Anthony_L_Rostain_MD_MA_-_ADHD_in_AdultsA Research Review

Psychiatry Research 2016 236:136-141.  DOI: 10.1016/j.psychres.2015.12.017  “Supplementary guanfacine hydrochloride as a treatment of attention deficit hyperactivity disorder in adults: A double blind, placebo-controlled study.” Butterfield ME, Saal J, Young B, Young JI.

Guanfacine hydrochloride is a selective alpha-2A partial agonist that is FDA approved for the treatment of ADHD in children and adolescents (see recent reviews by Faraone et al, 2013; Hirota et al, 2014 and Ruggiero et al 2014).  It can be given alone or in combination with psychostimulant medication as its mechanism of action is complementary to these agents.   Despite growing scientific evidence of its effectiveness for this age group, very little is known about the potential benefits of guanfacine for the treatment of ADHD in adults.

In view of concerns about the importance of finding suitable non-stimulant ADHD medications for this population, the authors carried out a randomized placebo controlled trial of extended release guanfacine (GXR) as supplemental treatment for subjects with a suboptimal response to stimulant-only medication treatment. 

Subjects were recruited from local advertisements and from the clinic practice of the authors in suburban Detroit.  Entry criteria included a current diagnosis of ADHD, current treatment with a stimulant medication, and suboptimal response to this medication as evidenced by a score of > 28 on the Attention Deficit Hyperactivity Disorder Rating Scale (ADHD-RS) or of > 4 on the Clinical Global Impression – Severity (CGI-S) Scale.  Exclusion criteria included having another severe Axis I psychiatric disorder, along with subjects with a history of autism, chemical dependence or psychosis.  Subjects with hypertension or any medical condition that might be exacerbated by the study medication.  A total of 26 subjects in the age range of 19 – 62 years were recruited for the study, of which roughly 50% were women, and 85% were Caucasian.  Subjects were randomly assigned to receive either placebo or incremental doses of GXR ranging from 1 to 6 mg daily on a weekly basis over a 10-week study period. 

The primary outcome measures were the ADHD Rating Scale and the Clinical Global Impression – Severity.  Secondary outcome measures included the Arizona Sexual Experience Questionnaire, the Fatigue Symptom Inventory, the Pittsburgh Sleep Quality Index, the Hamilton Anxiety Inventory and the Hamilton Depression Rating Scale.  Baseline and weekly measures of cardiovascular status were collected throughout the study. 

Contrary to the study authors’ expectations, although subjects in both the placebo and the treatment arms of the study showed significant improvements in both primary and secondary outcome measures, the two groups did not differ from one another.  For instance, the mean ADHD-RS score of the placebo group decreased by 10.92 (from 35.23 to 24.31) and that of the GXR treated group decreased by 11.85 (from 35.92 to 24.08).  The CGI-S score in the placebo group decreased by 1.00 and that of the GXR group by 0.85.  There were no differences between the two groups on measures of tolerability, hemodynamics, sleep, anxiety or depression.  Moreover, no treatment x time x group effects were noted. 

The authors comment that several explanations can account for these findings including a strong placebo effect, a generalized study effect (i.e. participating in a clinical trial itself may be beneficial in and of itself), a “regression to the mean” effect for the placebo group, and a potential bias induced by participating in a clinical trial.   Of note, there were no between group differences seen in fatigue, sleep problems, sexual functioning or in hemodynamic measures – a finding that supports the tolerability and safety of GXR in adult patients. 

While this is a “negative study,” it is helpful in clarifying that GXR can be used safely in combination with stimulant medications, that it does not worsen other psychiatric symptoms (e.g. anxiety, depression) and that it may be a helpful adjunctive treatment for adults with ADHD whose stimulant medication is not sufficiently helpful in reducing their symptoms.  Further research with a larger sample size and with measures taken to minimize the placebo effect are certainly warranted.  In the meantime, clinicians who are considering using GXR can be reassured that it is well tolerated in this population.


Faraone SV, McBurnett K, Sallee FR, Steeber J, López FA (2013). Guanfacine extended release: a novel treatment for attention-deficit/hyperactivity disorder in children and adolescents. Clinical Therapeutics Nov;35(11):1778-93. doi: 10.1016/j.clinthera.2013.09.005

Hirota T, Schwartz S, Correll CU (2014). Alpha-2 Agonists for Attention-Deficit/Hyperactivity Disorder in youth: A Systematic Review and Meta-Analysis of Monotherapy and Add-On Trials to Stimulant Therapy. J. Amer.. Acad. Child Adolesc. Psychiatry 53(2):153–173.

