Adult Onset ADHD?

[ara96]

I've been seeing some patient's for new intakes in this clinic where I'm working and a lot of them come to me with complaints that are consistent with ADHD. In some cases, it seems that it might be due to anxiety (i.e. starting a job that involves more concentration than they are used to and dealing with supervisors/co-workers, customers etc). However, I feel like some of them genuinely have ADHD and would benefit from a stimulant. However, that little belief inside me says that if they were able to get through High School, College and in some cases Graduate school, then they should be able to do just fine without a medication. I think that also stems from the fact that I've been trained to avoid giving Benzo's and stimulants at all costs.

I've tried giving Wellbutrin to some individuals but a number of them only want to take a medication on a PRN basis (i.e. only work days). If there is not substance abuse history and the patient is compliant, is it acceptable to make this diagnosis and treat it in individuals who are 30-40 yo's?

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[ExecutiveDysfunction]

Sometimes children with ADHD become adults with ADHD. But in all seriousness, oftentimes higher functioning individuals can compensate well throughout much of their life despite having some of these symptoms and not experiencing significant issues until their stressors overwhelm their coping skills. Imagine a mildly dysexecutive kid who can keep it together through their schooling, only to fall apart when they have a high-stress job, spouse and kids, and all those stressors overwhelming them.

This is where accurate history taking comes in. Dig deep for signs of childhood issues, not just attention but disorganization, impulsivity, educational or behavioral issues, etc. In the absence of anything resembling symptoms in childhood or with onset past middle childhood you’re looking at a secondary attention disorder. Often times I like to have collateral info from a family member if the patient is willing in order to corroborate and get more info they might not be aware of.

As far as medication indications for secondary attention disorders, not my bag (neuropsychology). But I think a solid diagnosis helps in these cases. I see far too many people thinking they have adult onset adhd (which the research doesn’t really support) that have comorbid axis I disorders or other stressors that would better explain their symptoms.

 

[AcronymAllergy]

I don't always take the ability to make it through high school as indication that a person doesn't have ADHD, particularly for higher-functioning individuals. Although even if they pass, there can often be signs of interference (e.g., discrepancy between intellectual ability and grades). Then again, these difficulties can also be due to numerous other factors, such as a chaotic home life and/or abuse history.

Making it through college without difficulty is a bit more telling, and making it through graduate school potentially more so. If a person has been able to function without difficulty until their 30's or 40's, at which point they then have functional impairment, I would typically lean away from ADHD. They might have some symptoms/characteristics of the disorder, but these are often being exacerbated by something else; once the exacerbating factor(s) is/are removed, impairment may remit. In which case, probably not ADHD. And if it's not ADHD, it would seem that treating the underlying condition(s) would be more evidence-based than providing a stimulant for a secondary attention disruption. Conversely, for ADHD in adults, my understanding is that stimulant medication is a first-line treatment.

I also second the recommendation for collateral report, particularly of childhood symptoms, whenever possible. Research suggests that adults in their 30's and 40's can be relatively accurate in recalling childhood symptoms, but it also can be difficult to gauge the potential functional impact of these symptoms from a child's viewpoint, as well as making a comparison to same-age peers.

 

[FlowRate]

I'm generally of the opinion that high-functioning patients who excelled in grad school who present reporting ADHD are using that as a defense against dealing with the stressor, Axis I, or Axis II that actually need to be addressed. They're high functioning enough to figure out how to spin you a story that buys them the stimulants that will, in their fantasy, solve their unhappiness and difficulty feeling as accomplished at work as they'd like. If only they were perfect at work, everything else would fall into place. Or if they had more energy/focus then they would be able to handle their impossible social situation. I'm drawing on a few cases I've seen.

Alternatively, there are a bunch of reasons to be inattentive. Sleep is probably the most common one.

I'm especially interested in people's thoughts on "ADHD Hyperfocus." I feel like this "aspect" of ADHD really muddies the diagnostic waters in the same way mixed bipolar illness does for that diagnosis (especially in relation to complex trauma and EUCD), regardless of the fact that both symptom clusters may be "real" components of the illness. But when you have patients who are able to focus at a top 1% level when it counts (more skeptical case--standardized tests, surgery)/when doing something they enjoy (chess master), then do they really have ADHD?

 

[Stagg737]

I'm generally of the opinion that high-functioning patients who excelled in grad school who present reporting ADHD are using that as a defense against dealing with the stressor, Axis I, or Axis II that actually need to be addressed.

So a question that goes off of this. What about individuals who excelled at HS levels but then progressively got worse as educational levels went on in spite of working harder and 'smarter'.

Example: Individual is near top of their class in HS with little to no effort. Rarely has to study and excels. Then they get to college and are still able to do 'well' with little to no effort throughout most of their classes. Start studying in later years (3rd/4th year) and do better as they're now studying. Then get to grad school (or residency if we want to take it to an even higher level) and fail miserably due to not being able to have the organization and efficiency required to even be average. The individual showed some signs of ADHD when younger but never had issues in school because they were extremely intelligent and were able develop coping strategies to succeed in spite of their suspected deficits which then became unmanageable at the highest education level or excessively demanding career level.

