically, the Diagnostic and Statistical Manual of Mental Disorders (DSM)
has focused on ADHD as a childhood disorder. DSM-IV was the first to acknowledge
that ADHD may persist into adulthood.[1] In the text of DSM-IV, it says symptoms
attenuate during late adolescence and adulthood, although a minority pf patients
experience the full complement of symptoms of ADHD in mid-adulthood. Although
the DSM-IV Text Revision (TR)[2] acknowledges symptoms that persist into
adulthood, the criteria were developed and validated using mostly male children
and adolescents.[3] Thus, the developmental appropriateness of directly applying
the criteria to adults is questionable. The development of the DSM V provides a
great opportunity to revisit the criteria for adult ADHD, based on the growing
body of new research in adult ADHD. So let me open the discussion with this: I
think we're all familiar with the basic DSM-IV criteria for diagnosing ADHD.
Adult ADHD can be diagnosed by DSM-IV TR criteria that are modified for
addressing adult behavior. For example, we can substitute "restlessness" instead
of "running and climbing excessively." We can substitute "difficultly sustaining
attention on a boring task" for "difficultly sustaining attention in class," or
"difficultly remaining seated" for "squirms and fidgets."

Dr. Weisler, do we really need adult criteria to make this diagnosis and how
will that add to the field?

Richard H. Weisler, MD: Most of us who trained in my era were taught that ADHD
did not exist in adults, so we really didn't get much training, and the
diagnostic criteria over the years has had much less emphasis on adults.
Moreover, the field [of adult psychiatry] has not done as much research on adult
ADHD until fairly recently. As you mentioned, a lot of the symptoms really do
change as people grow up; they learn how to compensate, and how to choose a
career that might work for someone with ADHD. I've picked out 1 item from the
Adult ADHD Self-Report Scale (ASRS), which is an adult rating scale, as an
example.

Dr. Goodman: This is a scale that's used in research by investigators to query
ADHD symptoms and it's written in an adult context.

Dr. Weisler: Right. Now, the primary prompt [in this rating scale] is actually
part of the original DSM-IV TR criteria,[2] which is "fails to give close
attention to details, or makes careless mistakes in schoolwork." So the adult
translation for the prompts regarding careless mistakes is: "is this because
you're careless, do you rush through work or activities, do you have trouble
with detail work, do you not check your work, do people complain that you're
careless, are you messy or sloppy, is your desk or workplace so messy that you
have difficulty finding things?" The scale uses similar translations for
hyperactivity type prompts for adults.

Dr. Goodman: These are useful because they are questions that not only query the
patient, but also help inexperienced or untrained clinicians to understand how
to ask the question and what specific issues they should be looking for.

Dr. Weisler: And it's important, I would say, for both psychiatry and primary
care, but primary care providers (PCPs) see a large majority of patients with
ADHD. In a survey a few years ago,[4] PCPs were fairly comfortable with making
the diagnosis in kids, but the majority felt uncomfortable making a diagnosis in
adults and believed it was much harder. So these kinds of prompts or suggestions
can make a difference for the providers. You don't have to incorporate all of
them into a clinical practice, but at least understanding what the translation
would be can be very important.

Dr. Goodman: Let's get Tony to weigh in. Why do we need adult criteria?

Anthony L. Rostain, MD: First and foremost, we need adult criteria to improve
the accuracy of making a diagnosis. If we just stick to the childhood types of
symptoms, we are going to miss adults who have ADHD. Second, as we were just
discussing, you really want to create an opportunity for the clinician to probe
what types of problems the patient is experiencing that could best be explained
by ADHD. It is really important to know that we're not just applying childhood
criteria, which many adults no longer have. Appropriate diagnostic criteria will
give the adult a chance to talk about how executive dysfunction and other kinds
of cognitive problems, as well as restlessness, might be very much impairing
their functioning as adults.

Dr. Weisler: Now, when you say adult ADHD, we're saying you wake up at 32 and
all of a sudden you have ADHD?

Dr. Rostain: Well no, obviously not; the other part of this is to try to get a
handle on the developmental issues. We generally agree that ADHD is something
that starts in childhood, but again, we've talked in the past about the notion
of ADHD being present before age 7. Now, many adults do not remember or can't
report on what it was like for them when they were 7. Many of them say they
didn't have problems until they were in high school. Should that individual be
excluded from having the diagnosis of the ADHD? Well actually, research is
showing that that's a big mistake.

Dr. Goodman: I'm going to put [the issue of age of onset criteria] on hold
because we're going to cover that topic later. So, we need adult criteria
because the presentation of symptoms and impairments manifests differently in
adults than children. For example, whereas children have impairments in the
educational arena, adults have difficulty not only in education, but also in
work and social domains.

Dr. Weisler: And you need to tease these out clinically, not only for diagnostic
purposes, but a good clinician will pick target symptoms to track how the person
responds to treatment, whether it be pharmacotherapy, or psychotherapy type
treatment or behavioral approaches. You want to track symptoms to see how
somebody is doing. So you have to translate that and educate your patients and
their families about what to expect, and what to look at, and that takes time.

