Interface of Primary Care and Undiagnosed Adults Affected By ADHD

Blog by Roberta Waite EdD, MSN, RN and Meghan Leahy MS, NCC

Meghan Leahy, M.S. Leahy Learning

While many more primary care providers (PCPs), including advanced practice nurses, physicians, and physician assistants, are recognizing adult ADHD and acknowledging that it is more than a disorder of childhood, the recognition of ADHD in adults in primary care is still an area in need of improvement. Many PCPs report that they do not feel that they have adequate training on the topic, and that overall they feel that adult ADHD is not well understood by the medical community.

Roberta Waite, EdD Drexel University

Roberta Waite, EdD
Drexel University

Screenings for mental health conditions such as depression (using the PHQ-2/PHQ-9) and anxiety (using the GAD-7) among adult populations have increased in primary care settings. However, screening for adult ADHD remains relatively uncommon. Therefore, fundamental knowledge related to screening for adult ADHD within primary care is important.

Distinguishing the clinical presentation of ADHD among adults is different from affected children and adolescents. ADHD adults may present with more functional impulsivity, as well as prominent feelings of internal restlessness (versus running around or being disruptive). Many undiagnosed ADHD functioned well enough to get through primary and secondary school, but eventually hit a ceiling in terms of their ability to cope and adapt when their symptoms become more apparent.
Apart from the core symptoms, these untreated adults with ADHD are likely to struggle with implementing and completing tasks, poor time management, and distractibility, especially in academic or job-related activities. Interpersonal relationships may suffer from the difficulties, too. Moreover, untreated ADHD may also present with comorbid conditions, such as substance use disorder, mood instability, sleep disorders, and obesity. There are effective treatments for adult ADHD that have the potential to be cost effective in terms of the likelihood of improved functional outcomes and reducing costs to society.

This lack of understanding and, in turn, confidence, leads most PCPs to refer adults seeking an ADHD diagnosis to a psychiatrist or a psychologist. This begs the questions: what happens to patients who are suffering from adult ADHD but do not have the resources or understanding of their symptoms to seek specialty assessment and specialty care from adult ADHD experts?
Within ambulatory care settings, early detection is needed which can be mobilized by increasing knowledge about adult ADHD among PCPs and integrated BHCs. While there are a multitude of validated, brief screening and rating scales for suspected ADHD – the Adult ADHD Self-Report Scale (recently revised for DSM-5), ADHD Clinician Diagnostic Scale, Barkley Adult ADHD Rating Scale-IV, and the Conners’ Screening Scale to name a few – many PCPs may not be aware of them or have access to them. Of course, a screening scale is not sufficient to confirm a diagnosis of adult ADHD, but requires a more comprehensive evaluation.
Some primary care settings increasingly offer integrated services, more and more including licensed behavioral health clinicians, some of which with ADHD expertise; in other cases, a patient would need to be referred to a specialist in the area if they screened positive and could not be treated by the primary practice. Having a seamless connection with an on-site ADHD specialist would be ideal for both the patient and providers in terms of trust, convenience, and timeliness.

 

Take Away Points

  • Primary care providers include advanced practice nurses, physicians, and physician assistants and all are the frontline for patients’ physical and mental health.
  • As the concept of integrated health becomes more popular, more practices include LPCs, LCSWs, psychologists, advanced practice psychiatric nurses, and LMFTs to provide a team approach to treatment with licensed primary care providers (PCPs).
  • Screenings for depression and anxiety have increased, but PCPs report that the diagnosis and treatment of adult ADHD is still limited, mainly due to a lack of knowledge which in turn leads to diminished confidence in their ability to diagnose adult ADHD.
  • Adult ADHD remains under recognized, underdiagnosed, and undertreated compared to other disorders such as mood, anxiety, or substance use, which impedes the appropriate care and management for almost 5% of the population.
  • Undiagnosed and untreated ADHD can have a devastating impact on not only the affected individual, but their relationships with everyone around them – their partner, family, co-workers, friends – their professional careers, and their finances.
  • Early detection is key, especially for patients suffering from adult ADHD but lacking the resources or understanding to seek and secure an accurate assessment and effective treatment can be an obstacle.
  • While screenings and integrated services will improve outcomes, the best case scenario includes connecting with an on-site team member such as an integrated BHC with expertise in ADHD who evaluates the patient real time to provide treatment in a familiar environment with trusted professionals, thereby leading to the most successful rates of intervention and follow-up treatments.

Resources
Adler, L., Shaw, D., Sitt, D., Maya, E., & Morrill, M. (2009). Issues in the Diagnosis and Treatment of Adult ADHD by Primary Care Physicians. Primary Psychiatry, 16(5), 57-63. Retrieved from http://primarypsychiatry.com/issues-in-the-diagnosis-and-treatment-of-adult-adhd-by-primary-care-physicians/
Ginsberg, Y. Quintero, J., Anand, E., Casillas, M, & Upadhyaya, H. (2014) Underdiagnosis of ADHD in adult patients. A review of the literature, The Primary Care Companion for CNS Disorders, 16(3). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195639/
Hines, J., King, T., & Curry, W. The Adult ADHD Self-Report Scale for Screening for Adult Attention Deficit–Hyperactivity Disorder (ADHD). Journal f the American Board of Family Medicine, 25(6), 847-853. Retrieved from http://www.jabfm.org/content/25/6/847.long
Knutson, K. & O’Malley, (2010). Adult attention-deficit/hyperactivity disorder: A survey of diagnosis and treatment practices. Journal of the American Academy of Nurse Practitioners, 22(11), 593–601.
Waite, R., Vlam, R., Irrera-Newcomb, M., & Babock, T. (2013). The diagnosis less traveled: NPs’ role in recognizing adult ADHD. Journal of the American Association of Nurse Practitioners, 25, 302–308.

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