Attention Magazine December 2023

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ADHD is a neurodevelopmental psychiatric condition that occurs in childhood and often persists throughout an individual’s life. While the United States has established diagnostic and treatment guidelines for childhood ADHD (American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, Society for Developmental and Behavioral Pediatrics), similar guidance for adults with ADHD remains conspicuously absent.

The surge in adults seeking care for ADHD, coupled with a steady increase in ADHD medication prescriptions, has informed the American Professional Society for ADHD and Related Disorders Association (APSARD) and Children and Adults with ADHD (CHADD) about the pressing need for diagnostic and treatment guidelines for adults with ADHD. APSARD has started the rigorous academic process to develop guidelines. CHADD, in coordination with APSARD, will develop clinical diagnostic and treatment tools specific to medical and clinical specialists. This article gives an overview of the rationale for crafting these guidelines, including the challenges and complexity of this endeavor.

Understanding ADHD

ADHD is the most prevalent neurodevelopmental psychiatric disorder in children and ranks as the second most common among adults.^1,2 Symptoms typically manifest in childhood or early adolescence, persisting into adulthood for a substantial portion of this population. Research indicates that between sixty and ninety percent of individuals continue to experience ADHD symptoms into the adult years.^3,4 The cause of ADHD is mainly familial (seventy-five to eighty percent), with environmental factors also playing a role. The economic burden of ADHD in the United States is substantial, ranging from $143 to $266 billion, with the adult impact of $105 to $194 billion accounting for most of these costs.⁵

Coordinated efforts of CHADD and APSARD

The American Psychiatric Association and the former Institute of Medicine (now the National Academy of Medicine) provide a format, based on specific parameters, for the development of clinical practice guidelines. The sequential steps in this process include an extensive search of published adult ADHD research, reviewing the publications to judge relevance and quality, selection of experts from multiple disciplines to populate review committees (which includes checks for conflicts of interest to avoid any undue influences), identifying and determining the relevance and importance of clinical/patient based assessments and interventions, writing a draft manuscript that incorporates the chosen assessments and treatments (including identification of the scientific basis based on research paper citations), providing the draft for public comments, incorporating relevant feedback into the manuscript, and, finally, submitting the guidelines manuscript for peer review and publication. APSARD is responsible for the implementation and completion of this process.

CHADD is addressing the needs of specific medical providers and specialty organizations through their DaTAA (Diagnosis and Treatment of Adult ADHD) Project committee. Working in concert with APSARD, this committee will be kept appraised of APSARD’s progress and will adapt the guidelines to the needs of different medical and mental health specialists and patient populations. This process includes focus groups with different medical and mental health specialists that will provide information about the needed tools to facilitate accurate diagnosis and effective treatments for their patients.

Since diversity of thought and perspective are important, both organizations have recruited representatives from several different medical and mental health organizations, including, but not limited to, the American Psychiatric Association, the American Psychological Association, the American College Health Association, the American Association of Nurse Practitioners, the American Academy of Neurology, and the National Alliance on Mental Illness.

Current challenges

There are a number of challenges in the present care model for adult ADHD.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM 5-TR), published in 2022, introduced updates to the descriptors for adult symptoms of ADHD. While international organizations have published diagnosis and treatment guidelines for adult ADHD after decades of global research, the United States lags behind in this crucial aspect.^6,7,8,9

Most clinicians understand childhood ADHD but are less prepared to diagnose and treat adults with the condition. Unfortunately, this gap in formal training not only affects physicians but also extends to psychiatric and other resident physicians, psychology graduate students, nurse practitioners, physician assistants, and clinical social workers.

A substantial percentage of ADHD medications are written by non-mental health clinicians, such as family practice physicians, internists, nurse practitioners, neurologists, and physician assistants, who may have a limited understanding of the nuances regarding adult ADHD diagnosis and management and of the other disorders that may superficially resemble ADHD.

The limited access to formal training in adult ADHD leaves many clinicians uninformed and unsure of the best approach to provide medical and psychological services to this patient population. Consequently, patients with adult ADHD face frustration when seeking care from professionals familiar with the disorder.

The absence of clinical practice guidelines for adult ADHD in the United States presents a significant gap in mental healthcare.

The importance of clinical practice guidelines

Why are clinical practice guidelines (CPGs) important, and how will they be helpful for adults and families living with ADHD?

• Standardizing care.
  CPGs will establish a basic clinical standard of care for evaluating and treating adults with ADHD. This standardization will ensure a more uniform diagnostic and treatment approach across the United States while allowing for flexibility based on individual patient presentation and clinical judgment.
• Guiding clinicians.
  CPGs will provide clinicians with invaluable guidance for screening, diagnosing, and treating adults with ADHD. Since these guidelines cannot address every variable in a patient’s presentation, clinical judgment remains a critical factor in providing personalized care.
• Enhancing training.
  CPGs have the potential to elevate the validity of adult ADHD as a subject for training programs. Ideally, this would inspire educational institutions to incorporate adult ADHD topics into their curricula, ensuring that future clinicians are better equipped to recognize and manage adult ADHD.
• Influencing third-party payers.
  CPGs may help structure the decisions of third-party payers regarding the coverage of medical benefits for evaluating and treating adult ADHD. Consequently, these guidelines could lead to modifications in coverage policies.
• Medico-legal impact.
  CPGs may have a significant impact on medicolegal considerations related to adult ADHD care, potentially influencing the surrounding legal framework.