Dr. Rostain: Another issue is that [we need] to really make sure the diagnosis
in adults becomes a valid entity that's recognized not only by the patients, but
also by employers and insurance companies, so that we're not just throwing
something together in a haphazard way. Evidence is growing, especially in the
past decade, that not only do the symptoms persist into adulthood, but also that
they are very impairing and deserve to be treated. So, this is an entity that
really has been undervalued, underexamined, until very recently.

Dr. Weisler: These symptoms really are so common. Most of us have some of these
traits. The question is, do they cause impairment?

Dr. Goodman: That's a critical problem because the diagnosis gets minimized and
discredited in the public arena because we all, as adults, have some
disorganization or inattention or distractibility because of stress, poor sleep,
medications, medical illnesses, or conflict in our environment. But this has a
childhood onset that persists chronically, pervasively, and impairingly into
adulthood in up to 60% of the children that have it.[5,6] The difficultly is for
the adults who might be bright or work in structured environments. The
impairments may not be so evident, so that patients and families really need to
look very specifically at the impairments. Would you agree that there are
modifications that have to occur?

Dr. Weisler: Absolutely. The other thing is, the clinician has to, if possible,
talk to a significant other, a friend, somebody else who can give you a feel
[for the impairment]. Because the persons who live with that issue of a
developmental disorder, they've lived with this all their lives. So, for
example, if you had visual problems for all your life, you may assume that's
normal. That's the same thing that happens with ADHD.

Dr. Rostain: Right. People compensate throughout their lives for their
difficulties. If you're not a good tennis player, you might be okay at golf. If
you're not good at balancing lots of different tasks, you might change the
choice of your career and really reduce some of your responsibilities to
something marginal and limited, compared to what your siblings might have
achieved. So we really think about this as not just, do you meet criteria, but
have you in fact been impaired by this disorder, such that you're not getting
the results that others around you are getting with the same amount of effort?
For example, I ask people, along with being inattentive or having trouble
getting things done, do you feel like it's really hard to achieve what you know
you should be capable of achieving? Are you putting in too much effort? Are you
getting too few miles to the gallon? You know you might be only getting 10 miles
to the gallon, and how can we improve your functioning?

Dr. Weisler: Many adults have learned to avoid things that they have problems
with. And that can be as big of a problem, quite honestly, as some of the other
symptoms.

Dr. Goodman: Now Dr. Barkley and Dr. Murphy[7] have come up with some
suggestions on specific symptoms for adults. Tony can you just expand on that?

Dr. Rostain: They've done extensive research, based on a large scale study[7]
that they conducted at the University of Massachusetts, looking at symptom
profiles in adults and quantifying the kinds of complaints that bring them in
and comparing those to other adults with different psychiatric disorders. They
also included data from the Milwaukee study,[7] which longitudinally followed
the symptom profiles of adults as they moved through the lifespan. What these
studies documented first and foremost is that inattentiveness, disorganization,
and working memory problems really are core features of ADHD, but so is
impulsivity, which may not be manifested as much through getting up out of your
seat, necessarily, but driving too quickly, making reckless decisions, and
having conflicts with people. So these criteria, as they've evolved, really do
capture in an evidenced-based way, the highest number of criteria that this
group found to be salient across their population of patients.

Dr. Goodman: Now when you say this is evidence based, you're saying that these
symptoms were extracted by factor analysis and statistical analysis.

Dr. Rostain: Right. They conducted structured interviews, semistructured
interviews, and focus groups; they culled all of these data and came up with a
list of 9 typical symptoms in the inattentive area and 9 in the
hyperactive/impulsive area. I think their proposal for criteria should be looked
at very closely.

Dr. Weisler: In adults, you tend to see the inattentive symptoms become more
frequent. Robison's work has highlighted that pretty carefully,[8] but even in
that work, what they found was that the combined type of ADHD was still the most
common in both men and women. But for adults, inattentive symptoms begin to
increase in prevalence.

Dr. Goodman: The current diagnostic criteria require symptoms before age 7. How
did that age cutoff evolve and how was age 7 decided upon? And then, what age do
you anticipate will be in the DSM-V, based on the research that has emerged?

Dr. Rostain: The truth be told, the age 7 cutoff was sort of an arbitrary number
that a group of people, researchers, sat in a room and said, "Okay, by what age
should we be seeing these problems?" Okay, second, third grade. A number of good
studies have been conducted to look at this criterion. For example, Steve
Faraone[9] at Harvard, began a project where they looked at individuals who had
met criteria by age 7 and compared those who did not develop symptoms until
about age 16, which he described as late-onset ADHD. And when he followed them
along and looked at some of their current functional problems, comorbidities,
and severity of ADHD symptoms, there was absolutely no difference. So really, I
think we do our patients a disservice if we insist on evidence of these symptoms
prior to age 7, because a number of them, especially the women, the girls, don't
manifest ADHD as clearly until middle or high school.

