Guidelines for Diagnosing and Treating Adult ADHD by APSARD

27th of December, 2022

The U.S. is overdue for its guidelines for diagnosing and treating adult attention deficit hyperactivity disorder (ADHD). Adults living with ADHD deserve quality healthcare, and the providers also need reliable resources for effective practices related to adult ADHD. The American Professional Society of ADHD and Related Disorders (APSARD) is working on guidelines for diagnosing and treating ADHD in adults—the first of such in the U.S. The release of these guidelines is expected in 2023.

There has been a surge in the number of adults diagnosed with ADHD in the recent years. This trend can be attributed to years of research that have led to better understanding of ADHD as a lifelong disorder. Although ADHD is usually identified during childhood, more adults are being diagnosed later in life, offering them the clarity and relief they didn't have before. It's not uncommon to find late-diagnosed ADHD in women, minorities, and gifted individuals.

As more people recognize adult ADHD, it is also becoming apparent that diagnosing and treating the symptoms in adults can be challenging. Many adults living with ADHD first seek treatment for conditions such as depression or anxiety. Therefore, the evaluation process for adult ADHD necessitates an approach different from pediatric procedures. At present, there are only U.S. practice guidelines for childhood ADHD. The lack of similar guidelines for adults is a gap that needs to be filled.

There is increased patient demand for healthcare providers who can diagnose and treat adult ADHD. Guidelines that offer effective care protocols for adult patients are necessary to cater for this growing demand, which includes new adult ADHD cases and long-term patients diagnosed as children.

There is currently a shortage of traditional ADHD specialists, such as psychiatrists and psychologists. This shortage became more noticeable during the pandemic as many specialists were overwhelmed with the increasing number of ADHD patients. Some digital health startups have helped fill the gap by accepting some of these patients.

Due to the high patient demand, primary care practitioners, coaches, social workers, and allied healthcare workers, who might not have formal training or guidelines, have found themselves diagnosing and treating adult ADHD. These providers would greatly benefit from official guidelines to guide their practice, particularly in selecting appropriate diagnostic tools, titrating medications, and deciding when to use non-pharmacological therapies such as cognitive behavioral therapy (CBT).

Diagnosing ADHD is a complex process because there is no single indicator of the disorder. It requires careful examination, considering other possible mental disorders. Many individuals experience common ADHD symptoms like forgetfulness, disorganization, or restlessness, especially during stressful situations. Hence, providers have to determine whether these experiences are indeed symptoms of ADHD.

ADHD symptoms are often internal; difficulty focusing or aversion to mental effort are examples of "invisible" symptoms. Since healthcare professionals cannot directly observe these symptoms, they rely on the patients' description of their experiences. In some cases, it's helpful to interview the patient's close contacts to provide further insight on the impact of ADHD on the patient's life.

The subjectivity of ADHD symptoms, coupled with misleading information on social media, makes its evaluation more challenging. Some adults, after encountering inaccurate information about ADHD online, may wrongly self-diagnose as ADHD sufferers. The label offers them a sense of belonging in an online support community, or sometimes, as a way to blame their faults on a condition.

Sometimes adults without ADHD purposefully fake or over-report symptoms to obtain a stimulant medication prescription or to qualify for educational accommodations, like extra time on tests.5, 6, 7

Many other conditions may cause problems with concentration, like depression and anxiety; drug and alcohol abuse; sleep problems; and hypothyroidism. The list goes on. ADHD is also highly comorbid with many mental conditions. Perhaps the biggest challenge facing new or inexperienced providers is teasing apart ADHD from other and/or co-occurring conditions. Accurate diagnosis matters because each condition is treated using very different methods.

ADHD treatment is similarly complicated, especially to the unfamiliar practitioner. It requires a holistic approach that combines patient education — including informing patients on the lifestyle factors that improve and worsen ADHD symptoms — with ongoing monitoring of a patient’s progress in a given treatment, as well as potential comorbid physical and mental health conditions.

Even deciding on an appropriate treatment is a challenge. For one, providers have various medications to choose from, and must consider the effects, risks, and benefits of a medication on a patient’s underlying ADHD symptomatology and on any associated comorbid health conditions. Lifestyle management and routine follow-up, where providers check for vital signs, medication adherence and potential misuse, side effects, and changes in medical and psychiatric comorbidities is essential. What’s more, providers also have non-pharmacological options to integrate into care.

Guidelines would clarify to providers the degree to which various interventions, including non-pharmacological treatments, demonstrate effectiveness for adult ADHD. Ultimately, guidelines would help clinicians deliver holistic, safe, and appropriate care.

Prescription rates for ADHD medications have surged alongside new diagnoses in recent years. Prescriber patterns vary and include potentially problematic practices, such as over-reliance on formulations with higher abuse potential. In fact, some telehealth companies are under federal investigation for their prescribing practices, highlighting a need for clarity on appropriate practices for the prescription of stimulants – a first-line treatment for ADHD.