Podcast Transcript
Diagnosis and Treatment of Adult ADHD
Summary:
ADHD often persists from childhood into adulthood, with the symptoms of inattention and difficulties in organization, planning, and follow-through being most prominent in adults, even when outward functioning appears normal. Diagnosis is based on behavioral history and requires evidence of symptoms since childhood and impairment across multiple life areas. A comprehensive diagnosis will distinguish ADHD from co-occurring conditions like anxiety, depression, learning disorders, and sleep problems. First-line treatment is stimulant medication due to its strong effectiveness, with nonstimulants as alternatives, but medication alone is not sufficient. Cognitive behavioral therapy, structured routines, and lifestyle adjustments (sleep, exercise, environment) are key for managing daily functioning. Effective care often involves a collaborative team and ongoing monitoring. Without treatment, ADHD is associated with increased risks such as accidents, mental health issues, and poor self-management, highlighting the importance of comprehensive, evidence-based intervention.
Max Wiznitzer, MD
Max Wiznitzer, MD, is a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio. He is a professor of pediatrics and neurology at Case Western Reserve University. He has a longstanding interest in neurodevelopmental disabilities, especially ADHD and autism, and has been involved in local, state, and national committees and initiatives, including autism treatment research, Ohio autism service guidelines, autism screening, and early identification of developmental disabilities. He is on the editorial board of Lancet Neurology and the Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities. He is co-chair of CHADD’s professional advisory board.
Craig Surman, MD
Craig Surman, MD, is an associate professor of psychiatry at Harvard Medical School and scientific coordinator of the adult ADHD research program at Massachusetts General Hospital. He is the author of Fast Minds: How to Thrive if You Have ADHD (Or Think You Might) and editor of ADHD in Adults: A Practical Guide to Evaluation and Management. Dr. Surman has directed or facilitated over fifty studies on the impact of ADHD in adults. He is co-chair of CHADD’s professional advisory board.
Learning Objectives for this podcast:
- Discuss the ADHD symptoms that often persist into adulthood.
- Identify other conditions that share symptoms with ADHD.
- Discuss the process for diagnosing adult ADHD.
- Discuss pharmacologic and nonpharmacological interventions for adult ADHD.
- Learn who should be included in a clinical team providing care for an adult with ADHD.
Learning Objectives for CHADD Podcast Series PD4969:
- Identify ADHD symptoms throughout the lifespan to improve diagnosis and treatment precision.
- Describe common coexisting conditions in people with ADHD to enhance care strategies.
- Explain effective principles of ADHD medication management for better outcomes.
- Discuss the importance of integrating behavioral and other interventions in managing ADHD for comprehensive care.
- Describe the role of interprofessional collaboration in delivering effective ADHD treatment.
The following transcript has been edited for clarity.
Announcer (00:00): You are listening to Pocket MD training on ADHD in children and adults.
Dr. Max Wiznitzer (00:06): Welcome to another episode of the Pocket MD podcast. My name is Dr. Max Wiznitzer. I'm a pediatric neurologist at Rainbow Babies and Children's Hospital in Cleveland, Ohio, and co-chair of the professional advisory board for CHADD, the national advocacy group for ADHD. Today, we have the privilege and honor of having a conversation with Dr. Craig Surman about adult ADHD. Dr. Surman is the director of clinical and research program in adult ADHD at Massachusetts General Hospital, associate professor at Harvard Medical School and co-chair of the professional advisory board at CHADD.
So, let's just go straight to what's going on, Dr. Surman, and ask our first question. And we thank you for being here today. Everyone knows about childhood ADHD. It's been known for decades. But ADHD doesn't appear to disappear when you get into the adult years. Many individuals continue to be symptomatic. So, one of the key questions is, How do they present themselves and how do their symptoms differ from the children?
Dr. Craig Surman (01:08): Thank you for having me today to discuss this important set of themes. People present with ADHD often as variable as they are different from other people. And what I mean by that is that the patterns of struggle, while it reflects an underlying ADHD presence, is going to be unique to the individual. Inattention symptoms tend to persist into adulthood more than impulsive hyperactive symptoms. There's just better behavioral control in adults and in children. And the impulsive hyperactive symptoms can be particularly hidden as a result where frankly, and we'll get into how to interview to identify ADHD symptoms later, you need to ask questions about the internal experience of the person and the efforts they're putting in to manage their moments and their days.