Dr. Weisler: That's clear, actually, and [girls may not manifest] even before
age 12; but, again, there is some overlap. Right now, if you have symptoms and
the person can't remember, and let's say they tell you they had it at age 10,
then it can be called ADHD NOS (not otherwise specified); but before age 12, it
looks about the same in terms of treatment, even though the diagnosis would be
ADHD NOS under current criteria. But going forward, what should it change to?
What age cut-off is realistic? There's a long study that followed people for 20
years,[7] and there was an observer bias showing that even though the people
were treated and diagnosed before age 7, these patients remembered [being
diagnosed] more than 4 years later than that, so more like 10 or 11, even though
the data shows that they were diagnosed earlier.

Dr. Goodman: So if we look at the symptoms and the progression, age 7 might have
been arbitrarily set because the focus at that point was on hyperactivity and
disruptive behavior, mostly in boys. As we get older, we see more of the
inattentive type emerge because academic demands increase the pressure and these
patients can't compensate.

Dr. Rostain: And the demand for what we would call self-regulation or
self-organization skills, moving from class to class, doing long-range projects,
also increases. So as we've evolved in thinking about ADHD not as just attention
or hyperactivity, but as a problem with executive control, then you begin to see
these more, these greater impairments in environments where children, now as
adolescents, are expected to be able to make the right choices with less
supervision and have to keep track of a lot more. So I think we can make a good
argument that we've missed a lot of patients. And the gender bias in our earlier
criteria, I think, is a really serious concern.

Dr. Weisler: We're going to talk more about gender, as well, while we're talking
about age, if we could. When we look at who gets diagnosed and at what age, in 1
large trial,[10] [the average age] was 34.9 years, I believe, when people were
diagnosed.

Dr. Goodman: Now say that again.

Dr. Weisler: First diagnosis for somebody who had ADHD with symptoms before age
7 was at 34 years. Which makes you think, what would happen for a patient to go
that long [without the diagnosis]? What they found was that these patients
frequently would be women who had compensated, like you said, and who didn't
have the hyperactivity. But when you get into a career, you've got kids, you've
got a job, you've got a relationship that you're trying to keep up, and that's
when it becomes overwhelming for some people and that's why they seek treatment.

Dr. Goodman: In the National Comorbidity Survey Replication (NCSR),[11] when
they looked at those adults with ADHD, who were in mental health treatment, only
1 in 4 were actually being treated for their ADHD, which means the mental health
professionals were missing this diagnosis. They weren't querying for it and they
might have been ascribing the patients' difficulties to other comorbidities.

Dr. Weisler: Yes, and in fact, in that same study, only about one fourth of the
people, wherever they were treated, were diagnosed and only 10% were treated
within a year's time, and they didn't use a stringent definition of treatment
either. You know, it was just any kind of treatment.

Dr. Goodman: So, we need the DSM-V to do what?

Dr. Rostain: The DSM-V has to better discriminate the profile of ADHD in adults
and late adolescents, and to give us guidelines to help clinicians make the
diagnosis across a variety of types of individuals, women and men. It has to be
less gender-biased and has to also signal to everybody that the existence of
comorbid conditions should not reduce your index of suspicion. It's not an
either/or, if anything, comorbidities should raise [your index of suspicion].

Dr. Goodman: So DSM-V needs to take a look at age of onset and changing that,
based on the research by Dr. Faraone[9] and Dr. Barkley.[7] We need to redefine
impairments, because compensatory skills, IQ, structured environment, and so
forth, can change the manifestation of the impairment. We need to make sure that
the diagnosis begins with childhood symptoms, at least somewhere in the
adolescent range. We need to understand that adults may not be able to report
symptoms they experienced before age 7, but that doesn't eliminate them from the
diagnostic possibility of having ADHD.

Dr. Weisler: And possibly benefiting from treatment. That's why it's crucial as
well.

Dr. Goodman: And all of these symptoms can't be accounted for by another
psychiatric condition. You can't show up intoxicated and say I have ADHD.

Dr. Rostain: That's right, and you can't suddenly emerge after you began smoking
pot everyday during college, and now you can't focus.

Dr. Weisler: If you think of someone, for example, who is 34 years of age,
coming in and they tell you they've been diagnosed, these people have had
symptoms throughout their lives, it's just a matter of asking the right
questions. Doctors, educators have frequently failed to really probe this
carefully, and we didn't know as much about it. But if you can take the time and
ask the questions, you can really change people's lives.

Dr. Goodman: Now, we know ADHD is highly heritable, 75% to 80% of the cause is
contributed by genes.[12,13] The current DSM doesn't include family history as
part of the criteria. As clinicians, what role does that play in nailing down
the diagnosis?

