What Prompts Patients to Seek an Evaluation for ADHD

Transcript: Theresa Cerulli, MD: What are the signs and symptoms that would prompt an evaluation for ADHD [attention deficit hyperactivity disorder]? In other words, what brings patients through your door? Andy would you like to lead us off?

Andrew J. Cutler, MD: Sure. Of course, it’s very important to evaluate for the symptoms. That’s what we use in our diagnostic checklist, and that’s what we use to establish a diagnosis. But what often brings people in is not the symptoms per se, but the consequences of the symptoms—the negative impact on behavior and on achievement and performance. For instance, children are often brought in because they’re disruptive in school or in class. They can’t sit still. They can’t participate in quiet time or nap time. They may be talking too much.

As they get older, there are more cognitive demands. They get in trouble for not paying attention in class, for not doing homework assignments, and for not being able to work independently. Then, as we get into managing adolescents and adults, there can be significant problems with their organizational skills. Again, meeting deadlines and tasks and doing things they’re supposed to do.

Very often, we see people when they’re in a crisis. It can be that the child either is about to be expelled or has been expelled, or maybe they will be held back a grade in school. Sometimes we’re seeing people when there is a significant crisis going on. For adults, it’s fascinating to me that a lot of times what brings people in are things that we would generally consider positive developments in their life. For instance, they get a promotion, they get married, they have a child, or they are thinking about going back to school. That is a very common scenario that brings people back in. Or they’re studying for an exam or a certification.

Generally, it’s the functional or quality-of-life consequences of the symptoms that seem to bring people in. For instance, a man will come in and say, “My wife is saying if that I don’t get help, she can’t take it anymore and she’s going to leave me.” So I think it’s really important to focus on symptoms but also to look at the functions and the consequences. Because if we fix symptoms but don’t address those very important functional aspects that bring them in, we’re not doing them a service.

David W. Goodman, MD: Andy, when patients go to a clinician, they’ll talk about either their distress—“I’m anxious or depressed”—or their impairments—“I can’t get my work done, and I can’t be on time.” And so depending on how the patient presents their symptoms, the clinician gets falsely directed to a distraction. Then the patient gets diagnosed with anxiety or depression, or they get diagnosed with some kind of organizational or cognitive impairment. Can you parse out how to direct the primary care physician or the clinician to not focus on the presenting symptoms but go beyond that in regard to the diagnosis?

Andrew J. Cutler, MD: Absolutely. You’re bringing up something that is critically important. Sometimes, we do focus on the tip of the iceberg and don’t see the big iceberg underneath the water. A lot of times, when working with primary care doctors, we have to teach them to listen with their inner ear. We teach them to listen for what is underneath the anxiety or depression. What might be causing it? Is this something the patient has been struggling with for a long time? Is it the consequences of these symptoms of ADHD? Unfortunately, what ends up happening is they get treated for depression and anxiety, and then they get referred for treatment-resistant depression or treatment-resistant anxiety. So teaching them about that can also be helpful.

Transcript Edited for Clarity