CLINICAL PRACTICE
The diagnosis less traveled: NPs’ role in recognizing adult ADHD Roberta Waite, EdD, APRN, CNS-BC (Associate Professor)1 , Rebecca C. Vlam, LCSW (Behavioral Health Consultant)2 , Maria Irrera-Newcomb, FNP (Primary Care Coordinator)2 , & Thomas Babcock, DO (Associate Director)3 1
Interdisciplinary Research Unit, Doctoral Nursing Department, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania Eleventh Street Family Health Services of Drexel University, Philadelphia, Pennsylvania 3 Shire Development LLC, Wayne, Pennsylvania 2
Keywords Healthcare delivery; nurse-managed clinics; nurse practitioners; psychiatric disorders; attention deficit hyperactivity disorder (ADHD). Correspondence Roberta Waite, EdD, APRN CNS-BC, Interdisciplinary Research Unit, Doctoral Nursing Department, College of Nursing and Health Professions, Drexel University, 1505 Race Street, Bellet Bldg, 527, MS 1030, Philadelphia, PA 19102. Tel: 215-762-4975; Fax: 215-762-4080; E-mail: [email protected] Received: December 2011; accepted: July 2012 doi: 10.1111/j.1745-7599.2012.00788.x Disclosures The 4th author, Thomas Babcock DO, is an employee of Shire Development Inc. and holds stock in the company.
Abstract Purpose: To stimulate critical thought about sociocultural implications of unrecognized and undiagnosed attention deficit hyperactivity disorder (ADHD), and how these factors interface with healthcare delivery models and care that nurse practitioners (NPs) provide. Data sources: Health science databases—Psych Info, Proquest, Sage, PubMed, and authors’ professional experiences. Conclusions: NPs, often the main healthcare provider for underserved populations in community practice settings, have little training in assessing adult ADHD. ADHD, often unrecognized and undiagnosed among adults, contributes to global impairments adversely affecting individuals’ social, behavioral, academic, and cognitive functioning. Increased insight and awareness about adult ADHD is warranted to facilitate appropriate diagnosis. Implications for practice: ADHD is found in all sectors of our society; however, assessment and diagnosis among those whose socioeconomic status limits access to resources is a problem. Working in integrated care clinical settings facilitates recognition of patient problems and colocates resources required to manage the ADHD patient effectively. While this practice model may not be the norm, it is critical for NPs to have: (a) heightened awareness of the presentation of adult ADHD; (b) skills and/or resources to facilitate proper diagnosis of adult ADHD, and (c) models of practice that support optimal NP care delivery.
Introduction Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder where inattentive and/or hyperactive-impulsive traits, common human behaviors, are observed at higher levels and in a more persistent pattern than in peers without the disorder. The symptoms of ADHD contribute to significant impairments in social relationships and in academic and workplace functioning. While onset of ADHD occurs in childhood, these behaviors and impairments often persist into adulthood (American Psychiatric Association [APA], 2000). A national survey of English-speaking households in the United States, conducted between 2001 and 2003 noted that there is 4.4% prevalence of ADHD among adults (Kessler et al., 2006). However, in adulthood, symp-
302
toms of hyperactivity and impulsivity often become less obvious or more subtle (e.g., inner restlessness, disorganization, and impairment in behaviors related to executive functioning). Some have criticized the diagnosis of ADHD in adults, suggesting the symptoms represent behavioral or personality disorders, normal variation in human behavior, or characteristics of comorbid psychiatric conditions (Moncrieff & Timimi, 2010). Others point out the common clustering of symptoms, with their distinctive patterns of genetic and environmental influences. Predictable improvement with treatment has demonstrated that the disorder is an established syndrome whose recognition and treatment can reduce psychiatric and psychosocial morbidity (Asherson et al., 2010). Adult ADHD is a recognized disorder, and when it is undiagnosed or undertreated, individuals challenged with
C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 302–308 C 2012 American Association of Nurse Practitioners
