Mina Boazak, MD
Medical Director at Animo Sano Psychiatry, firstname.lastname@example.org
Disclosure: The author is the founder and medical director of Animo Sano Psychiatry, PLLC, a private practice clinic specialized in the treatment of adolescent and adult ADHD; as of the writing of this article the author provides consulting services with Holmusk USA, Inc., the author is an investigator of trials funded by Otsuka pharmaceutical and the Georgia CTSA.
ADHD Defining the Problem:
- ADHD is a common neurodevelopmental condition that is highly heritable (Figure 1), results in significant dysfunction (Figure 2), and is tragically undertreated despite being one of the most responsive behavioral health conditions to pharmacologic management.
- Once thought to be predominantly a diagnosis of childhood, ADHD is now recognized to commonly occur in adults. The lifetime prevalence of ADHD is approximately 8% (NIMH, 2017)and prevalence rates in adults are estimated to be approximately 4% (NIMH, 2017) at a roughly 2:1 ratio in males: females.
Figure 1: Heritability of ADHD in Sibling Cohort (h2-NATIONAL) and SNP Based Heritability (h2-SNP) as compared to other mental illnesses(Pettersson et al., 2019)
Awaiting Permission Approval From: Pettersson, E., Lichtenstein, P., Larsson, H… et al. (2019). Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls. Psychological Medicine, 49(07), 1166–1173. https://doi.org/10.1017/S0033291718002039
Figure 2: Rates of social dysfunction in young adults in normal vs ADHD subjects(Harpin, 2005)
With Permission From: Harpin, V. A. (2005). The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Archives of Disease in Childhood, 90(suppl 1), i2–i7. https://doi.org/10.1136/adc.2004.059006
Symptoms of Adult ADHD:
The DSM-5 lists 9 different inattentive and hyperactive symptoms for the diagnosis of ADHD (Table 1). These symptoms are the building blocks that allow for the identification of ADHD and its subtypes (predominantly inattention, predominantly hyperactive, or the combined type). According to current criteria for an adult patient to have any of the ADHD sub-types (American Psychiatric Association, 2013):
- they need to have 5 or more symptoms from the corresponding symptom category (in the case of the combined sub-type they need 5 of each category);
- some of their symptoms must have been present prior to the age of 12;
- their symptoms need to be present in at least two settings (home, school, social settings, work…etc);
- their symptoms need to cause impairment and;
- their symptoms should not be better explained by an alternate disorder
Table 1: Symptoms of ADHD (Kadiyala, 2020)
|Use mnemonic ATTENTION
A: Attention difficulty
T: Trouble listening, even when spoken to directly
T: Tasks requiring sustained mental effort difficult
E: Easily distracted
N: Necessary things for tasks are lost
T: Trouble finishing tasks
I: Is forgetful
O: Organizational skills lacking
N: Not concerned with details/careless mistakes
|Use mnemonic RUN FIDGET
R: Runs, climbs, or restless
U: Uninhibited in conversation
N: Not able to play quietly
F: Fidgets or squirms in seat
I: Interrupts or intrudes on others
D: Difficulty waiting for his or her turn
G: Get going or acting as if driven by a motor
E: Evacuates seat unexpectedly
T: Talks excessively
Practically speaking many patients with ADHD present with reports of declining/poor work or school performance, family conflict related to difficulty keeping up with responsibilities, missed bills, missed appointments, and late shows to clinic appointments. In such instances, you should consider evaluating for the disorder.
Workflow for Diagnosing ADHD:
If you or your patient are concerned about the possible presence of an ADHD diagnosis then you can follow the linked workflow algorithm for diagnosis (see below). You can use the Adult ADHD Self Report Scale (ASRS-S) Screener for screening (Table 3). The scale should guide your evaluation, but be aware that the scale has been reported to have sensitivity and specificity as low as 60 and 70% respectively(Dunlop et al., 2018). You should therefore use the screener with caution, recognizing that it is one of the best freely available and rapid self-report questionnaires for this diagnosis. Ultimately, current guidelines stipulate that the ADHD diagnosis be based on clinical observation. If a patient screens positive, or if your suspicion for ADHD is high enough, then you should conduct a full clinical evaluation.
A note on neuropsychological testing: Neuropsychological testing is expensive, time-consuming, and is most beneficial in the evaluation of cognitive and neurologic disorders that may be co-morbid with ADHD (such as learning disorders or autism spectrum disorder). Neuropsychological testing should not be used to diagnose ADHD and is not the gold standard. As stated previously, ADHD should be diagnosed through clinical evaluation. Where you are uncertain of the diagnosis, the patient should be referred for specialty (psychiatric) evaluation, rather than neuropsychiatric testing.