Dr. Weisler: I can tell you, a lot of the adults I see have kids who have been
diagnosed and they say, "My son or my daughter was recently given the diagnosis,
and I'm wondering if I have this, I think I may have it." Then they also need to
know that if they have 1 child with the condition, to be alert, that their
second child or third child may develop the problem.

Dr. Goodman: Can you give us percentages on that? If the parent has it, what's
the risk to the child? If the child has it, what's the risk to the parent?

Dr. Rostain: Something like 40%.

Dr. Goodman: If you have a child with ADHD, there's [roughly] a 40% chance that
a parent has it. If you have a parent with ADHD, there's about a 50% chance that
a child has it.[13,14]

Dr. Rostain: The important point for clinicians who work across the lifespan,
family practitioners or pediatricians, when they diagnose ADHD in a child, is to
actually inquire about the symptoms in the parent. It provides an opportunity to
get people the help they need. Because we know that parenting is challenging in
today's age, but if you, as a parent, have ADHD, and you have a child with ADHD,
that's a much more complicated task.

Dr. Weisler: Especially in the economic environment we have now, if you have
ADHD and you're distractible, you don't finish your work, things are messy, you
don't keep your appointments, you may lose your job, and your child or your
spouse loses a provider.

Dr. Goodman: Dr. Rostain, as a professor of pediatrics, do you tell your
pediatric colleagues that when they diagnose the child, that's not the end of
the treatment, turn to the parents and see which one of them [might have ADHD].

Dr. Rostain: I see this as a major public health issue. Get the parents to look
at themselves without being critical of them, being supportive, looking at how
this might be impairing them. They may say, "Oh, I really ran around a lot as a
kid, but I'm not running around as much." Yes, but mom, are you still having
trouble getting things done on time or keeping track of everybody's schedule?
"Oh yes, it's overwhelming me," and that's the opening to getting them to get
evaluated.

Dr. Goodman: When you say this is a public health issue, give me some numbers.
What's the prevalence rate? I mean Rick you can speak to this. What's the
prevalence rate in childhood? What's the prevalence rate in adults?

Dr. Weisler: A very large study was done in North Carolina by the National
Institute of Environmental Health Sciences, where they went into a school system
actually and took a look at who was being diagnosed and treated.[15] It turned
out to be about 15% of the boys and about 5% of the girls. There was no
difference by ethnicity, in terms of the diagnosis rates or access to care
differences and treatment differences. But in general, that was what it was in
elementary school, and the ranges vary. Now in adults, I think you mentioned
Kessler's study,[11] and again, the estimate was that around 4.4% of the adult
population have it. Some studies take it up to 5%. If you include a broader
criteria like Dr. Faraone is talking about, which would allow presentation
somewhere between age 7 and 12, then the numbers would be even larger.

Dr. Goodman: I might add at this point, that someone might be watching us and
say that adult ADHD is a United States phenomenon; ADHD in the United States is
driven by the pharmaceutical companies, and we consume all these stimulants and
it's really not seen in the rest of the world, can you comment on that?

Dr. Rostain: I have colleagues in Britain, in all parts of Western Europe who
see patients with ADHD, and we have studies now that replicate this in Australia
and in Japan. [16,17] There is a growing recognition [worldwide]. It is
important to comment that it wasn't until this last NCSR that the ADHD category
was included. So it shows you the bias in the field. We've had epidemiologic
surveys for the past 50 to 60 years, and only in the 2000 iteration [of the
DSM], did they include ADHD in adults, which shows that we weren't looking for
it. Now we know when we look for it, we see it, it's there. It's always been
there. So, why are we suddenly finding all this? Well, we're finally asking the
question, and until we ask the question, we're not going to find it.

Dr. Weisler: When I was in training, we were taught it didn't exist once you got
to be 18, so we never saw it. I just got back from the World Psychiatric
Association meeting in Italy, and I can tell you from talking to people in Italy
and Germany, all over Europe, and other countries as well, they see ADHD in
their country if they look for it. If they don't look for it, they don't see it.
In the United States, we can't brag too much either because, again, the majority
of people never get diagnosed with ADHD at this point.

Dr. Rostain: One other cultural and environmental factor is that as we move into
the information age, and more and more complex tasks are expected of your
average citizen, these symptoms become even more obvious and more impairing. So
it's not that they weren't there before, but I think in an agrarian society, or
even in the industrial society where you worked at a fairly routine job and you
didn't have a million things to do, these symptoms were there, but may not have
been as obvious or as impairing. But now, in the time when we're supposed to be
able to manage huge amounts of information with technology, and with these
expectations of people going to college, which wasn't there a generation before,
now suddenly we see the ADHD. In Italy, among college students, the rate of ADHD
is 4.5%, almost exactly the same as that in the United States.[18]

Dr. Goodman: That's interesting, because people will say that all this
technology and all these distractions are creating ADHD. What you're saying,
then, is that the technology and the demands that are placed on people now have
grown and they tax the ability of those who have ADHD to compensate and to stay
ahead.

