“Adult” ADHD

[TexasPhysician]

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“Adult ADHD” wasn’t a term used in my training. Is it a new DSM thing that I missed? I'm hearing other psychiatrists use this term now, and I don't feel that there is a consensus on what it means. Am I just old?

 

[mistafab]

There is no consensus and the term was made up. The diagnosis has not changed. Front-facing popular info (i.e. through social media, magazines) are using the term, and encouraging people to seek "treatment." Providers are prescribing stimulants to adults with increasing frequency, and insurance panels are requesting "Adult ADHD" scales to be used prior to approving the script.

 

[littlefred]

Other psychiatric or medical diagnosis causing concentration issues.

Substance use causing concentration issues.

Drug seeking behavior.

Lastly, the none of the above option is missing.

 

[claypigeon]

I use to to describe how ADHD tends to present and/or change in adults compared to what they showed as a child

 

[PsyDr]

It's a term for: "Person who wants Adderal. IR, none of that XR crap."

 

[romanticscience]

I find it so frustrating to have a diagnosis based on non-specific phenomenology (behavior) strongly influenced by subjective observation--expectancy and then be told, "oh, no, the results of object testing don't matter; people who score fine still have the disorder."

 

[mistafab]

I find it so frustrating to have a diagnosis based on non-specific phenomenology (behavior) strongly influenced by subjective observation--expectancy and then be told, "oh, no, the results of object testing don't matter; people who score fine still have the disorder."

"Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults." - Adult ADHD Symptom Rating Scale

The leaders in the field themselves encourage retrospective diagnosis, and self-reported symptoms for adults. Leaders at NYU and Harvard are among the folks pushing this. The form itself shades in for the patient where a clinical impairment would be significant. Nowhere on the form does it encourage the provider to collect collateral.

Down the road, when stims become the next opioid crisis, we will ask "how did it get this bad?" The answer is people prioritizing Justice over Non-malfeasance... A lesson we should have already learned from the opioid crisis.

 

[arkgal]

"Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults." - Adult ADHD Symptom Rating Scale

The leaders in the field themselves encourage retrospective diagnosis, and self-reported symptoms for adults. Leaders at NYU and Harvard are among the folks pushing this. The form itself shades in for the patient where a clinical impairment would be significant. Nowhere on the form does it encourage the provider to collect collateral.

Down the road, when stims become the next opioid crisis, we will ask "how did it get this bad?" The answer is people prioritizing Justice over Non-malfeasance... A lesson we should have already learned from the opioid crisis.

I don't disagree with you, but people aren't falling over dead left and right due to Adderall overdose. Opioid abuse causes a lot of fatalities.

I personally think benzodiazepines will be the next crisis.

 

[whopper]

I liken ADHD to a person playing basketball. There's the height of the hoop (exiting factor of the subject material), the innate skill of the player (the person's IQ), and their height (how much DA and NE the brain is utilizing for attention).

Most young heterosexual men, even with ADHD will have no problem looking a pics of attractive young nude women. The "exciting" factor is there, thus in effect pushing the hoop down to a level where anyone can slam dunk the basketball. If the same men, however, were told to write a paper on quantum physics, the height of the hoop is now thrust up to 20 feet.

People with higher IQ even with ADHD can compensate up to a degree.

The problem here, and getting to the point is we live in a society where there's more data-driving factors in the economy such as IT, data processing, the sciences being more advanced, etc (height of the hoop is pushed up), children are being exposed to screen time more and more lowering their attention span + exercising less + worse diets (making their innate skill at shooting basketballs worse), making to the point where the diagnosis of ADHD can become more subjective.

If children are being raised on excessive amounts of screen-time and thus more of them as older individuals now score in the ADHD criteria is this really ADHD? Is this someone with just a poorly trained attention? What's the difference?

I've seen people do an ASRS and score in the ADHD range, but do well in school. Such people likely do have ADHD but their higher IQs are compensating. Then they reach a subject matter at an intensity (such as graduate school) where the high IQ can't cut it anymore. They need the med. In such a case, where the person had identifiable symptoms even in childhood I truly believe the person had ADHD despite good performance in school.

The problem, however, and as mentioned above, becomes people who don't remember their histories, we don't have records and now they're doing bad. Simply giving out an ADHD med is too simplistic an approach. Further the person if doing a self-report scale may be biased to score that they have ADHD cause they want to take a med, or the specific job may have the questioning their own attention in an unfair manner.

 

[arkgal]

"Because this disorder is often misunderstood, many people who have it do not receive appropriate treatment and, as a result, may never reach their full potential. Part of the problem is that it can be difficult to diagnose, particularly in adults." - Adult ADHD Symptom Rating Scale

The leaders in the field themselves encourage retrospective diagnosis, and self-reported symptoms for adults. Leaders at NYU and Harvard are among the folks pushing this. The form itself shades in for the patient where a clinical impairment would be significant. Nowhere on the form does it encourage the provider to collect collateral.

Down the road, when stims become the next opioid crisis, we will ask "how did it get this bad?" The answer is people prioritizing Justice over Non-malfeasance... A lesson we should have already learned from the opioid crisis.

I don't prescribe stimulants, but even in patients where adhd is suspected, I think other disorders like MDD that cause cognitive impairment need to be treated first. Cognition may improve significantly with proper treatment. Once that is stable and in partial remission, we can talk about ADHD. I find patients are usually understanding of that. Same goes with things like an SUD or medical issues like OSA and hypothyroidism.

