Canadian Psychiatric Association
Association des psychiatres du Canada
Letter to the Editor
Adult Attention-Deficit Hyperactivity Disorder is Hard to Diagnose and is Undertreated
Dear Editor: Dr Joel Paris and colleague’s1 observations regarding overdiagnosis of adult attention-deficit hyperactivity disorder (ADHD) are a cause for concern. However, it is important to distinguish misdiagnosis form overdiagnosis. The National Comorbidity Survey2 provides convincing epidemiological data regarding the known prevalence of adult ADHD in the community. This study showed that most of the adults with this condition have never been assessed or treated. There are now numerous carefully designed longitudinal studies of ADHD through the lifespan from childhood into adult years.3 The consistent finding across these studies is of significant functional impairment in activities of daily living, including academic underachievement, poor work record, marital breakdown, and dysfunctional parenting. Since 2000, the Canadian Medical Association guidelines for determining medical fitness to operate motor vehicles has recognized the dangers of problem driving in adults with ADHD and the benefits of stimulants in reducing problem driving in adults with this diagnosis.4 A Canadian metaanalysis of ADHD and problem driving and recent studies from Europe have shown further evidence of the benefits of stimulants in epidemiological samples of adults with ADHD in reducing motor vehicle collisions.5,6 The collective impact on morbidity and mortality of this common and underdiagnosed adult condition remains significant. Dr Paris presents sensible clinical advice regarding the need for a comprehensive evaluation of concerns regarding adult ADHD. His observations about the need for careful assessment of the developmental history and gathering of functional impairment data with collateral information are a standard requirement for conducting an assessment. Canadian practice guidelines developed by Canadian ADHD Resource Alliance (CADDRA) emphasize planned evaluation with an emphasis on functional impairment and assessment of comorbidity. These guidelines, now used internationally, provide readily available, clinical instruments that can be downloaded without charge from the CADDRA website.7 Most adult ADHD is currently being managed by family physicians in the community rather than adult psychiatry. Training of psychiatric residents in Canadian departments of psychiatry is still very limited but slowly improving.
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(1) 59 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743715619937 TheCJP.ca | LaRCP.ca
Psychiatric residents need clinical training with clinicians committed to careful assessment of this underdiagnosed disorder and very treatable condition. The effectiveness of psychoeducation and psychosocial and life style issues should be part of a comprehensive management plan for this chronic disabling condition. More exposure to assessing and managing adult ADHD could reduce misdiagnosis and more importantly reduce underdiagnosis and undertreatment of this disabling condition. Perhaps we should see Dr Paris’ article as a call to arms for better training and assessment and management of ADHD, both in family practice and in psychiatric residency programs. Yours sincerely, Laurence Jerome, FRCPsych, FRCPC Western University, London, Ontario [email protected] References 1. Paris J, Bhat V, Thombs B. Is adult attention-deficit hyperactivity disorder being overdiagnosed? Can J Psychiatry. 2015;60(7): 324-328. 2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716-723. 3. Barkley RA, Murphy KR, Fisher M. ADHD in adults: what the science says. New York (NY): Guilford Press; 2010. 4. Canadian Medical Association (CMA). CMA driver’s guide: determining medical fitness to operate motor vehicles. 8th ed. Ottawa (ON): CMA; 2012. p 39. 5. Jerome L, Segal A, Habinski L. What we know about ADHD and driving risk: a literature review, meta-analysis and critique. J Can Acad Child Adolesc Psychiatry. 2006;15(3):105-125. 6. Chang Z, Lichtenstein P, D’Onofrio BM, et al. Serious transport accidents in adults with attention-deficit/hyperactivity disorder and the effect of medication: a population-based study. JAMA Psychiatry. 2014;71(3):319-325. 7. Canadian ADHD Resource Alliance (CADDRA). CADDRA Canadian ADHD practice guidelines [Internet]. Markham (ON): CADDRA; 2013 [cited 2015 Nov 18]. Available from: http://www.caddra.ca/practice-guidelines/download.
