The Current Situation with Adult ADHD

The field of adult ADHD research, assessment, and treatment is changing quickly. These are some current and upcoming developments that are important to note.

A vast body of research on young white boys has been used to inform the diagnostic criteria for ADHD. Many individuals with the disease do not experience the symptoms listed in the DSM-5, such as being “driven by a motor” or constantly “on the run.” For those who were overlooked by the ADHD community during their youth, misdiagnosis, missing diagnoses, and insufficient treatment have been longstanding issues due to the discrepancy between clinical recommendations and real-world symptoms.

Ninety percent of children with ADHD continue to have the disorder into adulthood. Symptoms do not miraculously go away; rather, they develop and alter throughout time. In fact, ADHD is referred to as a “public health concern” by the CDC and Prevention due to its long-term effects. Scientific research confirms the long-term nature of ADHD and the finding that three boys are diagnosed with the disorder for every girl. Because of this, the number of individuals seeking a first-time diagnosis for ADHD symptoms that they have had their entire lives and may have gotten worse as they have gotten older is on the rise.

During an April 2024 ADDitude webinar, David Goodman, M.D., assistant professor of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine, stated, “It is not that ADHD symptoms necessarily get worse with age.” “However, as you get older, ADHD symptoms start to bother you as well; when you are younger, they are disruptive and inconvenient to others.”

Adult patients have an increasing need for ADHD examinations, but doctors currently lack consistent, trustworthy measures to assess these symptoms. Adult diagnosis guidelines found in the DSM-5 are contentious and generally regarded as insufficient. Furthermore, according to data presented by the American Professional Society of ADHD and Related Disorders (APSARD) at its 2024 conference, only 33% of pediatricians, 30% of family practitioners, 25% of nurse practitioners, and 22% of internists stated that they received adequate training on ADHD in medical school.

Goodman stated during the ADDitude webinar, “ADHD in Older Adults: Clinical Guidance and Implications,” that “ADHD is the second most common psychiatric disorder in adults, but it is rarely focused on” by medical professionals. “Older patients should not be easily discounted as having age-related cognitive decline and dismissed.”

Initial Guidelines for Adult ADHD

APSARD is striving to address this significant barrier to care. A task force consisting of 27 members was established in 2023 with the goal of creating clinical practice standards for the diagnosis and management of adult ADHD. Goodman, who is in charge of the task force’s medical subcommittee, believes that adult ADHD guidelines that are grounded in science, clinically informed, and patient-centered would have the best chance of being widely adopted.

Nevertheless, there are not enough studies on women, people of color, adults over 50, or minority groups such adults with ADHD who are autistic. How comprehensive or useful can the APSARD guidelines be if they are based on a framework of scientific research when there is little to no unbiased scientific research on large patient populations?

In a January 2024 presentation at the annual APSARD conference, Goodman stated, “I would not claim that we are going to develop ‘excellent’ standards because ‘good’ is defined in the present as what is supported by evidence.” We are establishing a fundamental level of care. These policies will change in light of new information.

Nevertheless, the clinical practice guidelines for ADHD in adults published by APSARD have significantly more implications than only treatment and diagnosis rates. Some experts predict that insurance companies will be forced to fully cover the medical treatment of ADHD in adults, which is rarely the case currently, by established rules based on excellent scientific evidence. Some people think the rules would affect the Drug Enforcement Administration’s (DEA) national quotas for Schedule II prohibited substances, which would make stimulant prescriptions used to treat ADHD more widely available. Furthermore, a lot of supporters believe that adult ADHD guidelines will help patients’ mental health outcomes by raising public awareness, improving medical education, reducing stigma, and improving patient results.

According to committee member Frances Levin, M.D. of the Columbia University Irving Medical Center, the adult recommendations will address many of the major comorbid diseases associated with ADHD and are scheduled for release in late 2024 or early 2025. Levin affirmed that subject-matter experts on bipolar disorder, depression, and substance addiction, among other ADHD-related diseases, are meeting with her panel.