R. Waite et al.
ADHD often have substantial social and personal concerns (Young et al., 2011). The clinical challenges and opportunities for improving patient care need to be addressed in a proactive manner. Inquiring about when, what, where, and how ADHD is considered is critical when patients come to a primary care clinic challenged with these life impairments. While there is a need for assessment, diagnosis, and management of adult ADHD, primary care providers (PCPs) such as nurse practitioners (NPs), have little training in the assessment of adult ADHD. The intent of this article is to stimulate critical thought about obstacles to observing the possibility of ADHD and ways of addressing these obstacles while considering sociocultural implications of unrecognized and undiagnosed ADHD. Our discussion will then focus on a central component to mitigating these concerns— examining how these factors interface with healthcare delivery models and care that NPs provide. Approaches to care for individuals in underserved communities are a central focus, because primary care serves as the de facto mental health provider for many of these people.
Obstacles to recognition of ADHD Several important factors influence if, when, and how ADHD is recognized among adult populations. These include: (a) use of the Diagnostic and Statistical Manual, 4th Edition-TR (DSM-IV-TR) criteria; (b) life span developmental and functional impairments; (c) assessment tools (e.g., rating scales); (d) important patient and provider variables; and (e) health service delivery models.
A look at the DSM-IV-TR Symptom descriptions for ADHD in the DSM-IV-TR are suited more for children than adults, because ADHD was originally described as a childhood neurobehavioral disorder (APA, 2000). However, now we understand it to be a life span disorder (Asherson et al., 2012). Although the DSM-IV-TR is useful, it is important to remember that “it is a catalog based on lists of symptoms” (Perry & Szalavitz, 2007, p. 11); it is a system based on outward manifestations of childhood behavior without a firm understanding of the underlying neurobiological processes. Perry and Szalavitz (2007) further reported, “it is kind of like a computer manual written by a committee with no knowledge of the machine’s actual hardware or software, a manual that attempts to determine the cause of and cure for the computer’s problems by asking you to consider the sounds it makes” (p. 11). Additional obstacles presented with DSM-IV-TR criteria for diagnosis as it relates to adults include: (a) needing at least six of the nine hyperactive/impulsive or six
Recognizing adult ADHD
of the nine inattentive symptoms, or both; (b) symptoms must occur in at least two different contexts; (c) these symptoms not only cause clinically significant impairment in different contexts, but some should have been present before the age of 7; and (d) symptoms must be pervasive, not episodic in nature (Asherson et al., 2012). These current DSM-IV-TR criteria can lead to misdiagnosis and underdiagnosis for adults because they do not account for developmental changes that affect how ADHD presents in the adult population. Moreover, research indicates that objective measures of ADHD decrease with age, even though significant impairments (e.g., clinical and psychosocial) continue to exist (Asherson et al., 2012).
Life span developmental and functional impairments It is important to illustrate how some of the life span developmental and functional impairment factors appear and impact the lives of those who have undiagnosed and untreated ADHD. These challenges may be demonstrated in the home setting, at work, and in social interactions (Barkley, Fischer, Smallish, & Fletcher, 2006). Compared to those without ADHD, these individuals often fail to graduate from school and are more likely to have been fired from a job or to have quit a job (Barkley et al., 2006; Biederman et al., 2006; de Graff et al., 2008). They may have had more sexual partners, higher risks for pregnancy, and more sexually transmitted diseases, and/or have had overall poorer quality in relationships than non-ADHD peers (Barkley et al., 2006; Biederman et al., 2006). Compared to those without ADHD, adults with ADHD often have poorer driving records and have more accidents and citations; they are also more likely to have been arrested or abused drugs (Biederman et al., 2006). Adults with untreated ADHD often lack skills for appropriate money management and have more problems with making impulsive purchases, saving money, and paying bills than their non-ADHD peers. One clearly sees how unrecognized and untreated ADHD is associated with significant functional impairments that are not only a burden on patients, but also on families. Furthermore, the effects on the workforce and on public safety also make ADHD a public health concern. When one considers the multiple impairments affecting multiple life domains, why does adult ADHD go undiagnosed and untreated? The child with ADHD is in close, direct contact with parents and teachers who observe behavior in a variety of contexts throughout much of the day. Beginning in adolescence, the consistency of observation may be lost, as students visit multiple classrooms and spend increasing time with peers rather than parents. Also, 303
