ADHD Treatment- Why Are We Missing the Diagnosis? Adult ADHD Medications + Adult ADHD Test

I sometimes wonder if the fear of diagnosing adult ADHD would exist if treatment didn’t involve stimulants.

Many people question the legitimacy of adult ADHD as a diagnosis. Some clinicians believe it is over diagnosed and that stimulants are overprescribed. Psychiatrists often worry about being labeled as doctors who “overprescribe.” While stimulants are the standard treatment for adult ADHD, the diagnosis should depend on proper assessment.

Are some people misdiagnosed with ADHD when they actually have another condition? Yes. Many, especially college students, misuse stimulants to boost performance or energy. However, adult ADHD is often underdiagnosed, leaving many without proper treatment. Adult ADHD affects at least five percent of the population, and nearly 75% of adults with ADHD never receive an accurate diagnosis or effective treatment.

An estimated 3% to 5% of U.S. adults have ADHD, but only 15% are aware of their disorder, according to Rafael Klorman, a psychology professor and director of clinical training at the University of Rochester in New York. Dr. David L. Katz, the director of the Prevention Research Center at Yale University, states, “Available data indicate we are concomitantly under-diagnosing and over-diagnosing ADHD, under- and over-treating it.”

Costs of Missing the Diagnosis and Not Having ADHD Treatment

ADHD causes significant lifelong impairment for those it affects. Left untreated, it impacts financial stability, educational achievements, relationships, and overall health.

According to Dr. Biederman, “Overall, people with ADHD have less annual income. This was true for both males and females. Those with ADHD earn approximately $10,791 less each year among high school graduates and about $4,334 less for college graduates compared to their peers without ADHD.” The estimated yearly income loss for adults with ADHD in the United States is $77 billion. Biederman also notes the staggering costs of related issues: $58 billion for drug abuse, $85 billion for alcohol abuse, and $43 billion for depression. “You can see that ADHD is one of the costliest medical conditions we have,” he adds.

Over the years, I have seen hundreds of patients who have suffered for decades from untreated ADHD. Many suspected that something was amiss, feeling that life was more challenging than it was for their peers. When they learn about ADHD and realize that their difficulties stem from it, they often wonder why their teachers, parents, and previous therapists did not recognize the signs.

Case Example

Recently, I met a 26-year-old client, let’s call him Ryan*. His law school advisor referred him for anxiety and depression. He never suspected ADHD. Despite performing well in high school and college, he gained admission to a prestigious law school at a steep price. Anxiety plagued him, and he was afraid of failure, spending countless hours studying and worrying. Previous therapists and psychiatrists had diagnosed him with depression, OCD, or generalized anxiety disorder, treating his symptoms with antidepressants and benzodiazepines. Unfortunately, these medications left him feeling lethargic and foggy.

The Assessment

The Treatment

I prescribed Adderall, leading to a profound shift in his perception. The cobwebs cleared, and he began to see the world more clearly. Anxiety decreased significantly, reigniting his hope to pursue his passions and goals. Did he still keep extensive notes, make lists, and experience some anxiety? Yes. Did he continue to struggle with forgetfulness and organization? Absolutely.

Medications are not a complete solution. Employing the coping strategies he had developed over the years, he also worked with an ADHD coach to prioritize tasks and learn additional strategies. Collaboration with a therapist helped him address other sources of anxiety and set realistic goals, taking into account his strengths and weaknesses.

Adult ADHD Testing

A comprehensive diagnosis of adult ADHD requires a thorough psychiatric assessment. This process includes speaking with family members to gather collateral information and obtaining records from previous psychiatrists or therapists. Collecting extensive family histories, childhood report cards, teachers’ comments, and work evaluations is also crucial.

Validated questionnaire instruments play a vital role in achieving an accurate diagnosis. Clinicians typically use the Barkley Adult ADHD Rating Scale-IV (BAARS-IV), the Barkley Deficits in Executive Functioning Scale, and the Weiss Functional Impairment Rating Scale for ADHD symptom-specific evaluations. The Conners Adult ADHD Rating Scales (Conners-3 and CAARS) are equally important.

