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Approach to Evaluating and Managing Adult Attention-Deficit/Hyperactivity Disorder in Primary Care

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Approach to Evaluating and Managing Adult Attention-Deficit/Hyperactivity Disorder in Primary Care REVIEW Approach to Evaluating and Managing Adult Attention-Deficit/Hyperactivity Disorder in Primary Care 03/10/2021 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= by https://journals.lww.com/hrpjournal from Downloaded Hsiang Huang, MD, MPH, Heather Huang, MD, Margaret Spottswood, MD, MPH, and Nassir Ghaemi, MD, MPH Downloaded from Abstract: Requests for the evaluation of potential adult attention-deficit/hyperactivity disorder (ADHD) is on the rise https://journals.lww.com/hrpjournal across primary care clinics. Many health care providers, however, may feel ill equipped to diagnose and manage adults presenting with inattention and impulsivity. The diagnosis of ADHD is often complicated by medical and psychiatric con- ditions that can contribute to inattention symptoms. In this article, the authors provide a pragmatic clinical approach for evaluating and managing adult ADHD in the primary care setting. Keywords: attention-deficit/hyperactivity disorder (ADHD), attention-deficit disorder (ADD), primary care by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= dult attention-deficit/hyperactivity disorder (ADHD), tendency to leave projects incomplete, inattention, impulsivity, with a prevalence of about 2.8%,1 is currently con- poor school performance, difficulty functioning at work, prob- ceptualized as the persistence of childhood ADHD lems with time management, difficulty controlling their tem- A 4 symptoms into adulthood that is associated with impairments per, and anxiety. The majority come in on their own, and a in social and occupational functioning.2 Clinical presentation small percentage (5%) are referred by family, therapists, or of adults with inattention requesting evaluations for ADHD others.4 These individuals will sometimes have a childhood di- has been growing recently. In the past ten years, the preva- agnosis of ADHD or past treatment with stimulants. lence of adult ADHD has increased, and stimulant prescrip- tions in young adults has exceeded that of children.3 Many health care professionals may feel ill prepared to diagnose ADULT ADHD DIAGNOSIS IN CONTEXT and treat adult ADHD. This clinical review will provide a The diagnostic validity of any disease is based on four criteria: pragmatic approach to the diagnosis and treatment of adult symptoms, course, genetics, and biological markers.5 In adult ADHD in primary care settings. ADHD, the course of illness should be given careful consider- ation. Does ADHD in adults reflect the continuation of symp- PRESENTATION toms from childhood, independent of other diagnoses? It is Adults typically present in primary care describing struggles one matter to see adults with inattention and executive dys- with attending to work, school, or home duties. They report function, consistent with the ADHD clinical picture. It is an- symptoms of poor concentration, general disorganization, other matter to ascribe these symptoms to adult ADHD as opposed to other diagnoses. on 03/10/2021 In prospective studies, adults often meet Diagnostic and From Harvard Medical School (Drs. Hsiang Huang and Ghaemi); Cambridge Statistical Manual of Mental Disorders [DSM]–5 criteria for Health Alliance, Cambridge, MA (Drs. Hsiang Huang and Ghaemi); Univer- current ADHD with no history of childhood ADHD. Two sity of Wisconsin School of Medicine and Public Health (Dr. Heather Huang); Department of Psychiatry, University of Vermont College of Medicine such studies showed that approximately 90% of adults who (Dr. Spottswood); Community Health Centers of Burlington, Burlington, VT meet criteria for ADHD did not have ADHD in childhood.6,7 (Dr. Spottswood); Tufts University (Dr. Ghaemi). Since those studies were prospective, some lasting three de- Original manuscript received 13 August 2019; revised manuscript received cades, researchers knew definitely whether or not those pa- 23 December 2019, accepted for publication 15 January 2020. tients had childhood ADHD. In clinical practice, the matter Correspondence: 1493 Cambridge St., Cambridge, MA 02139. Email: [email protected] is different, since clinicians must rely on recall on the part of © 2020 President and Fellows of Harvard College. This is an open-access ar- patient. These prospective studies suggest that such recall is ticle distributed under the terms of the Creative Commons Attribution-Non mostly false. The same two studies also found that most chil- Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi- dren with ADHD did not experience symptoms into adult- ble