And what I mean by that is the end result may be that the person's employed as a family doing things other people are doing, but underneath that if you ask them, you find out that they're inefficient. They're staying up later, taking longer to do things. They find themselves unable to get themselves to operate, you know, in a planned full way. And we often say that it's trouble getting to, sticking with and finishing things on self-command is a problem. But the outside world may not see that. But if you ask them, can you rely on yourself to get to stuff and stick with it and finish it? They may say, “Gosh, you know, it really depends on what it is.”
And overall, there's a pattern you'll hear of being reactive rather than proactive. People are up against a deadline to get things they wouldn't get done otherwise. They're not planning the next day and positioning themselves for success because they're just putting out fires, especially in areas of their life that they may find to be less structured and more independent. There's an important connection, I think, neurologically and phenomenologically between attention problems and basically behavioral organization that I want to point out early in our conversation, which is that we have to pay attention to form a memory and then we need to sleep in order to form a long-term memory. We'll talk more about the intersection between ADHD and sleep later. But people may say, Why is attention so important? We have all these tools to help us remember things, and you can be flexible about how you work now. And can't you just accommodate?
Well, you know, self-governance really requires like remembering the plan that you made for yourself and that's based upon maybe a conversation you had with yourself in prior days. So, even just the matter of what time we do something, whether we remember to do something, may be a result of our attention even to our own thoughts, let alone to the communications of other people or inputs we have otherwise.
Dr. Max Wiznitzer (03:57): Well, thank you. Basically a two-part question. One is can the symptoms of ADHD be hidden when adults compensate or avoid situations that expose them? And number two, is it possible for a person to become clinically symptomatic? First show the real overt features of ADHD as an adult, even though they may have had some features as a child, but not to the level that it really interfered with their day-to-day functioning.
Dr. Craig Surman (04:24): These are great questions. So, as I've emphasized, the effort can be invisible. And we talk about interviewing, you want to find out what the effort is that people are putting in. And people, as they get older, by choice or just by necessity, may avoid situations that would bring out obvious symptoms. So, children are in, hopefully, classrooms and environments that they're being asked to do what the people around them are also being asked to do. But there's a self-selection where, for example, if reading's not someone's thing, they may not be in a job or spending much time reading later in their life. If math isn't their thing, they may not be in a job or spending much time doing math later in their life. And so, it's often those areas that show up in childhood because they're demanded of people that are not demanded later.
Now we see patterns, for example, of underemployment. We see people having multiple jobs. There's a ceiling threshold of what people can get themselves to do, even though they have aptitude in a particular area. The big difference also to talk about between kids and adults that's relevant here is that the accommodation may be built-in in childhood that's not there in adulthood. What I mean by that is having a parent to pack your bag for you, so you have all your school stuff for the next day and your lunch with you. Now that's typically up to an adult to do for themselves if they're leaving the home. And so, this need to self-care ends up being a very important, frankly, medical theme for me in my work with adults with ADHD, is I'm interested in whether they can, in their private time, follow through on things that I care about medically, like are they tucking themselves in at night, which a parent might have done when they were a kid? Are they feeding themselves well? Are they getting themselves to exercise well?
And when that stuff is there, I frankly would prioritize it over some of the other chief complaints I make here, which we can talk about more later. The impairment really can fluctuate, though, in adults based upon the situations they're in. Countless people will tell me, I'm here because of work. Their spouse may say, actually, no, it affects our home life. But private time, when they're on their own, I may not hear about. And depending upon whether they've gotten feedback recently, you know, from an employer, from their spouse, I'm going to hear different things in the office at different points in time. So, I need to interview and ask and understand how they're actually operating. And if there's actually impairment they're not aware of, but it actually may be that people go in and out of life circumstances where there's built in accommodation.
