In this month’s edition of Medication Talk, we are talking with Dr. David Cooperman about ADHD in adults.
ADHD is usually diagnosed in childhood. Is it something that can be missed and only first diagnosed as an adult? Can you develop it later in life, or would people with an adult diagnosis have had it for their whole life and only just noticed it now?
ADHD used to be known as a childhood disorder that clinicians previously thought that people grew out of as they got older. ADHD is now known to persist throughout the lifespan. ADHD symptoms are often primarily associated with childhood hyperactivity, however many people do not exhibit these symptoms. Children can be inattentive but not have behavioral problems and may not be receive a diagnosis until adulthood.
How can you explain someone who has been successful in school and work before suddenly getting diagnosed with ADHD as an adult?
There are a number of people who develop compensatory strategies that enable them to be successful despite having untreated ADHD. Symptoms of ADHD differ across developmental stages, so ADHD symptoms can appear quite different from childhood to adulthood.
Most people have been inattentive or have procrastinated throughout their lives, so the symptoms of ADHD can often go unnoticed. There are also overlapping symptoms with other disorders and there can be a tendency to misattribute ADHD symptoms by only focusing on anxiety, depression, and or substance use. It is critical to remember that comorbidity is the norm with ADHD, so often times there may be partial treatment for symptoms but treatment may be incomplete until the person is diagnosed and treated for underlying attentional issues.
For example, an adult with ADHD may have a history of frequent career switching, losing or quitting jobs, career underachievement, may have deficits with executive functioning e.g. organizing, paying bills, relationship problems due to disorganization or not completing tasks etc. There may be a history of projects that are uncompleted or they may be inconsistent.
Some people are able to function well in highly structured settings or have had significant support or protection from family members or a spouse which can mask the symptoms of ADHD. The person with ADHD usually has no frame of reference, as this is the way that they have always been, so this can complicate when the person is seen for treatment.
What medications are recommended for ADHD? What’s the difference between medications like Focalin, Strattera, Ritalin, and Vyvanse? How do you decide which one to prescribe?
Stimulant medications remain the first line treatment for ADHD. These medicines include either a methylphenidate (Ritalin) preparation or a dextroamphetamine (Adderall, Vyvanse etc). Medication choice is often based around the time frame needed for duration of action, as well as tolerability. Roughly 30% of people will respond to one preparation over another, so this is often achieved through trial and error.
When it comes to medications for ADHD and people who have abused substances in the past, what medications are best? Can someone who has struggled with substance abuse ever take a stimulant medication?
It is possible for someone who has previously struggled with substance abuse to take a stimulant medication. Stimulants can have a paradoxical effect on an individual, which may make them less impulsive, which may be a core feature of their substance abuse issues. Careful monitoring, understanding the risks and benefits, and choosing less abusable stimulant preparations such as Vyvanse, may result in successful treatment outcomes.
What are the top non-medication strategies you recommend for someone who is trying to cope with ADHD?
As medication management is one part of ADHD treatment, it is critical to make a full assessment as non-pharmacological treatments are not one size fits all. Targeting executive dysfunction, improving organization, decreasing clutter, improving time management skills, delegating tasks, and capitalizing on strengths are some of the strategies that can prove effective. Providing psycho-education is critical for a person to understand how their ADHD manifests so that symptoms can be thoroughly targeted and managed.