to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from hood. For instance, one study found that only 17% of the journal. children with ADHD continue to meet criteria for ADHD as DOI: 10.1097/HRP.0000000000000248 young adults.6 100 www.harvardreviewofpsychiatry.org Vo lu me 2 8 • Number 2 • March/April 2020 Adult ADHD in Primary Care Furthermore, these studies found that about one-half of these symptoms cause impairment, affecting function across patients with adult ADHD also had other psychiatric or sub- multiple domains, and (3) excluding medical, psychiatric, or stance use diagnoses that cause similar inattention/executive other causes of inattention or hyperactivity/impulsivity. For dysfunction. Among those with late-onset ADHD symptoms, a flow chart regarding diagnosis and treatment, see Figure 1. most experienced these symptoms in the context of psychiat- According to DSM-5, ADHD occurs when one has inat- ric conditions and substance use.8 Thus, the apparent preva- tention or hyperactivity/impulsivity across multiple settings lence would need to be halved when other psychiatric that interferes with one’slife.9 Impairments in adults with causes of cognitive ADHD-like symptoms were taken into ac- ADHD tend to manifest in various domains of life—for ex- count. In short, adult ADHD symptoms in themselves usually ample, work, academic settings, and relationships. Adults do not mean that someone has ADHD. with ADHD tend to have low job stability and behavioral problems and poor performance at work, and they are DIAGNOSIS more likely to be fired than those without ADHD.10 In The diagnosis of adult ADHD is a clinical one, arrived at evaluating occupational impairment, we like to ask, “Do based on a carefully collected history of symptoms (ruling you have problems getting along with bosses or co- out other causes), without placing too much weight on neuro- workers? How are your performance reviews? Have you psychological testing or screening instruments. Clinical as- changed jobs a lot?” Adults with ADHD are more likely to sessment should focus on (1) evaluating current inattention have higher rates of divorce and separation, problems in rela- or hyperactivity/impulsivity symptoms, (2) establishing that tionships, and difficulty fulfilling parental responsibilities.2,11 Figure 1. AUDIT-C, Alcohol Use Disorders Identification Test–C; CBT, cognitive-behavioral therapy; CIDI, Composite International Diagnostic Interview; DAST-10, Drug Abuse Screening Test–7; GAD-7, Generalized Anxiety Disorder–7; MDD, major depressive disorder; PHQ-9, Patient Health Questionnaire–9. Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 101 H. Huang et al. In evaluating relational problems, we may ask patients substance use disorders (SUDs; especially alcohol use dis- about past relationships/marriages and whether they strug- order).17 This high degree of correlation between adult in- gle as parents. attention and other psychiatric conditions would suggest Given the current conceptualization of adult ADHD as that the symptoms of inattention may reflect an underlying persistence of childhood symptoms into adulthood, diag- psychiatric disorder. Although it has been postulated that nosing ADHD in adults requires establishing the presence symptoms of inattention cause mood disorders, no diag- of ADHD symptoms in childhood (prior to the age 12 in nostic studies actually support this causal claim.2 By con- DSM-5). Unfortunately, access to childhood medical re- trast, studies have shown that mood states and anxiety cords documenting inattention symptoms is often not pos- conditions are associated with poor concentration and im- sible. Accuracy of self-reportofsuchearlysymptomshas paired attention.18 In fact, the DSM-5 includes the symptom not been found to be valid, making reliance on this criterion of poor concentration as one of its diagnostic criteria for for adults questionable.12 It would thus be worthwhile to mood and anxiety disorders.9 use collateral sources such as family members to describe Since mood disorders contribute to symptoms of inatten- the patient’s childhood symptoms that would be suggestive tion in adults seeking ADHD evaluations, these conditions of ADHD. should be screened with validated instruments that are feasi- One may also indirectly assess childhood symptoms ble for use in primary care settings. Positive results on the through inquiry of childhood academic impairment. Children screens can then be followed by an evaluation by the health with ADHD do not perform as well in school (lower grade care provider that would include a history of illness, family point average and class ranking), and are more likely to have history, mental status exam, neurologic/physical exam, and had any of the following in their histories: grade retention, re- laboratory
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