Dr. Weisler: The percentage of people who graduate from high school, and who
have gone on to technical school or college is higher. Now, instead of working
all day out in the field in an agrarian society, you may be expected to be
behind a desk and sit still and focus on 1 thing for a long time. That's very
different from being a farmer.

Dr. Goodman: Tell me a little bit about the gender differences you mentioned
earlier. The difference between girls and boys in childhood, and then how they
present as men and women.

Dr. Rostain: First and foremost, little boys who run around a lot get noticed
early. Little girls who are chatty and friendly and disorganized as all heck,
don't get noticed because they're not creating a disruption; they're charming. I
have a little girl, I used to call her babbling brook, and she could talk her
way out of any situation, but when you opened up her school bag, everything was
a mess. She never finished her assignments. But she wasn't diagnosed until age
10 and her older brother had been diagnosed at age 7. So there's at least a 3-
or 4-year lag in the diagnosis of ADHD between girls and boys.

Dr. Weisler: There's also a developmental delay, as well, that you might want to
talk about.

Dr. Rostain: We're learning more and more that there are a number of kids [with
ADHD] whose brain images show that it's a delay in maturation. But the
complexity in girls is such that recent studies have shown that the level of
complexity of the presentation is greater, because women are in many ways, not
as disruptive, not as aggressive.[8] Then what we're left with are things like
inattention, slow cognitive tempo, women come in anxious or they come in
depressed instead of saying, I can't focus because of ADHD. And clinicians are
liable to say, well you're not focusing because you have anxiety disorder.

Dr. Weisler: Women also have a low self-esteem because they don't have any
explanation for it in many cases, and that results in depression. And we know
that women are probably twice as likely to experience an affective disorder
anyway, like major depression.

Dr. Goodman: Right. It's my understanding, prepubescent, the depression rate,
male to female is 1 to 1. But in the postpubescence, it's 2 to 1, female to
male.

Dr. Rostain: In the NCSR,[11] the ratio of men to women [with ADHD] was only 3
to 2, whereas we were taught the ratio was 4 to 1 male to female in the
diagnosis. So when you look at an epidemiologic sample of adults, the ratio is 3
to 2 [male to female], which really speaks to this idea that the presentation is
different in adults and if ADHD does not present with clinically obvious
symptomatology, it often is missed.

Dr. Weisler: Again, if you think about the world as it is right now: you're a
woman, you finished school, now you've got a job, you've got kids you're trying
to raise at home, you're trying to be a good spouse, it's a pretty challenging
job. And that may be when the symptoms really are en masse.

Dr. Goodman: Now you've talked about the difference between agrarian societies
and industrial societies, but let's talk about cross cultural. Tell me about the
access to care of minorities vs whites and how that affects practitioners in
different practice and environment situations.

Dr. Weisler: A few years ago, the National Institute of Environmental Health
Studies found that if you were Hispanic, as I remember, you had about a 1 in 6
chance of getting treatment; if you were white, around 60% of people got
treatment, and if you were African American, about one third got treatment.[19]
So a lot of it depends on cultural views as well, as to whether you see this as
a problem or not. Some of it relates to access to care issues that are important
and this varies from place to place around the country. Quite honestly, there
are not enough providers who are knowledgeable about the condition. Certainly,
there are not enough child psychiatrists. I know in North Carolina, roughly 40%
of the counties have no child psychiatrists in the entire county. So there's a
good chance primary care doctors or adult psychiatrists have to make the
diagnosis.

Dr. Goodman: And I can only imagine there are primary care providers watching
us, shaking their heads going, "Right. I have no place to refer these patients,
even after I identify them."

Dr. Rostain: I think that in terms of the economic obstacles, it's also the case
that not having access to care is probably one of the biggest factors for people
not getting treatment.

Dr. Goodman: Let's move on to comorbidity, because comorbidity presents with a
level of symptom severity that clinicians focus on very quickly, and they don't
think [about ADHD in these cases], it's not on their radar, they don't believe
in ADHD, and so it never gets into the initial evaluation. Tell me how you would
insinuate ADHD as part of the initial evaluation, even when the patient comes in
and says, "Dr. Rostain, I'm about to lose my job because I got a poor job
performance, and I'm really anxious, so I'm having a fight with my wife and she
is going to leave me because she says I never follow through."

Dr. Rostain: Well first of all, starting with the data from the NCSR,[11] people
with ADHD have much higher rates of comorbidity, anywhere from 3 to 7 times the
rate of mood disorders, anxiety disorders, substance use disorders. I would dare
say that in our program, easily 80% of our patients have at least 1 comorbid
condition.

Dr. Weisler: And sometimes 2 or 3.