Would you still consider this as someone who is using ADHD as a defense for another stressor or would you label this as ADHD? Assuming you would label as ADHD, would you give them stimulants? Let's say after further history you determine they had the hyperactive type but they are no longer displaying signs of that type as an adult, would you still treat?

Note: This is vaguely based off a patient I saw on a rotation as a med student. Curious what thoughts of others are.

I'm especially interested in people's thoughts on "ADHD Hyperfocus."

I guess my question would be about how long can they maintain that hyperfocus? 5 minutes? 15 minutes? An hour? 4 hours? From my attending who specialized in ADHD I'm pretty sure he'd say that being hyper-focused in short spurts would be pretty typical of ADHD. Being able to stay hyper-focused for longer periods like an hour would not.

 

[whopper]

Agree with the above. The ADHD likely isn't adult-onset. It likely already existed before or the person may be grabbing for straws because of the demands of work. I've typically noticed there are people who've had it, were able to compensate with other things like high IQ or working harder, but when they get to higher levels of competition and expectation those compensating factors aren't enough.

I myself have ADHD. I had it as a little kid but only became aware of it after medical school. How do I now know? I missed the bus about once a week cause I'd zone-out while buses were being announced, and I locked myself out of my car about once every 2 months (I intentionally have a smart-key system to prevent this). I lost things several times, important things like the permission slip, or the parking pass while I was an adult. In almost all of my classes from kindergarten up the teacher would mention that I was daydreaming most of the day. Also, while I excelled in mathematics I hated it which my math teachers didn't get, but courses I liked, history and art, were never a problem despite my aptitude in math. Despite being a psychology major I never was exposed to the DSM criteria until medical school and when I saw it I had most of the inattentive criteria and some of the hyperactive criteria. Also my IQ is high so when I zoned out, by the time I woke up again I could figure out what happened.

What camouflaged the ADHD from being diagnosed was it wasn't hyperactive. That's the type that's easy to catch. It wasn't well known in the 70s to 80s as much as it is today. People also back in the day erroneously correlated ADHD with being stupid and my IQ testing misled people into thinking I couldn't have it. Further my mother is a psychiatrist and never pointed anything out. (And she is a very bad psychiatrist. She's the exact type of psychiatrist I can't stand. She's retired now).

In hindsight I should've had it treated. Medschool was utter hell for me. I've often ranted about pre-med and medschool and I still stick by those complaints (e.g. a professor saying he's going to fail half the class no matter how well everyone does--that's bogus and yes I've been a professor and graded exams. It's basically a lazy and/or sadistic professor), but had I gotten treatment it would've made it much easier. I didn't try coffee earlier cause of denial. I kept thinking how could I have ADHD if I got into medical school and scored high on IQ tests? Also coffee decades ago was debated as being unhealthy so I didn't take it up when I should've.

I didn't get medicated for it until after residency. I don't take stimulants, I used to take Wellbutrin and it helped tremendously but I stopped taking it cause I like to paint D&D miniatures and it gave me a fine hand tremor that otherwise didn't hurt my quality of life at all except for that. So I started drinking much more coffee and it was fine.

 

[AD04]

I myself have ADHD. I had it as a little kid but only became aware of it after medical school. How do I now know? I missed the bus about once a week cause I'd zone-out while buses were being announced, and I locked myself out of my car about once every 2 months (I intentionally have a smart-key system to prevent this). I lost things several times, important things like the permission slip, or the parking pass while I was an adult. In almost all of my classes from kindergarten up the teacher would mention that I was daydreaming most of the day. Also, while I excelled in mathematics I hated it which my math teachers didn't get, but courses I liked, history and art, were never a problem despite my aptitude in math. Despite being a psychology major I never was exposed to the DSM criteria until medical school and when I saw it I had most of the inattentive criteria and some of the hyperactive criteria. Also my IQ is high so when I zoned out, by the time I woke up again I could figure out what happened.

Maybe your IQ is so high that the external world bores you and you retreated to a more-exciting internal world. Hence daydreaming and zoning out and D&D. That happens to me too (not the D&D) during forced lectures and other boring events. But when I work on my own projects and studies, I am extremely focused and time would just fly by.

In hindsight I should've had it treated. Medschool was utter hell for me. I've often ranted about pre-med and medschool and I still stick by those complaints (e.g. a professor saying he's going to fail half the class no matter how well everyone does--that's bogus and yes I've been a professor and graded exams. It's basically a lazy and/or sadistic professor), but had I gotten treatment it would've made it much easier. I didn't try coffee earlier cause of denial. I kept thinking how could I have ADHD if I got into medical school and scored high on IQ tests? Also coffee decades ago was debated as being unhealthy so I didn't take it up when I should've.

It sounds like your medical school sucked. The professor has no incentive teach well because he's getting paid either way and he has a captive audience. Don't worry, I hated mine as well.

 

[FlowRate]

So a question that goes off of this. What about individuals who excelled at HS levels but then progressively got worse as educational levels went on in spite of working harder and 'smarter'.

