COMMENTARY

Diagnosing and Treating Adult ADHD: A Guide

Matthew A. Goldenberg, DO

Disclosures

February 01, 2016

In This Article

Evidence of Significant Clinical Impact

Physicians are in many cases high-functioning, "type A," and overachievers. Therefore, it can be difficult for us to differentiate true functional deficits and impairment caused by ADHD from poor organizational skills or low motivation.

Beyond our own subjective comfort level in diagnosing ADHD, the DSM-5 states that the ADHD symptoms must cause a significant clinical impact in order for a diagnosis to be made.[2] The challenge is that the clinical impact of ADHD is often difficult to objectively assess. Some true examples of significant negative impact include disciplinary action at work, risk for job loss, relationship discord, or frequent automobile accidents or accidents at home.[3]

I use these objective markers of the negative impact of the ADHD symptoms in two ways. First, I use them as benchmarks that will serve as objective measures for improvement as treatment progresses. This way, I can use both the previously mentioned symptom rating scale and these more objective measures (eg, report cards, work evaluations, improvement in relationships) when evaluating treatment progress and outcomes.

The second way I use these objective measures is to decrease risks and misdiagnosis. My addiction psychiatry fellowship training has taught me to be keenly aware of the inherent risks of prescribing stimulant medications, which can be abused and to which patients can develop addiction. Accordingly, these objective examples of the negative impact of their ADHD serve as confirmation of the accuracy of the diagnosis.

As previously noted, there is a high rate of co-occurring substance abuse in patients with ADHD. This does not mean ADHD should not be treated with stimulants. Conversely, it means that practitioners must be very careful to accurately diagnosis ADHD and all co-occurring diagnoses in order to effectively develop an individualized treatment plan and decrease the risk for stimulant abuse or diversion.

I should also note that it is important to include the patient's subjective experience of the significance of their ADHD symptom burden in your analysis. In my experience, most patients are very in tune with how much or how little their ADHD symptoms are affecting their ability to function. In other words, trust but verify.

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