Working adeptly to diagnose and treat adult ADHD

THE CASE

Emily L* is a 20-year-old woman who, on the advice of her college counselor, has made an office appointment to discuss her difficulty in keeping up with college classes. She achieved good grades in high school but is now struggling to deal with the quantity of reading in her courses. She was often able to complete assignments the night before the due date in high school, but this strategy is no longer working. She is having some doubt about her abilities, and is feeling overwhelmed, but is able to enjoy activities with friends. Her college counselor suggested she see her doctor for an assessment of her attention problems.

Ms. L’s family physician interviewed her and, aided by parental input, was able to identify a pattern of disorganized and impulsive behavior that was present even in grade school. Mood disorders and substance abuse were ruled out from the interview and lab testing, and cognitive ability was confirmed through a review of school testing.

● HOW WOULD YOU PROCEED WITH THIS PATIENT?

* The patient’s name has been changed to protect her identity.

Attention-deficit/hyperactivity disorder (ADHD) is classified as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), its hallmarks being inattentive, hyperactive, or impulsive behaviors that affect functioning or development.¹ ­Historically, it was thought that ADHD was a disorder of children and adolescents, and that patients “grew out” of their behaviors once adulthood was reached. It is now estimated that 50% of children with ADHD will carry the diagnosis into adulthood,² resulting in a prevalence of 5.9% to 7.1% for children³ and 3.4% for adults.⁴ There are 3 presentations of ADHD, known as ADHD-I (inattentive), ADHD-HI (hyperactive-impulsive), and ADHD-C (combined). The inattentive type accounts for 47% of adult cases, and adult ADHD disproportionately affects males compared with females.²

ADHD is a powerful risk factor for future substance use.

An overall pattern of underachievement and variable performance is common throughout life in patients with ADHD. Adults are much more likely to report subtle impairments in higher executive functions such as organization, time management, and modulating emotions. Consequences include poor performance at work, attendance issues, difficulty with social interactions, and an increased likelihood of unemployment.⁵ Among those employed, there is a large disparity in income compared with counterparts without ADHD.⁶ Increased risk of substance use, injury, and traffic accidents also has been reported.¹

Disorders that can mimic or coexist with ADHD

The differential diagnosis for ADHD is wide, and comorbidity with other disorders is common.

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