Recognizing adult ADHD
adolescents may not have a sole clinician responsible for primary healthcare. PCPs who traditionally serve adults may be unfamiliar with a patient’s pediatric history and with adult ADHD in general (Hechtman, 2011). The adult provider is often more familiar with anxiety, depression, and perhaps conduct disorder and substance abuse disorder. These conditions are often comorbid with ADHD and have an overlapping symptom profile (Biederman, 2004; Spencer, Biederman, & Mick, 2007). PCPs, including NPs, are more likely to be trained to diagnose these comorbidities and may fail to identify subtle differences in symptom characteristics that would suggest an alternative diagnosis of ADHD (Hechtman, 2011; Heiligenstein & Keeling, 1995). Thus, unrecognized ADHD may contribute to the person’s experiences of failure and selfblame and poor career choices and career functioning, all of which increase the person’s social problems and perpetuate his or her socioeconomic disadvantage (Painter, Prevatt, & Welles, 2008; Rucklidge, Brown, Crawford, & Kaplan, 2007).
Assessment measures Most primary healthcare visits (70%) are actually psychosocial in nature rather than being strictly related to a physical problem (Robinson & Reiter, 2007). While it may be difficult for the PCP to look beyond the presenting physical problem during a visit, it is important because of the reported 4.4% prevalence of ADHD among adults, of which
The diagnosis less traveled: NPs’ role in recognizing adult ADHD Roberta Waite, EdD, APRN, CNS-BC (Associate Professor)1 , Rebecca C. Vlam, LCSW (Behavioral Health Consultant)2 , Maria Irrera-Newcomb, FNP (Primary Care Coordinator)2 , & Thomas Babcock, DO (Associate Director)3 1
Interdisciplinary Research Unit, Doctoral Nursing Department, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania Eleventh Street Family Health Services of Drexel University, Philadelphia, Pennsylvania 3 Shire Development LLC, Wayne, Pennsylvania 2
Keywords Healthcare delivery; nurse-managed clinics; nurse practitioners; psychiatric disorders; attention deficit hyperactivity disorder (ADHD). Correspondence Roberta Waite, EdD, APRN CNS-BC, Interdisciplinary Research Unit, Doctoral Nursing Department, College of Nursing and Health Professions, Drexel University, 1505 Race Street, Bellet Bldg, 527, MS 1030, Philadelphia, PA 19102. Tel: 215-762-4975; Fax: 215-762-4080; E-mail: [email protected] Received: December 2011; accepted: July 2012 doi: 10.1111/j.1745-7599.2012.00788.x Disclosures The 4th author, Thomas Babcock DO, is an employee of Shire Development Inc. and holds stock in the company.
Abstract Purpose: To stimulate critical thought about sociocultural implications of unrecognized and undiagnosed attention deficit hyperactivity disorder (ADHD), and how these factors interface with healthcare delivery models and care that nurse practitioners (NPs) provide. Data sources: Health science databases—Psych Info, Proquest, Sage, PubMed, and authors’ professional experiences. Conclusions: NPs, often the main healthcare provider for underserved populations in community practice settings, have little training in assessing adult ADHD. ADHD, often unrecognized and undiagnosed among adults, contributes to global impairments adversely affecting individuals’ social, behavioral, academic, and cognitive functioning. Increased insight and awareness about adult ADHD is warranted to facilitate appropriate diagnosis. Implications for practice: ADHD is found in all sectors of our society; however, assessment and diagnosis among those whose socioeconomic status limits access to resources is a problem. Working in integrated care clinical settings facilitates recognition of patient problems and colocates resources required to manage the ADHD patient effectively. While this practice model may not be the norm, it is critical for NPs to have: (a) heightened awareness of the presentation of adult ADHD; (b) skills and/or resources to facilitate proper diagnosis of adult ADHD, and (c) models of practice that support optimal NP care delivery.
