Underdiagnosis of Adult ADHD

Theresa R. Cerulli, MD: That leaves me wondering, Alice, how often is adult ADHD [attention-deficit/hyperactivity disorder] not diagnosed? What can be done to improve the diagnosis of ADHD in adults?

Alice Mao, MD: The diagnosis of ADHD in adults has expanded. People are aware that oftentimes, as children advance into adolescence, the hyperactivity may diminish but the problems with concentration, distractibility, and executive functioning, persist into adulthood. In my practice, when they come in for treatment, perhaps they were treated as children and thought they had outgrown the symptoms. As they move into college or work life, they’re noticing that they’re falling behind their peers because they’re not able to pay attention, they’re forgetful, they often have difficulty prioritizing which tasks to work on. For those reasons, when they come in, they may not show as severe impairment as children in terms of being disruptive, getting out of their chairs, but they often have good examples of how their behaviors have created havoc in their lives. For example, I had a man come in with his wife, and he told me how he had packed up his car because they were going on vacation. He carefully put in all the suitcases, then he drove off in his car and his wife was left standing on the sidewalk. About 10 minutes later, he came back and said, “I forgot some baggage.”

Needless to say, that vacation didn’t start well for them, but it was 1 of the incidents that precipitated his wife bringing him in for treatment. Other times, adults come in who are noticing that they’re unable to meet deadlines and procrastinating on tasks that are important. When they come in, we ask them to fill out checklists, such as the adult ADHD screening instrument, so we can identify the symptoms that are posing problems. If necessary, we may do other tests, such as the test of variable attention, to give some objective confirmation of their findings. Other types of tests can be done, but we have to look at cross-situational impairment. It’s not about not being able to focus at school or work. Folks are able to say that it prepares their social interaction because they’re not listening at important social gatherings, or they’re forgetful in doing important tasks at home, like picking up their kids from school or remembering engagements that they committed to. ADHD is very impairing in adults, and it’s even more important to treat them and help them progress and feel more successful in their lives.

Theresa R. Cerulli, MD: What do others think? What can you add to that, Dr Feld?

Michael Feld, MD: In my practice, ADHD in adults is missed most of the time. Mostly, as child-adolescent psychiatrists, we treat families. Obviously, it’s easy to diagnose parents, but the other adults primarily come in because of their comorbidities being diagnosed first. But the more important reason is why now? What has happened that made them seek the diagnosis of ADHD? Sometimes it’s as simple as having genetic relatives. Sometimes it’s as easy as having tried someone’s medication. But usually, it’s more related to something happening in their life at a key point. There’s functional impairment, and they realize that for every other compensation in place, it wasn’t because of anxiety, depression, substance use, or other behavioral and health-related issues.

It’s time to figure out why they’re having such struggles and why there’s such difficulty in 1 area of their life, whether it’s occupationally, relationship-wise, health-wise, legal, addictions. There are multiple areas of life that we know ADHD impacts people. Honestly, what we can do more than anything is train providers and prescribers to look for ADHD in adults and know how to diagnose it. What we’re going to learn more than anything is to teach people to look for the functional impairment that has happened throughout their life but now is being exacerbated in adulthood.

Andrew Cutler, MD: Mike, I agree. Especially if we train people to look for the underlying people with mood disorders and anxiety that don’t respond to appropriate treatment, sometimes this is the rest of the iceberg under the water.

Theresa R. Cerulli, MD: Go ahead, Birgit.

Birgit H. Amann, MD, PLLC: I agree with both of you. Not to reiterate exactly what you said, but it’s more commonly not diagnosed than diagnosed based on what I’m seeing. We automatically screen every new intake that comes in, no matter what age, no matter why they come in. We feel we’re doing a better job diagnosing as a result. A lot of it would have been missed if we didn’t ask everybody those questions. It’s no different from how we ask everybody about depression or anxiety.

Andrew Cutler, MD: Yes, I agree. Part of the problem, and I’m sure my colleagues would agree, is that we’re not doing a great job in our training programs, educating people about ADHD in general and specifically in adults.

Theresa R. Cerulli, MD: Yes. It’s often overlooked in our residency training programs. I’m not sure why. Perhaps it goes back to the old thought that kids grow out of ADHD, and our clinicians and adult clinicians weren’t trained because of that. I want to expand on the idea of screening because 1 of the mistakes that gets made is that screening for ADHD doesn’t mean screening only for ADHD. We have to screen for everything simultaneously even though the comorbidity that the person is presenting with can cause attention problems and coexist with the ADHD. Screening means screening for general conditions as well, including in ADHD. In our practice, that’s the approach we’ve taken. One affects the other, and sometimes the comorbidities coexist with the diagnosis of ADHD. Statistics I’ve seen—correct me if I’m wrong, Dr Cutler; you’re the numbers guy—are that 75% to 80% of the time we’re missing this diagnosis in adults with ADHD.

Andrew Cutler, MD: Yes. Research says up to 80% of adults with ADHD are undiagnosed. That means there’s quite an opportunity. Part of our job is convincing our colleagues that it does exist in adults and how common it is, and that’s why the new Maggie Sibley data to me are so important.

Transcript Edited for Clarity