The absence of clinical practice guidelines for adult ADHD in the United States presents a significant gap in mental healthcare. Developing these guidelines and clinical tools for a broad range of healthcare providers will address numerous challenges, from standardizing care to enhancing clinician training and influencing the legal and insurance landscape. As both CHADD and APSARD take up the mantle to address this need, the future holds promise for better care and support for adults and families living with ADHD.

David W. Goodman, MD, LFAPA, is an assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and an internationally recognized expert on ADHD in adults. He is also the director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville, Maryland, and the director of Suburban Psychiatric Associates, LLC. Dr. Goodman has been a principal investigator for ADHD clinical trials, authored 30-plus peer-reviewed scientific publications and presented over 600 lectures to clinicians. Dr. Goodman has continued a full-time clinical practice focusing on the diagnosis and treatment of mood disorders, adult ADHD, anxiety disorders. For almost thirty years, he has been teaching psychiatric residents at The Johns Hopkins Hospital. His psychiatric commentary has been featured on national (ABC World News, CNN Anderson Cooper 360, ESPN Sports Center) and regional television around the country, PBS and national affiliate stations, national magazines (U.S. News and World Report, Wall Street Journal, New York Times, USA Weekend Magazine, Boston Globe, BusinessWeek) and radio interviews around the country. Dr. Goodman has been an ADHD consultant to Major League Baseball and now a consultant to the National Football League. He is a former member of CHADD’s professional advisory board and served on its board of directors. For more information, visit ADDadult.com.

Max Wiznitzer, MD, is a pediatric neurologist and interim chief of pediatric neurology in the neurologic institute at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, Ohio. He is a professor of pediatrics and neurology at Case Western Reserve University School of Medicine. Dr. Wiznitzer completed a pediatrics residency and a fellowship in developmental disorders at Children’s Hospital Medical Center, Cincinnati, Ohio, and a fellowship in pediatric neurology at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. He completed his postdoctoral training as a National Institutes of Health National Research fellow in higher cortical functions at Albert Einstein College of Medicine, Bronx, New York. His special interests include ADHD, autism spectrum disorders, developmental and behavioral disorders, and pediatric neurology. Dr. Wiznitzer earned his medical degree from Northwestern University Feinberg School of Medicine. He serves on CHADD’s board of directors, co-chairs its professional advisory board, and is on the editorial advisory board of Attention magazine. He is on the editorial board of Lancet Neurology and the Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities.

REFERENCES

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2. Hasin DS, Sarvet AL, Meyers JL, et al. Epi­demiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry. 2018;75(4):336-346. https://doi.org/10.1001/jamapsychiatry.2017.4602 PMID:29450462

3. Faraone SV, Silverstein MJ, Antshel K, et al. The Adult ADHD Quality Measures Initia­tive. J Atten Disord. 2019;23(10):1063-1078. https://doi.org/10.1177/1087054718804354 PMID:30511593

4. Sibley MH. Diagnosing ADHD in older adults: critical next steps for research. Am J Geriatr Psychiatry. 2021;29(7):679-681. https://www.ajgponline.org/article/S1064-7481(20)30565-0/fulltext

5. Doshi JA, Hodgkins P, Kahle J, et al. Economic impact of childhood and adult attention-deficit/hyperactivity disorder in the United States. J Am Acad Child Adolesc Psychiatry. 2012;51(10):990- 1002.e2. https://pubmed.ncbi.nlm.nih.gov/23021476/

6. Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD Interna­tional Consensus Statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021;128:789-818. https://doi.org/10.1016/j.neubiorev.2021.01.022 PMID:33549739

7. Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treat­ment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010;10(1):67. https://doi.org/10.1186/1471-244X-10-67 PMID:20815868

8. Canadian ADHD Resource Alliance (CAD­DRA): Canadian ADHD Practice Guide­lines, 4.1 Edition. Canadian ADHD Re­source Alliance. 2020. Accessed August 28, 2023. https://adhdlearn.caddra.ca/wp-con­tent/uploads/2022/08/Canadian-ADHD-Practice-Guidelines-4.1-January-6-2021.pdf

9. May T, Birch E, Chaves K, et al. The Australian evidence-based clinical practice guideline for attention deficit hyperactivity disorder. Aust N Z J Psychiatry. 2023;57(8):1101-1116. https://doi.org/10.1177/00048674231166329 PMID:37254562