Throwing stimulants at stimulant naive patients presenting with cognitive symptoms and asking for ADHD treatment isn't the answer. My side gig is telehealth and the company I work with doesn't do any controlled substances, which is very nice as it avoids most drug seeking patients. I'm not a fan of telehealth companies that cater to adult ADHD.

My guess is 'adult' ADHD is used to describe individuals who presented with ADHD symptoms as a child but went undiagnosed. I work primarily with adults 50 and older in my full time job and I do see this a lot. ADHD wasn't on people's radars 50+ years ago. Some of these patients get much better when bupropion or atomoxetine are trialed. Their anxiety often improves too.

 

[R. Matey]

Adult ADHD Symptom Rating Scale

CAARS is better for Adults b/c it at least has a validity scale attached to it. That Harvard scale is horrible.

 

[clozareal]

I don't think the validity of adult-onset ADHD has been established since you need to have evidence of symptoms before age of 12. I do think there's quite a bit of camouflaging though, especially for overprotective parents or for those with high IQ or are well adjusted enough to compensate for their deficits with strengths.

I've seen plenty of people who thought they had adult onset ADHD actually have severe anxiety, depression, OCD, substance use, sleep disorders, and even some a few months/years prior to the diagnosis of Alzheimer's but were put on stimulants (???).

 

[Stagg737]

I don't think the validity of adult-onset ADHD has been established since you need to have evidence of symptoms before age of 12. I do think there's quite a bit of camouflaging though, especially for overprotective parents or for those with high IQ or are well adjusted enough to compensate for their deficits with strengths.

I've seen plenty of people who thought they had adult onset ADHD actually have severe anxiety, depression, OCD, substance use, sleep disorders, and even some a few months/years prior to the diagnosis of Alzheimer's but were put on stimulants (???).

My first question here is are we talking about adult-onset ADHD, which is what I typically think of when hearing "Adult ADHD" and which I don't believe exists, or "adult ADHD" as in just an adult with ADHD?

To me, I colloquially think of "Adult ADHD" as "Adult-onset ADHD". In terms of real diagnoses, "adult ADHD" is the same as saying "an adult with ADHD" to me. So just "ADHD", no need for the "adult" specifier.

 

[pittfan53]

The form itself shades in for the patient where a clinical impairment would be significant. Nowhere on the form does it encourage the provider to collect collateral.

My residency clinic used this scale and this was MY EXACT POINT! Really not hard to malinger/convince yourself when it shows you the exact answers to select. Unfortunately my outpatient attending is very stimulant happy because her husband has ADHD so our clinic is known to sling stimulants at everything...

 

[AcronymAllergy]

I would say IMO the "correct" interpretation in terms of conceptualization and understanding of the condition is "adult ADHD" reflects either ADHD diagnosed in childhood and persisting into adulthood, or suspected but undiagnosed childhood ADHD persisting into adulthood. I never use the term myself, because it implies there's a version of ADHD with onset in adulthood, which there is not. DSM-5 is pretty clear on that point. I also will tell adults who had a h/o of ADHD in childhood that most people "outgrow" the diagnosis, but that most people also still have some symptoms that may persist into adulthood and that can be exacerbated by various things. I'll also discuss that the nominal symptoms of ADHD are ridiculously common and nonspecific in most instances. That's why I dislike many of the very face-valid self-rating forms.

When I actually seen the term written in a chart, it's almost always in reference to adult-onset ADHD, which just isn't a thing. I agree with what I've read (i.e., skimmed) above that ADHD is a frequently-misunderstood condition. If someone had a moderate or severe TBI and is reporting attention/concentration problems, or they have severe anxiety and say they can't focus, that's not "adult ADHD," but I'll sometimes see it diagnosed or referred to as such.

 

[AcronymAllergy]

CAARS is better for Adults b/c it at least has a validity scale attached to it. That Harvard scale is horrible.

Agreed, although I wish they'd update for DSM-5 just so we can say the diagnostic mapping isn't based on DSM-IV. I also like the CAT-A for that reason (and because it has a retrospective report section). The BDEFS by Barkley also isn't bad and is less face-valid with its ADHD items, but no internal validity scale other than the author basically saying, "if everything's at the 90th percentile or above, it's probably reflective of overreporting."

 

[Liquid8]

The form itself shades in for the patient where a clinical impairment would be significant. Nowhere on the form does it encourage the provider to collect collateral.

This is exactly why I don’t bother with the ASRS and think that it’s garbage.

The problem, however, and as mentioned above, becomes people who don't remember their histories, we don't have records and now they're doing bad.

I voted for options 1 and 2. I have found that those who report the onset of symptoms in adulthood without having elements of dysfunction in childhood to be extremely rare, and tend to be far more suspicious of those who claim they "can't remember anything" about that period in their life. Most patients can remember basic things like whether they were a good or bad student, best/worst subjects, relationships with teachers/peers etc. Usually I will prod and prompt on a range of matters, like whether their parents compensated for any behaviours, or whether other siblings may have been more dysfunctional and hence made them think they were doing fine in comparison. But I can remember one referred patient who was clearly drug seeking, and also far too stupid and impatient to tolerate questioning, simply insisting on a dexamphetamine prescription despite already saying they'd abused it and that it had no beneficial effect.