Example: Individual is near top of their class in HS with little to no effort. Rarely has to study and excels. Then they get to college and are still able to do 'well' with little to no effort throughout most of their classes. Start studying in later years (3rd/4th year) and do better as they're now studying. Then get to grad school (or residency if we want to take it to an even higher level) and fail miserably due to not being able to have the organization and efficiency required to even be average. The individual showed some signs of ADHD when younger but never had issues in school because they were extremely intelligent and were able develop coping strategies to succeed in spite of their suspected deficits which then became unmanageable at the highest education level or excessively demanding career level.

I guess my question would be about how long can they maintain that hyperfocus? 5 minutes? 15 minutes? An hour? 4 hours? From my attending who specialized in ADHD I'm pretty sure he'd say that being hyper-focused in short spurts would be pretty typical of ADHD. Being able to stay hyper-focused for longer periods like an hour would not.

Interesting case in that it represents one part of the grey area on this issue. IMO the hyperfocus issue is inherently linked to the case you presented and the reason we're talking about people who did well in college/grad school. In college we had tests that took 100% focus for two+ hours straight in order to do reasonably well. The best in our classes never finished on time and the worst simply finished less. It's hard to imagine someone has ADHD but is able to do well in that sort of situation simply because they learned new "study skills" which somehow "coped" for their ADHD yet, when it came down to it, they were able to maintain sustained attention without any issues. Not to mention taking GMAT/MCAT/STEP exams.

As a counterpoint to my own line of argument, this invokes the fact that we treat syndromes which are based on cutoffs on distribution curves of specific components of human behavior. Maybe there are people in the 15th percentile for attention who don't exactly have "ADHD" but can still get significant benefit from a stimulant. The line isn't obvious.

I still submit, however, that someone who was top 10% in everything, all the way through to being an attending, almost by definition can not have ADHD... They've spent pretty much their entire waking life utilizing sustained attention.

 

[whopper]

In medschool it wasn't so much the case as premed. I went to college at Rutgers where at least when I was there about 50% of the incoming freshman class was premed. Bear in mind this is a university with over 50K students and the state only takes about 300 students per year for medical school. Several science courses would have a "half the class fails" or more or less a very significant number get grades that didn't reflect their true knowledge. I went to Syracuse for 2 years (where hardly anyone is a premed, had about 3.8 GPA there, transferred to Rutgers and first time I had about a 2.8 for a semster. A medschool dean I knew told me that Rutgers is basically a school designed to weed out people and told me I should've stayed in Syracuse. He then told me "take your premed classes where they actually teach and grade them fairly" and I had to follow his advice to salvage my GPA and took several of my premed classes over the summer at other places.

Aside that I saw several talented students torpedoed from their dreams of becoming a physician, that had they simply gone to a different school they would've been fine, I saw several biological majors who had no intention of going to medical school also get torpedoed cause more than half of the people in their classes were premed. A buddy of mine actually was a bio major-to be a bio researcher for real and dropped the major cause he couldn't stand taking classes anymore where significant chunks failed and the professors didn't teach, thinking it was like this in all universities, and not just very specific ones like Rutgers.

Maybe your IQ is so high that the external world bores you and you retreated to a more-exciting internal world.

Thought crossed my mind. Some buddies of mine told me this. I don't agree. While I am bright, I'm not hyper-bright like 180 IQ. It was more on the order of high 130s. When I do drink coffee or when I took Wellbutrin I did enjoy the things more so that I used to zone-out on. I'm much less forgetful when I treat it. The forgetfulness was to the point where it'd tick off my wife. E.g. she'd call me up to buy a critical ingredient for dinner and I'd forget and this type of thing happened all the time. I think the problem with math was I found no emotional connection to it where as with history and art there were emotional rungs my attention could grab onto.

The forgetfulness thing didn't hurt me in residency cause I love psychiatry too much and was always able to keep attention to it.

 

[AcronymAllergy]

RE: hyperfocus, I conceptualize it in much the same way I do other ADHD symptoms--as executive dysregulation that interferes with the effective and appropriate shifting and directing of attention (among other things). If the hyperfocus doesn't cause problems and is entirely under the individual's control, I don't know that I would conceptualize it as ADHD. If it interferes with their life (e.g., it happens when they don't want it to and/or occurs in sporadic spurts, they can't turn it "off" to shift gears when they should, etc.), that might be more in line with disordered attentional control.

 

[thoffen]

This has been discussed many times here in different ways. Some basic points:
1. ADHD is not ever an adult onset disorder. It may be that symptoms don't come to attention for treatment until adulthood, particularly when having to deal with a life that is much less structured.
2. Symptoms of ADHD may very well overlap with many other disorders but are also commonly comorbid.
3. If ADHD is an important part of the picture, in my view it is not reasonable to think you can't assess ADHD until you've fixed someone's anxiety and depression because you probably can't do that without treating the ADHD anyway, and that's a pretty optimistic position for treatment success sans ADHD too
4. In my experience, people with ADHD will frequently not frame things as ADHD symptoms. They will have normalized their mental experience of having the impairments all their life. Moreover, they will develop depressive cognitions (lazy, don't care enough, always my responsibility, etc.) as internalized ideas from external and incorrect explanations for their repeated failure to conform to expectations. They may also be functional for getting people off your back when you feel exposed. Anxiety may be functional to provide a motivation to try and overcome deficits, but it isn't very effective
5. Intelligence itself isn't an adequate attribute to allow someone with ADHD to function without obvious impairment through schooling. Environment, creativity, mental flexibility, social relationships/support, craftiness in repairing problems, etc. help. Obviously there are plenty of super-intelligent folks without ADHD that can't hack it academically

 

[Bernardo_11]

Agree with the above. The ADHD likely isn't adult-onset. It likely already existed before or the person may be grabbing for straws because of the demands of work. I've typically noticed there are people who've had it, were able to compensate with other things like high IQ or working harder, but when they get to higher levels of competition and expectation those compensating factors aren't enough.

