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Are We Afraid of Adderall?

Introduction

I sometimes wonder if the treatment of ADHD didn't involve stimulants such as Ritalin or Adderall, if there would be such a fear of diagnosing Adult ADHD. Therefore, effective screening and treatment for adult ADHD are essential to provide your clients the highest level of care. As a psychiatrist specializing in adult ADHD, I have seen for over 20 years the benefit of an accurate diagnosis and effective treatment.

Many people question whether or not adult ADHD exists as a legitimate diagnosis. Indeed, many claims that ADHD is overdiagnosed and that stimulants are overprescribed. Psychiatrists are afraid of becoming one of these doctors who "overprescribe." Even though stimulants are the standard of treatment for Adult ADD, whether or not someone has ADHD should not hinge on the treatment but on the proper assessment and diagnosis.

Are some people misdiagnosed with ADHD? Sure. And many people, notoriously college students, misuse stimulants to improve their performance or energy. However, more often than not, Adult ADD is under-diagnosed and under-treated. Adult ADHD affects at least 5% of the population, and it is estimated that nearly 75% of Adults with ADHD never receive an accurate diagnosis or effective treatment. An estimated 3 percent to 5 percent of U.S. adults have ADHD. Still, only 15 percent are aware they have the disorder (Steven Reinberg, Healthday, Internet)

Dr. David L. Katz, the director of the Prevention Research Center at Yale University's Schools of Public Health and Medicine, said, "Available data indicate we are concomitantly under-diagnosing and over-diagnosing ADHD, under- and over-treating it."

Costs of Missing the Diagnosis

ADHD causes significant lifelong impairment in those it affects. Left untreated, it affects financial status, educational achievements, relationships, and health.

"Overall, people with ADHD have less annual income," Biederman said. "This was true for males and females. Those with ADHD had income approximately $10,791 lower  per year among high school graduates, and about $4,334 lower for college graduates than their counterparts without ADHD."

Biederman said that the estimated yearly income loss for adults with ADHD in the United States is $77 billion. The numbers for drug abuse are $58 billion, alcohol abuse $85 billion, and depression $43 billion, he said. "You can see that ADHD is one of the costliest medical conditions we have," he said.

I have seen hundreds of patients who have suffered for decades with ADHD. Some may have suspected something wasn't right or that school and life were more difficult for them than their peers. When they learn more about ADHD, they realize their challenges are due to ADHD. They often wonder why their teachers, parents, and previous therapists or psychiatrists didn't pick up on the ADHD

For example, the other day, I saw a 26-year-old* who had been referred by his law school advisor for anxiety and depression.

This client never suspected that he had ADHD. He had performed well in high school and college and was accepted into a leading law school. Other therapists and psychiatrists had diagnosed him with depression, OCD, or generalized anxiety disorder and attempted to treat his symptoms with antidepressants and benzodiazepines. These medications would make him feel depressed, lethargic, and foggy.

As I explored his history, he told me that he was always well behaved as a child but would often daydream in class. He had difficulty socializing with his peers and felt like "the other kids were playing by rules that he was never taught." People often call him space cadet, and his parents tested him several times for his hearing because he seemed not to listen. He constantly lost his school supplies and had a messy desk and room. He did not do well in elementary school, and his parents often yelled at him about his poor grades. Instead, they hired tutors for him and set a rigorous and regimented study schedule that continued throughout junior high and high school. He started earning better grades and was proud of his performance. However, he still couldn't understand why it seemed to take him 2-3 times more time to do his work than it took his peers.

When he went to college, he struggled. Without the rigid structure his parents and school imposed, he became overwhelmed. His grades were mediocre, and he suffered from bouts of anxiety and depression.

My client was determined to attend law school and struggled with the application process. He did get accepted to a lower-ranked law school and decided to go. But, with the new demands of law school, his previous coping strategies were starting to fail. So he was getting further behind when he was finally referred to me for an assessment.

As It turned out, he did not have depression, anxiety, or OCD, but he had ADHD. His parents were shocked by the diagnosis. 

In addition, he related to me how he walked around in a fog most of the day and felt that he had cobwebs in his brain, the way that someone might when they first wake up in the morning or when they have the flu. However, this was how he had felt his entire life and assumed this was how other people also felt. He didn't realize that some people can focus, concentrate and stay on task without the need to rely on an excessive amount of effort and anxiety.

I started him on Adderall. Suddenly, a light bulb went off, the cobwebs cleared, and he saw the world the way most people do. In addition, his anxiety greatly diminished, and he finally had the hope to pursue his passions and life goals. 

Medications are not a total cure. With our work together, he learned strategies to improve his focus, organization and time management.

How to Diagnose Adult ADHD?

Adult ADHD is a clinical diagnosis made by an experienced mental health professional such as a psychologist or psychiatrist. Many clinicians were taught that if someone presents with depression and ADHD, first treat the depression, THEN treat the ADHD. Very often, the patient relates feeling depressed and frustrated; usually, this is because he has experienced one failure after another or jumped from one job to the next. In my experience, when you treat the ADHD, the person has the ability to pursue his goals both professionally and personally.