Ruggiero S, Clavenna A, Reale L, Capuano A, Rossi F, Bonati M (2014). Guanfacine for attention deficit and hyperactivity disorder in pediatrics: A systematic review and meta-analysis.  European Neuropsychopharmacology 24: 1578-1590.

David_Goodman_MD_ADHD_in_AdultsAttention Deficit Hyperactivity Disorder is the most common childhood psychiatric disorder and the second most prevalent adult psychiatric disorder second to Major Depression. Yet, until recently, ADHD in adults over age 50 was not identified. As we have come to understand, ADHD symptoms with impairments persist into adulthood for 60% of ADHD children.

For those adults with ADHD, how many will have symptoms that persist for the rest of their lives? How do these symptoms and impairments present? How do we discern ADHD symptoms from other factors contributing to cognitive change with age? How do we obtain clinical history in those patients who can’t remember childhood or adolescent symptoms? Would objective tests differentiate diagnoses? What treatments work well for this age group? What medical considerations are necessary for prescribing ADHD treatments to those with medical illness and multiple medications? What safety parameters need to be considered in this age group when prescribing ADHD medications? What are the drug-drug interactions that may be clinically relevant?

For clinicians and researchers, these questions represent opportunities to expand our fund of knowledge to better serve the needs of ADHD patients in all age categories.

The population of persons older than 65 years of age in the U.S. will grow from 43.1 million to 88.5 million between 2012 and 2050. A recent review of the literature on ADHD in older adults reports a prevalence rate of 2.8% in the Netherlands, 3.5% in Sweden, and 3.5% in Germany. A meta-analysis of ADHD prevalence in studies utilizing different age ranges spanning 18-78 years suggests that prevalence may decline with age. However, given that these studies used DSM-IV criteria with a symptom age threshold of 7 and the absence of a validated ADHD symptom profile for older adults, these cited prevalences may underestimate the ADHD population.

Reliance on childhood ADHD diagnosis to substantiate ADHD in older adults is often not useful because in the National Comorbidity Survey Replication in the U.S., 75% of ADHD adults ages 18-44 had not been diagnosed as children and no ADHD adults ages 60-77 were diagnosed as children. Remember that these people grew up in the 1950s and 1960s when ADHD was rarely identified and then only in the most hyperactive/impulsive and disruptive males.

I believe that ADHD in older adults will become the next clinical frontier. While there is some research beginning to accumulate to support identifying and treating this population, the relative absence of trained ADHD clinicians for this population means many unidentified older adults will be diagnosed inaccurately with age related cognitive disorders. To exemplify this likelihood, a U.S. study canvassing memory clinics demonstrated that only 1 in 5 clinics currently screen for ADHD. Therefore, older adults with ADHD are not identified and offered effective ADHD medication and treatment. The result may be ineffective treatment, unnecessary increased medical costs, and the decline in quality of life.

For those of you reading this blog, I would encourage you to consider ADHD in older adults whose cognitive complaints have been long-standing, whose negative consequences and impairments echo an ADHD life course, and in whom a first degree relative has ADHD.

A Brief Interview with Dr. David Goodman

Joseph Biederman MD ADHD in Adults

Is ADHD Always a Childhood Onset Disorder?

by Joseph Biederman, MD – August 4, 2016

Recent population based studies raise the intriguing question as to whether adult ADHD is always preceded by childhood onset of symptoms or can develop anew in adult life. From Brazil, one group argues that child and adult ADHD are “distinct syndromes”; from the United Kingdom (UK), another group states that adult ADHD is “more complex than a straightforward continuation of the childhood disorder” and from New Zealand (NZ), a third group claimed that adult ADHD is “not a neurodevelopmental disorder”.

In each study, adult onset ADHD refers to cases in which full-threshold ADHD had not been diagnosed by the investigators at prior assessments. In the NZ study, compared with controls, the adult onset ADHD group had more teacher-rated symptoms of ADHD, more conduct disorder (CD) in childhood and were more likely to have had a combined parent/teacher report of ADHD symptom onset prior to age 12. (DSMV recognizes onset of ADHD until the age of 12.) Likewise, the adult onsets in the UK study had high rates of ADHD symptoms, CD and oppositional defiant disorder (ODD) in childhood. Thus, many “adult onsets” of ADHD cases appear to have neurodevelopmental roots.