Dr. Rostain: Yes, and sometimes it's 2 or 3. Exactly. So yes, the patient is
anxious or may even be losing sleep or becoming deeply depressed, but if you go
back in time and look at the origin of this problem, it wasn't that she was
anxious and therefore couldn't perform her job, it's that she became anxious
because she wasn't able to perform her job, and she couldn't perform her job
because she has undiagnosed ADHD.

Dr. Weisler: Now, you have a background in pediatrics. But as an adult
psychiatrist, quite honestly, I came in late to looking at ADHD because I didn't
have very much of it as part of my training. So once I treated somebody's
depression, once I treated their anxiety, or their bipolar disorder, then I
would see that there were still problems that were impairing them significantly,
in terms of accomplishing what they needed to accomplish at home, at work, or in
social relationships.

Dr. Goodman: So if I, if I treat only adults with mood disorders -- I have a
mood disorder clinic with adults -- how many ADHD patients would you anticipate
in that practice?

Dr. Rostain: I'd like to take a stab at this. If it was bipolar disorder,
probably 1 in 10 of your patients, or a little more [would have ADHD]. And if
it's depression, roughly 15% are going to have some sort of ADHD symptoms that
you're missing.[11]

Dr. Weisler: David, what would you think? It would be even higher I would think.

Dr. Goodman: Tony is right, it's about 1 in 10, maybe 1 in 8, in the patients
with depression; it's 1 in 5 in bipolar.[11] But let's put the prevalence rate
of 4.5% for adult ADHD into perspective. The prevalence rate of schizophrenia is
1%, bipolar disorder is about 2.5%, generalized anxiety disorder is 3%, ADHD in
adults is 4.5%, major depression is 7%.[11] You have a major psychiatric
condition that's not included as part of the initial evaluation by adult
psychiatrists or even primary care providers and it's no fault of our own. We
were never trained, even to this day; there are few residency programs that even
have a single lecture on adult ADHD. So this idea that we need to be sensitive
if a patient presents with comorbidities, I would back up and say that given the
prevalence rate, it should be part of every initial mental health evaluation for
an adult. Let's compare this with the AACAP (American Academy of Child and
Adolescent Psychiatry) recommendations. What are the AACAP recommendations for
children with ADHD?[20]

Dr. Rostain: Again, from the clinical side, you have to probe every possible
other mental disorder that's most likely to be affecting your patient's current
function. So you'll ask about anxiety symptoms, depression, posttraumatic
symptoms, but you'll also want to ask about ADHD symptoms. Because that might be
the lynch pin around which all of these other symptoms have now become focused;
I can't function, I can't concentrate, I can't get things done, and it's getting
worse, and actually, I've started drinking more. Suddenly, you see this
unfolding picture of the very, very complex comorbid patient, which should not
dissuade you as a clinician from piecing it all together and coming up with a
priority list; saying, yes, we need to address your depression. As you were
saying earlier, the depression may not fully resolve if you don't address the
ADHD. The concentration isn't there, the impulse control isn't there, they may
not be feeling as down, but they're still not handling all of the information
they need to be handling.

Dr. Goodman: But say I'm a primary care provider, I appreciate the time you
spend interviewing the patients, but I don't have that kind of time, I can't go
through the whole DSM. Rick, tell me how I'm supposed to do this and put ADHD
into the evaluation of an adult patient who comes in complaining about a variety
of other things.

Dr. Weisler: We have some simple screeners as well as the more comprehensive
ones. For example, the adult screener that was developed by the World Health
Organization,[21] the ASRS, has 6 simple questions and is a self-rated type
scale; it is free, you can download it on the Internet. Quite honestly, I use
tools like that, different types of screeners, and let family members and
patients fill it out in the waiting room. In that way, I can incorporate it into
the evaluation and I can find out, again, how the family members see them.

Dr. Goodman: Often it's said that we should be sensitive to ADHD. If a patient
comes in with psychiatric condition "A," maybe we should also think about ADHD.
I like to say that ADHD should be part of the inquiry of every adult mental
health evaluation, for this reason.

Dr. Weisler: We were talking earlier about the percentages of people [with
comorbid conditions]. Tony could you mention that again, in terms of percentages
of people with these different comorbid conditions?

Dr. Rostain: People with ADHD have 3 to 7 times the rate of other mental
disorders, compared to the general population. And if you look at it the other
way around, for people with bipolar disorder, anywhere from 1 in 6 to 1 in 5,
will have ADHD,[11] with similar rates for depression or anxiety disorders. The
rates of substance abuse disorders are much higher in people with ADHD who have
not been treated. The practicing clinicians in the primary care setting are now
doing a very good job of identifying depression. There was a huge effort in the
past decade to identify undiagnosed depression and the rates of treatment for
depression have gone up remarkably in the past 10 years. That is where we are
now with ADHD. Our job is to move that agenda forward; to say, don't just screen
for the depression, also screen for ADHD because you'll have a much better
chance of getting the therapeutic results you're looking for.

Dr. Weisler: If you look, for example, at bipolar patients; bipolar patients
with ADHD tend to have higher rates of suicidality, so it's important from a
clinical perspective to address the ADHD.