And what do I mean by that? I might have someone who, for example, works as a freelance graphic designer on deadlines that are far apart. And they tell me, gosh, this is really hard to get myself to do my work. But if they're working in an office with other people side by side on short-term deadlines and have accountability to the person on the right and the left that they have to deliver images to, they're saying, gosh, that just goes really well. So, we can see situations where the environment matters because it's activating people, structuring people, and the more life is like that, the less impairment there is, and they seem to go in and out of impairment. And that's been shown in some studies that you see in follow-up, people going in and out of impairment over time.
And this mystery of, gosh, why is ADHD showing up now, I think is often one of the person's abilities mismatching the environment. So, going to college, suddenly having to comport themselves without help from the people around them, you know, is a very common time that you'll see people starting to get diagnosed who didn't meet the criteria before.
Dr. Max Wiznitzer (08:02): The symptoms of ADHD can also be seen to some degree in other disorders. How do anxiety, mood disorders, learning disabilities, or sleep problems overlap with ADHD symptoms?
Dr. Craig Surman (08:14): Yes, so many conditions can make it hard for people to be poised, have the energy to follow through. And the patterns, though, of some of the medical and mental health conditions we identify are not as long-standing as ADHD. ADHD is one of the first things we can identify in people across the lifespan. And it's a neurodevelopmental disorder by definition. So, there have to be traits ever since childhood. But there are some conditions that are less episodic. And by episodic, I mean things like major depression or someone going through a major loss and then they're not sleeping well, for example. Those are periods of their life that they're struggling, but there are traits that may be harder to disentangle sometimes historically from ADHD like chronic night owling, people having trouble getting enough sleep against having to be up the next morning or learning pattern challenges.
So, it could be dyslexia or problems with math like dyscalculia or something that's harder to tease out, often like processing speed challenges where it takes someone a while to compose their interpretation and reaction to things. You see a delay where later on or the next day they know what to say, for example, after a previous prompt, but not right away. And these kinds of struggles of learning style, communication style, really do take some sort of situational discernment. And I can talk more about how to do that in a minute. The, I think, “episodicness” versus long-standing “traitness,” the persistence of the conditions is a really important theme. In interviewing, like I'm often asking people, When you were feeling at your best, were these traits there? Like, how much of your life do you feel like we're talking about? Or is it just recently, as you've been suffering from whatever else you're suffering from?
Dr. Max Wiznitzer (10:05): What helps clinicians tell these disorders apart and to differentiate them from ADHD?
Dr. Craig Surman (10:12): Well, besides the periods where they conveniently didn't have the other condition, and the pervasiveness of it, there's an internal consistency to how people overall are operating. Because I'll often think, gosh, this person's really depressed, this person's really anxious, preoccupied. But then I can compare it to other people, being a psychiatrist, those are the kinds of things they hear a lot about, who are anxious or preoccupied. And I'm hearing a difference. It doesn't mean, for example, that people will have trouble getting to tasks or that their pattern of their days will feel like they're winging it in the last minute and misplacing objects and forgetting things. There's a lot of our mental health conditions where people are not well and preoccupied and their brains aren't working well, but they tend to not necessarily have the whole rest of the pattern of ADHD.
Dr. Max Wiznitzer (11:04): Are there circumstances when the person doesn't have primary depression or primary anxiety, but they're actually due to the ADHD? So, that if you treat the depression, if you treat the anxiety, you don't get to the root problem and you don't come, don't get to a cure, basically?
Dr. Craig Surman (11:21): It's a very important point. There are many people who present with demoralization, burnout, exhaustion because of ADHD. And some of those people will look like they have depression. There are many people who have legitimate worry that they're not going to follow through, stick with incomplete tasks, and be in trouble for it, and have had bad experiences. They're conditioned to be concerned and fearful. These secondary manifestations of mood and anxiety can resolve when people are treated for their ADHD. It's worth also mentioning, though, that these can be hard things to disentangle. And often it's important to treat the most pervasive condition that you think is present rather than guessing wrong and treating something just on hope that it'll improve a more pervasive condition. Major depression criteria if it's met or full generalized anxiety disorder criteria when it's met really deserves addressing those symptoms first.
Dr. Max Wiznitzer (12:24): There's no scan or lab test to really diagnose adult ADHD. So, how is it diagnosed?
