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Advances in the Management of ADHD in Adult Population - Episode 1

Attention-Deficit/Hyperactivity Disorders in Pediatric and Adult Populations

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Drs Cerulli, Feld, Cutler, Mao, and Amann discuss prevalence and presentation of ADHD in pediatric, adolescent and adult populations.

Theresa Cerulli, MD: Hello, and welcome to this HCPLive® Peer Exchange® titled “Advances in the Management of ADHD in Adult Population.” I’m Dr Theresa Cerulli, a neuropsychiatrist at Beth Israel Deaconess Medical Center in Boston. My group practice, Cerulli & Associates in North Andover, Massachusetts, specializes in treating children, adolescents, and adults with ADHD [attention-deficit/hyperactivity disorder] for over 20 years.

Theresa R. Cerulli, MD: Joining me for this discussion are 4 of my colleagues and friends. Would each of you introduce yourselves? Let’s start with Dr Amann.

Birgit H. Amann, MD, PLLC: Hello, my name is Dr Birgit Amann. I am a child, adolescent, and adult psychiatrist. I have a private practice, the Behavioral Medical Center in Troy, Michigan, and we have physicians, nurse practitioners, and therapists. We see many patients with complex comorbid ADHD and I’m very excited to be here. Thank you.

Theresa R. Cerulli, MD: Thanks, Birgit. Dr Cutler?

Andrew Cutler, MD: Hi, I’m Dr Andy Cutler. I’m a clinical associate professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, as well as the chief medical officer of the Neuroscience Education Institute in Carlsbad, California. I’m based in Lakewood Ranch, Florida. I’ve been treating and studying ADHD and doing research for over 20 years in patients of all ages. I’m also thrilled to be here with people I like and respect so much.

Theresa R. Cerulli, MD: Thanks, Andy. Dr Mao, welcome.

Alice Mao, MD: Hello, my name is Alice Mao. I’m a professor of psychiatry from Baylor College of Medicine in Houston, Texas. In my academic teaching clinic, I work with children and adolescents with autism and comorbid conditions such as ADHD, anxiety disorders, and mood disorders. In my private practice, I’ve had the privilege of treating children, adolescents, and adults with ADHD, watching them grow up to lead very productive lives. It’s a pleasure to be here with my colleagues. I’m very excited to be talking about new ADHD advances.

Theresa R. Cerulli, MD: And Dr Feld.

Michael Feld, MD: I’m Mike Feld. I’m a child, adolescent, and adult psychiatrist in the Chicago, Illinois area. I have a private practice that I do a lot of psychotherapy in but also a lot of psychopharmacology. I work a lot with ADHD as a child and adolescent psychiatrist. In adults, we treat a lot of patients with ADHD with complicated comorbidities. I also work a lot with exercise, nutrition, light exposure, parenting, and other executive function issues. In addition, I consult at a few residential facilities and community mental health agencies in the Chicago area. Like everyone else, I’m truly honored to be part of this panel.

Theresa R. Cerulli, MD: Thank you everyone for being here, and thanks to the audience listening. We’re going to discuss the management of ADHD in pediatric and adult patient populations and the factors guiding treatment selection in younger and older patients. We’ll also discuss the changing treatment landscapes of ADHD and how emerging data are likely to influence the treatment of ADHD.

Theresa R. Cerulli, MD: Let’s get started with the first segment, ADHD in pediatric and adult populations. We’ll start by discussing ADHD and its prevalence in children, adolescents, and adults. Andy, what percentage of children diagnosed with ADHD during childhood will also have ADHD in adulthood?

Andrew Cutler, MD: That’s a great question. First, I quickly want to say for our audience that ADHD classically has been defined as 2 clusters of symptoms: inattention and hyperactivity or impulsivity. As we all know, there are lots of other associated features. That can play into how hard it is to recognize sometimes. Classically, we’ve been told that the prevalence is approximately 10% in children and that it seems to wane over time, which is a little unusual.

When I trained, we were taught that there was no such thing as adult ADHD, that this was exclusively a childhood disorder and that somehow you magically grow out of it. That doesn’t make sense. More recent estimates are that it persists from childhood into adulthood about 50% to 60% of the time. But that was based on point prevalence estimates—in other words, looking at 1 point in time. More recent research has been by Maggie Sibley and colleagues. As a matter of fact, there was a landmark article published this year in the Green Journal, the American Journal of Psychiatry. When you follow adults over time, over several years, you find is that 90% of these children have persistent ADHD into adulthood. But for the majority of them, it’s a fluctuating course, a waxing and waning course. It seems to be related to stressors and environmental events in their life. People may be able to compensate for a period of time until things change, and the stressors come on. I’d love to hear what my colleagues think, but accurately fits what I see clinically.

Theresa R. Cerulli, MD: I agree, Andy. That’s so true. Part of the reason we thought kids grew out of their ADHD is that it sometimes presents so differently in adulthood from how it presents in kids. I don’t know. Birgit, do you want to weigh in on that? How would you say the presentation of adult ADHD differs from pediatric or adolescent ADHD?

Birgit H. Amann, MD, PLLC: Theresa, if I think about how a child or adolescent presents, most commonly teachers are driving that evaluation. They’re letting Mom or Dad know that this child is not focusing, or they’re impulsive, or they’re fidgety, or they’re disruptive and certainly not meeting their academic potential. As I reflect on the adults who come in, 1 of the most common ways is that that’s the parent of that child or adolescent reflecting on what they’re hearing about their kid and then saying, “This sounds like how it was for me back then, but I can identify with a lot of this even as an adult.” That’s a common presentation.

Another 1 that comes up all the time is the adult who’s never been considered for a diagnosis of ADHD. If you listen to their story, they talk about, “I’ve had a very difficult time in my various jobs over the years. I’ve had a terrible time with relationships.” That tells a sad story, frankly. What they share is that they’ve been diagnosed with depression over and over. They’ve been on all sorts of antidepressants. Some of them work a little, most of them don’t work much. At the end of the day, my job is to come back full circle and say, “Maybe part of the problem is that no one is ever considered ADHD for you.” Those 2 presentations come up commonly in my practice. I don’t know if my colleagues have had similar experiences.

Andrew Cutler, MD: Yes, Birgit. I agree. I like to say that kids usually present with ADHD. It’s pretty obvious that’s what’s going on. But adults very often present with a comorbidity—depression, anxiety, substance abuse—and we discover the ADHD later. I’d also add to your presentation. The third 1 that I see is someone who was diagnosed as a kid took methylphenidate or something for a while and has been off it. He says, “Now, I realize I need to be back on it.”

Transcript Edited for Clarity