DSM V Guide to ADHD Diagnosis downloadBecause population studies use non-referred samples, those being diagnosed may not be self-aware of their symptoms, which increases the risk of false negatives. In population studies the ability of the subject to report on his or her own symptoms is critical since it requires insight and self awareness. It has been well documented that youth with ADHD are very poor reporters of their own symptoms. Such difficulties can certainly extend to adult years. Consistent with this idea, another longitudinal study found that current symptoms of ADHD were under-reported by adults who had had ADHD in childhood and over-reported by adults who did not have ADHD in childhood.4 Thus, the UK, Brazilian and NZ studies may have underestimated the persistence of ADHD and overestimated the prevalence of adult onsets. In contrast, self awareness is not an issue for subjects referring themselves to clinical care since, by definition, it is their self awareness that brings them to the clinic.

These reports do very little to help clarify whether these “adults” do not recall childhood symptoms, are unable to report on them, or are unable to distinguish onset of symptoms form onset of symptoms-associated impairments that may account for the different ages of onset. In these cases, the onset of symptoms and impairment could be separated by many years, particularly among those with strong intellectual abilities and those living in supportive, well-structured childhood environments. Such intellectual and social scaffolding would help ADHD youth to compensate in early life, only to decompensate into a full ADHD syndrome when the scaffolding is removed.

Such an interpretation would suggest that the etiology of ADHD leads to a wide variability in age at onset of initial symptoms, symptoms exceeding diagnostic threshold and impairment arising from those symptoms. Such variability is accepted for many other medical disorders. It is also consistent with the idea that ADHD is the extreme and impairing tail of a continuum. This view of posits that ADHD symptoms and ADHD impairment emerge due to the accumulation of environmental and genetic risk factors. Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset with symptoms and impairment. Yet, because these effects are multifactorial, there is no clean separation of etiologic factors in people above and below a certain age.

In this context it is important to remember that the age of onset of ADHD of 12 years proposed in DSM-V, while an improvement from the previous age of onset of 7 years, is still completely arbitrary, creating the immediate dilemma on how to diagnose patients who have an onset of symptoms after 12 years of age. Such a scenario may suggest that ADHD may be a disorder with a continuum of ages of onset, with some subjects starting their symptoms earlier while others later.

These concerns do not argue against the existence of adult onset ADHD or the idea that it is a clinically relevant syndrome. In fact, as a group, the adult onset cases showed significant functional impairments. Moreover, some of the studies ruled out the idea that adult onset ADHD is a misdiagnosis of another disorder. Further support for the validity of adult onset ADHD comes from a study of referred adults who retrospectively reported childhood symptoms 5. Based on clinical features and familial transmission, that study concluded that onsets of ADHD in late adolescence and early adulthood were valid.5


ADHD Consensus Statement download




1. Faraone S, Biederman J, Mick E. The Age Dependent Decline Of Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis Of Follow-Up Studies. Psychological Medicine. 2006;36(2):159-165.
2. Moffitt TE, Houts R, Asherson P, et al. Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am J Psychiatry. 2015:appiajp201514101266.
3. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402-409.
4. Sibley MH, Pelham WE, Molina BS, et al. When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment. J Consult Clin Psychol. 2012;80(6):1052-1061.
5. Chandra S, Biederman J, Faraone S. Assessing the Validity of the Age at Onset Criterion for Diagnosing ADHD in DSM-5. Journal of attention disorders. In Press.
6. Lecendreux M, Konofal E, Cortese S, Faraone SV. A 4-year follow-up of attention-deficit/hyperactivity disorder in a population sample. J Clin Psychiatry. 2015;76(6):712-719.
7. Asherson P, Trzaskowski M. Attention-deficit/hyperactivity disorder is the extreme and impairing tail of a continuum. J Am Acad Child Adolesc Psychiatry. 2015;54(4):249-250.

Adult Onset ADHD: Does it Exist?
Is it Distinct from Youth Onset ADHD?

by Stephen V. Faraone, PhD – August 4, 2016

Stephen V Faraone, PhD, ADHD in AdultsThere is a growing interest (and controversy) about ‘adult’ onset ADHD. No current diagnostic system allows for the diagnosis of ADHD in adulthood, yet clinicians sometimes face adults who meet all criteria for ADHD, except for age at onset. Although many of these clinically referred adult onset cases may reflect poor recall, several recent longitudinal population studies have claimed to detect cases of adult onset ADHD that showed no signs of ADHD as youth (Agnew-Blais, Polanczyk et al. 2016, Caye, Rocha et al. 2016). They conclude, not only that ADHD can onset in adulthood, but that childhood onset and adult onset ADHD may be distinct syndromes (Moffitt, Houts et al. 2015).

