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

ADHD and PTSD

Lenard_A_Adler_MD_ADHD_in_Adults

J Atten Disord. 2014 Feb 24. [Epub ahead of print] The Neuropsychological Profile of Comorbid Post-Traumatic Stress Disorder in Adult ADHD. Antshel KM, Biederman J, Spencer TJ, Faraone SV.

This article describes an examination of potential differences in neuropsychological functioning between a cohort of adults with ADHD (n=186), ADHD and PTSD (n=20) and a non-ADHD control group (n=123) who received psychiatric evaluations and neuropsychological tests (including WAIS intelligence, tests of frontal executive function (Wisconsin Card Sorting Test, Stroop Color and Word Test) the California Verbal Learning Test (CVLT) the Rey-Osterrieth Complex Figure Test (ROCF) and an auditory working memory continuous performance task (CPT). 

CME LEARN HERE  Improving Executive Function   in Adult ADHD

Overall the group with ADHD (whether they had PTSD or not) had significantly lower scores on the battery of neuro-psychological tests than the non-ADHD controls. However, the group with ADHD and PTSD had lower neuropsychological test scores on a number of measures versus the group with ADHD alone (WAIS full scale IQ and block design, ROCF copy accuracy and copy time and Stroop Color T-score). 

Measures of quality of life were not shown to be predictors of PTSD status. Additionally, in this study, the group with ADHD had lower socio-economic status and were more likely to be of non-Caucausian ethnicity.

Interpretation of the findings of this trial is somewhat limited by the small cohort of ADHD and PTSD patients.  Never the less, this study is important as it is the first investigation to examine neuropsychological deficits in individuals with ADHD and PTSD; it also adds to our increasing understanding of the increased burden of having ADHD and PTSD. Prior studies have shown that PTSD may be a vulnerability factor for developing future ADHD. 

These studies indicate that clinicians should be careful in screening individuals with ADHD for co-morbid PTSD and that the combination of disorders may carry a higher neuropsychological burden that should be accounted for in making the adult ADHD diagnosis.

Eva O’Malley, ADHD Adult: My son’s ADHD was diagnosed when he was six and I call it his gift to me because it eventually got me to where I am now. After so many years of researching and looking for answers and going to doctors, I started to become very clear about some of these behaviors that are existing in my world as well.

Adults with ADHD often get labeled with some very mean things like “lazy”, “rude”, “crazy” – things that you know are attributable to some of their symptoms, and it hurts. I’m guilty of doing this to my children because my daughter was diagnosed when she was 20.

I couldn’t understand why a 20-year old could not do these basic things. 

ADHD Success Story Evas Story cW8ZuA

After I was diagnosed it was easier for me to be aware that people’s behavior is not necessarily all that’s going on. And just to look past the behavior and to look into what’s driving the behavior is more important. So those labels then fall off of the people that are “rude” and the people that are “lazy.”

My daughter’s issues all of a sudden became crystal clear once I was diagnosed. It wasn’t selfishness, it wasn’t laziness. It was ADHD.

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

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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.