Dr. Craig Surman (12:31): So, we have criteria that are based upon behavior and the pattern of this behavior over time. So, you'd need the presence of symptoms, enough symptoms, and it's five of inattentive or five of impulsive-hyperactive type symptoms. And there's a specific list of nine of each of those that are in the DSM criteria that we use. And very importantly, you need two areas of impairment that are where the impairment's caused by the symptoms. The areas can be a role or can be a setting. So, work, school, home, but I would include, for example, self-care as a role. It's important as well.
There's also a provision for unspecified type ADHD, meaning it doesn't meet criteria for another condition, but there's subthreshold for all those traits I just mentioned and there's meaningful impairment. That differentiating it from other conditions is essential as well and often takes a fair amount of the evaluation time.
So, one of the tips I recommend is to move away from the chief complaint area that people present with when you're diagnosing ADHD and ask them about other areas of their life, and especially things that you've asked a lot of other people about when you're asking about ADHD symptoms, like everyday tasks. And I mean things like putting away bags of groceries or putting away dishes. And in my way of thinking about it, the inattentive ADHD symptoms are the most important because they're the most prevalent in ADHD in adults. And you can think of them as broken down into moment-to-moment attention issues or longer time-scale kinds of problems. So, moment to moment is things like I'm hunting the top rack of a dishwasher, putting it in cupboards in my own home. Am I sidetracked by other thoughts? Are there things I'm noticing around me that I'm thinking about doing instead? What does it take for me to stick with that task?
In and of itself, we get the task done, maybe it doesn't matter, but interviewing about what does it take to do a simple hands-on task like this may reveal a lot of momentary, attentional problems. Similarly, longer time-scale things like going in the other room to put some laundry in a basket, bringing something back into the room that you were in, those require more sort of long working memory, holding things in mind. And if you interview in a way that sort of differentiates between shorter and longer timescale, you are doing a proxy for the severity of the ADHD. The more severe ADHD is, the more moment-to-moment focus problems there really are often. The interview itself can really only be done when someone's healthy enough to give you information that's good about the last week. And you really may need to defer the interview for when people are better. When someone's really stressed out or upset or in a depression, it may not be the time to do the full interview about ADHD.
I typically would prompt in the past week, how much effort is it taken and also are there any problems for the symptoms that we're interested in? Things like misplacing things, having to hunt for stuff, forgetting to bring things with you from one place to another, being sidetracked as you do tasks like I referred to before. And you're really just going through each of the inattentive items, asking them, Is this something that is happening frequently enough? And my last comment on this is, I want to know if I'm going to be able to interview this person during treatment and monitor symptoms. If I'm finding it hard just in the interview, then they could sell the ADHD, but I may not be able to make the diagnosis in a way that's going to help me track treatment.
Dr. Max Wiznitzer (16:07): How do you decide when to use self-report, third-party input, and neuropsychological testing in your assessment and evaluation of individuals with ADHD?
Dr. Craig Surman (16:18): It's always enriching to involve third-party information. And I typically would ask an individual before they come to see me to collect some third-party report on rating scales of ADHD symptoms. Things like the Adult ADHD Self-Report Scale (ASRS), which is available online; it's not diagnostic, but it goes through the criteria of symptoms. And you can get a sense if loved ones, people that knew them when they were little, are agreeing about the presentation.
Adults often don't remember early childhood very well. And if someone has access to old school reports, there's a Wender Utah rating scale, for example, which evaluates a lot of age symptoms that children can have. And some of those are ADHD symptoms as well. But you can get a picture of behavioral mental health problems that happened in childhood that may help you differentiate whether there's something else that's been happening pervasively their whole life, like a learning challenge or an emotional challenge or sleep problem, [and this information] can be very valuable.
I'm really interested, though, in doing evaluation in a way similar to the way I'm going to track treatment. So, doing these big investigations that involve third parties when they're not going to be available potentially to during the treatment plan, I find not to be as useful. But a spouse that's around often and can help us monitor treatment, I want their input at baseline as well because we're going to know if we've moved the needle when we start to do treatment.