In each study, the prevalence of adult onset ADHD was much larger than the prevalence of childhood-onset adult ADHD). These estimates should be viewed with caution. The adults in two of the studies were 18-19 years old. That is too small a slice of adulthood to draw firm conclusions. As discussed elsewhere (Faraone and Biederman 2016), the claims for adult onset ADHD are all based on population as opposed to clinical studies. Population studies are plagued b the “false positive paradox”, which states that, even when false positive rates are low, many or even most diagnoses in a population study can be false.

Another problem is that the false positive rate is sensitive to the method of diagnosis. The child diagnoses in the studies claiming the existence of adult onset ADHD used reports from parents and/or teachers but the adult diagnoses were based on self-report. Self-reports of ADHD in adults are less reliable than informant reports, which raises concerns about measurement error. Another longitudinal study found that current symptoms of ADHD were under-reported by adults who had had ADHD in childhood and over-reported by adults who did not have ADHD in childhood (Sibley, Pelham et al. 2012). These issues strongly suggest that the studies claiming the existence of adult onset ADHD underestimated the prevalence of persistent ADHD and overestimated the prevalence of adult onset ADHD. Thus, we cannot yet accept the conclusion that most adults referred to clinicians with ADHD symptoms will not have a history of ADHD in youth.

ASRS Professional Screener DownloadThe new papers conclude that child and adult ADHD are “distinct syndromes”, “that adult ADHD is more complex than a straightforward continuation of the childhood disorder” and that that adult ADHD is “not a neurodevelopmental disorder”. These conclusions are provocative, suggesting a paradigm shift in how we view adulthood and childhood ADHD. Yet they seem premature. In these studies, people were categorized as adult onset ADHD if full-threshold ADHD had not been diagnosed in childhood. Yet, in all of these population studies there was substantial evidence that the adult onset cases were not neurotypical in adulthood (Faraone and Biederman 2016). Notably, in a study of referred cases, one-third of late adolescent and adult onset cases had childhood histories of ODD, CD and school failure (Chandra, Biederman et al. 2016). Thus, many of the “adult onsets” of ADHD appear to have had neurodevelopmental roots.

Looking through a more parsimonious lens, Faraone and Biederman (2016)proposed that the putative cases of adult onset ADHD reflect the existence of subthreshold childhood ADHD that emerges with full threshold diagnostic criteria in adulthood. Other work shows that subthreshold ADHD in childhood predicts onsets of the full-threshold ADHD in adolescence (Lecendreux, Konofal et al. 2015). Why is onset delayed in subthreshold cases? One possibility is that intellectual and social supports help subthreshold ADHD youth compensate in early life, with decompensation occurring when supports are removed in adulthood or the challenges of life increase. A related possibility is that the subthreshold cases are at the lower end of a dimensional liability spectrum that indexes risk for onset of ADHD symptoms and impairments. This is consistent with the idea that ADHD is an extreme form of a dimensional trait, which is supported by twin and molecular genetic studies (Larsson, Anckarsater et al. 2012, Lee, Ripke et al. 2013). These data suggest that disorders emerge when risk factors accumulate over time to exceed a threshold. Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset.

In conclusion, it is premature to accept the idea that there exists an adult onset form of ADHD that does not have its roots in neurodevelopment and is not expressed in childhood. It is, however, the right time to carefully study apparent cases of adult onset ADHD to test the idea that they are late manifestations of a subthreshold childhood condition.



Agnew-Blais, J. C., G. V. Polanczyk, A. Danese, J. Wertz, T. E. Moffitt and L. Arseneault (2016). “Persistence, Remission and Emergence of ADHD in Young Adulthood:Results from a Longitudinal, Prospective Population-Based Cohort.” JAMA.

Caye, A., T. B.-M. Rocha, L. Luciana Anselmi, J. Murray, A. M. B. Menezes, F. C. Barros, H. Gonçalves, F. Wehrmeister, C. M. Jensen, H.-C. Steinhausen, J. M. Swanson, C. Kieling and L. A. Rohde (2016). “ADHD does not always begin in childhood: E 1 vidence from a large birth cohort.” JAMA.

