ADHD commonly does co-occur with other mental health conditions including substance use disorders 20% of the time, depressive disorders probably also somewhere around 20% to 25% of the time, bipolar disorder 10% to 15% of the time, anxiety disorders. So what you want to be sure is that the symptoms that are presenting are from ADHD and not something else and the way the clinician does that is by taking a lifelong history and looking when the symptoms started and what else was going on.
Q: What if these conditions are co-occurring with the ADHD?
Dr. Adler: It is important for patients and clinicians to understand that they can co-occur because very commonly it’s not only looking for the co-occurring condition with ADHD, it’s also the reverse. Many patients with the other disorder who present for treatment for the other disorder have ADHD and the ADHD has been missed. Adult ADHD is vastly under recognized and undertreated. According to the National Co-morbidity Survey, the largest epidemiologic community based survey that is done for mental health disorders, only about 10% of the individuals with ADHD were diagnosed and treated for their condition. We just published findings from a large survey of primary care physicians who treat patients with mental health disorders. When surveyed about their understanding of ADHD, their comfort level in treating it, and what level of training they had, it was very clear that they were about twice as comfortable treating depression and anxiety as they were ADHD and they had received very little training in ADHD. So there is a huge knowledge gap here that needs to be addressed.
Q: And that is where APSARD comes in…
Dr. Adler: That’s the part where APSARD comes in because part of our mission is outreach and education. APSARD is a society of professionals involved in the treatment and evaluation of ADHD. Part of the mission in outreach and education is improving the rate at which individuals who have ADHD are diagnosed and treated. We hope to do this by involving the broad spectrum of professionals involved in the treatment of ADHD, including psychiatrists, child psychiatrists, psychologists, social workers, neurologists, primary care physicians, nurse practioners, coaches and educators. Our intent is to provide the latest and up to date information about ADHD through our website, APSARD.org.
The impairments in ADHD are very real. Adults with ADHD, again who are mostly untreated at this point, have higher rates of divorce and separation, are twice as likely to use substances we think in part because they are self-medicating, are twice as likely to smoke cigarettes and are much less likely to quit smoking. They also underperform on the job, change jobs more frequently and have lower earning values. And there are also other impairments. Dr. Russell Barkley has written extensively on the driving impairments associated with untreated ADHD in terms of higher accident rates, more severe accidents, more speeding tickets. If you think about driving, it’s a very attention demanding task. This all highlights the need for treatment.
Q: What percentage of adults with ADHD does receive treatment?
Dr. Adler: Right now we think it is anywhere from 10 to 25%. The 10% figure comes from the National Co-morbidity Survey and the 25% comes from the prescription data base survey done by Medco where they found that 1% of individuals in their entire data base were being treated with ADHD. So, not matter how you look at it there is vast undertreatment.
Q: Is that because of a lack of education about adult ADHD or not recognizing the symptoms?
Dr. Adler: Well, I think it’s from several factors. ADHD used to be conceived of as a childhood disorder. This was a disorder that children had that somehow they were magically supposed to grow out of as they went into adolescence. Now, looking back that may not make the most sense because ADHD is a neurobiological disorder. Until the mid 1970s the concept of treating adults with ADHD with the medicines we use for kids to treat ADHD didn’t even exist. Then Paul Wender, MD, who was at the University of Utah had a group of adults who presented with ADHD-like symptoms and had been diagnosed with ADHD in childhood. He gave them stimulant medication and their symptoms improved. Until 1987 we could not even make a full active diagnosis of ADHD in adults in our diagnostic manual. So in part the knowledge gap exists because of the way the disorder was conceptualized. There has been a lot of research going forward since then, but obviously there is a lag because ADHD in kids has been described since 1900 by George Still, MD, who was a pediatrician who wrote about clinical presentation of kids who would look like ADHD kids today.
Q: If an adult is concerned they may have ADHD, where do they start?
Dr. Adler: There is a screening test for ADHD, called ASRS or Adult Self Report Scale screener, which we developed with the World Health Organization. If individuals are worried whether they may have ADHD, this is a great place to start. The ASRS is 6 questions designed to identify individuals at risk. If you have at least 4 of these 6 significantly, you may be at risk for ADHD. So that means if you screen positive, you really need to talk with your doctor and see if this is an issue.
View the ASRS Adult Self Report Screener
Lenard Adler, MD. Phone interview. June 26, 2009.