For a broader perspective, the Connors Comprehensive Behavior Scale (CBRS) can be employed. Together, these tools provide a detailed understanding of an individual’s challenges, ensuring effective ADHD diagnosis and treatment.

Adult ADHD Treatment

Once diagnosed, effective treatment can significantly enhance a patient’s quality of life. Patients learn to manage their goals, improve relationships, and meet daily responsibilities, leading to increased competence and confidence. However, many clinicians still believe that treating depression must precede ADHD treatment. This often results in patients feeling frustrated and overwhelmed due to repeated failures or frequent job changes.

Treating ADHD empowers individuals to reclaim their motivation and zest for life. Unfortunately, when patients receive treatment only for depression, often with antidepressants or atypical antipsychotics, symptoms may not improve and can even worsen. A fundamental lesson learned in training is to never take away a patient’s dopamine, as it is essential for focus and motivation.

For individuals with ADHD, low dopamine levels can inhibit their potential. Antidepressants and antipsychotics can further decrease dopamine function in the frontal lobes and limbic system, exacerbating ADHD symptoms. A precise diagnosis and tailored treatment are critical for unlocking the full potential of those affected by ADHD.

The Role of Neuropsychological Testing

In some instances, neuropsychological testing can be helpful, especially when there is a suspicion of a learning disorder, such as dyslexia. However, testing is not always indicated, nor is it always accurate. It is generally time-consuming, very costly, and may miss the diagnosis. Testing may show that a person’s executive functioning, focus, and distractibility are normal, but testing is performed over a short period. A key feature of adult ADHD is that the symptoms are consistently inconsistent! The challenge that ADHD presents is the lack of sustained attention, focus, and executive skills throughout the day and over prolonged periods. Thus, one may function reasonably well during neuropsychiatric testing over a brief period and with prompting from the tester but may not be able to do this for extended periods.

Neuropsychological testing is helpful in complex cases or where the diagnosis is equivocal. However, it is crucial to recognize that someone may have clinical ADHD even though testing was negative, much in the same way that someone may clinically have a seizure disorder despite a negative EEG.

How to Help Our Clients with Adult ADHD Treatment-Five Key Tips

1. Screen All Clients

So, how can we help our clients who have adult ADHD? First, it is important to understand the impact that ADHD has on someone’s life and that it is frequently misdiagnosed or underdiagnosed. It is essential to understand that ADD/ADHD does exist and that the stigma of ADHD and the anxiety about using stimulants keeps people from getting diagnosed and treated.

It is important to screen all clients for adult ADHD by using a simple five-minute screening tool in the office or waiting room.

Here is a site that can be utilized as a screening tool:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many of our clients also feel that adult ADHD is not a “real diagnosis” and thus doesn’t get evaluated or treated. However, explaining to the patients that brain scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a real issue.

2. Refer For An Assessment and Treatment

With a client where there is a high suspicion of adult ADHD, refer to a psychiatrist or psychologist who specializes in ADHD for assessment and treatment. Medications are a cornerstone of treatment and can be life-changing for many patients who have been suffering for decades with an inaccurate diagnosis and without effective treatments.

3. Cognitive Behavioral Therapy

Another cornerstone of treatment is developing strategies to address the particular challenges of the individual case.

“Cognitive behavior therapy (CBT) has been successfully applied to this client group even with minimal contact (Stevenson et al., 2002; Wilens et al., 1999). “Individuals with ADHD require structure in terms of personal organization, social boundaries, and practical help to cope with everyday problems” (Susan Young, 2007, pp 50)

By using CBT in sessions with your client, you can help them address their most critical challenges. Often, these challenges include difficulties with time management, prioritizing, strategizing, planning, mood regulation, social skills, organization, focus, and motivation.

It is beneficial to encourage your clients to purchase a weekly calendar and to use it regularly instead of relying on Post-it notes or smartphones. Many ADHD patients do better when they see things visually.