Chandra, S., J. Biederman and S. V. Faraone (2016). “Assessing the Validity of the Age at Onset Criterion for Diagnosing ADHD in DSM-5.” J Atten Disord.
Faraone, S. V. and J. Biederman (2016). “Can Attention-Deficit/Hyperactivity Disorder Onset Occur in Adulthood?” JAMA Psychiatry.
Larsson, H., H. Anckarsater, M. Rastam, Z. Chang and P. Lichtenstein (2012). “Childhood attention-deficit hyperactivity disorder as an extreme of a continuous trait: a quantitative genetic study of 8,500 twin pairs.” J Child Psychol Psychiatry 53(1): 73-80.

Lecendreux, M., E. Konofal, S. Cortese and S. V. Faraone (2015). “A 4-year follow-up of attention-deficit/hyperactivity disorder in a population sample.” J Clin Psychiatry 76(6): 712-719.

Lee, S. H., S. Ripke, B. M. Neale, S. V. Faraone, S. M. Purcell, R. H. Perlis, B. J. Mowry, A. Thapar, M. E. Goddard, J. S. Witte, D. Absher, I. Agartz, H. Akil, F. Amin, O. A. Andreassen, A. Anjorin, R. Anney, V. Anttila, D. E. Arking, P. Asherson, M. H. Azevedo, L. Backlund, J. A. Badner, A. J. Bailey, T. Banaschewski, J. D. Barchas, M. R. Barnes, T. B. Barrett, N. Bass, A. Battaglia, M. Bauer, M. Bayes, F. Bellivier, S. E. Bergen, W. Berrettini, C. Betancur, T. Bettecken, J. Biederman, E. B. Binder, D. W. Black, D. H. Blackwood, C. S. Bloss, M. Boehnke, D. I. Boomsma, G. Breen, R. Breuer, R. Bruggeman, P. Cormican, N. G. Buccola, J. K. Buitelaar, W. E. Bunney, J. D. Buxbaum, W. F. Byerley, E. M. Byrne, S. Caesar, W. Cahn, R. M. Cantor, M. Casas, A. Chakravarti, K. Chambert, K. Choudhury, S. Cichon, C. R. Cloninger, D. A. Collier, E. H. Cook, H. Coon, B. Cormand, A. Corvin, W. H. Coryell, D. W. Craig, I. W. Craig, J. Crosbie, M. L. Cuccaro, D. Curtis, D. Czamara, S. Datta, G. 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Montgomery, J. L. Moran, D. Moreno-De-Luca, G. Morken, D. W. Morris, E. M. Morrow, V. Moskvina, P. Muglia, T. W. Muhleisen, W. J. Muir, B. Muller-Myhsok, M. Murtha, R. M. Myers, I. Myin-Germeys, M. C. Neale, S. F. Nelson, C. M. Nievergelt, I. Nikolov, V. Nimgaonkar, W. A. Nolen, M. M. Nothen, J. I. Nurnberger, E. A. Nwulia, D. R. Nyholt, C. O’Dushlaine, R. D. Oades, A. Olincy, G. Oliveira, L. Olsen, R. A. Ophoff, U. Osby, M. J. Owen, A. Palotie, J. R. Parr, A. D. Paterson, C. N. Pato, M. T. Pato, B. W. Penninx, M. L. Pergadia, M. A. Pericak-Vance, B. S. Pickard, J. Pimm, J. Piven, D. Posthuma, J. B. Potash, F. Poustka, P. Propping, V. Puri, D. J. Quested, E. M. Quinn, J. A. Ramos-Quiroga, H. B. Rasmussen, S. Raychaudhuri, K. Rehnstrom, A. Reif, M. Ribases, J. P. Rice, M. Rietschel, K. Roeder, H. Roeyers, L. Rossin, A. Rothenberger, G. Rouleau, D. Ruderfer, D. Rujescu, A. R. Sanders, S. J. Sanders, S. L. Santangelo, J. A. Sergeant, R. Schachar, M. Schalling, A. F. Schatzberg, W. A. Scheftner, G. D. Schellenberg, S. W. Scherer, N. J. Schork, T. G. Schulze, J. Schumacher, M. Schwarz, E. Scolnick, L. J. Scott, J. Shi, P. D. Shilling, S. I. Shyn, J. M. Silverman, S. L. Slager, S. L. Smalley, J. H. Smit, E. N. Smith, E. J. Sonuga-Barke, D. St Clair, M. State, M. Steffens, H. C. Steinhausen, J. S. Strauss, J. Strohmaier, T. S. Stroup, J. S. Sutcliffe, P. Szatmari, S. Szelinger, S. Thirumalai, R. C. Thompson, A. A. Todorov, F. Tozzi, J. Treutlein, M. Uhr, E. J. van den Oord, G. Van Grootheest, J. Van Os, A. M. Vicente, V. J. Vieland, J. B. Vincent, P. M. Visscher, C. A. Walsh, T. H. Wassink, S. J. Watson, M. M. Weissman, T. Werge, T. F. Wienker, E. M. Wijsman, G. Willemsen, N. Williams, A. J. Willsey, S. H. Witt, W. Xu, A. H. Young, T. W. Yu, S. Zammit, P. P. Zandi, P. Zhang, F. G. Zitman, S. Zollner, B. Devlin, J. R. Kelsoe, P. Sklar, M. J. Daly, M. C. O’Donovan, N. Craddock, P. F. Sullivan, J. W. Smoller, K. S. Kendler and N. R. Wray (2013). “Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs.” Nat Genet 45(9): 984-994.