An individual’s chance of dying young increases dramatically for each mental health condition that is identified in addition to ADHD, claims Goodman. Citing a 2019 study published in JAMA Psychiatry, he claimed that the risk of premature death is 1.56 times higher for an adult with ADHD compared to one without ADHD, and 29.29 times higher for an adult with ADHD and four comorbid disorders.

Subthreshold ADHD: An Overview

Members of the task force also presented the idea of “subthreshold” ADHD at the APSARD conference. Although subthreshold ADHD may not fulfill the DSM-5 criteria for a diagnosis in childhood, Maggie Sibley, Ph.D., head of the diagnosis and assessment subcommittee, noted that moderate symptoms may worsen as a result of menopause or the stress of parenthood. As stated in the current DSM-5, a person may not have impairment symptoms prior to the age of twelve in order to be diagnosed with subthreshold ADHD. Sibley contended during a presentation at the 2024 APSARD conference that these misdiagnosed, untreated people, however, may face severe distress later in life and an increased risk for substance addiction, burnout, and personal and professional issues as a result.

“Those who do not quite fit the diagnostic criteria for a diagnosis of subthreshold ADHD may be severely impaired,” stated Stephen Faraone, Ph.D. at the APSARD presentation. Faraone is a distinguished professor in the SUNY Upstate Medical University departments of psychiatry and neuroscience & physiology.

Citing data from 2022, Sibley stated, “We need to know that ADHD symptoms are not stable; they wax and wane over the lifespan.” This research revealed that 63.8% of individuals with ADHD saw symptom variations throughout their lives.

One way to enhance diagnosis and treatment is to remove or modify the DSM criteria that symptoms of ADHD must be present before the age of twelve. Expanding the symptom criteria for adult ADHD to incorporate emotional dysregulation—a prevalent and debilitating ADHD feature not currently included by the DSM-5—might be another strategy. According to certain specialists, such as Anthony Rostain, M.D., “other DSM illnesses allow’suffering’ or ‘distress'” as a reason for a diagnosis, but an impairment is necessary for an ADHD diagnosis.” Can we substitute impairment or distress?”

Consequences for care and treatment

The APSARD task force will probably “address the issue of prescriptions for older individuals with ADHD,” according to Goodman, even if its primary objective is to produce clinical practice standards for the diagnosis and management of ADHD in adults. The safety of using stimulant medications in older persons and the possibility of developing or aggravating cardiovascular problems are the main causes for caution. A meta-analysis of 19 observational studies, totaling 3.9 million participants, was published in JAMA in 2023. The findings indicated that patients of any age are not more vulnerable to cardiovascular problems such as hypertension and heart failure when taking ADHD drugs, both stimulants and non-stimulants. Even among middle-aged and older persons, the study showed no statistically significant correlation between cardiovascular disease (CVD) and ADHD drugs. Even so, some doctors are hesitant or outright refuse to give ADHD drugs to patients who are older than 50.

During a presentation on treatment hurdles for adults with ADHD, APSARD Past President Ann Childress, M.D., revealed something unexpected: the average length of therapy for adults with ADHD is presently barely seven months. Citing a 2022 study published in BMC Psychiatry, she stated that “suboptimal management of ADHD symptoms” accounts for more than half of adult discontinuations from ADHD medication.

Childress proposed that in order to buck the trend, more clinician education should be provided about the advantages of long-acting stimulant medicine for patients who might benefit from symptom control in both personal and professional contexts. According to APSARD President Greg Mattingly, M.D., an associate clinical professor at Washington University School of Medicine, 48% of adult ADHD patients currently use a short-acting stimulant. In an APSARD presentation, Mattingly stated that for a large number of his patients, long-acting stimulants work better, sometimes in conjunction with a non-stimulant drug.

In order to help clinicians with the evaluation process, APSARD is working with Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) to develop clinical tools based on the upcoming adult ADHD guidelines, according to Goodman.

According to Mattingly, regular ADHD testing have to be a component of yearly doctor appointments.

“Depression screening was done by 20% of pediatricians five years ago, but now it is a standard quality measure,” he stated. “ADHD screening can be used as a quality measure and has a greater rate of dependability.”

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