I myself have ADHD. I had it as a little kid but only became aware of it after medical school. How do I now know? I missed the bus about once a week cause I'd zone-out while buses were being announced, and I locked myself out of my car about once every 2 months (I intentionally have a smart-key system to prevent this). I lost things several times, important things like the permission slip, or the parking pass while I was an adult. In almost all of my classes from kindergarten up the teacher would mention that I was daydreaming most of the day. Also, while I excelled in mathematics I hated it which my math teachers didn't get, but courses I liked, history and art, were never a problem despite my aptitude in math. Despite being a psychology major I never was exposed to the DSM criteria until medical school and when I saw it I had most of the inattentive criteria and some of the hyperactive criteria. Also my IQ is high so when I zoned out, by the time I woke up again I could figure out what happened.

What camouflaged the ADHD from being diagnosed was it wasn't hyperactive. That's the type that's easy to catch. It wasn't well known in the 70s to 80s as much as it is today. People also back in the day erroneously correlated ADHD with being stupid and my IQ testing misled people into thinking I couldn't have it. Further my mother is a psychiatrist and never pointed anything out. (And she is a very bad psychiatrist. She's the exact type of psychiatrist I can't stand. She's retired now).

In hindsight I should've had it treated. Medschool was utter hell for me. I've often ranted about pre-med and medschool and I still stick by those complaints (e.g. a professor saying he's going to fail half the class no matter how well everyone does--that's bogus and yes I've been a professor and graded exams. It's basically a lazy and/or sadistic professor), but had I gotten treatment it would've made it much easier. I didn't try coffee earlier cause of denial. I kept thinking how could I have ADHD if I got into medical school and scored high on IQ tests? Also coffee decades ago was debated as being unhealthy so I didn't take it up when I should've.

I didn't get medicated for it until after residency. I don't take stimulants, I used to take Wellbutrin and it helped tremendously but I stopped taking it cause I like to paint D&D miniatures and it gave me a fine hand tremor that otherwise didn't hurt my quality of life at all except for that. So I started drinking much more coffee and it was fine.

Holy cow man, it's like I was reading my own biography! You noted med school to be utter hell. Did you find the material though easy to comprehend but just had problems with the amount you had to learn? Hard to get started with studying and end up cramming near test day? How about residency. Were getting discharge summaries done an issue for you?

And finally, have you been able to overcome having to do long notes that are typically seen in your field. If you figured something out please tell me, these Developmental Behavioral peds notes continue to be a thorn on my side.

Nardo

 

[Par4thecourse]

I've been seeing some patient's for new intakes in this clinic where I'm working and a lot of them come to me with complaints that are consistent with ADHD. In some cases, it seems that it might be due to anxiety (i.e. starting a job that involves more concentration than they are used to and dealing with supervisors/co-workers, customers etc). However, I feel like some of them genuinely have ADHD and would benefit from a stimulant. However, that little belief inside me says that if they were able to get through High School, College and in some cases Graduate school, then they should be able to do just fine without a medication. I think that also stems from the fact that I've been trained to avoid giving Benzo's and stimulants at all costs.

I've tried giving Wellbutrin to some individuals but a number of them only want to take a medication on a PRN basis (i.e. only work days). If there is not substance abuse history and the patient is compliant, is it acceptable to make this diagnosis and treat it in individuals who are 30-40 yo's?

I managed to graduate from high school and college, thanks in part to drinking 40 cups of coffee a day. If they have suffered from ADHD symptomology since childhood and meet the majority of the other major suggested criteria, it seems reasonable. I was first diagnosed at 40 and the difference medication has made in my brain is nothing short of miraculous. My youth was spent in hell, thanks to this damnable disorder. My brilliant Ivy League educated parents condemned me daily for being a bum and not applying myself in school. I loved to learn. I just wasn't good at it until stimulants were introduced into my body.

 

[VA Hopeful Dr]

I managed to graduate from high school and college, thanks in part to drinking 40 cups of coffee a day. If they have suffered from ADHD symptomology since childhood and meet the majority of the other major suggested criteria, it seems reasonable. I was first diagnosed at 40 and the difference medication has made in my brain is nothing short of miraculous. My youth was spent in hell, thanks to this damnable disorder. My brilliant Ivy League educated parents condemned me daily for being a bum and not applying myself in school. I loved to learn. I just wasn't good at it until stimulants were introduced into my body.