Moffitt, T. E., R. Houts, P. Asherson, D. W. Belsky, D. L. Corcoran, M. Hammerle, H. Harrington, S. Hogan, M. H. Meier, G. V. Polanczyk, R. Poulton, S. Ramrakha, K. Sugden, B. Williams, L. A. Rohde and A. Caspi (2015). “Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study.” Am J Psychiatry: appiajp201514101266.

Sibley, M. H., W. E. Pelham, B. S. Molina, E. M. Gnagy, J. G. Waxmonsky, D. A. Waschbusch, K. J. Derefinko, B. T. Wymbs, A. C. Garefino, D. E. Babinski and A. B. Kuriyan (2012). “When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment.” J Consult Clin Psychol 80(6): 1052-1061.

Lenard A. Adler, MD, ADHD in Adults
Ettinger AB1, Ottman R, Lipton RB, Cramer JA, Fanning KM, Reed ML. Attention-deficit/hyperactivity Len_Adler_AIAdisorder symptoms in adults with self-reported epilepsy: Results from a national epidemiologic survey of epilepsy. Epilepsia. 2015 Jan 15. doi: 10.1111/epi.12897. [Epub ahead of print]

The purpose of this study was to examine symptoms of ADHD and resulting functional consequences in a large community cohort of individuals with epilepsy. There is a somewhat higher rate of ADHD observed in pediatric samples of ADHD, but little data exists in terms of the comparative rates of ADHD, co-morbidity and quality of life in adults with epilepsy.

This study is important because it extends the observation of higher rates of ADHD seen in studies of pediatric ADHD to adult ADHD; the observed prevalence rate of ADHD (using a proxy of being screen positive on the ASRS v1.1) was nearly three times in this population of adults with epilepsy as compared to the general population, with substantial functional consequences in these individuals. The study also highlights the need to examine adults with epilepsy for the possibility of co-morbid ADHD.

ASRS Professional Screener Download

This study examined through telephone survey as part of The Epilepsy Comorbidities and Health Study (EPIC), 1361 respondents who had been told they had epilepsy and were receiving anti-epileptic drugs (AEDs). The group was divided into a likelihood of having ADHD via the ASRS v1.1 Screener, if they had a total score on these six items > 14 (ASRS v1.1 Screen positive and ASRS v1.1 Screen negative). Measures of co-morbidity included depression: the Physicians Health Questionnaire (PHQ-9), and generalized anxiety disorder: the Generalized Anxiety Disorder Assessment 7 (GAD-7).

Quality of life and disability were assessed with the Quality of Life in Epilepsy Inventory 10 (QOLIE-10), Quality of Life and Satisfaction Questionnaire (Q-LES-Q) and the Sheehan Disability Scale (SDS). 251 of the 1361 (18.4%) respondents were found to be at risk for having adult ADHD (ADHD+). ASRS v1.1 Screener positive vs. negative cases were significantly more likely to have seizures and AED use, along with significantly higher depression and anxiety symptom scores. The ASRS v1.1 Screen positive cohort (controlling for covariates) had lower QoL and social functioning (Q-LES-Q) and increased family and occupational disability (SDS).

Potential confounds in the data include: 1) that a formal diagnosis of adult ADHD was not obtained (just individuals at risk for the disorder, but prior trials have found that a substantial proportion of screen positive individuals when assessed, actually have adult ADHD) and 2) the possible presentation of ADHD-like symptoms from epilepsy or treatment with AEDs.