Association des psychiatres du Canada
Letter to the Editor
Adult Attention-Deficit Hyperactivity Disorder is Hard to Diagnose and is Undertreated
Dear Editor: Dr Joel Paris and colleague’s1 observations regarding overdiagnosis of adult attention-deficit hyperactivity disorder (ADHD) are a cause for concern. However, it is important to distinguish misdiagnosis form overdiagnosis. The National Comorbidity Survey2 provides convincing epidemiological data regarding the known prevalence of adult ADHD in the community. This study showed that most of the adults with this condition have never been assessed or treated. There are now numerous carefully designed longitudinal studies of ADHD through the lifespan from childhood into adult years.3 The consistent finding across these studies is of significant functional impairment in activities of daily living, including academic underachievement, poor work record, marital breakdown, and dysfunctional parenting. Since 2000, the Canadian Medical Association guidelines for determining medical fitness to operate motor vehicles has recognized the dangers of problem driving in adults with ADHD and the benefits of stimulants in reducing problem driving in adults with this diagnosis.4 A Canadian metaanalysis of ADHD and problem driving and recent studies from Europe have shown further evidence of the benefits of stimulants in epidemiological samples of adults with ADHD in reducing motor vehicle collisions.5,6 The collective impact on morbidity and mortality of this common and underdiagnosed adult condition remains significant. Dr Paris presents sensible clinical advice regarding the need for a comprehensive evaluation of concerns regarding adult ADHD. His observations about the need for careful assessment of the developmental history and gathering of functional impairment data with collateral information are a standard requirement for conducting an assessment. Canadian practice guidelines developed by Canadian ADHD Resource Alliance (CADDRA) emphasize planned evaluation with an emphasis on functional impairment and assessment of comorbidity. These guidelines, now used internationally, provide readily available, clinical instruments that can be downloaded without charge from the CADDRA website.7 Most adult ADHD is currently being managed by family physicians in the community rather than adult psychiatry. Training of psychiatric residents in Canadian departments of psychiatry is still very limited but slowly improving.
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(1) 59 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743715619937 TheCJP.ca | LaRCP.ca
Psychiatric residents need clinical training with clinicians committed to careful assessment of this underdiagnosed disorder and very treatable condition. The effectiveness of psychoeducation and psychosocial and life style issues should be part of a comprehensive management plan for this chronic disabling condition. More exposure to assessing and managing adult ADHD could reduce misdiagnosis and more importantly reduce underdiagnosis and undertreatment of this disabling condition. Perhaps we should see Dr Paris’ article as a call to arms for better training and assessment and management of ADHD, both in family practice and in psychiatric residency programs. Yours sincerely, Laurence Jerome, FRCPsych, FRCPC Western University, London, Ontario [email protected] References 1. Paris J, Bhat V, Thombs B. Is adult attention-deficit hyperactivity disorder being overdiagnosed? Can J Psychiatry. 2015;60(7): 324-328. 2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716-723. 3. Barkley RA, Murphy KR, Fisher M. ADHD in adults: what the science says. New York (NY): Guilford Press; 2010. 4. Canadian Medical Association (CMA). CMA driver’s guide: determining medical fitness to operate motor vehicles. 8th ed. Ottawa (ON): CMA; 2012. p 39. 5. Jerome L, Segal A, Habinski L. What we know about ADHD and driving risk: a literature review, meta-analysis and critique. J Can Acad Child Adolesc Psychiatry. 2006;15(3):105-125. 6. Chang Z, Lichtenstein P, D’Onofrio BM, et al. Serious transport accidents in adults with attention-deficit/hyperactivity disorder and the effect of medication: a population-based study. JAMA Psychiatry. 2014;71(3):319-325. 7. Canadian ADHD Resource Alliance (CADDRA). CADDRA Canadian ADHD practice guidelines [Internet]. Markham (ON): CADDRA; 2013 [cited 2015 Nov 18]. Available from: http://www.caddra.ca/practice-guidelines/download.