That's why getting a solid childhood history is so important

 

[FlowRate]

That's why getting a solid childhood history is so important

In the end it's an easy diagnosis to game so it's really up to having to trust that your adult patients aren't just using you for drugs. And I don't mean that in an always-conscious way. There are plenty of people who are convinced they have/had ADHD for likely misguided reasons (including many other reasons to be inattentive.)

I really wish the Wender-Utah had a long form with scales for symptom amplification and internal consistency.

 

[justfolks]

Just a patient, but my spouse has what his psych refers to as ADD, I guest it's ADHD inattentive type? Anyway, not diagnosed or treated until his 40s, but I saw it up close and personal in grad school in early 20s, he's lucky he graduated fram grad school at all, I had to help him through several classes (think typing and editing papers at the last minute). This is someone who had straight As in HS, although bored out of his mind, multiple ivy league college accepts, then good but not as good as he should have been in college. Basically, as the work load and need for any organizational skills increased, his ability to overcome total lack of focus/organizational skills though sheer intellect diminished. His internship during grad school was a disaster, he graduated with no job, finally got one at a pretty lackluster place and then bounced from job to job over the next few years. Now takes Vyvanse on work days. Weekends without it are hell for me, if we are spending the day together I basically have to be his executive function all day long. Honestly, I blame his parents for not getting him help much, much sooner. When he told his father his diagnosis (again, in his 40s), his father said it was a relief that he wasn't just stupid. So yeah, it's not "adult-onset," but I would say it's "adult diagnosis." If you can ask a family member about their experience of the person, and observe them for a while, I think you will get all the confirmation you need.

 

[Par4thecourse]

That's why getting a solid childhood history is so important

The damage to one's self-esteem is practically indescribable. Being called "big dummy" and "stupid" and being laughed at repeatedly throughout my first 40 years was agonizing and I know my experience is not unique. It is common for us to be humiliated and I fear too many (1 is too many) still suffer needlessly in part because ADHD doesn't generate the kind of concern other crippling neurological disorders do.
Every child should be screened for it annually, IMO.

 

[Par4thecourse]

In the end it's an easy diagnosis to game so it's really up to having to trust that your adult patients aren't just using you for drugs. And I don't mean that in an always-conscious way. There are plenty of people who are convinced they have/had ADHD for likely misguided reasons (including many other reasons to be inattentive.)

I really wish the Wender-Utah had a long form with scales for symptom amplification and internal consistency.

The

Woodcock​

–​

Johnson​

Tests of Cognitive Abilities​

may be a better choice to flush out ADHD weaknesses, particularly because of its emphasis on measuring Fluid Intelligence

 

[WisNeuro]

The
Woodcock

Johnson

Tests of Cognitive Abilities
may be a better choice to flush out ADHD weaknesses, particularly because of its emphasis on measuring Fluid Intelligence

The WJ is no better than any other neurocognitive test for an individual diagnosis of ADHD, There is no reliable/valid cognitive profile of ADHD. Cognitive testing is useful in fleshing out the cognitive strengths and weaknesses, or to rule out other conditions, but it should not be used for diagnosis.

 

[Par4thecourse]

I'm generally of the opinion that high-functioning patients who excelled in grad school who present reporting ADHD are using that as a defense against dealing with the stressor, Axis I, or Axis II that actually need to be addressed. They're high functioning enough to figure out how to spin you a story that buys them the stimulants that will, in their fantasy, solve their unhappiness and difficulty feeling as accomplished at work as they'd like. If only they were perfect at work, everything else would fall into place. Or if they had more energy/focus then they would be able to handle their impossible social situation. I'm drawing on a few cases I've seen.

Alternatively, there are a bunch of reasons to be inattentive. Sleep is probably the most common one.

I'm especially interested in people's thoughts on "ADHD Hyperfocus." I feel like this "aspect" of ADHD really muddies the diagnostic waters in the same way mixed bipolar illness does for that diagnosis (especially in relation to complex trauma and EUCD), regardless of the fact that both symptom clusters may be "real" components of the illness. But when you have patients who are able to focus at a top 1% level when it counts (more skeptical case--standardized tests, surgery)/when doing something they enjoy (chess master), then do they really have ADHD?

Attention deficit disorder is all about distraction… until it’s not! One of the most surprising aspects of ADHD is hyperfocus — a person’s ability to hone in on a specific task, sometimes to the exclusion of everything else.
Someone with an interest in computer programming may happily hunt for a bug in thousands of lines of code, regardless of the fact that he usually can’t sit still. A musician may write a symphony in only a few weeks.

A Blessing and a Curse
Unfortunately, hyperfocus can’t be reliably sustained or controlled. When parents tell me how their daughter breezed through a challenging science fair project only to settle into a spotty classroom performance, I know that she was hyperfocusing. Adults can find that kind of focus in a new job — working intensely for a year, say, to fix major problems in their department. When things finally run smoothly, they lose interest and move on.

Ned Hallowell​

And he goes on to make recommendations to help those who do hyperfocus at times to their detriment

 

[erg923]

The
Woodcock

–

Johnson

Tests of Cognitive Abilities
may be a better choice to flush out ADHD weaknesses, particularly because of its emphasis on measuring Fluid Intelligence

There is no evidence of any association between ADHD and fluid intelligence.