Editor’s Note: We interviewed several leading ADHD experts on treating ADHD in primary care and acquired some very interesting insights into how clinicians can learn about and treat ADHD in their practices.

Anthony_L_Rostain_MD_MA_-_ADHD_in_AdultsAnthony Rostain, MD MA: Physicians are often afraid about prescribing stimulant medications because they’re not familiar with the diagnosis of ADHD and they’re not sure whether they’re legitimately correct in prescribing these medications. Let’s start first by examining ADHD as a diagnosis. It is a legitimate diagnosis.

There is a medical procedure for making the diagnosis that includes taking careful history, getting the patient to fill out scales, getting collateral information from important others who understand something about the patient’s behavior. In addition you have to gather developmental history and educational history. You have to be aware of all of the different facets of the patient’s functioning and understand that ADHD is impacting and impairing that individual.

Brendan Montano AIA jZJbzOBrendan Montano MD: With familiarity and use of stimulant medications in ADHD I know I became much more willing and able to use them. Also many pediatricians have no problem with stimulants and I feel that that will also occur when the primary care network begins to treat ADHD more vigorously, diagnose it and treat it. Our pediatric allies had been used to treating ADHD in childhood and they’d been familiarized and become comfortable with the use of stimulant medications. I believe the same thing will occur with our adult primary care providers. Familiarity and seeing the beneficial effect will give comfort to those who treat with stimulant medications. Remembering again there are some non-stimulants that are also quite effective. Now, it is important to be aware of the fact that stimulant medications can be diverted, they can be misused, they can be abused.

Stephen Faraone, PhD:
And that’s a reasonable concern. However, today that concern is mitigated by several factors. First, we have new formulations of stimulants that are much less abusable than the immediate-release Ritalin many of you are used to. Second, there are now FDA-approved non-stimulant alternatives for ADHD. So you really do have a very large toolbox of therapies to use for adultswith ADHD.

Brendan Montano, MD: The more you become familiarized and screen for this illness, the more you become familiarized with treating the illness. So I became comfortable by seeing the beneficial effects and the outcomes which were otherwise not going to occur in my ADHD patients. The lack of training of primary care practitioners has created a shortage of treatment for adults with ADHD. We have methodological studies that prove there are 10 million undiagnosed adults with ADHD in the United States. I think the 10 million people who have this disorder really deserve for us to become familiarized not only with how to diagnose ADHD but how to treat it.

Anthony Rostain, MD: It’s important to keep in mind that if you follow sound clinical practice and document what you’re doing, including how you made the diagnosis of ADHD, that you informed the patient about treatment options and that you gave the patient all kinds of patient education materials to warn them about the danger of misusing the medication, then you’re following standard medical practice and you won’t be in any medical or legal difficulty.

Let me tell you about a success story of mine, a college student who I’ll call Carrie. Carrie is about to finish her sophomore year in college after a very, very rocky start to her college career. She was a bright, enthusiastic and vivacious high school student who managed to get by through her intelligence, her energy, and being able, at the last minute, to get her work done. She also had very supportive teachers who gave her the benefit of the doubt if she did turn in assignments late.

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Now, Carrie thought she might have ADHD but she never went for help. She actually was kind of skeptical about it and thought she just needed to try harder. So she was active in the high school drama club and actually went off to college hoping to become a playwright someday. So, after arriving at college, Carrie became very active in one of the drama clubs on her campus. She began to stage-manage and she started hanging out with all of the drama club students and was enjoying a great deal, and contributing great deal, to the activities of that organization. She also used the same studies, strategies that she had used in high school. So she talked a lot in class but never really read all of the assignments and she’d waited until the last minute to do the reading or to turn in the papers. She found herself cramming for the exams. It turned out that she ended up spending too much time with her extracurriculars and not enough time studying.

So after failing two classes in her spring semester, Carrie was asked to take an academic leave of absence from her college. She came back home and was evaluated in our program and we did in fact diagnose her with ADHD. We explained to her exactly how it was that she had managed to do fine until college and that she had managed to get by until she was in this unstructured learning environment. We spent a lot of time teaching her about adult ADHD, we started her on an ADHD medication, and she began coming for weekly cognitive behavioral trainings sessions.

Ask_Experts_ADHD_and_College_Students_y8zpLAOver the course of the next few months, she began to get more and more comfortable with the diagnosis and with figuring out what she needed to do to get difficult tasks done. She managed to get a job in selling tickets in local theater company and eventually she decided to take some courses in community college. She did extremely well and she really figured that she was now ready to go back to college.