Throwing stimulants at stimulant naive patients presenting with cognitive symptoms and asking for ADHD treatment isn't the answer. My side gig is telehealth and the company I work with doesn't do any controlled substances, which is very nice as it avoids most drug seeking patients. I'm not a fan of telehealth companies that cater to adult ADHD.

One common pattern I find with those more likely to abuse medications is that they have trouble explaining how long a medication lasts for, and these inconsistencies become more apparent over time. My usual approach is to change to a long acting agent if I'm told an immediate release drug only lasts 1-2 hours, and the vast majority of patients accept the rationale behind this. For those prone to abusing it, a long acting medication isn't a deterrent as they'll often take it multiple times a day and again will have trouble explaining the duration of effect or expectations, usually defaulting to vague "I don't feel it" type responses.

Here we have had a bunch of pop-up telehealth companies appear charging thousands of dollars for ADHD assessments. Some of them are setup to not even prescribe, delegating that responsibility to referring GPs, or even trying to palm off patients to other psychiatrists. A colleague recently mentioned that one of them had applied for join their clinic expecting the existing psychiatrists to see their followups.

 

[allantois]

I think it’s possible one could develop ADHD sx as a result of TBI as an adult; otherwise, ADHD is something patients are born with and not something that magically develops at age 40

 

[WisNeuro]

I think it’s possible one could develop ADHD sx as a result of TBI as an adult; otherwise, ADHD is something patients are born with and not something that magically develops at age 40

Well, that would just be neurocognitive dysfunction due to TBI, and not ADHD. Also, the attention issues and presentation with moderate and severe TBI tend to look a lot different than typical ADHD.

 

[PsyDr]

IMO, the "adult ADHD" construct is a way to ignore IQ. What's the better answer? You're just not smart enough? Or if you could just focus a bit more, then it will all work out? IQ is a continuum. You can't achieve anything you put your mind to. It's easier to prescribe something, which we know doesn't actually improve performance for non-ADHD samples. It's harder to explain to people, "you're not cut out for that.".

You get a job, you try to emulate unrealistic ideas promoted through media, you get promoted to the edge or beyond of your intellectual abilities, and your workplace tries to push more productivity (which doubled 2008-2012)... and eventually you can't keep up.

 

[smalltownpsych]

Selling drugs to just the people who need them and will use them wisely isn’t very profitable, you really want to expand your market to the majority of the population and make sure to capture the people with more addictive potential that will buy lots and lots. That’s what I think when I hear adult ADHD.

 

[romanticscience]

A lot of these "adult ADHDers" would have been neurasthenic, neurotic, "anxious" in the 70s, "depressed" in the 80s, and "bipolar" in the 90s. Just check to see which drugs are still brand. What time is it? 2023, Vyanse is still brand. Cool!

I love hysteria, it's a condition that can so easily conform to non-specific diagnostic disease constructs through suggestion (*cough* advertisements) and make those interested in some major $.

 

[calvnandhobbs68]

A lot of these "adult ADHDers" would have been neurasthenic, neurotic, "anxious" in the 70s, "depressed" in the 80s, and "bipolar" in the 90s. Just check to see which drugs are still brand. What time is it? 2023, Vyanse is still brand. Cool!

I love hysteria, it's a condition that can so easily conform to non-specific diagnostic disease constructs through suggestion (*cough* advertisements) and make those interested in some major $.

Hey and don't worry when Vyvanse goes off patent next year pharma still has Adzenys, Cotempla, Jornay, Azstarys, Mydayis, Dyanavel, Quillichew and Quillivant to fall back on.

 

[Jules A]

A majority I see who use that term actually describe what was likely untreated ADHD symptoms as a child but were functional due to being intelligent enough to develop work arounds. They are now college educated, productive adults and it tends to come off as a desire for performance enhancement especially as they enter midlife. I suspect the inquires are fueled by media and Americans' general sense of entitlement that everything can and should be perfect.

 

[clausewitz2]

This is exactly why I don’t bother with the ASRS and think that it’s garbage.



I voted for options 1 and 2. I have found that those who report the onset of symptoms in adulthood without having elements of dysfunction in childhood to be extremely rare, and tend to be far more suspicious of those who claim they "can't remember anything" about that period in their life.

I have never met someone with true ADHD persisting into adulthood who has trouble coming up with many, many examples of experiences that led them to believe they were a f***-up or a slacker or lazy or a space cadet. It might take some prompting for them to recall lots of details but once the floodgates open there is always a lot they can recall.

Here we have had a bunch of pop-up telehealth companies appear charging thousands of dollars for ADHD assessments. Some of them are setup to not even prescribe, delegating that responsibility to referring GPs, or even trying to palm off patients to other psychiatrists. A colleague recently mentioned that one of them had applied for join their clinic expecting the existing psychiatrists to see their followups.

So drug-dealers, then.

 

[clozareal]

My residency clinic used this scale and this was MY EXACT POINT! Really not hard to malinger/convince yourself when it shows you the exact answers to select. Unfortunately my outpatient attending is very stimulant happy because her husband has ADHD so our clinic is known to sling stimulants at everything...

