In medical school, many of us were taught that ADD and ADHD generally affected boys who would eventually outgrow the disorder. We now know better. Girls have ADD/ADHD. And many children never outgrow the disorder.
As a primary care clinician, you probably now see adults who-- as children-- were treated with amphetamines or methylphenidate for ADD/ADHD and who now want to resume treatment. These patients may attribute their perceived cognitive limitations as a manifestation of ADD. Other patients believe that undiagnosed ADD is to blame for their struggles in a number of areas.
In the context of a busy primary care practice, how can you efficiently determine whether a patient really has ADD and -- if he or she does-- develop a treatment plan?
The following questions can help you quickly establish a diagnosis.
1. Were you diagnosed with ADD/ADHD as a child or adolescent?
If the answer is yes, ask:
2. At what age during childhood was ADD diagnosed?
3. What behaviors or symptoms led to that diagnosis?
4. Who made the diagnosis and what was his/her training?
5. What was the treatment and what, if any, medications were used?
6. What, if any, symptoms or behaviors were altered by therapy?
7. How long did you continue treatment?
8. Why was treatment terminated?
9. What behaviors or symptoms lead you to believe that you have ADD/ADHD now?
10. What medications are you currently taking? (Get precise information here: the patient could be overdosing on a medication and creating symptoms as a result.)
11. Are you using an illicit drug? (Illicit drugs can create symptoms of ADD.)
Tip: If a patient does not give a childhood history that supports an ADD diagnosis, then it is less likely that he or she has ADD. However, a careful past and current history of potential ADD symptomatic behaviors must be elicited to definitively rule out ADD. It is possible that the diagnosis was missed when the patient was a child. Be sure to assess the duration of the symptomatic behaviors and the reasons why the patient feels they are issues now. Many disorders can lead to difficulties in concentration and functioning. In some of these disorders, the use of stimulants will exacerbate the symptoms.
Before making a definitive diagnosis of ADD/ADHD, ask yourself:
1. Are there other possible diagnoses that could account for the reported behavior?
2. Are there signs of another psychiatric or medical disorder?
Keep in mind that ADD can coexist with bipolar disorder or any other psychiatric disorder. ADD may also mimic symptoms or behaviors of other psychiatric disorders. A number of medical disorders may need to be considered; for example, hyperthyroidism can cause difficulty in concentration.
Patients with ADD and a comorbid psychiatric disorder are best referred to a psychiatrist for ongoing treatment. (Stimulants may trigger a manic episode in bipolar patients.) Any medical disorder that could mimic or exacerbate ADD should be treated before the patient is given any medications for ADD.
When you are certain that the patient has ADD without any comorbid disorder, you can develop a treatment plan. First, work with the patient to clarify the behaviors that he or she wants to change. Then see if any life-style measures could address the behaviors.
If- - after a careful review with the patient - - you both believe that medication is essential, you can review the various drug options. North Short Long-Island Jewish Health System has an ADHD Medication Guide that provides information on currently used drug options.
Some would start with a long acting-medication, such as Adderall XR 30 mg, and then titrate the dose. Others would use short acting drugs, such as Ritalin, 20 mg. Short-acting medications are usually less expensive, but the patient may need multiple daily doses.
There is no optimal way to select the right medication. Knowledge of the patient’s routine daily activities is critical in scheduling dosing. It is important not to overdose the patient and to know how long each medication exerts its effect. Patients who work at night will need medication with effects that last into the evening. But be careful that the medication you prescribe doesn’t interrupt sleep.
Finally, review with your patient the pluses and minuses of the medication approach you select. Also review medication side effects. Make it clear that the medication will not adversely affect any other medical problems the patient might have.