Clinicians May Overlook ADHD Symptoms in Adults

Suppose an adult patient sitting across from you incessantly taps his foot. Does it mean that he is likely a musician? Is impatient to get out of your office? Or has attention-deficit/hyperactivity disorder (ADHD)?

It could, of course, mean any number of things, but both foot tapping and impatience are common symptoms of adult ADHD, according to speakers at the annual meeting of the Canadian Psychiatric Association in St. John's, Newfoundland, in August.

The speakers were Timothy Bilkey, M.D., an adjunct professor of psychiatry at the University of Western Ontario, and Pratap Chokka, M.D., a clinical professor of psychiatry at the University of Alberta.

Still another common symptom of adult ADHD is putting something down, then forgetting where it was put, Bilkey reported. “I'm terrible with details,” an adult ADHD patient might say. “My memory is very bad; if I don't write down appointments, I forget them.”

Adults with ADHD may likewise have an impaired sense of time and invariably arrive late for office appointments, they noted. Further, they may be bright, but nonetheless have a long-term pattern of underachievement—say, being passed over for promotions. And if they engage in risky behaviors along with some of the other behaviors noted above, it may signal the presence of ADHD, Chokka reported. He had one adult ADHD patient, for example, who drove so recklessly that he racked up $3,000 worth of speeding tickets in one year.

Expect Comorbid Conditions

Another hallmark of adult ADHD, Chokka said, is that it rarely occurs alone. From 60 percent to 70 percent of adult ADHD patients have other psychiatric conditions as well, notably bipolar disorder, depression, or substance disorders. Twenty percent of people with bipolar disorder also have ADHD. Up to 50 percent of adults with ADHD have substance use problems as well, he pointed out.

But perhaps, Bilkey noted, the best tip-off that an adult has ADHD is this:“ They may not know that they have it, but most people around them do.”

So, how can psychiatrists increase the likelihood that they will correctly diagnose adult patients who have ADHD? First, take a comprehensive clinical history, said Bilkey. “You are dealing with someone who has had this for many years, so get a sense of this person from early childhood on.” For instance, as a youth the patient may not have excelled at school, but may have done very well in sports, or as an adolescent he or she may have driven recklessly, engaged in risky sexual behaviors, or binged on alcohol, food, or drugs.

Besides using the DSM-IV for diagnosis, Chokkka advised using the Adult ADHD Self-Rating Scale since it's easy and quick. In fact, since adult ADHD usually occurs in tandem with other psychiatric disorders, he said he now routinely uses the scale to screen all of his adult patients for ADHD. He suggested that other psychiatrists might consider adopting this practice as well.

Usually Start With Psychostimulant

The first line of treatment for adult ADHD is a psychostimulant, Chokka said. He advised starting off at a low dosage, but moving it up fairly quickly if needed, since psychostimulants are some of the better-tolerated psychotropic medications. Some patients, however, may say, “Don't medicate me so much that it takes away the positive aspects of having ADHD, like being fast on my feet.” Respect their wishes in this regard, he advised.

“Marital disorder is a huge problem for adult ADHD patients,” said Chokka. Male patients may say, “Doc, my wife and I are at the end of our relationship. She told me to get help or to get out.” Thus, marital therapy can be valuable for many adult ADHD patients, Chokka stressed.

Cognitive-behavioral therapy (CBT) can benefit adults with ADHD as well, Chokka pointed out. The problem though is that few psychotherapists are trained to provide CBT expressly for adult ADHD. However, adults with ADHD might be able to do some CBT work themselves by referring to a 2005 book titled Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program, by Steven Safren, Ph.D., and colleagues. This is probably the most definitive work on the subject, Chokka said.

And there are other actions that adults with ADHD can do to help themselves, Bilkey noted—for example, keeping appointments in a book and carrying the book wherever they go, or undergoing “mindfulness” training.

On the whole, it is gratifying to treat adults with ADHD, Chokka concluded, because positive results are usually seen quickly. ▪