I made my own scale without the shading. I only use it for screening and for tracking outcomes rather than diagnosis. I do like the DIVA-5 or CAT-A if it's equivocal based on the clinical interview, but I've done so many ADHD evaluations in kids and teens that I rarely pull out the semi-structured interviews anymore.

 

[Liquid8]

So drug-dealers, then.

It’s not quite that – more that they will assess and diagnose ADHD at high rates of pay, but not take on the responsibility of actually treating it. One colleague has dubbed it #psychocapitalism, and it does have a “pay to win” mentality which make me somewhat uncomfortable.

One of my regular GP referrers called me once, asking what to do about a patient who come to him for the first time demanding that he prescribe him “all the stimulants.” The patient in question had paid thousands for a telehealth assessment and been sent a brief letter with a generic management plan stating he could be on any of Ritalin, Concerta, Dexamphetamine and Vyvanse up to the maximum doses which they were not comfortable initiating.

Can remember reading another complaint on social media, where someone was upset that they’d paid 1000s and had to wait weeks for the psychiatrist to send a letter to the referring GP who could start prescribing after they received it – a very Veruca Salt “I want it now” attitude.

I suspect that part of this non-prescribing practice might be due a combination of risk mitigation and the impracticalities and inconveniences around scripts via telehealth. Not all medical software is linked with escript provisions, and many of us don’t use said software anyway, so to do have a telehealth setup one will end up having to manually fax and post out a lot of scripts which adds up to a lot of extra work as well as phone calls with chemists who are legally obligated to check too.

 

[futureapppsy2]

IMO, the "adult ADHD" construct is a way to ignore IQ. What's the better answer? You're just not smart enough? Or if you could just focus a bit more, then it will all work out? IQ is a continuum. You can't achieve anything you put your mind to. It's easier to prescribe something, which we know doesn't actually improve performance for non-ADHD samples. It's harder to explain to people, "you're not cut out for that.".

You get a job, you try to emulate unrealistic ideas promoted through media, you get promoted to the edge or beyond of your intellectual abilities, and your workplace tries to push more productivity (which doubled 2008-2012)... and eventually you can't keep up.

I've seen a case where an adult (mid-50s) very, very clearly had ADHD but wasn't diagnosed, in part *because* she is extremely smart (graduated from a top tier med school, etc). From childhood on, she could never consistently sustain attention or initiate tasks unless it was do or die, but managed to get things done very well in short bursts, because she is, well, really smart. As a result, it basically worked out academically/professionally but made her kind of miserable. She sought treatment from masters-level therapists for years (who didn't diagnose anything), but for some reason, none of them picked up on it, even though the inattentive symptoms were blatant and pretty textbook. Unusual case, but they do exist.

 

[AcronymAllergy]

Yeah, it's not unusual for high-IQ folks to pass through childhood (and public school) without being diagnosed. Plus, for folks who are more on the inattentive than hyperactive/impulsive side, the symptoms can be more easily missed in childhood but become more impairing in adulthood given the changes in typical life demands.

As for recollection of childhood, Barkley's done some work showing that by about the mid-20's or so I believe, self-report is about as accurate as parent report. But anecdotally, I've seen enough adults with ADHD who I would describe as "vague" historians (e.g., ok for general themes but bad with details) for me to not think it's coincidence, and which also makes sense given the nature of the condition. But if they just came in and said, "I don't remember anything about my childhood," I'd be suspicious.

 

[docksan]

Attributing adult ADHD to drug seeking would be like attributing adult depression to attention seeking.

Is that really a schema you want to abide by or can we return to practicing medicine now?

 

[allantois]

Attributing adult ADHD to drug seeking would be like attributing adult depression to attention seeking.

Is that really a schema you want to abide by or can we return to practicing medicine now?

Some depression is attention seeking hmm

 

[heartsink]

This debate reminds me of the multiple twists and turns the opioid use debate made: The initial move was overloading postop patients with opioids to treat pain - successful in controlling pain, but with obvious drawbacks we're now aware of. The next move was a kneejerk-180 where I witnessed the surgeons I worked with were trying to give no opioids postoperatively when ever possible (doable for uncomplicated laparoscopic hernia repairs). And now we're witnessing the latest correction where we're acknowledging even patients with opioid use disorder suffering from postoperative pain are being given opioids.

This latest correction makes sense to me as it re-prioritizes the wellbeing of the patient with a more moderate stance toward the addictive risk, rather than prioritizing the addictive risk over the wellbeing of the patient.

In the ADHD parallel then, we're in the kneejerk-180 phase, where many are questioning if we should be giving adults stimulants at all. I'm glad to read there are some in this thread who I think already see the next move; patients that have gone undetected into adulthood have compensated to the extent they can, and now there is room for improving their function with treatment of the underlying deficit while still having a healthy acknowledgement of the risks without overly prioritizing the risks.

 

[smalltownpsych]

A lot of these "adult ADHDers" would have been neurasthenic, neurotic, "anxious" in the 70s, "depressed" in the 80s, and "bipolar" in the 90s. Just check to see which drugs are still brand. What time is it? 2023, Vyanse is still brand. Cool!

I love hysteria, it's a condition that can so easily conform to non-specific diagnostic disease constructs through suggestion (*cough* advertisements) and make those interested in some major $.