 

[Par4thecourse]

The WJ is no better than any other neurocognitive test for an individual diagnosis of ADHD, There is no reliable/valid cognitive profile of ADHD. Cognitive testing is useful in fleshing out the cognitive strengths and weaknesses, or to rule out other conditions, but it should not be used for diagnosis.

I disagree. The scatter in the scoring on the subtests should serve as an important clue, and

working memory skills should be significantly weaker. ​

 

[erg923]

I disagree. The scatter in the scoring on the subtests should serve as an important clue, and
working memory skills should be significantly weaker.

People with ADHD, on average, tend to score slightly lower on tests of working memory, processing speed, and verbal fluency than on tests of visual–spatial reasoning, fluid reasoning, and crystallized intelligence. However, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. Thus, a diagnosis of ADHD cannot be ruled in by any particular cognitive profile, nor can any particular cognitive profile rule it out.

 

[WisNeuro]

I disagree. The scatter in the scoring on the subtests should serve as an important clue, and
working memory skills should be significantly weaker.

This is simply not true according to the available data. While the group level data can show something like this pattern, the individual level data is where this falls apart. The specificity of that finding on the individual level is absolutely terrible. You cannot extrapolate group level data to the individual level, particularly when the variability in the data is so high.

 

[Par4thecourse]

There is no evidence of any association between ADHD and fluid intelligence.

Results showed hypoactivation in ADHD in regions critical for fluid reasoning.

Fluid Reasoning Deficits in Children with ADHD: Evidence from fMRI​

Leanne Tamma,* and Jenifer Juranekb​

I wouldn't say there is no evidence. ​

 

[Par4thecourse]

People with ADHD, on average, tend to score slightly lower on tests of working memory, processing speed, and verbal fluency than on tests of visual–spatial reasoning, fluid reasoning, and crystallized intelligence. However, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. Thus, a diagnosis of ADHD cannot be ruled in by any particular cognitive profile, nor can any particular cognitive profile rule it out.

I didn't say that these tests should be the basis for a diagnosis of ADHD.

 

[clausewitz2]

Results showed hypoactivation in ADHD in regions critical for fluid reasoning.

Fluid Reasoning Deficits in Children with ADHD: Evidence from fMRI

Leanne Tamma,* and Jenifer Juranekb

I wouldn't say there is no evidence.

fMRI cannot in principle tell you anything about the distribution of scores on a psychometric construct between two populations that psychometric testing cannot tell you. It can show correlations with psychometric results and can generate interesting hypotheses and maybe some day with more robust machine learning approaches could be useful for better characterizing neural endophenotypes but there is not a brain region that is solely and only responsible for fluid reasoning, or indeed outside of motor and association cortices any other part of cortex that just does the one thing.

Let's not resurrect phrenology.

 

[grebes4lyfe]

I had to take this long ass test where I had to hit a botton whenever something flashed on a computer screen.

It was all fun and games for the first 5 minutes. Then I lost interest. And it got hard. So I failed the next 20 minutes pretty epically.

Apparently I’m “extremely impulsive” ........ I didn’t need to hit a button on a keyboard to know that

(Also sorry for creepin on the psychiatry threads.... the adult adhd thing showed up in my feed and drew my very deficient attention)

 

[VA Hopeful Dr]

The damage to one's self-esteem is practically indescribable. Being called "big dummy" and "stupid" and being laughed at repeatedly throughout my first 40 years was agonizing and I know my experience is not unique. It is common for us to be humiliated and I fear too many (1 is too many) still suffer needlessly in part because ADHD doesn't generate the kind of concern other crippling neurological disorders do.
Every child should be screened for it annually, IMO.

As one of the people responsible for all the screening, pass.

Maybe, and this is a big maybe, at ages 5 and 7-8. Problem is, a good screening test has almost by definition a fairly high false positive rate (because you want a very low false negative rate). You're going to get lots of kids referred to an already overwhelmed mental health system. That or lots of kids treated unnecessarily.

 

[WisNeuro]

As one of the people responsible for all the screening, pass.

Maybe, and this is a big maybe, at ages 5 and 7-8. Problem is, a good screening test has almost by definition a fairly high false positive rate (because you want a very low false negative rate). You're going to get lots of kids referred to an already overwhelmed mental health system. That or lots of kids treated unnecessarily.

In our metro area, these evals are currently at a 6-9 month wait list for peds. At least for the competent evals. You are definitely correct that most screeners have a VERY high false positive rate. Throw those false positives all into the wait list and you'd probably be looking at a 2 year+ wait to get this eval in school age children.

 

[Par4thecourse]

In our metro area, these evals are currently at a 6-9 month wait list for peds. At least for the competent evals. You are definitely correct that most screeners have a VERY high false positive rate. Throw those false positives all into the wait list and you'd probably be looking at a 2 year+ wait to get this eval in school age children.

