Editorials

ADHD in Adults: A Commentary

STEVEN R. PLISZKA, M.D.
University of Texas Health Science Center,
San Antonio, Texas

See article on page 2077.

In this issue, Searight and colleagues¹ focus on an area of growing importance to primary care practitioners: the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in adults. This disorder was once considered a childhood condition with few adult consequences, but it is now clear that a significant number of children with ADHD continue to have difficulties that persist into adolescence and adulthood. By the time patients with ADHD are in their mid-20s, follow-up studies show that the prevalence of continuing ADHD ranges from 4 percent¹ to 80 percent.² If a child has ADHD with no other psychiatric diagnoses (particularly conduct disorder or severe affective disorder) and no comorbid learning disabilities, the prognosis is likely to be benign. Conversely, if complicating psychiatric factors are present in addition to ADHD, the prognosis is more guarded and the patient stands a greater chance of having adult ADHD, substance abuse and personality disorder.

ADHD that persists into late adolescence and young adulthood is associated with a number of health risks. While driving, teenagers with ADHD have significantly more crashes, speeding tickets and license suspensions.³ Children with ADHD are more likely than their peers to smoke cigarettes; adults with ADHD more often smoke than those in control groups and report having significantly more difficulty quitting smoking.^4,5 Adults with ADHD have higher lifetime rates of psychoactive substance abuse disorders than control subjects.⁶

It is important to note that stimulant treatment of ADHD in childhood does not predispose patients to become substance abusers; indeed, the opposite is true. In a long-term follow-up study, Biederman and colleagues⁷ compared 117 teenagers with ADHD who had been treated with medication with 45 children with untreated ADHD and 344 control subjects. In adulthood, the rate of substance abuse disorders did not differ between the medication-treated ADHD group (13 percent) and the control group (10 percent), but it was significantly higher in the untreated ADHD group (33 percent). This was a statistically significant difference that persisted even after controlling for poverty, family history of substance abuse and conduct disorder.

Early treatment of childhood ADHD may play a role in protecting against the development of substance abuse disorders in this vulnerable population. It is possible that continuing treatment of adult ADHD may be imperative in preventing a range of dire health consequences.

The authors discuss the process of diagnosing adult ADHD, with particular emphasis on two critical factors: documenting childhood onset and examining for other psychiatric disorders. The first step is particularly important, as a diagnosis of adult ADHD cannot be made in its absence. As the authors point out, obtaining a history from the patient's parents or examining old school or medical records is critical. Occasionally, a patient who presents with a history of very good early school performance is now having problems in higher education or on the job. Such a patient may claim that superior intelligence compensated for ADHD when he or she was younger, but that he or she is now symptomatic because of the higher cognitive demands of the current environment. A family physician should refer such a patient for in-depth testing before beginning treatment.

Depression and anxiety disorders frequently impair concentration in adults and constitute the principal disorders in the differential diagnosis. Major depression typically is pervasive in the patient's life and is associated with neurovegetative signs (sleep, appetite and energy loss), as well as suicidal ideation or guilt. Patients with ADHD, in contrast, often have brief periods of irritability, frustration with life and poor temper control.

The authors discuss the wide range of psychopharmacologic interventions available for adults with ADHD. As with children, stimulants are the first-line treatment in adults, except when the ADHD patient has an active substance abuse problem. The physician should treat the patient with stimulants (i.e., amphetamine mixed salts [Adderall], dextroamphetamine [Dexedrine], methylphenidate [Ritalin]) before trying the nonstimulants (i.e., tricyclic antidepressants, bupropion [Wellbutrin]). Adults with ADHD may also benefit from cognitive behavior therapy, provided it focuses on developing higher level organization skills. Spouses may benefit from therapy that suggests what they can do to help organize their distracted partner.

Research into the neurobiology of ADHD is progressing steadily and may lead to improved treatment of this problematic condition. These authors have done a good job of concisely reviewing a complex area in which family physicians will play an expanding role.

REFERENCES

1. Searight HR, Burke JM, Rottnek F. Adult attention deficit hyperactivity disorder (ADHD): evaluation and treatment in family medicine. Am Fam Physician 2000;62:2077-86,2091-2.
2. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult psychiatric status of hyperactive boys grown up. Am J Psychiatry 1998;155:493-8.
3. Barkley RA, Guevremont DC, Anastopoulos AD, DuPaul GJ, Shelton TL. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey. Pediatrics 1993;92:212-8.
4. Pomerleau OF, Downey KK, Stelson FW, Pomerleau CS. Cigarette smoking in adult patients diagnosed with attention deficit hyperactivity disorder. J Subst Abuse 1995;7:373-8.
5. Milberger S, Biederman J, Faraone SV, Chen L, Jones J. ADHD is associated with early initiation of cigarette smoking in children and adolescents.
   J Am Acad Child Adolesc Psychiatry 1997;36:37-44.
6. Biederman J, Wilens T, Mick E, Milberger S, Spencer TJ, Faraone SV. Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. Am J Psychiatry 1995;152: 1652-8.
7. Biederman J, Wilens T, Mick E, Spencer T, Faraone SV. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104:e20.

