Presentations Of ADHD

Although ADHD is often associated with children, this disorder is diagnosed in clients across the lifespan. While many individuals are properly diagnosed and treated during childhood, some individuals who have ADHD only present with subsyndromal evidence of the disorder. These individuals are often undiagnosed until they reach adulthood and struggle to cope with competing demands of running a household, caring for children, and maintaining employment. For this Discussion, you consider how you might assess and treat individuals presenting with ADHD.



The Case: The scatter-brained mother whose daughter has ADHD, like mother, like daughter

The Question: How often does ADHD run in families?

The Dilemma: When you see a child with ADHD should you also evaluate the parents and siblings?

Pretest Self Assessment Question (answer at the end of the case)

Patients with comorbid ADHD and anxiety should in general not be prescribed stimulants

A. True B. False

Patient Intake • 26-year-old woman • Has a daughter with ADHD • Psychiatrist noted symptoms in the mother and suggested she come

in for her own evaluation • See the previous Case 13, p 133 for presentation of the daughter’s


Psychiatric History • During interviews with the patient’s daughter (also attended by the

patient) over the past several months, it was not only noted that the daughter has ADHD with comorbid ODD, but that the mother also exhibited multiple symptoms consistent with lifelong and undiagnosed ADHD including

– Mother misses appointments or is late for appointments – Often appears disorganized – Did not fi ll out her child’s forms on time – Did not deliver forms to her child’s teacher, forgot, lost them – Admits being very disorganized since her second child started

school – Feels overwhelmed by two children and her life circumstances – Could also have some signs of depression – Can’t get organized to take her child to CBT – Has a hard time keeping a regular schedule and also keeping her

daughter on a regular schedule of going to bed and waking up – Was unable to remember to remove the daughter’s skin patch

unless she set a cell phone alarm – All these suggest further evaluation of the mother is indicated

since ADHD commonly runs in families and has a very high genetic contribution

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• Has always done poorly academically • Has always felt intimidated by any type of testing • In addition, reports that she has always been worried about the future

and fi nancial stability of her family • Says she sometimes mentally “freezes when it gets to be too much” • When her eight year old daughter was diagnosed with ADHD, she

suddenly realized that she had similar problems as a child • The psychiatrist explained to her that ADHD was highly heritable and

that there was a 75% chance of having a child with ADHD if both parents have ADHD and thus was asked to fi ll out an Adult ADHD screening form

Social and Personal History • High school drop out, age 17 after getting pregnant • Married age 17, divorced 2 years later • Two children, ages 8 and 6 • Smoker • No drug or alcohol abuse • Single mother works full time in retail • Father not much involved with his children

Medical History • None notable • BP normal • BMI normal • Normal lab tests

Family History • 8-year-old daughter: recently diagnosed with ADHD • Other family history unknown as the patient was adopted • See the previous Case 13, p 133 for presentation of the daughter’s


Patient Intake • The last time the patient brought her child to see the psychiatrist, the

mother was asked to fi ll out her own checklist, the Adult ADHD Self Report Scale Symptom Checklist

– She endorsed many items, mostly inattentive but not really hyperactive or impulsive such as:

– Having trouble wrapping up the fi nal details of a project once the challenging parts have been done

– Diffi culty getting things in order – Diffi culty remembering appointments or obligations

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– Making careless mistakes on diffi cult projects – Diffi culty keeping attention on repetitive work – Misplacing things at home and work – Distracted by activity around her – Diffi culty unwinding and relaxing when having time to herself – Diffi culty focusing/listening during conversations

• Earlier, the mother was also requested to obtain copies of her report cards from fi rst and second grade

– Her own mother had kept these in storage – Showed grades that were quite low – Her teachers had commented on some of the problems endorsed

in the adult ADHD checklist that she continues to experience as an adult

• Asked how these problems affect her life, she states that: – They cause great diffi culty managing family matters – She used to be unable to stay focused in conversations with her

ex-husband, which made him feel she did not care about him • Additional complaints include:

– Constantly feeling overwhelmed with taking care of the two children while working fulltime

– Blaming herself for her daughter’s academic diffi culties – Feeling very emotional and overwhelmed

– “I’m sorry, doctor, but two kids are just too much for this single mom”

• Having diffi culty sleeping and being irritable with the children at night, which she regrets later on

• Has many worries, about fi nances, about the future, about her children’s futures, about getting a better job, about getting her own education, about fi nding a new partner

Based on just what you have been told so far about this patient’s history and symptoms, what do you think is her diagnosis?

• Appropriate response to her circumstances with her severe psychosocial stressors

• Mostly just stress and anxiety • ADHD • ADHD and stress • Generalized anxiety disorder (GAD) • Major depressive episode • ADHD and GAD • Other

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Attending Physician’s Mental Notes: Initial Psychiatric Evaluation • Here is a case that indeed is ADHD, but her symptoms also suggest

that she suffers from GAD – Constant worry – Feeling on edge – Fatigue – Diffi culty concentrating and her mind going blank – Irritability – Trouble sleeping

• Most adults with ADHD are comorbid for a second psychiatric disorder, and the most common is GAD

• Also, this patient is a smoker which may be related to her ADHD since a disproportionate number of ADHD patients smoke, perhaps because of the therapeutic effects of nicotine on ADHD symptoms

How would you treat her?

• Stimulant for her ADHD • SSRI/SNRI for her GAD • Benzodiazepine as need for GAD and insomnia • Stimulant plus an SSRI/SNRI or benzo for both ADHD and GAD • CBT for both ADHD and GAD • Other

Attending Physician’s Mental Notes, Initial Psychiatric Evaluation, Continued • It seems as though the primary disorder is ADHD and it will be

simplest if this is treated fi rst, with a single drug, probably a stimulant • An SSRI/SNRI and/or benzodiazepine can be added at a later time

once the actions of the stimulant are evident • Even though patients with GAD alone or even normal controls may be

“over stimulated” by a stimulant, in many cases of ADHD comorbid with GAD, the stimulant is paradoxically calming and well tolerated and even works for GAD symptoms as well as ADHD symptoms without having to prescribe a second medication for the GAD

• Any stimulant could be chosen but not all are explicitly approved for treatment of ADHD in adults

• She was started on mixed salts d,l amphetamine XR (Adderall XR) • She was referred to a local mental health training program where she

could possibly get CBT for free or for a reduced rate from a trainee receiving supervision

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Case Outcome: First, Second, and Third Interim Followup Visits, Weeks 4, 8 and 12 • Due to scheduling issues, by the time the patient had her fi rst CBT

session, she had already been titrated to 20 mg of mixed salts of d,l – amphetamine XR

• She thought that the medication had already started to help her and in fact that she would not have been able to cooperate with the CBT assignments had she not been on the medication

• Because of lack of side effects but continuing ADHD and GAD symptoms, the dose of d,l-amphetamine XR increased to 30 mg (off label since the maximum approved dosage for adults is 20 mg)

• Her BP and pulse were stable on the 30 mg dose but she felt jittery particularly in the morning and around noon; she also felt very anxious about her job situation and being able to provide for her family

• Dose lowered to 25 mg, but the jitteriness persisted so the dosage was further lowerd to 20 mg

• The jitteriness abated but her ADHD symptoms were not well controlled on the 20 mg dose anymore

• Instructed to stay on 20 mg for two more weeks as she is going on vacation and not to change the dose until after her vacation and then retry the 25 mg dose again

• Complained of feeling overwhelmed and irritable • For most patients, a week between…