Isn't it better to have to deal with waiting lists than to risk a child's welfare? As one who went undiagnosed for 4 decades, the downsides to screening may be abundant and formidable, but saving kids from years of torture should make it all worthwhile.
By screening, I'm not referring to testing alone. Feedback from parents, teachers, friends, and personal interviews would make up a part of an evaluation "packet" of sorts. Third grade seems to be a pivotal time for many children.
I think it's clear, too, that we need an army of real, experienced, experts in this field. So far, from my vantage anyway, the lack of respect for the condition feeds a certain reluctance to become fully committed to specializing in it.
For example, it is unseemly for almost anyone to rave about the wonders of Ritalin or Adderall or any other stimulant for the profoundly positive impact they can and often do have in our lives, but it is taboo. Imagine that. It's easy if you try. It's crazy.

 

[FlowRate]

Isn't it better to have to deal with waiting lists than to risk a child's welfare? As one who went undiagnosed for 4 decades, The downsides to screening may be abundant and formidable, but saving kids from years of torture make it all worthwhile.
By screening, I'm not referring to testing alone. Feedback from parents, teachers, friends, and personal interviews would make up a part of an evaluation "packet" of sorts. Third grade seems to be a pivotal time for many children.

People are already hyperaware of ADHD. I don't think that screening will fix the issue for those who go undiagnosed. While I get that you don't want what happened to you to happen to other people, you have to recognize that you grew up in a completely different time when the ADHD diagnosis was more rare. These days, if a child has severe ADHD and doesn't get diagnosed, it's a failure in a huge system of teachers, parents, coaches, and parents of friends.

And let's be clear, there is real potential harm that comes from liberally applying psychostimulants to kids, especially if the kids don't actually have ADHD.

 

[Par4thecourse]

People are already hyperaware of ADHD. I don't think that screening will fix the issue for those who go undiagnosed. While I get that you don't want what happened to you to happen to other people, you have to recognize that you grew up in a completely different time when the ADHD diagnosis was more rare. These days, if a child has severe ADHD and doesn't get diagnosed, it's a failure in a huge system of teachers, parents, coaches, and parents of friends.

And let's be clear, there is real potential harm that comes from liberally applying psychostimulants to kids, especially if the kids don't actually have ADHD.

Exactly. I agree. I am not thinking in terms of fixing a problem, though. I, too, see that there is a greater awareness of ADHD generally speaking, yet the myths surrounding it cast a shadow over attacking it in an aggressive and responsible fashion. Your last paragraph is a perfect example. I am not in favor of (nor would true medical experts, IMO) liberally prescribing drugs to kids. And therein lies the rub. Often, it seems to me, that among the "downsides" of even discussing treating ADHD properly and with confidence, are the instantaneous fears that are triggered of excessively and needlessly drugging children.

 

[WisNeuro]

Isn't it better to have to deal with waiting lists than to risk a child's welfare? As one who went undiagnosed for 4 decades, the downsides to screening may be abundant and formidable, but saving kids from years of torture should make it all worthwhile.
By screening, I'm not referring to testing alone. Feedback from parents, teachers, friends, and personal interviews would make up a part of an evaluation "packet" of sorts. Third grade seems to be a pivotal time for many children.
I think it's clear, too, that we need an army of real, experienced, experts in this field. So far, from my vantage anyway, the lack of respect for the condition feeds a certain reluctance to become fully committed to specializing in it.
For example, it is unseemly for almost anyone to rave about the wonders of Ritalin or Adderall or any other stimulant for the profoundly positive impact they can and often do have in our lives, but it is taboo. Imagine that. It's easy if you try. It's crazy.

Interminable waiting will only continue to delay treatment, and as someone mentioned, lead to children inappropriately given stimulants. This plan likely causes much more harm than good. We already overmedicate a significant portion of people who do not have this disorder, this will increase that problem. You have to balance out the Type I and Type II errors, blindly focusing on one side of the equation will have serious deleterious consequences.

 

[Par4thecourse]

Experts in the field of ADHD diagnosis and treatment are the missing piece of the ADHD dilemma. We need more bright, gifted, capable, articulate medical experts to become involved in promoting screening of kids and taking the reality of ADHD to the public. Hallowell has done amazing work. He deserves enormous credit for saving the lives of many. Yet, he can't do it all.

 

[Par4thecourse]

In terms of knowing whether it is ADHD when someone struggles with and/or fails upon reaching the highest educational demands like medical school presents, keep this thought in mind. When you need to concentrate, when you need to direct your attention to something/anything and sustain it, but you cannot do it consistently, that is classic ADHD.

 

[Par4thecourse]

As you know, there is a continuum. No one pays attention perfectly all the time. And most of us can pay attention at least enough to function within the context of our overall intelligence and educational background.
ADHD robs us of the opportunity to live up to our potential. Successful treatment makes available to us at our discretion the ability to utilize and to develop the talents/skills/assets we possess. Proper treatment doesn't endow us with supernatural gifts. But, many of us have untapped potential and will be thrilled to discover that by being able to focus our attention when and where we want, we can achieve things beyond our wildest dreams.