Steven R. Pliszka, M.D., is an associate professor and chief of child and adolescent psychiatry at the University of Texas Health Science Center, San Antonio.

Address correspondence to Steven R. Pliszka, M.D., Division of Child and Adolescent Psychiatry, University of Texas Health Science Center, 7703 Floyd Curl Dr., Mail Code 7792, San Antonio, TX 78229-3900.

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Relationships and Routines in Preventive Service Delivery

KURT C. STANGE, M.D., PH.D.
Case Western Reserve University
School of Medicine
Cleveland, Ohio

See Policy Center One-Pager on page 1968.

The "Policy Center One-Pager" published in this issue¹ contains take-home lessons for family physicians and challenges for policy makers. The study cited in the report found that children and adults with a usual source of care were more likely to have received preventive services, compared with patients who do not have a usual source of care. In addition, adults seeing an internist were more likely to receive these services than adults seeing a family physician. There are a number of potential reasons for these differences, but two implications of the findings are particularly worth considering.

First, the data appear to validate the importance of developing a relationship with a generalist clinician to obtain preventive services. Specific aspects of the relationship affect the delivery of different types of services.^2-4 If the context of a physician-patient relationship is vital for delivery of relatively routine preventive services, it is even more important for care of chronic illnesses, recognition of mental health problems and guiding access to appropriate subspecialty care.^5,6 However, the relationship context for the commodities of health care is being disrupted in the current health care environment, with detrimental consequences to the quality of patients' care.^7,8 In addition, for the more than 44 million Americans who do not have access to regular medical care because of a lack of insurance, ongoing health care relationships are scarce and preventive care remains a largely unmet need.^9,10

The services listed in the "One-Pager,"¹ with the exception of prostate cancer screening and perhaps the general medical examination, are well-supported by scientific evidence and are generally well-accepted by patients.¹¹ Therefore, regardless of the difficulties in maintaining ongoing patient-physician relationships, these services should be routinely available to all people. Yet, because of the competing demands and opportunities to meet a broad array of patient needs in family practice,¹² physicians often have little time left for prevention after other needs are met.¹³

Involving nurses and office staff in systems for identifying patients eligible for these routine services and delivering services is effective.¹⁴ Outreach to patients who do not visit the office routinely is another important strategy and is a potentially valuable role for managed care organizations.¹⁵ Developing systems and team approaches can free up physicians to selectively deliver more intensive preventive services to high-risk patients or to take advantage of teachable moments that are linked to risk factors and illness presentations.^3,16 The higher rates of preventive service delivery by internists are a reminder of the need to ensure routine delivery of important services that don't make it onto the agenda of the broad and more time-limited family practice visit.

All Americans deserve a relationship with a primary care physician. We need to design a health care system that fosters this relationship. We also need to design our practices so that the aspects of care that particularly benefit from a relationship are facilitated by well-established routines.

REFERENCES

1. The importance of primary care physicians as the usual source of healthcare in the achievement of prevention goals. Robert Graham Center: Policy Studies in Family Practice and Primary Care. Am Fam Physician 2000;62:1968.
2. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with the delivery of clinical preventive services. Med Care 1998; 36(suppl 8):AS21-30.
3. Flocke SA, Stange KC, Goodwin MA. Patient and visit characteristics associated with opportunistic preventive services delivery. J Fam Pract 1998;47 (3):202-2.
4. Medalie JH, Zyzanski SJ, Goodwin MA, Stange KC. Two physician styles of focusing on the family: their relationship to patient outcomes and process of care. J Fam Pract 2000;49(3):209-15.
5. Franks P, Clancy CM, Nutting PA. Gatekeeping revisited--protecting patients from overtreatment. N Engl J Med 1992;327:424-9.
6. Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract 1998;46(5):363-8.
7. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract 1997;45(2): 129-135.
8. Kahana E, Stange KC, Meehan R, Raff L. Forced disruption in continuity of primary care: the patients' perspective. Sociological Focus 1997;30: 177-87.
9. Woolhandler S, Himmelstein DU. Reverse targeting of preventive care due to lack of health insurance. JAMA 1988;259:2872-4.
10. Himmelstein DU, Woolhandler S. Care denied: U.S. residents who are unable to obtain needed medical services. Am J Public Health 1995;85:341-4.
11. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
12. Jaén CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38(2):166-71.
13. Kottke TE, Brekke ML, Solberg LI. Making "time" for preventive services. Mayo Clin Proc 1993; 68:785-91.
14. Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. BMJ 1992;304:687-91.
15. Thompson RS, Taplin SH, McAfee TA, Mandelson MT, Smith AE. Primary and secondary prevention services in clinical practice. Twenty years' experience in development, implementation, and evaluation. JAMA 1995;273:1130-5.
16. Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive services delivery: Are time limitations and patient satisfaction barriers? J Fam Pract 1998;46(5):419-24.

Kurt C. Stange, M.D., Ph.D., is professor of family medicine, epidemiology and biostatics, oncology and sociology at Case Western Reserve University School of Medicine in Cleveland, Ohio, and is the associate director for Prevention, Control and Population Research at the Ireland Comprehensive Cancer Center at CWRU and University Hospitals.

Address correspondence to Kurt C. Stange, M.D., Ph.D., Dept. of Family Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106.

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