John J. Murphy, MDLinx | August 12, 2017
Background: Up until about a decade ago, attention-deficit/hyperactivity disorder (ADHD) was largely considered a condition that appeared primarily in children. As ADHD was recognized as a disorder that also affected adults, diagnoses (and medical prescriptions to treat it) increased in step.
Many critics in the public eye, and also in the medical and psychiatric fields, questioned the veracity of ADHD in adults, saying that it's "not a scientifically valid condition" and "not an illness or disease." Others have said that ADHD is "an invention" created by pharmaceutical companies to make money.
But psychologist and ADHD expert Stephen Faraone, PhD, maintains that not only is adult ADHD a real condition, it also has real consequences.
Stephen V. Faraone, PhD, SUNY Upstate Medical University, Syracuse, NY
"In addition to being a burden to those with the disorder and their families, it also costs society more than $100 million annually in lost work productivity, accidents, hospitalizations, and health care costs," he said.
In this interview, Dr. Faraone busts some of the myths and misconceptions surrounding ADHD in adults. He also distinguishes how ADHD manifests differently in adults than in children, and he explains the disorder's genetic pathophysiology, and its current and future treatments.
Dr. Faraone: It's a disorder that is widely misunderstood. Number one, it's a highly prevalent disorder, occurring in roughly 5% of the adult population in the United States. That means that there are many adults with ADHD in every physician's practice, most of who are probably not currently diagnosed or treated for the disorder.
Sometimes it's described as a childhood disorder that disappears in adulthood. But there have been many follow-up studies of children that show it's a condition that often persists into adulthood.
There's also the myth that it's somehow not a "serious" condition—that schizophrenia is "serious," for example, but adult ADHD is not. There's now a wide body of evidence that shows that this disorder causes many difficulties. Some of the prominent ones are substance abuse and other co-morbid psychiatric conditions. Also, car accidents are a particular problem for adults with ADHD, although accidents of any kind are a serious problem for them. We also know that they are at a higher risk for certain medical outcomes: obesity is a well-documented example. Hypertension is another one. There's also good data now based on studies of almost a million people that there's a very small, but very real, increased risk for premature death, which we believe is due to these accidents as well as the medical morbidities.
For those primary care doctors who think they don't have adults with ADHD in their practices, consider how many patients you treat for depression and anxiety on a regular basis. We know from much research that roughly one-third of those people will have either a history of ADHD or will have ongoing problems with ADHD. So if you're looking for adult ADHD in your practice, the first place to start would be among those patients, particularly those who don't seem to be responding well to their antidepressants or to their anti-anxiety treatment. That's because some of the non-response is probably due to the ADHD, in addition to those other disorders.
Dr. Faraone: It is a little bit different. In children, it's a disorder where we see the full range of symptoms: hyperactivity, impulsivity, and inattention. In adults, we do see all those symptoms, but we also notice that hyperactivity diminishes with age. For example, little children run around rooms, they climb on furniture—adults don't do that. By the time people with ADHD reach adulthood, it manifests in a different form. Adults with ADHD have a hard time being in situations where they can't move around—they don't like to sit at long board meetings, for example. Instead, they seek out occupations where they can move around a lot, such as a car salesman, for example. That hyperactivity tends to diminish; however, the inattention stays pretty steady.
We also see that the impulsivity decreases a little bit, although it's still there. So these adults will engage in all sorts of impulsive behaviors. The one that's most irritating to people is they often interrupt in conversations. But they can also make impulsive and rash decisions that could have very big consequences for them, such as in the workplace, for example. If you can't regulate your behavior, you can't control impulses to, for example, emotional outbursts, so you have a very difficult time maintaining yourself in a workplace. That results in another one of the big impairments we see in adults with ADHD—they have a lot of occupational disability and they're more likely to be unemployed.
Dr. Faraone: People with adult ADHD typically get referred when some big problem occurs in their life and they recognize that there's something they can't control or can't deal with. Frequently these people self-refer because they read something in the newspaper or they see something on television and they say, "That sounds like me." We've had cases of adults who come in for treatment because their child has been treated for ADHD and they say to themselves, "Well, I was like that as a kid and I kind of have the same problems." Then when you work them up, you find out that they do have these problems.
