Is ADHD a valid diagnosis in older adults?
Surman C, Goodman DW. ADHD Atten Def Hyp Disord. Jan2017.
Surman C, Goodman DW. ADHD Atten Def Hyp Disord. Jan2017.
Young J, Goodman DW. Primary Care Companion CNS Disord. 2016,18(6)
Goodman DW, Adler LA. Medscape, September 2016. CME accredited
I was invited to assist with background information on ADHD in women and offered my insights on the gender differences when dealing with ADHD. I invite you to read the article and celebrate the increased attention to the gender differences of ADHD.
ADHD in women is now an ongoing topic of research and discussion since it has been recognized as occurring more often than previously realized. Those disruptive boys sure got the teachers attention but the quiet girls in the classroom were overlooked. Now, as adults, the women with ADHD find great difficulties and challenges in their lives. The negative consequences are problematic and constrict success in occupational pursuits and relationship satisfaction.
The Catherine Pearson of the Huffington Post picked up on the recent Canadian study of ADHD women and its report that “women with ADHD had triple the prevalence of insomnia, chronic pain, suicidal ideation, childhood sexual abuse and generalized anxiety disorder and double the prevalence of substance abuse, current smoking, depressive disorders, severe poverty and childhood physical abuse in comparison with women without ADHD”. This is direct quote from the results section of this study of over 100 ADHD women.
Therefore, when evaluating women with anxiety, depression, and substance abuse, please look for ADHD and vis a versa. Many clinicians will focus on the primary complaint of the patient without a more comprehensive evaluation of all possibly co-existing psychiatric disorders. Unless patients rise the consideration for ADHD, it is often overlooked. If, after reading articles on ADHD and identifying with these experiences your whole life, raise it with your doctor and/or therapist.
Our website has many professional articles and videos on ADHD to get you started.
I continue to thank those of you interested in my insights and advocacy for ADHD.
David W. Goodman, M.D.
Despite decades of articles on the science and research of ADHD, it never ceases to amaze me when I have a conversation with people who don’t believe in ADHD. While I understand concerns of “the label” and “bad medicine”, I have seen thousands of patients who, when treated for the first time in adulthood, say “If I had only known…” or “my parents didn’t believe in it when teachers raised the issue when I was a child”. Then there are the parents who apology to their adult child who gets treated for ADHD and functions at a higher level.
Myths of ADHD persist today despite overwhelming international research refuting non-believers. So, Reader’s Digest asked me to help develop an article looking at some myths that people continue to believe.
1. ADHD is not a real medical disorder.
2. There is no clear medical proof for ADHD.
3. If you weren’t diagnosed as a child, you can’t have ADHD as an adult.
4.”Bad parenting” produces ADHD in children.
5. ADHD just makes it hard to concentrate, it doesn’t cause serious problems.
6. ADHD is just an American disorder.
7. ADHD medications are toxic and turn kids into addicts.
8. People with ADHD are just lazy and disorganized.
I invite you to read the article and see how I offer medical research to answer these myths. As a famous astrophysicist likes to say, “Science exists whether you believe it or not.”
Since the recent publication of our literature of published research on ADHD in adults over age 50, several news outlets have been interested in bring this subject to the public eye. ADHD in adults persists throughout one’s life. It does not go away because you got your AARP card or Medicare benefits.
Because I believe in the importance of accurate diagnosis and effective treatment for ADHD regardless of age, I wrote an editorial piece that U.S. News and World Report published online on March 7, 2016. This article was picked up by several news (Yahoo News) and professional organizations (American Professional Society for ADHD and Related Disorders – an organization of international clinicians and researchers, and the National Resource Center-a CDC funded organization affiliated with Children and Adults with ADHD Association CHADD).
For most people with ADHD, it is a lifelong condition to be understood, appreciated, respected, and treated effectively. Quality of function and life are greatly effected regardless of your age. I always encourage people with lifelong symptoms of ADHD to get a competent evaluation and learn more about managing these symptoms to improve daily functioning.
It appears that the topic of ADHD in older adults is catching some attention. I was invited by Ann Fisher of WOSU Radio (NPR affiliate) in Columbia, Ohio to discuss adult ADHD especially in older adults. The host, Ann, asked insightful questions about identification and diagnosis in older adult and how that’s different from younger adults and children. We also covered treatment options including medication and cognitive behavioral therapy.
I am very excited that some media outlets have decided that ADHD in older adults is an opportunity to increase public awareness that “ADHD is not just for kids.”
I invite you the listen to the 20 minute interview. You can find it here. On the time scroll bar, move it to 14:40 minute mark to listen.
David W. Goodman, M.D.
Goodman DW, Mitchell S, Rhodewalt L, Surman CBH. Drugs and Aging. Dec 2015. p1-10.
Although previously considered a disorder of childhood, studies in the last decade have demonstrated that attention-deficit hyperactivity disorder (ADHD) continues to impair function into adulthood and responds to pharmacotherapy. Due to age-specific changes in roles and challenges, it is possible that presentation and response to intervention may differ between older and younger adults. A literature search for papers that identified older adults with ADHD, including papers describing its epidemiology, manifestation, and treatment, was the basis for this paper. There is a paucity of data on ADHD in older adults; however, small observational studies have characterized the presence, impact, and treatment of ADHD in adults over the age of 50 years, and larger epidemiologic studies have demonstrated that ADHD symptoms exist in older adulthood. Optimal criteria for diagnosis of ADHD and methods of treating ADHD in older individuals have not been systematically explored. In light of the limited data, this review discusses considerations for differential diagnosis and safe pharmacotherapy of ADHD in older adults.