Unfortunately, many patients are misdiagnosed. They are treated with antidepressants, mood stabilizers, and other medications or treatments. 

In some instances, neuropsychiatric testing can be helpful, especially when there is a suspicion of a learning disorder, such as dyslexia. However, testing is not always indicated, nor is it always accurate. It is generally time-consuming, very costly, and may miss the diagnosis. For example, testing may show that a person's executive functioning, focus, and distractibility are normal, but testing is performed over a short period. A key feature of adult ADHD is that the symptoms are consistently inconsistent.


How to Help Our Clients with Adult ADHD-Five Key Tips

1. Screen All Clients

So, how can we help our clients with adult ADHD? First, it is vital to understand the impact that ADHD has on someone's life and that it is frequently misdiagnosed or under-diagnosed. It is essential to understand that ADHD does exist and that the stigma of ADHD and the anxiety about using stimulants keeps people from getting diagnosed and treated. 

It is essential to screen all clients for Adult ADHD by using a simple five-minute screening tool in the office or waiting room.

Here is a site that can be utilized as a screening tool:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many clients also feel that adult ADHD is not a "real diagnosis" and thus don't get evaluated or treated. However, explaining to the patients that SPECT and PET scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a real issue.

2. Refer For An Assessment and Treatment

For a client with a high suspicion of adult ADHD, refer to a psychiatrist or psychologist specializing in ADD/ADHD for an assessment and treatment. Medications are a cornerstone of treatment and can be life-changing for many patients who have been suffering for decades with an inaccurate diagnosis and without effective treatments.

3. Cognitive Behavioral Therapy

Another cornerstone of treatment is developing strategies to address the specific individual and unique challenges.

"Cognitive behavior therapy has been successfully applied to this client group (Stevenson et al., 2002; Wilens et al., 1999). "Individuals with ADHD require structure in terms of personal organization, social boundaries, and practical help to cope with everyday problems" (Susan Young, 2007, pp 50)

CBT sessions can help them address their most critical challenges. Often, these challenges include difficulties with time management, prioritizing, strategizing, planning, mood regulation, social skills, organization, focus, and motivation.

It is essential to encourage your clients to purchase a weekly calendar and use it regularly instead of relying on post-it notes or a smartphone. Many ADHD patients do better when they see their schedule and tasks visually.

Another behavioral intervention for your clients is to teach them to develop a to-do list with a way to prioritize each item. Then, have them place the items at a specific time on the calendar. More structure can facilitate better outcomes.

If you do not specialize in CBT or the client has significant career challenges, hiring a coach to help the client overcome these specific challenges, develop strategies and increase accountability can help improve success in work and personal life. Coaching can be an essential piece of treatment, but it can be challenging to find an effective coach. Ideally, the coach should have extensive experience working with clients who have Adult ADD/ADHD.

4. Address the Shame

Growing up with diagnosed or undiagnosed ADHD can often lead to feelings of shame and defectiveness. There is often a significant shortfall in academics, career history, and relationships. Furthermore,  there is often a history of criticism by parents and teachers. 

Help the client see that they have many strengths and that ADHD is just one aspect of their identity. Validate that it may have been a difficult struggle and that their lives can improve significantly.

5. Minimize the Potential Fallout from ADHD

Even when a client understands some of the challenges that ADHD has created, it is often unclear how it has impacted other areas of their life. Help the client understand that many behaviors such as underperforming at work, engaging in high-risk sexual activity, or facing struggles in their personal relationships are pervasive in patients with ADHD. Reassure them that this can improve over time with treatment, medications, behavioral treatments, or a combination.

Conclusion

Adult ADHD is a severe disorder that affects all aspects of a client's life. However, many clients may not have received an accurate diagnosis or treatment for ADHD. 

However, overcoming the stigma that implies ADHD is not a "real diagnosis" and understanding its significant impact on a client's life and course of therapy can make a substantial difference to your client. In addition, screening for Adult ADHD in each of your clients, referring them for assessment and treatment, and utilizing cognitive behavioral therapy can significantly impact their lives.

To learn more about adult ADHD, visit my website which has many additional articles on adult ADHD.

*Disclaimer: Details of cases have been altered to protect the confidentiality of any and all individuals.
References:
Reinberg, Steven. Adult ADHD Costs Billions in Lost Income. HealthDay Reporter at HealingWell.Com. 2004. Retrieved from http://www.news.healingwell.com/indesx.php?p=news1&id=521145
Young, Susan et al.: ADHD in Adults; A Psychological Guide to Practice. John Wiley and Sons, Ltd. 2007
Wilens,T.E. Cognitive therapy in treating adults with ADHD: a systematic chart review of 26 cases. Journal of Cognitive Psychotherapy: an International Quarterly, 13, 215-226.