ADHD in Adults: A Quiz for Primary Care

The symptoms of attention deficit hyperactivity disorder, ADHD, are often crystal clear in children. If a child is able to compensate for the condition during school age and adolescent years, however, the characteristic restlessness, inability to concentrate, and socially maladaptive behavior may not emerge until adulthood. At that point, neither the affected adult nor those around him may realize that marital problems, trouble staying on task at work, invading personal “boundaries” among family and peers and other problems are adult manifestations of the disorder.

Would you recognize ADHD in one of your adult patients? What signs/symptoms should be on your radar? Our quiz questions and answers may help.

1. Approximately what percent of adults may be affected by adult ADHD?A.    3%
B.    5%
C.    7%
D.    9%
 

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Answer: A. 3%

Meta-analyses suggest that between 2.5 and 3.4% of adults may be affected by ADHD.^1,2 However, some adults who are diagnosed in adulthood do not meet criteria for the disorder during childhood. The standard explanation is that children with high IQs and supportive home and school environments may develop compensatory behavioral mechanisms. Once these children enter adulthood, potentially leaving supportive structures and relationships, the full disorder emerges. Another hypothesis holds that ADHD may emerge later due to impaired maturation of cortical control during adolescence.³    

2. According to the American Psychiatric Association’s DSM-5, which of the following is not an age-appropriate symptom in adult ADHD?A.    Fails to finish tasks in the workplace
B.    Falls asleep during meetings
C.    Problems paying bills
D.    Uses other people’s belongings without permission

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Answer: B. Falls asleep during meetings(not a recognized symptom of adult ADHD)

In an attempt to improve diagnosis of adult ADHD, the DSM-5 includes a list of age-appropriate symptoms. These include⁴:

3. Which of the following conditions might coexist in children with ADHD?A.    Sleep apnea
B.    Tic disorders
C.    Seizures
D.    Coordination disorders
E.    A and C
F.    All of the above

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Answer: D. All of the above

Children with ADHD may have various comorbid behavioral, developmental, and physical disorders. These include learning disabilities, language disorders, disruptive behavior, anxiety, mood disorders, tic disorders, seizures, developmental coordination disorder, and sleep disorders such as sleep apnea. The American Academy of Pediatrics (AAP) ADHD clinical practice guidelines recommend that primary care physicians should include such comorbid conditions in the evaluation of a child for ADHD. Having a comorbid disorder could change treatment and management, or necessitate referral to a specialist. Adolescents newly diagnosed with ADHD should be evaluated for substance abuse.⁵

4. Males are more likely to be diagnosed with ADHD during adolescence than in childhood.A.    True
B.    False

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Answer B. False

In males, hyperactivity/impulsivity symptoms can predominate, making it more likely for them to receive a diagnosis of ADHD during childhood. Because females are more likely to present with symptoms of inattention, they may tend to be diagnosed at a later age. During adolescence, ADHD symptoms may become more obvious in females. During adulthood, these differences tend to converge, so that the rate of diagnosis in men and women is about the same.⁶

5. According to AAP guidelines, children in which age range should be evaluated for ADHD by primary care physicians?A.    4-12 years
B.    6-12 years
C.    4-18 years
D.    6-18 years

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Answer: C. 4-18 years.

The 2011 AAP guidelines for the diagnosis, evaluation and management of ADHD in children and adolescents expanded the age range in previous guidelines, from 6-12 years to 4-18 years. Current guidelines recommend evaluation of ADHD in children aged 4-18 years who have academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. Accumulating evidence has suggested that the age range should include preschool children and adolescents. ADHD represents the most common neurobehavioral disorder of childhood, affecting about 8% of children and adolescents. Children who go undiagnosed are at risk of worse outcomes, such as poor performance in school and substance abuse.⁵For References, please scroll down.

References:

1. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402-9. http://www.ncbi.nlm.nih.gov/pubmed/?term=Br+J+Psychiatry.+2007+May%3B190%3A402-9
2. Simon V, Czobor P, Bálint S, et al. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194:204-11. doi: 10.1192/bjp.bp.107.048827. http://www.ncbi.nlm.nih.gov/pubmed/?term=.+Br+J+Psychiatry.+2009+Mar%3B194(3)%3A204-11
3. Asherson P, Buitelaar J, Faraone SV, et al. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatry. 2016;3:568-78. doi: 10.1016/S2215-0366(16)30032-3. Epub 2016 May 13. http://www.ncbi.nlm.nih.gov/pubmed/?term=Lancet+Psychiatry.+2016+Jun%3B3(6)%3A568-78.
4. APA. Diagnostic and Statistical Manual of Mental Disorders DSM 5 (5th ed.), American Psychiatric Publishing, Washington, DC (2013).
5. Wolraich M, Brown L, Brown RT, et al for the Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007-22. doi: 10.1542/peds.2011-2654. Epub 2011 Oct 16. http://pediatrics.aappublications.org/content/128/5/1007.long
6. Brahmbhatt K, Hilty DM, Hah M, et al. Diagnosis and treatment of attention deficit hyperactivity disorder during adolescence in the primary care setting: a concise review. J Adolesc Health. 2016 May 18. pii: S1054-139X(16)00104-X. doi: 10.1016/j.jadohealth.2016.03.025. http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.jadohealth.2016.03.025