But it's more common that the spouse of an ADHD person will recognize there is a problem before the ADHD person him- or herself recognizes it. Sometimes they come in saying, "Oh, my wife's complaining—she thinks I have this problem. Can you tell her she's wrong?" And often the spouse is right.
Sometimes the referral—especially someone who wasn't treated as a child—is stimulated by a change in their life that requires them to have to adapt and to self-organize more. A classic example is a young adult who graduates from college and goes into a job that requires even more self-organization and basically the ability to organize one's whole life. And they can't do that and they hit the wall. Another example is when a mother (with ADHD) has a baby, which is a big stress on the executive function—the brain functions that require us to organize our lives—and that can trigger a referral because the mother hits this wall and things start to fall apart.
Dr. Faraone: There are many treatments available for adults with ADHD, although there are fewer available on the non-pharmacologic side. The only non-medical treatment that's shown to be effective for ADHD in adults is cognitive behavioral therapy. However, we don't have evidence that it works in the absence of medication, so the current recommendation for first-line treatment is to start the person on one of the many adult ADHD medications, and then once they become stabilized on a medication with a dose that works well for them, you see if there are any problems that still persist. And if so, then we recommend they get referred for cognitive behavioral therapy.
Dr. Faraone: If it is ADHD, patients will usually report in the first week or two of treatment that things are much better. It might take up to four weeks or more to have a full effect, but they will typically notice a difference within the first week or two. So it's fairly straightforward. One of the key messages, particularly to doctors who don't treat it, is that ADHD is actually one of the easier disorders to treat. People typically respond well to the medications and they'll thank you because their life is very much improved after the treatment.
MDLinx: A recent report in Taiwan found that adults with ADHD have a higher risk for dementia. Have you seen that in your practice?
Dr. Faraone: We don't know a lot about that but, in fact, I'm doing a study right now—we're still in the process of completing the analysis for publication—in which we are finding that adults with ADHD have a higher risk of some dementias. It's a study of six million people, so it's a very big population, and we're finding that it's an increased risk but it's a small risk. So it doesn't mean that everybody with ADHD will have dementia. It's just that their risk may be slightly higher than the average person's risk.
Dr. Faraone: There's very strong evidence now that ADHD is a highly heritable, genetic disorder. The environment has some influence, but genes play a very strong role in its causes. From neuroimaging studies, we've learned that several brain region systems have been implicated, which further strengthens the concept that this is a neurobiological disorder. As I said earlier, some reports in the media might say that these are just lazy people who don't try hard enough. But now we know that it's a true brain disorder that runs in families and is highly heritable. We actually have confirmed now at least 12 genetic loci that increase the risk for the disorder. We need to learn a lot more, but we're very certain that this is a disorder in which genetic, as well as environmental factors, affect the brain in a way that leads to these symptoms of inattention, impulsivity, and hyperactivity.
Dr. Faraone: It is. One of the main goals of this kind of work is to improve current treatments by knowing more about the pathophysiology. We think we can eventually do better if we have a greater understanding of the real pathophysiology of the brain, but it will take some time. It's exceedingly complex. There are multiple issues so I'm not expecting any breakthroughs in developing treatments based on genetics—with perhaps one exception. There's a small company in Philadelphia that's working on a drug based on the finding that many people with ADHD have mutations in the glutamate genes. The researchers are identifying people who have these mutations and then treating them with this drug that works in the glutamate system. It's just an initial, open-label test study. But if that drug works, it will actually be the first drug in ADHD—probably the first drug in psychiatry—that's really driven by a known pathophysiology.
About Dr. Faraone: Stephen V. Faraone, PhD, is Director of Psychiatry Research, Distinguished Professor of Psychiatry, and Distinguished Professor of Neuroscience & Physiology at SUNY Upstate Medical University (SUNY UMU), in Syracuse, NY.
Dr. Faraone is also one of the leaders of ADHD in Adults, a partnership between SUNY UMU, the American Professional Society of ADHD and Related Disorders (APSARD), the National Association of Continuing Education (NACE), and InQuill Medical Communications.
ADHD in Adults was initially funded by a seed grant from the Agency for Healthcare Research and Quality (AHRQ). It is currently funded by Shire plc and Arbor Pharmaceuticals, LLC, as well as by website revenues for services.