This is the group I’m seeing more and more of these days. Have a local psych NP who seems pretty heavily stimulant dependent herself and who is prescribing it for patients more and more. One of my patients with severe trauma and substance abuse hx was prescribed vyvanse and now is working three jobs for about 60 hours a week. Now their CNS activation and avoidance pattern has been channeled into productivity, too bad the crash might be fatal. Since it probably won’t happen for a few years, maybe it’s not a problem? It also is a good way to help stay slim. Truth is, once a patient tries them and likes what they do, they aren’t likely to stop and I might as well discharge them from therapy because they wont really benefit much from it anymore.

 

[Jules A]

This debate reminds me of the multiple twists and turns the opioid use debate made: The initial move was overloading postop patients with opioids to treat pain - successful in controlling pain, but with obvious drawbacks we're now aware of. The next move was a kneejerk-180 where I witnessed the surgeons I worked with were trying to give no opioids postoperatively when ever possible (doable for uncomplicated laparoscopic hernia repairs). And now we're witnessing the latest correction where we're acknowledging even patients with opioid use disorder suffering from postoperative pain are being given opioids.

This latest correction makes sense to me as it re-prioritizes the wellbeing of the patient with a more moderate stance toward the addictive risk, rather than prioritizing the addictive risk over the wellbeing of the patient.

In the ADHD parallel then, we're in the kneejerk-180 phase, where many are questioning if we should be giving adults stimulants at all. I'm glad to read there are some in this thread who I think already see the next move; patients that have gone undetected into adulthood have compensated to the extent they can, and now there is room for improving their function with treatment of the underlying deficit while still having a healthy acknowledgement of the risks without overly prioritizing the risks.

I rarely prescribe stimulants for adults because I believe most, not all, with even legit ADHD as children are able to function sans meds without moderate to marked impairment. If an adult struggles with focus but has work arounds and are stable does that mean we should seek to fine tune this to the extent of adding a stimulant? Which we know will improve everyone's focus, productivity and reduce their appetite-especially attractive to people entering mid-life.

It takes me to the other thread about the PCP insisting a 70yo has ADHD. My first thought was yeah, ok even if ADHD I would probably recommend life coach/therapy rather than even consider a stimulant in a geriatric patient for ADHD. No easy answers. I appreciate everyone's thoughts and insights here.

 

[docksan]

Some depression is attention seeking hmm

And some abdominal pain is factitious. I'm not sure where you're going with this.

I frequently tell my patients of any psychiatric diagnosis that medicine isn't always necessary.

Not diagnosing ADHD because you don't want stimulants to be an option is bad medicine. Nothing says you have to prescribe them, but if you're withholding in a patient with severe symptoms because they're an adult and you don't even present the option you are practicing bad medicine, in my opinion.

There's a reason we learn about therapy and behavioral interventions. You can recommend those too, you know, just like you recommend lifestyle changes for hypertension. If someone comes in with a blood pressure consistently over 180 you're not going to withhold medical interventions because you're worried antihypertensive medicines are overprescribed. You're going to talk to your patient.

 

[PsyDr]

I've seen a case where an adult (mid-50s) very, very clearly had ADHD but wasn't diagnosed, in part *because* she is extremely smart (graduated from a top tier med school, etc). From childhood on, she could never consistently sustain attention or initiate tasks unless it was do or die, but managed to get things done very well in short bursts, because she is, well, really smart. As a result, it basically worked out academically/professionally but made her kind of miserable. She sought treatment from masters-level therapists for years (who didn't diagnose anything), but for some reason, none of them picked up on it, even though the inattentive symptoms were blatant and pretty textbook. Unusual case, but they do exist.

Explain the self report in light of what we know about the unreliability of recall, and the DSM instruction, "Adult recall of childhood symptoms tends to be unreliable, and it is beneficial to obtain ancillary information"

 

[calvnandhobbs68]

This debate reminds me of the multiple twists and turns the opioid use debate made: The initial move was overloading postop patients with opioids to treat pain - successful in controlling pain, but with obvious drawbacks we're now aware of. The next move was a kneejerk-180 where I witnessed the surgeons I worked with were trying to give no opioids postoperatively when ever possible (doable for uncomplicated laparoscopic hernia repairs). And now we're witnessing the latest correction where we're acknowledging even patients with opioid use disorder suffering from postoperative pain are being given opioids.

This latest correction makes sense to me as it re-prioritizes the wellbeing of the patient with a more moderate stance toward the addictive risk, rather than prioritizing the addictive risk over the wellbeing of the patient.

In the ADHD parallel then, we're in the kneejerk-180 phase, where many are questioning if we should be giving adults stimulants at all. I'm glad to read there are some in this thread who I think already see the next move; patients that have gone undetected into adulthood have compensated to the extent they can, and now there is room for improving their function with treatment of the underlying deficit while still having a healthy acknowledgement of the risks without overly prioritizing the risks.

Don’t know what you’re talking about with the knee jerk 180 phase being right now with stimulants. Were pretty obviously still in the “load people up with stimulants for saying they can’t focus” stage. This forum does not reflect the overall trend which has been increasing amounts of stimulants being prescribed every year and was accelerated by all the telemedicine ADHD companies before they started cracking down.