Neuropsychological testing is really useful for helping understand against norms how people perform on tasks. It also, if behavioral symptoms are evaluated, can give us a picture of the same things that an extended interview can evaluate. You can ask someone lots of questions or you can have a neuropsychologist have them do inventories and ask them a lot of questions. But unless the evaluation goes through the behavioral criteria for ADHD, it's not going to be diagnostic for ADHD. And it's a very important point, because there really is no test for ADHD. There's no requirement that people perform poorly on a task. And we do see that some executive function and continuous performance-type attentional working memory tasks in some people with ADHD, or that show up on neuropsych testing. But there are many people with adult ADHD, they meet all the criteria and do very well.
There's sort of a “rising to the occasion” that can happen where it's a confined area. It's not real life that they're performing in and they may perform differently than they do out there in the world as well. So, the last thing I'd say, though, is that there's a lot of formal documentation that requires neuropsychological assessment. Some advanced professional licensure, for example, if you're going to do extra time to be able to check answers, you may need to give documentation about your brain function on neuropsychological testing.
Dr. Max Wiznitzer (19:08): Well, once we've made the diagnosis, intervention clearly is indicated for those who are symptomatic and the ADHD features are different with life on a daily basis. Stimulants are often considered to be first-line treatment for adults with ADHD. Why is that?
Dr. Craig Surman (19:25): They have the highest, what we call effect size, meaning they move the symptoms lowest compared to clinical trials that are done with nonstimulant medications. And in these trials that the FDA requires to approve medication in the United States, for example, you're comparing placebo to active treatment in people and seeing which one, how much of a difference there is between the two. But there's another piece here, which is that the way ADHD was defined, I think many people feel is probably influenced by what stimulants can do in part because clinicians were aware at the time of what stimulants do for people. And this is an important distinction, because what a drug can do for a brain is a different thing than our criteria for diagnosis. And there may be medications besides stimulants that are actually better for a particular presentation of ADHD.
Dr. Max Wiznitzer (20:17): So, what you're saying is, stimulants may have the biggest bang for your buck. There are circumstances in which other medication options may be as, or perhaps even more useful. So, what are our other options for treatment?
Dr. Craig Surman (20:28): So, the nonstimulants for ADHD, all like stimulants, affect our sympathetic nervous system in our brain. And they're increasing norepinephrine in particular. Stimulants increase norepinephrine and dopamine. And all these drugs are effectively bringing circuits of the brain more online that may help people compensate. I think of it as waking up the conductor conducting an unruly symphony, so to speak. Waking that conductor up can help the symphony operate as it's supposed to, to produce the piece. And the contraindications for stimulants often drive the choice of nonstimulants. Things like people who have stimulant use disorders, for example, who you're concerned have misused a stimulant prescription or are likely to. Certainly, giving a nonstimulant would be more appropriate. Interestingly, all the stimulants have some sympathomimetic effect and all the nonstimulants in some way do as well.
There's some that go different directions, meaning there's one that may--guanfacine ER that is, you know, more indicated for kids based upon research than adults—but there's some small studies in adults that may lower blood pressure, for example, and on stopping, produce rebound hypertension. Whereas other agents like atomoxetine or viloxazine, which are indicated in the US for adults, may increase blood pressure as stimulants do and increase heart rate like stimulants do when you're on them. So, people may think, there's no side effects or fewer side effects with nonstimulants, but there's actually different side effects of non--stimulants.
And so, the way I think about it is, if you need a lot of effect for moment-to-moment focus, lots of ADHD symptoms, you really can't beat the stimulant's effects. But even on a stimulant, people may have trouble following through on how to use their focus. And they may find they're doing what's in front of them, but not following their plans for the day or being frankly organized. And the nonstimulants may be an add-on. In cases where the size of effect you need is lower, the nonstimulants may have enough effect as well. And there's a lot more convenience to non-stimulants in that refills are possible, and we find that to be problematic for adherence often in folks with ADHD.
Dr. Max Wiznitzer (22:45): What are the common side effects that people might expect from these medications?
Dr. Craig Surman (22:50): So, changes that are physical and sensory like dry mouth, decreased appetite, muscle tension, changes in heart rate or blood pressure are common across all these medications. You do see effects on trouble falling asleep if stimulants are taken too late for a particular individual. Decreased appetite also can be common.