Another behavioral intervention for your clients is to teach them to develop a to-do list to prioritize each item. Then, have them place the items at a specific time on the calendar. More structure can facilitate better outcomes.

If you do not specialize in CBT or the client has significant career challenges, hiring a coach to help the client overcome these specific challenges, develop strategies, and increase accountability can help improve success in work and personal life. Coaching can be an essential piece of treatment, but it can be not easy to find an effective coach. Ideally, the coach should have extensive experience working with clients who have adult ADHD.

4. Address the Shame and Instill Hope as Part of ADHD Treatment

Growing up with diagnosed or undiagnosed ADHD can create significant shame for your client. There is often a substantial shortfall in academics, career history, and relationships, and frequent criticism or ridicule from parents, teachers, and peers.

Help the ADHD client to see that they have many strengths and that ADHD is just one aspect of who they are. Also, they have been compensated for most of their lives. Validate that it may have been a difficult struggle and that their lives can improve significantly.

5. Minimize the Potential Fallout from ADHD

Even when a client understands some of the challenges that ADHD has created, it is often unclear how it has impacted other areas of their life. Help the client understand that many of their behaviors, such as underperforming at work, engaging in high-risk sexual activity, or facing struggles in their relationships, are very common in patients with ADHD. Reassure them that this can improve with treatment, medications, behavioral treatments, or a combination.

FAQ’s

Three common symptoms of ADHD include:

• problems with focus
• distractibility
• challenges with organization

Who can diagnose and treat ADHD?

Many specialists can diagnose and treat ADHD, including the following:

• Psychiatrist
• Neurologist
• Psychologist
• Neuropsychologist

There are many benefits of seeing a psychiatrist to diagnose and treat ADHD. Only a psychiatrist can provide both medications and strategy-focused therapy. In addition, a psychiatrist can address other common challenges that often occur with ADHD, including sleep problems, anxiety, shame, or depression.

Is ADHD genetic?

Many factors can lead to ADHD. ADHD is believed to be one of the MOST genetic disorders in psychiatry and tends to run in families. The latest research suggests that heritability is 76%.

Is Adderall or Ritalin better for Adult ADHD?

This is an exciting question. Both medications are highly effective in treating ADHD. However, some patients respond better to Adderall, and others respond better to Ritalin. However, the majority of people who react to medications will benefit from either Adderall or Ritalin.

What are common treatments for ADHD in adults?

There are many treatments for ADHD in adults, including medications, therapy, and other forms of treatment. According to the research, the most effective treatments for ADHD are medications. These include the stimulants such as Ritalin, Adderall, Focalin, Concerta, and Vyvanse. There are also non-stimulant medication treatments such as Strattera. In my opinion, the stimulants often work more effectively and with fewer side effects than Strattera. In addition, there are effective non-medication treatments for ADHD, including specialized and strategy-focused cognitive behavioral therapy (CBT) by a psychiatrist or therapist who is experienced in treating ADHD.

Conclusion

ADHD is a disorder that affects all aspects of a client’s life. Many of your current or future clients may not have received an accurate diagnosis or treatment for ADHD. Understanding that ADHD does not necessarily equal Adderall is imperative. Overcoming the stigma that implies ADHD is not a “real diagnosis” and understanding the significant impact that it has on a client’s life and the course of their therapy can make a substantial difference to your client. Also, screening for Adult ADHD in each of your clients, referring them for assessment and treatment, and utilizing cognitive behavioral therapy can make a significant impact on their lives.

If you want to learn more about ADHD or have any questions, don’t hesitate to contact Dr. Shapiro at scott@scottshapiromd.com or 212-631-8010.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.

References:

Reinberg, Steven. Adult ADHD Costs Billions in Lost Income. HealthDay Reporter at HealingWell.Com. 2004. Retrieved from http://www.news.healingwell.com/indesx.php?p=news1&id=521145

Young, Susan et al.: ADHD in Adults; A Psychological Guide to Practice. John Wiley and Sons, Ltd. 2007

Wilens, T.E. Cognitive therapy in the treatment of adults with ADHD: a systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: an International Quarterly, 13, 215-226.