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study

Prescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors)...

www.thelancet.com

 

[FlowRate]

People with higher IQ even with ADHD can compensate up to a degree

The difficulty I have with this concept is that it's probably both true and also overused as an argument for excusing lack of actual impairment. I have a bit of a hard time joining the idea that a patient has a fundamental inability to sustain attention and yet gets top marks on rigorous college/graduate school finals and standardized tests that require hours of... sustained attention. I find it much more compelling when the issue is more with hyperactivity symptoms but I think most of us find that compelling since generally that behavior is easily observable in the first place. Although inattentive symptoms, when actually present, should also be observable, they're just not present in 90% of the evaluations I do where patients are--with linear, concise, detailed, and sustained responses--giving me an "inattentive only" history.

Hey and don't worry when Vyvanse goes off patent next year pharma still has Adzenys, Cotempla, Jornay, Azstarys, Mydayis, Dyanavel, Quillichew and Quillivant to fall back on.

It'll be "interesting" to see what drug companies decide to do with the limited quantity of the DEA-controlled primary ingredients. I'm sure they'll prioritize medication access with the generic formulations and not try to shift toward branded drugs to capitalize on induced shortages of generic alternatives.

In the ADHD parallel then, we're in the kneejerk-180 phase, where many are questioning if we should be giving adults stimulants at all. I'm glad to read there are some in this thread who I think already see the next move; patients that have gone undetected into adulthood have compensated to the extent they can, and now there is room for improving their function with treatment of the underlying deficit while still having a healthy acknowledgement of the risks without overly prioritizing the risks.

I agree with calvin. The field at large is just getting started. The pharma companies explicitly laid out their plan to focus on "ADHD is different in women, inattentive only is so easy to miss because everyone is just so smart that they perfectly compensate" in order to expand the stimulant market and we're seeing the results of that over the last few years.

 

[FlowRate]

As for the OP question, "adult ADHD" to me means the pharma-supported attempt to sneak an "adult onset ADHD" concept into the field.

Although I don't think I ever use the phrase "adult ADHD," if I ever do it's probably referring to the many adults, who've never previously been diagnosed with ADHD, that I see presenting to tell me about the newfound realization of "their ADHD."

At this point, I'm shocked when an adult doesn't tell me that multiple friends and family members were recently diagnosed and so they thought they should "get diagnosed," too...

 

[vanfanal]

The difficulty I have with this concept is that it's probably both true and also overused as an argument for excusing lack of actual impairment. I have a bit of a hard time joining the idea that a patient has a fundamental inability to sustain attention and yet gets top marks on rigorous college/graduate school finals and standardized tests that require hours of... sustained attention. I find it much more compelling when the issue is more with hyperactivity symptoms but I think most of us find that compelling since generally that behavior is easily observable in the first place. Although inattentive symptoms, when actually present, should also be observable, they're just not present in 90% of the evaluations I do where patients are--with linear, concise, detailed, and sustained responses--giving me an "inattentive only" history.

I agree with you all the way. All my referrals for ADHD in the last year have said that they’ve managed their symptoms but still want meds because it’s “just hard to focus” at school or work. All have reasonable academic achievement, pretty good work history, and no driving issues (something a mentor once suggested as a good clue for ADHD). I only had one patient, in my first months after graduation, who I thought could truly have it, so in hesitation I asked her to come back with her BF for collateral and she never did; poor planning and time management…she probably had it 😬.

But if I don’t see the inattentive symptoms in front of me, then I have the treating a deficit vs cognitive enhancer discussion and let them know where I stand. Most are respectful or at least don’t cuss me out to my face. It’s the heavy THC users, to whom I say I can’t make a dx when you’re smoking so much, who give me a hard time. Cuz, you know, it’s legal.

 

[heartsink]

Don’t know what you’re talking about with the knee jerk 180 phase being right now with stimulants. Were pretty obviously still in the “load people up with stimulants for saying they can’t focus” stage. This forum does not reflect the overall trend which has been increasing amounts of stimulants being prescribed every year and was accelerated by all the telemedicine ADHD companies before they started cracking down.

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study

Prescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors)...

www.thelancet.com

Thank you, this is really helpful in correcting my perspective. As a medical student, I am heavily influenzed by the attendings on this forum in the absence of regular interaction with my own attendings; its a good reminder that I have limited exposure to the current trends. This does appear the pendulum is not done swinging.

 

[Marasmus1]

Ok I do have an ADHD which was diagnosed when I was 8. SO I can speak from first hand experience.

My parents refused to put me on stimulants until I was in high school when the demands started exceeding my capabilities. However, I find deciphering ''level of impairment'' by looking at ''academic/school/work performance'' rather simplistic and not capturing the true extent of ADHD symptoms. Until high school I was A+ student but I had significant level of impairment because I was impulsive, messy and disorganized, emotionally highly dysregulated and easily bored which led to significant isolation and bullying. It is when my grades went from A+ to A- my parents started worrying about my functioning and my journey with ritalin started. My school grades did not improve whatsoever but I became much less bored, more organized, more attentive in interpersonal relationships, emotionally more stable and much less impulsive which led to making actual friends and improving my relationship with my parents.

To this date, I have been on and off various stimulants. Can I function as a psychiatrist and perform well at work without stimulant ? Absolutely yes. So unless it is digged deep, some could claim that I overcame ADHD just by looking at my work performance. What most folks miss is that untreated ADHD wreaks havoc interpersonal relationships and emotion regulation. You are much less mindful and attentive to social cues externally. You can cover this at some extent but people who are close to you sense this rapidly. Internally, boredom and inner restlessness eat you up and you find yourself constantly seeking the ''thrill'' that no work I know of can give. This seeking sometimes lead to dangerous impulsive behaviors like promiscuity, drug seeking and high adrenaline activities.

