Overview of Attention-Deficit/Hyperactivity Disorders (ADHD)

Theresa R. Cerulli, MD: Hello, and welcome to this HCPLive® Peer Exchange titled “Advances in the Management of ADHD in the Adult Population.” I’m Dr Theresa Cerulli from Cerulli and Associates in North Andover, Massachusetts. Joining me in this discussion are 4 of my esteemed colleagues and friends. Would each of you be so kind as to introduce yourselves? Because bios are so long, my memory won’t serve me well enough to do them justice. Dr Greg Mattingly?

Greg Mattingly, MD: Greg Mattingly, coming to you from St Louis, Missouri. I’m an associate clinical professor at Washington University School of Medicine. I’m the president-elect for the American Professional Society of ADHD and Related Disorders. I’m happy to join you all.

Theresa R. Cerulli, MD: Wonderful. Welcome. Dr David Goodman?

David W. Goodman, MD: Hi, I’m David Goodman. I’m an assistant professor at Johns Hopkins School of Medicine and full time in private practice. I’m also the treasurer of the American Professional Society for ADHD and Related Disorders. I’m thrilled to be here and help everyone who’s watching this program.

Theresa R. Cerulli, MD: Thank you. Dr Birgit Amman from Michigan?

Birgit H. Amann, MD: Hello. I’m Birgit Amann, a child, adolescent, and adult psychiatrist in Troy, Michigan. I’m full time in private practice. Thank you for having me.

Theresa R. Cerulli, MD: Welcome. Dr Rakesh Jain?

Rakesh Jain, MD, MPH:Thank you. Hi, Theresa. Hello, everybody. My name is Rakesh Jain, and I’m a clinical professor of psychiatry at Texas Tech University Health Sciences Center School of Medicine in Permian Basin. And I’m in private practice in Austin, Texas. It’s good to be with everyone.

Theresa R. Cerulli, MD: It’s a pleasure to be with all of you and with our audience. We’re going to be discussing a number of topics pertaining to diagnosis, management, and treatment of attention-deficit/ hyperactivity disorder [ADHD] in the adult patient population. We’ll also discuss emerging data and recent approval in ADHD and how the treatment landscape is likely to change in the near future. Let’s get started with our first topic, which is understanding ADHD and its clinical burden. Dr Goodman, would you lead our discussion with an overview of ADHD, particularly its prevalence in the pediatric and adult populations?

David W. Goodman, MD: That’s a huge question, Theresa. Let me try to break it down for everybody. Let me put some numbers on the scoreboard. For children and adolescents, the prevalence rate in the United States is about 10%. If you look at this globally, it’s about 7.9%. A paper that came out in the past year showed that African Americans in the United States have a prevalence rate of about 14%. This is a sorely missed population in the African American, Asian, and Hispanic communities. It’s something that we really should take a look at because they’re not accessing care.

If you then look at how to break down a number of ages, I talked about the children, but for adults in the United States between ages 18 and 44, the National Comorbidity Survey Replication study has a prevalence rate of 4.5%. My particular interest is in ADHD over age 50. What would the prevalence rate of that be? The prevalence rate from the Amsterdam study group is about 3%. When you translate this, millions of patients have this affliction, this disorder, and it’s often not recognized. In the children, about 60% are identified and treated. In adults, about 25% are treated. In older adults, almost nobody is treated unless you’re seeing a specialist who understands this. Let me put the prevalence numbers out there and hand it back to you, Theresa, for further questions.

Theresa R. Cerulli, MD: Please, everyone, feel free to weigh in, even though I’m addressing the questions initially to 1 person. Let’s discuss the pathophysiology of ADHD. This is such a heterogeneous condition in the way it presents from person to person. Not only is it quite prevalent, but it’s quite persistent and also heterogeneous. Anything we can talk about with regard to pathophysiology that helps understand what roles different areas in the brain might play in the manifestation of symptoms of ADHD?

David W. Goodman, MD: Well, I’ll see how everybody else wants to weigh in on this. You can talk about the neurobiology. You can talk about brain circuitry. You can talk about dopamine receptors. And we quickly get bogged down into that. The general clinicians are not necessarily going to focus on that. Let me talk about how to take a look at these data in a way that clinicians can relate to.

You have psychological testing, which measures mental function and cognition. Then you have neuroimaging. Neuroimaging breaks down into structural MRIs, looking at structures. You have functional MRI that looks at brain activity in certain areas. You have something called diffusion tensor imaging, which looks at white matter connect. Then you have EEGs [electroencephalograms] that look at beta-theta ratios, which haven’t developed as much as people would like. But the other aspect of the EEGs is looking at the default network, which is an asynchronous electrical activity in the brain that’s quite different from ADHD.

I continually hear people who say, “I don’t believe in ADHD.” I don’t believe that medicine is faith based. It’s evidence based, and it’s science based. As Neil deGrasse Tyson likes to say, “The good thing about science is that it’s true, whether or not you believe in it.”

This is the point we have to make to all clinicians. We continue to make this at my colleagues on the panel. I’ve been talking for years. If you look at this panel, we’ve got decades of clinical experience. It would be great to hear from everybody else who wants to weigh in on how you look at the pathophysiology and the neuroscience of ADHD.

Greg Mattingly, MD: David, I like your simple way of thinking about it in some ways for clinicians out there. I’ll tell patients that this is 1 of the most highly genetic neurologic conditions in all of medicine. It’s no one’s fault, but it tends to run in families. The heritability is 75%. It’s 1 of the most genetic conditions in all of medicine. We know there are various areas of the brain that don’t modulate attention, distractibility, and organization the way they should. The other simplistic way that I’ll describe it to patients is top-down control. The prefrontal cortex needs to modulate thoughts, which modulate emotions, which modulates our behaviors. If those loops aren’t working correctly, then we wind up with the manifestations of ADHD.

Birgit H. Amann, MD: I try to leave them with a positive. I try to remind them that this is a very treatable condition. We can make very positive change relatively simply.

Theresa R. Cerulli, MD: It’s so true what all of you have just described.

Transcript Edited for Clarity