Applied Evidence
Addressing the unique issues of student athletes with ADHD
The impact of ADHD depends on an individual’s symptoms and chosen sport, which, along with specific medication recommendations and cautions, help...
Attention-deficit/hyperactivity disorder (ADHD) in adults brings with it unique challenges, not the least of which are arriving at a proper diagnosis and ensuring that any psychostimulant drugs that you prescribe are not misused. A number of conditions such as anxiety, bipolar disorder, and substance abuse can mimic some of the symptoms of ADHD, and diagnostic criteria for the condition in adults changed with the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Furthermore, for many of the estimated 4.4% of adults who have ADHD,1 psychostimulants provide necessary and effective treatment, but misuse and diversion of these agents are real concerns. In fact, recent research reveals that these issues are more common than previously thought.2 Data suggest that the prevalence of misuse and diversion of ADHD medication is 5% to 10% among high school students and 5% to 35% among college students.2,3
This is not meant to indicate that adults diagnosed with ADHD should go untreated. In fact, adults with ADHD often struggle in their professional and family lives because they do not receive the treatment they need.
Rather, family physicians should take certain steps, first to diagnose ADHD correctly, and then to ascertain and maintain correct use of psychostimulants and other treatments among their adult patient populations. Read on for several practical strategies.
Criteria for adult Dx differ from those in children
ADHD, a common behavioral disorder that often, but not always, begins in childhood, is characterized by deficits in paying attention, difficulty controlling impulses, and marked hyperactivity. Diagnosis of ADHD is based on the DSM-5 criteria and supplemented with historical data and clinical observations.4 Using self-report measures may also aid in the diagnosis, and psychological testing may be required for some individuals when the clinical presentation is unclear.
With the DSM-5 changes (TABLE 14), the diagnosis of ADHD in adults (people ≥18 years) requires fewer symptoms than the diagnosis of ADHD in children; just 5 symptoms from either of the 2 categories of diagnostic criteria are sufficient now, whereas 6 symptoms were required previously and still are required to make the diagnosis in young people. People may present with the inattentive profile (5 or more symptoms of inattention), the hyperactive-impulsive profile (5 or more hyperactive-impulsive symptoms), or a combination of the 2 (5 or more symptoms of inattention plus 5 or more symptoms of hyperactivity-impulsivity for a total of 10 or more symptoms). While children are more likely to present with the combined type of ADHD, adults of any age are more likely to present with the inattentive type.4
In addition, patients must meet the diagnostic criteria for ADHD for at least 6 months, have had some of the symptoms prior to age 12, and the symptoms must cause significant impairment in 2 or more environments (eg, home, work, school). When the diagnosis is unclear, it is important to obtain collateral information from the family, school, or workplace. The requirement regarding symptomatology before age 12 indicates the need for a review of the patient’s educational history. Research reveals that many adults with ADHD struggled in school and were considered “underachievers” as students.5
Common complaints and characteristics. Previous studies have shown the following to be common complaints and characteristics of adult patients diagnosed with ADHD:5
- difficulty meeting time limits
- vocational struggles, such as frequent job changes or nonpromotion at work
- anger issues
- addiction
- relationship/social strain
- comprehension problems, and
- a family history of ADHD.
Common correlates include low socioeconomic status, driving violations, frequent injuries, legal problems, alcohol and/or tobacco use, and self-reported maladjustment.5 People treated for ADHD have a comorbid DSM diagnosis 81% of the time with the most likely diagnoses being substance abuse, depression, and anxiety.6
Adult-onset ADHD? Even though the DSM-5 criteria for an ADHD diagnosis in adulthood require that some ADHD symptoms were manifest prior to age 12, recent longitudinal research on ADHD in Brazil and the United Kingdom reveals that a large portion of people who meet the criteria for ADHD in adulthood did not meet the criteria as children. The researchers in these studies proposed that there may be a form of ADHD that manifests later in life, a so-called “adult-onset ADHD.”7 While this information is something for clinicians to consider, further research is needed to justify a paradigm shift in how ADHD is diagnosed.
Self-rating measures can offer clarification. Whether or not history-gathering leaves the diagnosis murky, self-rating measures can be valuable in rounding out the clinical picture and alerting clinicians to any inconsistencies in symptoms.8 Four common ADHD self-rating measures are provided in TABLE 2. As one example, the Adult ADHD Self-Report Scale (ASRS) Symptom Checklist is a valuable ADHD screening tool that is free of charge and takes only 5 to 10 minutes.8 Other self-report measures require a similar amount of time, but are not available on a complimentary basis.
Psychological testing. Some adults who seem to have symptoms of ADHD may require a referral for psychological testing. These may be patients who present with complicated cases or whose histories and/or findings do not consistently indicate an ADHD diagnosis. In such cases, psychological testing can fill in the holes and provide a more complete picture of the patient’s neurocognitive abilities and deficits.9,10