So when I am off of my stimulants, pretty much nobody can see the difference in my ''performance'' from outside. But people close to me know very well that I am off of my stimulant when I turn into an emotional wreck and reckless adrenaline junkie.

 

[confused_doc]

It seems that some of you believe that ADHD manifests as an inability to focus and underachievement in academic or work settings is a required symptom. In reality, ADHD manifests as extreme difficulty with self-regulating attention not an inability to pay attention at all, so it's no wonder that those with high IQs can still be successful academically. But to reach that point, they commonly endure a cycle of chronic procrastination due to extreme difficulty with task initiation and sustaining attention, leading to chronic low level anxiety and depression, but once the urgency of the deadline kicks in that's enough stimulus to drive them to complete the task. So of course these people who look successful from the outside, are still seeking treatment, because they've never been able to regulate their attention which naturally has caused downstream mental health issues, and as they gain increased responsibilities and reduced structure as they age, their IQ simply won't be able to compensate.

I genuinely think most of the stigma of diagnosing and treating ADHD is largely due to stimulant medication. If SSRIs were the treatment, despite their questionable efficacy, people would be diagnosed and treated liberally like they are with anxiety and depression.

 

[PikminOC]

It’s not quite that – more that they will assess and diagnose ADHD at high rates of pay, but not take on the responsibility of actually treating it. One colleague has dubbed it #psychocapitalism, and it does have a “pay to win” mentality which make me somewhat uncomfortable.

One of my regular GP referrers called me once, asking what to do about a patient who come to him for the first time demanding that he prescribe him “all the stimulants.” The patient in question had paid thousands for a telehealth assessment and been sent a brief letter with a generic management plan stating he could be on any of Ritalin, Concerta, Dexamphetamine and Vyvanse up to the maximum doses which they were not comfortable initiating.

Can remember reading another complaint on social media, where someone was upset that they’d paid 1000s and had to wait weeks for the psychiatrist to send a letter to the referring GP who could start prescribing after they received it – a very Veruca Salt “I want it now” attitude.

I suspect that part of this non-prescribing practice might be due a combination of risk mitigation and the impracticalities and inconveniences around scripts via telehealth. Not all medical software is linked with escript provisions, and many of us don’t use said software anyway, so to do have a telehealth setup one will end up having to manually fax and post out a lot of scripts which adds up to a lot of extra work as well as phone calls with chemists who are legally obligated to check too.

They aren't prescribing because Cerebral and those places got shut down by the DEA for overprescription. Stimulant prescriptions went up by 20 percent during COVID

 

[PikminOC]

Attributing adult ADHD to drug seeking would be like attributing adult depression to attention seeking.

Is that really a schema you want to abide by or can we return to practicing medicine now?

Lots of Adderall being sold and diverted. Zoloft not so much.

 

[PikminOC]

I agree with you all the way. All my referrals for ADHD in the last year have said that they’ve managed their symptoms but still want meds because it’s “just hard to focus” at school or work. All have reasonable academic achievement, pretty good work history, and no driving issues (something a mentor once suggested as a good clue for ADHD). I only had one patient, in my first months after graduation, who I thought could truly have it, so in hesitation I asked her to come back with her BF for collateral and she never did; poor planning and time management…she probably had it 😬.

But if I don’t see the inattentive symptoms in front of me, then I have the treating a deficit vs cognitive enhancer discussion and let them know where I stand. Most are respectful or at least don’t cuss me out to my face. It’s the heavy THC users, to whom I say I can’t make a dx when you’re smoking so much, who give me a hard time. Cuz, you know, it’s legal.

Jobs nowadays are boring too. Esp IT work. They come out in droves for stims.

 

[PikminOC]

It seems that some of you believe that ADHD manifests as an inability to focus and underachievement in academic or work settings is a required symptom. In reality, ADHD manifests as extreme difficulty with self-regulating attention not an inability to pay attention at all, so it's no wonder that those with high IQs can still be successful academically. But to reach that point, they commonly endure a cycle of chronic procrastination due to extreme difficulty with task initiation and sustaining attention, leading to chronic low level anxiety and depression, but once the urgency of the deadline kicks in that's enough stimulus to drive them to complete the task. So of course these people who look successful from the outside, are still seeking treatment, because they've never been able to regulate their attention which naturally has caused downstream mental health issues, and as they gain increased responsibilities and reduced structure as they age, their IQ simply won't be able to compensate.

I genuinely think most of the stigma of diagnosing and treating ADHD is largely due to stimulant medication. If SSRIs were the treatment, despite their questionable efficacy, people would be diagnosed and treated liberally like they are with anxiety and depression.

Yes stimulants are in the same DEA category as Oxy. They are addictive and abused. Very different from Zoloft.

 

[Ceke2002]

The problem, however, and as mentioned above, becomes people who don't remember their histories, we don't have records and now they're doing bad. Simply giving out an ADHD med is too simplistic an approach. Further the person if doing a self-report scale may be biased to score that they have ADHD cause they want to take a med, or the specific job may have the questioning their own attention in an unfair manner.