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Vayarin is marketed as a “medical food” for the treatment of ADHD. Vayarin contains Phosphatidylserine 75 mg, Eicosapentaenoic acid (EPA) 21.5 mg, and Docosahexaenoic acid (DHA) 8.5 mg. These ingredients are omega3 fatty acids. The recommended dose is 4 pills daily.
The company sponsored a 15-week, double blind, placebo controlled trial followed by an open-label extension for additional 15 weeks in children ages 6-13 conducted in Israel. Two hundred children were randomized to receive either Vayarin or placebo and then 150 children continued in a 15-week open-label extension trial.
The bottom line: The primary measure to evaluate whether there was a statistically significant reduction in ADHD symptoms was teacher observations on 8 behavioral rating scales. The findings: No difference on any of the 8 scales.
The secondary measure was parent observations on the same 8 rating scales. There was only 1 positive finding out of 8: reduction in global: restless/impulsive scale. This is hardly an endorsement for effective outcome.
So, in their ads and presentations, how are they showing improvement?
After the company found no differences in the complete data set, they selected a subgroup of patients based on hyperactivity/impulsivity scores. This subgroup contains about half the number of subjects from the original 200 children. In this group, only 2 of 8 teacher ratings were positive (ADHD index and DSM-IV Hyperactive/Impulsive scales) and only 4 of 8 parent ratings were positive. While these findings may provide further guidance for later research, they cannot be accepted as demonstrating a positive effect because the data has been parsed to find a positive finding.
In the open-label extension, children on Vayarin remained on it while those children on placebo were changed to Vayarin. Open-label trials don’t generate high quality data because there is an expectation that “drug” is going to help. This is a bias similar to the placebo effect. Yet despite this potential bias, only 2 of 8 teacher ratings were positive and 5 of 8 parent ratings were positive. Well, we might expect that parents who know their children were changed to the “drug” would rate behaviors as improved. This is one of several possible interpretations of the data.
As my mentor used to say, “torture statistics long enough and they will confess to anything”. I have written this blog because I’m particular disturbed by the deliberate misuse of research data to mislead the public. Because the FDA does not directly regulate supplements and “medical foods”, there is limited oversight in the accurate presentation of “research” findings. When I last reviewed the literature on omega3 fatty acids for my book (2009), there were 5 placebo controlled studies of which 3 had not demonstrated reduction in ADHD symptoms. Negative studies are often not published so they can’t be considered in the totality of the research. When negative studies are published, they often receive little attention and are forgotten.
Why bother to post this blog? My goal for people with ADHD is to provide accurate medical information upon which to make treatment decisions. People side tracked by inaccurate claims spend money and time pursuing unnecessary and ineffective treatments to the profit of others. For those of you who follow my occasional blogs, you gain “behind the curtain” insights that allow you to make informed decisions about your care.
As always, thank you for your interest in my thoughts. Happy Holidays.
David W. Goodman, M.D.
Insurance companies and “health care coordinators” are increasingly insinuating themselves into the care of patients. While we are all accustom to generic substitutions as a cost saving measure, you may not be aware that a pharmacist of CareFirst is “working with primary care physicians” to review cost effective medication treatments when the cost of current medications are higher then insurance companies want to tolerate.
In my case, I received a call from Samantha, a pharmacist from CareFirst, to discuss my patients medications “to see if there were other options”. My patient is a woman in her early 50s with severe depressive episodes of crying repeatedly everyday, highly anxious, not leaving the house without a companion, and thoughts about her death (she is not terminally ill). We have been seeing each other for several years with periodic remission of symptoms lasting months. Nevertheless, she is on a complex regimen of psychiatric medications to achieve some level of relief, although not complete. Not working, she lives with her supportive husband, daughter and her husband.
When I called and spoke with Samantha, she suggested that I consider tapering and stopping her Latuda while increasing her seroquel. Interesting suggestion but what was the basis for the recommendation? Did she have information on the patient’s current symptoms? NO. Did she have information on the history of this woman’s depressions? NO. Did she know the level of suicide risk of this patient? NO. Did she know the history of psychiatric medication trials? NO. Did she know the side effects experienced by the patient with certain medications? NO. Did she know the patient’s medical conditions that effected psychiatric medication choices? NO. So what was the basis of her recommendation? “…for cost saving and optimizing treatment…” Here is the answer: Latuda is a costly medication as there is no generic, while seroquel is less costly in its generic form. Both drugs have FDA approval as additive agents to antidepressants for the treatment of depression.
I informed her that her recommendations without any clinical information about the patient had no relevance to me. And frankly, if I were to make and institute medical decisions without adequate clinical information, I’d be liable for malpractice. While it is appalling to me to see such “conversations” with physicians or any health care prescriber as standard operating procedure for insurance carriers, it is twice as infuriating to realize that patients have no idea how their care is being influenced.
So, the next time you see your doctor, ask them “Has my insurance company contacted you about changing my medications?” In the end, your physician has a far greater interest in your health than your insurance company.
I will continue to blog about ways in which insurance companies justify their procedures while patients suffer with suboptimal care and outcome.
David W. Goodman, M.D., FAPA