The nonstimulants, however, are a little more variable in their effect on sleep and effect on appetite. And you may see GI side effects, gastrointestinal-pattern things like nausea, in atomoxetine and viloxazine. And you may see sleep pattern differences or tiredness even on those medications, just to name some compare and contrast examples. But I would really encourage people to look at the package inserts for these agents and understand compared to placebo what to predict for people to be watching out for. There are black box warnings that are also important to pay attention to that can be managed with consultation or good evaluation.
Dr. Max Wiznitzer (23:52): Medication improves attention span, reduces impulsivity and hyperactivity, but medicine doesn't appear to basically do the tasks for you in terms of learning or doing your work or your relationships. So, beyond medicine, what non-pharmacologic treatments are evidence-based and useful for the adult population?
Dr. Craig Surman (24:12): So cognitive behavioral therapy is a way to reduce ADHD symptoms and also help people reduce overwhelm related to living with ADHD. And cognitive behavioral therapy has been demonstrated to help both an individual one-on-one work with a trained therapist going through a workbook, for example, or in a group setting. And we're beginning to learn whether or not apps on the phone, for example, that follow classic CBT for ADHD approaches may also be a sort of self-guided way that people can get some of these compensatory skills and reduce symptoms and impairment. There's really three elements to the CBT.
The important things are that people capture thoughts that are coming to their mind and try to allocate action on those thoughts to a specific time. This pattern’s not just behavior over the week and days, for example, but also patterns of thinking so that people may be more present. And what I mean by that is if I'm in middle of a meeting and a thought pops up, I should shop for something later online, you could write it down. And then over time, you may find that you are only thinking about it during your shopping time as opposed to during meetings.
Reminder systems and also breaking things down into steps and having a way of planning are also very core elements to CBT therapy. CBT therapy itself though, provides something that can be challenging to find outside of working with the therapist, which is structure. There's an accountability to working on these strategies with people. And I think that it's important to understand that cognitive behavioral therapy is effectively giving people homework to do. And it may be hard for people to do this homework unless their ADHD is treated with medication.
Dr. Max Wiznitzer (25:57): Are there any other options besides CBT and medication that would help with the management of ADHD?
Dr. Craig Surman (26:04): So, there's two broad themes I think here. One is how do people accommodate themselves by living an ADHD lifestyle? And the other piece is who's in that life with them? And what I mean by this is that, ADHD lifestyle is one that supports brain health, patterns of sleep, exercise, nutrition, just are going to happen hopefully fairly naturally. And there's choices people can make about how far they're commuting for jobs potentially, or where they're doing their work, or really agreements with spouses or other family members, people in their life that may make big differences about ability to refresh their brains and fit in things that are healthy for the brain.
Another thing that's important, I think, in terms of accommodation and living an ADHD lifestyle is tracking the impact of ADHD and planning for situations that you know are going to be hard based upon past experience. So, starting something new, moving, changing jobs, new relationship, there may be less muscle memory and routines that people are operating off of, and it may be useful to have more support during those times. And that support doesn't always have to come from working with a specialist or a therapist, it can come from peer support. And that's something that CHADD, which is sponsoring this podcast, has been doing for decades. And learning from other people what works for them can be a very valuable way to refresh strategies and keep at the game of living the ADHD lifestyle.
Dr. Max Wiznitzer (27:41): How do you structure, how do you build a clinical team to address the needs of an individual with ADHD? Who should be part of it?
Dr. Craig Surman (27:47): So, I break this down into for evaluation and for treatment. And from my perspective, I really want to have other individuals, professionals, do what they do best to support my patient. In disentangling, for example, is this ADHD or comorbidity? What's the priority between ADHD or other comorbidities? Are there other brain-based or systemic reasons?
And I mean things like sleep apnea or diabetes that are present that are reasons for the pattern of challenges a person has. And also, what's the safety of treatment in situations where people may have cardiovascular histories, personal or family, or have extreme patterns of mental health states like agitation, mania, psychosis. There may be very thoughtful conversations that have to happen between different providers.