This was the issue I had when I was first trying to get re-diagnosed as an adult. First diagnosed back in 1975, fast forward 20 or so years later and the clinic no longer exists, records have been destroyed, and most of my original treating physicians are deceased. What was most frustrating to me at that time were the Doctors who would book you in as a patient & then promptly end the session when what they considered 'proper documentation' couldn't be produced. It did make me wonder why they bothered accepting the appointment in the first place if they weren't even prepared to consider other forms of prior diagnostic evidence, such as school reports, work reports, interviewing friends and family members (etc). But of course I do get that, if done correctly, an ADHD assessment should not consist of the patient just rocking up & making sweeping claims with nothing to back those claims up.

I definitely agree that simply handing out medication is far too simplistic approach, especially if the diagnosis might not be what the person thinks it is and/or wants it to be. Medication can be a wonderful tool in a holistic approach to treatment of ADHD, but I can't see it doing much good (in my layperson's opinion at least) if the person's issue is actually something like panic disorder with childhood trauma & attachment issues, as opposed to them actually having ADHD.

 

[Ceke2002]

Ok I do have an ADHD which was diagnosed when I was 8. SO I can speak from first hand experience.

My parents refused to put me on stimulants until I was in high school when the demands started exceeding my capabilities. However, I find deciphering ''level of impairment'' by looking at ''academic/school/work performance'' rather simplistic and not capturing the true extent of ADHD symptoms. Until high school I was A+ student but I had significant level of impairment because I was impulsive, messy and disorganized, emotionally highly dysregulated and easily bored which led to significant isolation and bullying. It is when my grades went from A+ to A- my parents started worrying about my functioning and my journey with ritalin started. My school grades did not improve whatsoever but I became much less bored, more organized, more attentive in interpersonal relationships, emotionally more stable and much less impulsive which led to making actual friends and improving my relationship with my parents.

To this date, I have been on and off various stimulants. Can I function as a psychiatrist and perform well at work without stimulant ? Absolutely yes. So unless it is digged deep, some could claim that I overcame ADHD just by looking at my work performance. What most folks miss is that untreated ADHD wreaks havoc interpersonal relationships and emotion regulation. You are much less mindful and attentive to social cues externally. You can cover this at some extent but people who are close to you sense this rapidly. Internally, boredom and inner restlessness eat you up and you find yourself constantly seeking the ''thrill'' that no work I know of can give. This seeking sometimes lead to dangerous impulsive behaviors like promiscuity, drug seeking and high adrenaline activities.

So when I am off of my stimulants, pretty much nobody can see the difference in my ''performance'' from outside. But people close to me know very well that I am off of my stimulant when I turn into an emotional wreck and reckless adrenaline junkie.

I can definitely relate to this, and absolutely agree that an assessment of impairment levels in ADHD should take into consideration more than just one or two areas of a person's life.

I was diagnosed around the age of 3 (yes I realise that is highly uncommon), but still went on to manage reasonably well later on at school from an academic point (profoundly gifted, yada yada yada). I say 'reasonably well', because whilst I got the grades, it was still a major struggle for me to actually sit through a class, follow instructions/directions, hand work in on time, and so on. Other areas of my life (social, emotional, etc) were an unmitigated disaster. Someone merely looking at the nice little row of A's on my school reports might be forgiven for thinking everything was hunky dory when nothing could have been further from the truth.

Fast forward to my 20s & whilst I was no longer (quite literally at times) bouncing off the walls hyperactive, I was still nowhere near what anyone with half a brain would've described as 'functioning well'. First time I got behind the wheel of a car for a driving lesson I got distracted and zoned out to the point where I completely forgot I was in a car, driving along a road - ended up pulling out of a side street, and across 4 lanes of traffic without even realising (needless to say I don't drive now). Social events usually started with a quiet forewarning for anyone who might be meeting me for the first time, because I'd be talking to someone, get distracted and literally wander off in the middle of a conversation. Tried attending University and, well, let's just say I didn't go back for a second year (couldn't sit through lectures, couldn't keep my notes organised, often times spent the entire day being so distracted by anything and everything that I just literally forgot I was actually attending University). Now as with my academic grade performance as a child, I did also do contract IT & web design work during this time, as well as working as a bar tender, and I was darn good at those jobs. Talk to my employers at that time and you likely would've been given glowing references in terms of what a good, fast, reliable and hard worker I was. Anyone looking solely at my work history and/or references would've been forgiven for thinking I was going great guns - when that was nowhere near the actual truth of the matter.

Anyway, thank you for pointing this sort of stuff out. I think it's important for people to know, and understand, that functioning well with ADHD is more than just academic and work performance.

 

[Liquid8]

They aren't prescribing because Cerebral and those places got shut down by the DEA for overprescription. Stimulant prescriptions went up by 20 percent during COVID

If I was working in the US I would probably agree, but the likes of Cerebral and the associated prescribing behaviours never arrived on our shores (our midlevels don't prescribe) so the psychological underpinning behind what our practitioners are doing is a bit different.

Knowing a couple of psychiatrists running these new telehealth services, it was only a few years before Covid hit where they were quite adamant that they would never be seeing ADHD patients. Yet now they've had a sudden change of heart, but I suppose the realisation that one can charge thousands of dollars for an assessment while simultaneously avoiding all responsibility for anything prescribing related would be driving that epiphany.