Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that impairs focus, attention, and behavioral control. ADHD hinders and compromises major life activities. Initially considered exclusively a disorder afflicting children and adolescents, it is now widely accepted that ADHD continues into adulthood, impacting the lives of those plagued by this impairment and disability. Furthermore, ADHD symptoms may fluctuate over the lifespan of an individual who struggles with a myriad of incapacitating symptoms.
The diagnosis of ADHD has been thrust into the news over the last few years. The Food and Drug Administration (FDA) begrudgingly declared a shortage in the availability of stimulant treatments. The Drug Enforcement Agency (DEA) intentionally and unwisely reduced the quotas for the production of stimulants (controlled substances) used to treat ADHD. The United States Department of Justice (DOJ) engaged in a frenzy of unjust criminal enforcement actions against companies and physicians treating individuals with ADHD. The National Institutes of Health (NIH) has mysteriously delegated public discussions about ADHD to officials and scientists from the National Institute of Drug Abuse (NIDA) instead of clinicians and researchers from the National Institute of Mental Health (NIMH).
ADHD is among the most prevalent mental disorders in the United States, affecting 2.5 to 4 percent of US adults. Newer data from the Centers for Disease Control (CDC) suggest the prevalence could be as high as 7 to 10 percent of adults being afflicted with ADHD. Over the past five years, there has been a spike in the treatment of ADHD in adults. The COVID-19 pandemic contributed to this spike due to the significant increase in attentional demands. Such increases in the identification of ADHD and the demand for treatment have created concerns about triggering a stimulant use disorder crisis. The DOJ rushed into this public health crisis with criminal enforcement actions that frightened mental health systems, clinicians, and patients seeking psychiatric treatment for ADHD.
The medical model of ADHD, well known to pediatricians and child psychiatrists, relies on three core symptoms and associated features: the predominant attentional disturbance (mostly evident in girls with ADHD, referred to as “space cadets”), the hyperactivity component most evident in boys with ADHD (“ants in pants,” “like a motor”), and the impulse control difficulties that persist into adulthood. Additionally, a social model component for ADHD includes features that are less familiar to physicians. The social model describes several other issues that affect adults with attention deficit disorder, providing an understanding of how their minds work and why they struggle with certain issues such as rejection sensitivity dysphoria (emotional dysregulation in response to criticism), masking (struggling to act in socially acceptable ways to fit in), stimming (self-stimulatory behavior, e.g., doodling, hand-wringing), and problems with executive dysfunction. Losing objects in adulthood is one of the main signs that patients are rarely questioned about, signaling executive dysfunction. The morbidity and mortality associated with ADHD mostly impact adults, as ADHD adults are more likely to be involved in accidents causing injuries. There is a high association between untreated ADHD and fatal motor vehicle accidents.
ADHD treatment encompasses a combination of medications (stimulants and non-stimulants), therapy, and other interventions. Medications can help with focus, attention, and behavioral control, while therapy, including cognitive behavioral therapy and other interventions, can facilitate coping with other ADHD features such as rejection sensitivity dysphoria. Exercise, spending time in nature, and organizational strategies can be learned coping skills to lessen the severity of ADHD symptoms. Several software solutions, such as video games, have gained FDA approval or are in the process of approval to alleviate problems with attention and behavioral dyscontrol in individuals with ADHD.
Physicians feel uncomfortable with the diagnosis of ADHD in adults due to the lack of U.S.-published treatment and diagnosis guidelines for adults. Nonetheless, untreated ADHD is associated with multiple adverse outcomes, including increased mortality (accidental injuries, completed suicide). Patients fear being stigmatized and seen as drug-seeking, which increases barriers to treatment. In this melee of human suffering among adults with ADHD, there is tremendous discomfort from the physician community. Physicians fear facing a fate similar to those prosecuted for treating pain with opioids. Patients feel stigmatized and ostracized, and health care administrators and policymakers are asleep at the wheel. However, there may ultimately be efforts to optimize ADHD treatment access despite significant risks to individual patients.
There is a very small body of literature on the long-term efficacy of stimulant medications for the treatment of ADHD. The same applies to non-stimulant medications for ADHD. There is very limited guidance on what constitutes an adequate trial of ADHD treatment, how long to maintain treatments before evaluating or stopping, and how to choose between different treatments, such as stimulants and non-stimulants. System-level data from health insurers and the government could help guide treatment. Nonetheless, the DEA has rushed into using these databases not to benefit patients and the community, but to institute criminal prosecution and enforcement actions against physicians, companies, and pharmaceutical manufacturers.
Government regulators and the DOJ present the view that their efforts to curb the use of stimulant medications for ADHD are rooted in their attempt to decrease the risk of diversion and stimulant use disorder. This effort is presented akin to antibiotic stewardship to prevent the development of community resistance. Nonetheless, these efforts are misguided and deprive patients of treatments that would reduce morbidity and mortality related to ADHD. There is significant tension between the regulatory pressures on treating adults with ADHD and the use of stimulant medication, which is perceived as addictive. This is despite the fact that ADHD causes significant psychiatric and medical comorbidities with increased mortality and a significant individual, societal, and financial burden costing close to $200 billion yearly.
A scientific, collaborative approach between clinicians, patients, and health systems, free from undue legal interference from the DOJ and the DEA, could significantly improve the treatment of ADHD and minimize the risk of diversion and stimulant use disorder.
This article is discussed on The Podcast by KevinMD: Why ADHD diagnosis in adults is often overlooked.
This essay is cited in the KevinMD record on mental health.
Muhamad Aly Rifai is a practicing internist and psychiatrist in the Greater Lehigh Valley, Pennsylvania. He is the CEO, chief psychiatrist and internist of Blue Mountain Psychiatry. He holds the Lehigh Valley Endowed Chair of Addiction Medicine. Dr. Rifai is board-certified in internal medicine, psychiatry, addiction medicine, and psychosomatic medicine. He is a fellow of the American College of Physicians, the Academy of Psychosomatic Medicine, and the American Psychiatric Association. He is the former president of the Lehigh Valley Psychiatric Society.
He can be reached on LinkedIn, Facebook, X @muhamadalyrifai, YouTube, and his website. You can also read his Wikipedia entry and publications.
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