Multiple society guidelines exist on the management of ADHD. These include guidelines developed by the AAP (endorsed by the AFP), AACAP, CADDRA, NICE, and SIGN amongst others. Of these, this report uses the CADDRA guidelines and recent research in recommending treatments for adults as many others specifically focus on child and adolescent management.
- There is unanimous consensus across guidelines that stimulant therapy should be utilized as a first-line agent in adults with ADHD who are interested in pharmacologic management.
- A large 2018 network meta-analysis has demonstrated that adults with ADHD are more likely to respond to mixed amphetamine salts (MAS) than methylphenidate (MPH) agents(Cortese et al., 2018)
- Failure of a first stimulant agent should be followed with a trial of an agent of the alternate stimulant class (ie. If the initial agent was a MAS then switch to MPH and vice versa).
- Consider non-stimulants (atomoxetine or bupropion have multiple studies demonstrating efficacy in adult ADHD) as second-line treatments after adequate trials of stimulants of both the MAS and MPH class.
- If approaching third-line options then consider referral to a specialist for diagnostic assessment and treatment support.
- Follow-up during the titration phase should be held every 2-4 weeks and once the patient is stable could be extended to every 3-6 months.
- Track patient improvement using clinical measures such as the ASRS (see Table 3).
Table 2: Guidelines to review on the treatment of ADHD
|Canadian ADHD Practice Guidelines||2018||https://www.caddra.ca/wp-content/uploads/CADDRA-Guidelines-4th-Edition_-Feb2018.pdf|
|National Institute for Health and Care Excellence||2019||https://www.nice.org.uk/guidance/ng87|
|American Academy of Pediatrics||2019||https://pediatrics.aappublications.org/content/144/4/e20192528|
|American Academy of Child and Adolescent Psychiatry||2007||https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext|
Table 3: Patient-reported screening tools for ADHD evaluation and management
|ADHD Tool||Time Requirement||Evaluates||Link||License Required?|
|Adult ADHD Self-Report Scale (ASRS) v1.1 Screener||1-2 min||Symptoms||https://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/6Q_ASRS_English.pdf||Permission needed from Dr. Kessler: email@example.com.|
|Adult ADHD Self-Report Scale (ASRS) v1.1||<5 min||Symptoms||https://www.apaservices.org/practice/reimbursement/health-registry/self-reporting-sympton-scale.pdf||Free to use|
|WEISS SYMPTOM RECORD II||10 min||Symptoms||https://www.caddra.ca/wp-content/uploads/WSR-II.pdf||Free for clinical and research use.|
|WEISS FUNCTIONAL IMPAIRMENT RATING SCALE – SELF REPORT (WFIRS-S)||10-15 min||Function||https://www.caddra.ca/wp-content/uploads/WFIRS-S.pdf||Free for clinical and research use.|
|CADDRA Patient ADHD Medication Form||10 min||Treatment impact and side effects||https://www.caddra.ca/wp-content/uploads/CADDRA-Patient-ADHD-Medication-Form.pdf||Free to use|
Resources for patients:
- org and Additudemag.com: comprehensively cover all things ADHD in a manner that can be assimilated by patients.
- CHADD’s easy to follow guide for adults can be found here: https://chadd.org/understanding-adhd/
- The Triangle Area CHADD Support Group can be found here: https://www.chadd.net/chapter/176
- com/resources: the author has compiled a list of resources for patients on his clinic website on ADHD diagnostics, treatment, and some helpful apps.
- Seeking treatment: For therapy or where symptoms are complex enough as to require psychiatric management Duke provides excellent adult ADHD services; alternatively, patients can be referred to the author at Animo Sano Psychiatry (aspsychiatry.com) or; patients can visit psychologytoday.com to search for providers who accept their insurance and who are in their area.
If you have further questions about ADHD evaluation and management feel free to contact the author at firstname.lastname@example.org or 919-391-7202.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM–5).
Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet. Psychiatry, 5(9), 727–738. https://doi.org/10.1016/S2215-0366(18)30269-4
Dunlop, B. W., Wu, R., & Helms, K. (2018). Performance of the Adult ADHD Self-Report Scale-v1.1 in Adults with Major Depressive Disorder. Behavioral Sciences, 8(4), 37. https://doi.org/10.3390/bs8040037
Harpin, V. A. (2005). The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Archives of Disease in Childhood, 90(suppl 1), i2–i7. https://doi.org/10.1136/adc.2004.059006
Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: A scoping review. General Psychiatry, 33(3), e100109. https://doi.org/10.1136/gpsych-2019-100109
NIMH. (2017). Attention-Deficit/Hyperactivity Disorder (ADHD). Attention-Deficit/Hyperactivity Disorder (ADHD). https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd
Pettersson, E., Lichtenstein, P., Larsson, H., Song, J., Attention Deficit/Hyperactivity Disorder Working Group of the iPSYCH-Broad-PGC Consortium, Autism Spectrum Disorder Working Group of the iPSYCH-Broad-PGC Consortium, Bipolar Disorder Working Group of the PGC, Eating Disorder Working Group of the PGC, Major Depressive Disorder Working Group of the PGC, Obsessive Compulsive Disorders and Tourette Syndrome Working Group of the PGC, Schizophrenia CLOZUK, Substance Use Disorder Working Group of the PGC, Agrawal, A., Børglum, A. D., Bulik, C. M., Daly, M. J., Davis, L. K., Demontis, D., Edenberg, H. J., Grove, J., Gelernter, J., Neale, B. M., Pardiñas, A. F., Stahl, E., Walters, J. T. R., Walters, R., … Polderman, T. J. C. (2019). Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls. Psychological Medicine, 49(07), 1166–1173. https://doi.org/10.1017/S0033291718002039
All that fidgets are not ADHD.
Attention-deficit hyperactivity disorder
Pharmacologic Treatment of Attention Deficit-Hyperactivity Disorder
A Clinician’s Guide to ADHD Treatment Options
Postgraduate Medicine 2017
Drugs for ADHD
Medical Letter Drug Therapy 2020
Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review
Management of Attention-Deficit/Hyperactivity Disorder in Primary Care
Nursing Clinics of North America 2019
Adult ADHD: Addressing a Unique Set of Challenges
J Fam Practice 2017
Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls Author: E. Pettersson , P. Lichtenstein , H. Larsson , J. Song , A. Agrawal , A. D. Børglum , C. M. Bulik , M. J. Daly , L. K. Davis , D. Demontis , H. J. Edenberg , J. Grove , J. Gelernter , B. M. Neale , A. F. Pardiñas , E. Stahl , J. T. R. Walters , R. Walters , P. F. Sullivan , D. Posthuma , T. J. C. Polderman Publication: Psychological Medicine Publisher: Cambridge University Press Date: Sep 17, 2018 Copyright © 2018, Cambridge University Press Order Completed Thank you for your order. This Agreement between Mina Boazak (“You”) and Cambridge University Press (“Cambridge University Press”) consists of your order details and the terms and conditions provided by Cambridge University Press and Copyright Clearance Center. License number Reference confirmation email for license number License date Jul, 05 2021
7/5/2021 Rightslink® by Copyright Clearance Center https://s100.copyright.com/AppDispatchServlet 2/3 Licensed Content Licensed Content Publisher Cambridge University Press Licensed Content Publication Psychological Medicine Licensed Content Title Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls Licensed Content Author E. Pettersson , P. Lichtenstein , H. Larsson , J. Song , A. Agrawal , A. D. Børglum , C. M. Bulik , M. J. Daly , L. K. Davis , D. Demontis , H. J. Edenberg , J. Grove , J. Gelernter , B. M. Neale , A. F. Pardiñas , E. Stahl , J. T. R. Walters , R. Walters , P. F. Sullivan , D. Posthuma , T. J. C. Polderman Licensed Content Date Sep 17, 2018 Licensed Content Volume 49 Licensed Content Issue 7 Start page 1166 End page 1173
BMJ PUBLISHING GROUP LTD. LICENSE TERMS AND CONDITIONS Jul 01, 2021 This Agreement between Duke Center for Health System — Mina Boazak (“You”) and BMJ Publishing Group Ltd. (“BMJ Publishing Group Ltd.”) consists of your license details and the terms and conditions provided by BMJ Publishing Group Ltd. and Copyright Clearance Center. License Number 5100301005087 License date Jul 01, 2021 Licensed Content Publisher BMJ Publishing Group Ltd. Licensed Content Publication Archives of Disease in Childhood Licensed Content Title The effect of ADHD on the life of an individual, their family, and community from preschool to adult life Licensed Content Author V A Harpin Licensed Content Date Feb 1, 2005 Licensed Content Volume 90 Licensed Content Issue suppl 1 Type of Use website (Figure/table/extract) Requestor type Academic Institution
Format Electronic Portion Figure/table/extract Number of figure/table/extracts 1 Descriptionof figure/table/extracts Figure 4 Will you be translating? No Home page URL https://intranet.medschool.duke.edu/depts/admin/finance/SitePages/Home.aspx Client / Sponsor Duke University School of Medicine
Expected posting date Jul 2021 Portions Figure 4 Requestor Location Duke Center for Health System 505 wellingham dr DURHAM, NC 27713 United States Attn: Duke Center for Health System Publisher Tax ID GB674738491 Total 0.00 USD