 

[Mass Effect]

Isn't it better to have to deal with waiting lists than to risk a child's welfare? As one who went undiagnosed for 4 decades, the downsides to screening may be abundant and formidable, but saving kids from years of torture should make it all worthwhile

I don't think it's better to have to deal with waiting lists because the kids who are truly going through a rough time (I won't use the word torture), won't get seen for years due to all the kids who are happy-go-lucky and dealing with mild symptoms. The vast majority of those truly debilitated by ADHD these days get seen because awareness is at an all-time high. There are many kids who get through life successfully (many in med school and residency, in fact) without the diagnosis until adulthood because they compensate. It would be great if these kids were seen and diagnosed in childhood, certainly, but not at the expensive of those who are so disabled by the disorder that they drop out of high school for failure to succeed. You're not considering what your proposal -- and subsequent waitlist -- will do to these kids.

 

[Par4thecourse]

Without a thorough screening, I would not have been diagnosed during my childhood.
"Torture" is an appropriate word. That's the point, in fact. Avoiding terrible, hellish suffering is the goal.

 

[Par4thecourse]

Few people who haven't suffered from this disorder can appreciate the pain, the humiliation, the threat to one's integrity it inflicts.

I cannot imagine what it's really like to be blind, permanently and completely. Don't like to think about it. But, we must make the harm ADHD causes and the hope medication offers, real to the public at large.

Some believe overmedication is the problem while others are convinced it a matter of poor parenting, misbehavior or laziness. Those issues may exist. But for the ADHDer, he/she needs medical intervention yesterday.

 

[Par4thecourse]

"Interminable waiting will only continue to delay treatment, and as someone mentioned, lead to children inappropriately given stimulants"

Breast cancer screenings save lives as do other types of screenings. False positives may always be a factor. I don't think waiting for ADHD must be interminable and, I don't understand why it necessarily leads to incorrect diagnoses.​

 

[WisNeuro]

Breast cancer screenings save lives as do other types of screenings. False positives may always be a factor. I don't think waiting for ADHD must be interminable and, I don't understand why it necessarily leads to incorrect diagnoses.

Have you ever worked in healthcare? We deal with false positives, incorrect diagnoses, and inappropriate treatment all of the time. It depends on the sensitivity and specificity of the screening instrument, and, the specificity of the best ADHD screening instruments is less than adequate. We all agree that this is a problem that could be better addressed. But, almost all of us who actually work in mental health also agree that blanket screenings with the current measures and resources available will almost assuredly lead to more harm than good.

 

[Par4thecourse]

"...almost all of us who actually work in mental health also agree that blanket screenings with the current measures and resources available will almost assuredly lead to more harm than good."

I'm not certain how anyone can know what most healthcare workers believe. Has anyone taken a poll? Additionally, if it's true, that doesn't mean they are correct. Also, let's assume for the sake of argument that it is true. That reinforces my position. We need more and better professionals in the field and more resources targeted to diagnose and treat the condition. ​

 

[WisNeuro]

"...almost all of us who actually work in mental health also agree that blanket screenings with the current measures and resources available will almost assuredly lead to more harm than good."

I'm not certain how anyone can know what most healthcare workers believe. Has anyone taken a poll? Additionally, if it's true, that doesn't mean they are correct. Also, let's assume for the sake of argument that it is true. That reinforces my position. We need more and better professionals in the field and more resources targeted to diagnose and treat the condition.

If you want, you can take a poll here, you have dozens of professionals who deal with this on a regular basis. Some of us have done dozens upon dozens of ADHD evals ourselves.

Other than that, sure, let's get "more and better professionals" in this area. What's your proposal for doing that? Where does the money come from for training, how you do you entice people to specialize in this area, where does the research money come from? There is one of the other problems. There are literally hundreds of different avenues in psych clamoring for more attention, more providers, more research funding. What makes this any different than any of those? This is the reality of the situation, it's much more complicated than saying "X is terrible, we should do more about it." Besides the scientific complications, which many here have tried to help you understand, there are political issues that are dealt with in every step of the healthcare process.

 

[Par4thecourse]

Family doctors should include screening for ADHD and other developmental disorders routinely.

 

[WisNeuro]

Family doctors should include screening for ADHD and other developmental disorders routinely.

Sure, and when they get a positive on those screenings, what's the next step?

 

[Par4thecourse]

The CDC should recommend screenings for ADHD as they do for autism. It should be a formal announcement. That would be a start.

 

[VA Hopeful Dr]

Family doctors should include screening for ADHD and other developmental disorders routinely.

Yes because we have so much extra time

 

[Par4thecourse]

The American Academy of Pediatrics (AAP) recommends that healthcare professionals ask parents, teachers, and other adults who care for the child about the child’s behavior in different settings, like at home, school, or with peers. Read more about the recommendations.
The health professional should also determine whether the child has another condition that can either explain the symptoms better, or that occurs at the same time as ADHD.

 

[WisNeuro]

Yes because we have so much extra time

And, if you started to do this, with half the kids you screen coming up positive, you refer out for formal evals. Kid's parents come back to you and say that evals are scheduling out anywhere from 1.5-3yrs at this point, and they want something done now for their kid. What now? I imagine plenty of PCPs will just throw some stimulants at the kids to appease the parents. Other parents will seek out snake oil salesman (Amen and etc) will claim to identify and treat their problems, usually in a very expensive manner.