Dr. Goodman: I always compare the percentages to support the rationale for
including ADHD in the initial evaluation, because prevalence rate is high
compared to other disorders. As we mentioned earlier, the prevalence of
schizophrenia is 1%; bipolar disorder is 2.5%; GAD is 3%; adult ADHD is 4.5%;
and major depression is 7%. We have a major psychiatric condition that's not
being assessed and it's not being assessed because we weren't trained to address
it in residency programs.

We have been involved in some of the research presented in poster sessions [at
the 2009 annual meeting of the American Psychiatric Association]. I thought we
could just take a moment to talk about some interesting work [related to the
assessment of adult ADHD] for clinicians. One study we participated in asked
this question: the ADHD rating scale measures the 18 symptoms from the DSM, and
scores them on a 0- to 3-point scale; if the patient comes in severely impaired,
at 40 points, how many points towards improvement do I need to move that patient
to say that I'm really approaching an optimal treatment dose?[22] It is often
difficult to assess, by the patient's report, when he comes in and says, look I
feel better, thank you so much, I think this is a good dose. But in fact, when
they fill out their rating scales, it's not so good. To answer that question, we
conducted a linking study between the ADHD RS and the clinical global impression
(CGI). (The analysis was based on data from pivotal clinical trials of
lisdexamfetamine dimesylate [LDX] in children and in adults with ADHD.[23,24])

Dr. Weisler, could you tell us what the clinicians can take from that study?

Dr. Weisler: In primary care but also, quite honestly, for a lot of
psychiatrists, there isn't time to do the full 30- to 40-minute ADHD rating
scale (The Clinical Global Impressions-Improvement [CGI-I] and -Severity [CGI-S]
scales are based on clinical observations and may be better understood by
clinicians. In addition, the CGI reflects common clinical practice of grading
severity and improvement of illness over time.)

The literature indicates that a 25% to 30% decline in the ADHD RS score (8- 10
points) corresponds to a clinically meaningful change and about a 1-point
improvement in the CGI scale.[25] Obviously, you want to get as much improvement
as you can, you would love to see remission, but that's not often the case. But
we also can use these scales to help to determine who needs higher doses of
stimulant. So for those with moderate disease, it appears that the lower
stimulant doses work well, but the higher dose range may be needed for people
who are markedly or severely impaired, and that's why something like that may be
useful. Quite honestly I believe that any clinician should use a CGI, this takes
just a second, but it gives you something you can track as you go forward.

Dr. Goodman: CGI is the 7-point clinical global impression scale. A score of 4
points is no change in symptom severity, and plus numbers are incremental
improvement and negative numbers are worsening.

Dr. Weisler: When you [initiate treatment], you can use the CGI severity scale,
which again, 4 points would be moderate symptoms, 5 would be marked and going up
to extreme, very few people are extreme; if you don't have any symptoms at all,
the score would be a 1. So, if you begin with an idea of how much impairment the
symptoms are causing, you will know how much patients have to compensate for.
The CGI is a good place to start and you can track it.

Dr. Goodman: Right, so although the ADHD studies in children, adolescents, and
adults look at a threshold of 30% improvement in the rating scales, our linking
study showed that a 50% reduction in the scale score really is much more
functionally and clinically important. That was also demonstrated by Buitelaar
and colleagues in a pediatric study in Amsterdam.[26]

I wonder if we can just talk briefly about the statistically significant
negative impact of ADHD when it goes undetected and untreated. Can you quickly
discuss these consequences?

Dr. Rostain: There is no question that people with ADHD do not earn as much as
much money, they change jobs and are fired much more frequently, and are
delinquent at paying their bills, for example.[7] It's clear that ADHD also
impairs a person's academic performance, and certainly interferes with social
relationships and, in particular, intimate relationships.

I think that this issue of how ADHD affects important relationships, either with
your spouse or your kids, is really a critical area. I have 1 example of a
patient who actually used ADHD to his advantage at work; he was a radio talk
show host and he used this quick back and forth, moving from item to item,
answering telephone calls. He was fantastic. But when he went home, he couldn't
stay quiet and patient with his children. And he came to see me very, very
concerned that he was getting angry too quickly. He was too impatient at home.
So for him, even though his ADHD was present in every setting, it wasn't causing
impairment at work as much as at home. That was what he wanted help with. So
considering how ADHD affects all facets of functioning is crucial for
clinicians.

Dr. Goodman: But people will say look, the guy's had this, the woman's had this,
his or her whole life. They've learned to compensate, they've muddled through,
why bother treating? What would be your response to that?

Dr. Weisler: My response is that if you look again at areas of impairment,
especially if it's multiple areas, we know that ADHD affects work,
relationships, like Tony talked about, but it also affects driving. Russel
Barkley has done some nice work looking at driving.[7,27] Between the ages of 16
and 30, accidents are a leading cause of death. And if you have ADHD, you're
much more likely to be involved in an accident because you're distractible,
you're not paying attention.

