Advances in the Management of ADHD in Adult Population - Episode 6
Greg Mattingly, MD; David W. Goodman, MD; Birgit H. Amann, MD; and Theresa R. Cerulli, MD, evaluate the role of pediatric ADHD guidelines and common misconceptions in the diagnosis and treatment of ADHD.
Theresa R. Cerulli, MD: Greg, are you using any of the newer or pediatric ADHD [attention-deficit/hyperactivity disorder] guidelines in diagnosis with kids? If so, how does that translate to adult patients for you?
Greg Mattingly, MD: Certainly. A number of guidelines have come out from the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. It goes back to making sure you screen everyone who’s a child. The prevalence is 10%. This shouldn’t be something that falls through the cracks. It should be a routine part of health care. I’m going to slide that up to adults. As David said, the prevalence in adults is 5%. One of 20 patients you see has ADHD. That means it’s a routine part of health health care. We talk about screening for it. It has a more common prevalence than most of the other health conditions that you take care of every day in a primary care setting. Routine screening for children should lead to awareness in adults. If you see any of the warning signs, then make sure you screen for it in adults as well.
One of our good friends in Toronto [Tim Bilkey] cowrote a book called Fast Minds that talks about adults with ADHD and his mnemonic for screening for ADHD. I use this myself in my clinic: it’s PDF. If you see a patient with PDF, screen them for ADHD. PDF is procrastination, distractibility, forgetfulness. If you see somebody who comes in and is procrastinating, is in trouble with their job, isn’t paying their bills, and is procrastinating about routine follow-ups for health care. If you see somebody who seems distractable and unorganized. If you see somebody who seems like they’re forgetful and that’s 1 of their complaints, screen for ADHD.
David W. Goodman, MD: I always come at this from the clinician’s perspective. People will say to me, “You know something, if this is so important, how come nobody taught me this in my training program? If the prevalence rate is 4.5% in the United States”—by the way, it’s the second-most prevalent psychiatric condition, second only to depression—“If it’s so important, how come nobody ever taught me about this in my training program?”
Greg Mattingly, MD: David, it goes back to the myths of ADHD. When I teach my medical students at Washington University School of Medicine, I talk about the myths that I was taught. I was taught ADHD was a disorder of boys, not girls. Hyperactivity was the outward marker. When you went through adolescence, you grew out of it. Those were my lectures for ADHD when I was a medical student. All those things are myth. None of them is true. We know that girls have ADHD as well as boys. Girls are more likely to be missed. They likely to come in as women trying to get a diagnosis because it was missed. You can have inattentive symptoms but also impulsive symptoms that drive the bus and cause problems in your life. Finally, as we talked about with Maggie Sibley’s work, 90% of our adults with ADHD don’t grow out of it. It’s something they’ve had since they were kids. They may not have had the diagnosis. Often they don’t, but the symptoms don’t go away as they go through life.
Birgit H. Amann, MD: Sadly, when I was in training, most programs that were not psychiatric had 30 days of psychiatric training. I don’t hear these days that it’s improved that much.
David W. Goodman, MD: It has not.
Theresa R. Cerulli, MD: I would add to what everyone said with the updated pediatric guidelines. The take-home for me is to make sure we’re simultaneously screening for not only ADHD but also the coexisting conditions from the get-go. I’ve used the same guidelines into adulthood because we don’t have United States–based ADHD guidelines in practice guidelines for treating adults with ADHD. We’ve borrowed from the Canadian guidelines, but we don’t have our own in the United States.
Transcript Edited for Clarity