The treatment outcome monitoring piece is so much easier when there's multiple parties involved. If someone has a therapist or primary care that you're in communication with as a prescriber, for example. It just can crowdsource perspective and information beyond the brief time that you may have with them. And this kind of collaboration doesn't just help you pick and choose your treatment plan appropriately. It also can reduce risk and help the individual find nonmedication, nonmedical supports that may actually reduce the amount of medication intervention you need to do.
Dr. Max Wiznitzer (29:24): How can clinicians encourage patients to actually build this team, to put it together?
Dr. Craig Surman (29:31): I think clinicians can encourage patients to take some of the self-monitoring of medication effects and self-monitoring of ADHD symptoms into their own hands in a way that makes their care team work for them better. And what I mean by that is some simple things like doing symptom tracking on a rating scale or getting a home blood pressure cuff to monitor the cardiovascular effects of medication.
But it may start even before that in the interaction with patients, even before they come in, that I ask patients to do things that help me facilitate collaborative care. And for example, getting released to speak with previous treatment providers has been very valuable, especially if someone's already on treatment, to understand why choices were made and what the clinical concerns were of the other provider. It's also really important just for continuity of maintaining or treatment approach to talk to current providers as well as prior providers. This I think is a bit of a lost art and getting those release forms and getting how to communicate with other people that are part of the treatment team at the beginning of care I think is pretty essential.
People tend to find that their follow through on cognitive behavioral therapy, for example, may be better if it's sequenced. So, if I ask a patient to get a cognitive behavioral therapist, but their ADHD is not treated, for example, that may be a poor choice. I may say, let's see if you can do some homework on your own first before we have you go and add a cognitive behavioral therapy or the formal provider. And, you know, I really think frequency of visits with the prescriber may be less if people have more visits with other providers that, again, people are interacting with. But it's not just asking individuals to seek therapists trained in behavioral therapy or consulting with medical specialists about other medical conditions that helps build a care team. Peer groups, loved ones, and frankly, people's self-exploration of their ADHD through self-help, may actually be part of the whole overall care plan. And as people find that they can get to stick with and finish things better, I really try to assign them some exploration of, How do other people manage their ADHD? What are the kinds of things that this opens up for you in your life now that you're treated?
Dr. Max Wiznitzer (32:10): We've talked about ADHD and interdiagnosis and intervention. What happens to those individuals where the ADHD is not adequately managed? What is the natural history of that condition? And how does it impact their existence?
Dr. Craig Surman (32:27): So, we know that ADHD exacerbates what other vulnerabilities an individual has. If someone has dyslexia, for example, then it's going to be that much harder for them to read because they both have attentional problems and dyslexia. If someone doesn't naturally take good care of themselves and align towards healthy eating patterns, sleep patterns, and exercise, then those things may be worse. It's hard to know what the particular risk factors are that predict this.
But we see higher rates of accidents as, for example, the highest sort of reason for morbidity or mortality. And this is things like car accidents or other injuries that lead to visits to emergency rooms tend to be higher as an individual with ADHD. And any comorbidity we've ever looked at, substance use disorders, mood disorders, anxiety disorders, you tend to see exacerbation. You see worse, more frequent, and more intense experiences of those.
And the last comment I'll make is that adherence to medical treatment can be harder for people with ADHD, following through on, for example, antihypertensive medication intervention that's being recommended. So, the impact is individual, but it could be anything that the person's vulnerable to not being on top of otherwise.
Dr. Max Wiznitzer (33:46): I thank you, Dr. Surman, for your informative and insightful comments and the information about adult ADHD. We appreciate that you shared your knowledge and your expertise with our audience. We hope to hear from you in the future. As you pointed out, you're just one of the many resources that we have at CHADD, which is a good place for people to go to when they want to get more information about ADHD in the future. This episode featured Dr. Craig Surman from Massachusetts General Hospital. I'm Dr. Max Wiznitzer, who along with Dr. Surman is a co-chair of CHADD's professional advisory board. And we thank you for being here today.
Announcer (34:30): Pocket MD is brought to you by CHADD with funding from the U.S. Centers for Disease Control and Prevention and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.