She went back this past year and has done exceptionally well, getting most As and a few Bs, keeping herself very organized and able to balance the lifestyle that she wants. She’s able to get the studying done that she wants, she’s able to participate in the drama club and guess what, she’s pursuing her dream of becoming a playwright and is now a full-fledged English major in good standing.

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Let me tell you about a patient of mine named James who is 27 years old and has had a history of some serious substance abuse problems. Now James was diagnosed with ADHD in elementary school, and around middle school decided he didn’t want to take medications anymore. Beginning in late middle school and early high school he started experimenting with marijuana and alcohol, and eventually began to use other substances like cocaine, and finally, by the time he was finishing high school – and he barely graduated – James was using prescription opiates.

After high school he worked for a few years as a janitor, but this addiction to OxyContin got the better of him. He finally was in an accident, got a DUI, and was court mandated for treatment; and they discovered that he not only had an alcohol abuse problem, he also had marijuana and opiate addition. For this he was given the diagnosis of polysubstance abuse and was started in an outpatient treatment in our facility.

So James was started on suboxone to help him withdraw from opiates, and he was also started on citalopram because he was complaining of depression; and he was able to maintain sobriety, but he had a real tough time concentrating and getting simple things done. He wasn’t completing simple tasks around the house. He tried to go back to work and found it very difficult to stay focused on his job duties, and was reprimanded for coming in late.

So as a result, we then were asked to consult with, and lo and behold, we realized that, even though he was being treated for addition, he still had the ADHD that plagued him as a child. So we added OROS methylphenidate, and we began having him come for weekly cognitive behavioral therapy sessions in which he relearned what ADHD really is for someone his age, and where we began to help him overcome some of his negative attitudes about learning routines and doing things that required mental effort.

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James had dreams, wanted to do something with his life, but had always avoided them and had turned to substances to help him with things that made him anxious like social relationships.

As time went on, James began to talk about wanting to start his own business, and lo and behold, he was able to get started in this business. He sells collectibles online, and over the last few months he’s been so successful that he’s actually hired an assistant. What James likes to say now is that he wished that he had continued his treatment for administered; maybe he would have avoided substance use disorder. But he takes it all in stride.

He’s got a wonderful attitude, feels very positive about his life, and actually has offered to go and talk to some of the other patients in the recovery program to help them realize that some of them may, in fact, have ADHD that they ought to get treated.

So, I bring up this story of James in order to get you to think about the fact that maybe some of your patients who are in your office with other problems like substance use or alcoholism, or people who can’t quit smoking, maybe some of them have ADHD underlying all of their difficulties, and it would be worthwhile for you to learn how to assess them and maybe begin them in treatment because it could make a huge difference to their lives.

In two separate interviews, a clinician and an ADHD adult describe the two sides of ADHD symptoms and ADHD diagonsis.

Lenard Adler, MD:
I can think of an adult in their forties, a male, who came in after having their seven year old child diagnoses with ADHD, and in fact identify that, as he’s having his symptoms, he coped with them not all that well, was in a managerial position but not functioning optimally, had been passed over for promotions on numerous occasions mainly because he didn’t met his deadlines.

Robert Tudisco, Esq, ADHD Adult: I had to keep track of my time, I had to bill my clients, I had to run an office. It was all of those administrative tasks that were really a problem. At the same time, I thought I was setting a bad example for my son and I was having some difficulty in my marriage. And so, I sought some help, I found out about ADHD.

Lenard Adler, MD: In discussing things with the patient and his wife, she described lots of instances around at home where he didn’t listen to her, to do lists just weren’t completed, things weren’t being done on the weekend and she kind of felt that she was not only taking care of their seven-year-old son but also taking care of the husband. So the diagnosis of ADHD became clear after thorough evaluation and, in fact, this individual went on to treatment with a non-stimulating medicine and actually did quite well.

Robert Tudisco improved family relationships UMPwSv

Robert Tudisco, Esq:
There have been so many benefits since I’ve been diagnosed with ADHD. I think I’m a better father. I’m certainly a better husband. My relationship with my wife is much more relaxed because we understand each other a lot better. We also understand that ADHD is not an excuse for what happens and we understand where the behaviors come from so we can kind of work around them in the future. And I really think that a lot of adults would benefit from a diagnosis and it’s just one of the barriers, I think, to a lot of adults getting diagnosed is that there aren’t more clinicians that are diagnosing adults with ADHD.