Dr. Rostain: Another area that relates to driving is the use of substances. And
sexuality, especially unprotected sex and the numbers of unwanted pregnancies
that were shown to, in the Milwaukee study, to be many more times the case in
women with the ADHD vs the normal controls.[7] In other words, a lot of unwanted
problems in one's life come from impulsivity, recklessness, risk-taking. As life
goes on, you may not be as rambunctious, but you're certainly behind the wheel.
We all worry about talking on cell phones and driving, but if you have ADHD,
it's like always being on the cell phone when you're behind the wheel.

Dr. Weisler: The Mass General group and others followed 1001 people into
adulthood.[28] They clearly found much higher rates of all the things Tony is
talking about, the statistics were there. But drug abuse, smoking cigarettes,
was around 64% of people with ADHD smoking cigarettes. That takes away a lot of
years of life, it's harder to quit, and if you look at, if you start smoking and
you have ADHD in your childhood and adolescent years, the depression may well
follow, we know, and a few years later you might get into marijuana.

Dr. Goodman: So not only are these negative consequences that we look for in the
history to kind of support the diagnosis, but we also counsel our patients who
are resistant to treatment or family members who are prejudiced against
treatment to say look, this is the condition, this is what we believe is going
to happen if you don't address this and manage it. Treatment is beyond just
pharmacologic treatment, we're talking about a comprehensive treatment with
social interventions, organizational techniques, behavioral techniques, family
counseling, and a variety of therapies that help move somebody.

Dr. Weisler: What I would say as well is that a lot of the figures look very
scary if you're a clinician or a patient looking at them or a family member of
the patient. But the reality is that ADHD is a very treatable disorder; in fact,
it is one of the most treatable disorders in all of medicine. And if you combine
the things you're talking about, and also take a look at the affective and
anxiety-related components and treat those, look at substance use, etc, people
will lead very fulfilling lives and society really benefits. If you don't treat
it, society really suffers.

Dr. Rostain: The other point is that the role of the clinician is also to
provide hope to the patient and say I can help you to understand why all of this
has been so hard for you. Many of my patients will actually break down and start
crying out of gratitude and relief that someone finally understands, instead of
telling them that they're poorly behaved, or they're lazy, or asking what's
wrong with them, all the kinds of inner negative views of self. Just by simply
saying, there is an explanation for all this, it gets the patient to become
engaged in a hopeful process.

Dr. Goodman: It's nice to sit here with people who are researchers as well as
clinicians and who can meld the 2 fields together and then move this forward for
the education of our colleagues. I think establishing adult criteria, effective
treatment, and increasing physicians' and public awareness will lead to more
adults receiving treatment, increasing their productivity, and achieving a more
satisfying life. We hope that the education and treatment of ADHD across the
lifespan will improve educational, occupational, and social outcomes, while
reducing the negative consequences of untreated ADHD that we've discussed. In
summary, I'd like to ask our panel, what parting thoughts and pearls would you
convey to our viewers in a succinct message?

Dr. Rostain: Look for ADHD, get familiar with the criteria so that you can apply
very practically. Use the screening tools and probing questions, and always keep
your eye out for ways that you can be helping the patient and their family to
get a better handle on all of the different aspects of this, in their own
situation.

Dr. Weisler: Another point is that you're never too old to benefit from
treatment, or for that matter, too young, if you look for it. It is a very
treatable disorder. I see plenty of people who are diagnosed in their 40s and
sometimes even 50s or 60s; they've had a lifelong history. They respond to
treatment often as well as younger patients, and are very appreciative, just as
Tony said, to having their symptoms ameliorated. Their self-esteem can improve
dramatically. I recently saw a man who was a college-age student, and he was
beating himself up. He was referred in because he was on probation and he was
about to be kicked out of the university. With treatment, which involved some
coaching, educational therapy, as well as some medication, his grades went from
1.8 to a 3.8 average, and he gets into grad school. He now has a whole life
ahead of him. He has better job opportunities. If he hadn't done that, quite
honestly, he wouldn't have much of a career, then he would have looked at
relationships differently. You can really alter things.

Dr. Goodman: Right, and it's a ripple effect. Not only does the patient feel
better and emerge and blossom in their life, but also the family benefits, and
the clinician gains some satisfaction in treating someone so effectively.
Adult-specific criteria will need to be more accurate to describe and identify
the adults with ADHD, as you've heard from our discussion, to promote effective
treatments that are currently available and in development, and to improve daily
functioning. All initial mental health evaluations of adults should include the
screening for ADHD, regardless of the presenting complaint.

With that, I want to thank my colleagues and friends, Tony and Rick, for this
very interesting discussion, and I want to thank you for your interest in
broadening your understanding of ADHD. Thank you again for joining us.

SOURCE: http://cme.medscape.com/viewarticle/704424?src=cmemp