Introduction Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder where inattentive and/or hyperactive-impulsive traits, common human behaviors, are observed at higher levels and in a more persistent pattern than in peers without the disorder. The symptoms of ADHD contribute to significant impairments in social relationships and in academic and workplace functioning. While onset of ADHD occurs in childhood, these behaviors and impairments often persist into adulthood (American Psychiatric Association [APA], 2000). A national survey of English-speaking households in the United States, conducted between 2001 and 2003 noted that there is 4.4% prevalence of ADHD among adults (Kessler et al., 2006). However, in adulthood, symp-
302
toms of hyperactivity and impulsivity often become less obvious or more subtle (e.g., inner restlessness, disorganization, and impairment in behaviors related to executive functioning). Some have criticized the diagnosis of ADHD in adults, suggesting the symptoms represent behavioral or personality disorders, normal variation in human behavior, or characteristics of comorbid psychiatric conditions (Moncrieff & Timimi, 2010). Others point out the common clustering of symptoms, with their distinctive patterns of genetic and environmental influences. Predictable improvement with treatment has demonstrated that the disorder is an established syndrome whose recognition and treatment can reduce psychiatric and psychosocial morbidity (Asherson et al., 2010). Adult ADHD is a recognized disorder, and when it is undiagnosed or undertreated, individuals challenged with
C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 302–308 C 2012 American Association of Nurse Practitioners
R. Waite et al.
ADHD often have substantial social and personal concerns (Young et al., 2011). The clinical challenges and opportunities for improving patient care need to be addressed in a proactive manner. Inquiring about when, what, where, and how ADHD is considered is critical when patients come to a primary care clinic challenged with these life impairments. While there is a need for assessment, diagnosis, and management of adult ADHD, primary care providers (PCPs) such as nurse practitioners (NPs), have little training in the assessment of adult ADHD. The intent of this article is to stimulate critical thought about obstacles to observing the possibility of ADHD and ways of addressing these obstacles while considering sociocultural implications of unrecognized and undiagnosed ADHD. Our discussion will then focus on a central component to mitigating these concerns— examining how these factors interface with healthcare delivery models and care that NPs provide. Approaches to care for individuals in underserved communities are a central focus, because primary care serves as the de facto mental health provider for many of these people.
Obstacles to recognition of ADHD Several important factors influence if, when, and how ADHD is recognized among adult populations. These include: (a) use of the Diagnostic and Statistical Manual, 4th Edition-TR (DSM-IV-TR) criteria; (b) life span developmental and functional impairments; (c) assessment tools (e.g., rating scales); (d) important patient and provider variables; and (e) health service delivery models.
A look at the DSM-IV-TR Symptom descriptions for ADHD in the DSM-IV-TR are suited more for children than adults, because ADHD was originally described as a childhood neurobehavioral disorder (APA, 2000). However, now we understand it to be a life span disorder (Asherson et al., 2012). Although the DSM-IV-TR is useful, it is important to remember that “it is a catalog based on lists of symptoms” (Perry & Szalavitz, 2007, p. 11); it is a system based on outward manifestations of childhood behavior without a firm understanding of the underlying neurobiological processes. Perry and Szalavitz (2007) further reported, “it is kind of like a computer manual written by a committee with no knowledge of the machine’s actual hardware or software, a manual that attempts to determine the cause of and cure for the computer’s problems by asking you to consider the sounds it makes” (p. 11). Additional obstacles presented with DSM-IV-TR criteria for diagnosis as it relates to adults include: (a) needing at least six of the nine hyperactive/impulsive or six
Recognizing adult ADHD
of the nine inattentive symptoms, or both; (b) symptoms must occur in at least two different contexts; (c) these symptoms not only cause clinically significant impairment in different contexts, but some should have been present before the age of 7; and (d) symptoms must be pervasive, not episodic in nature (Asherson et al., 2012). These current DSM-IV-TR criteria can lead to misdiagnosis and underdiagnosis for adults because they do not account for developmental changes that affect how ADHD presents in the adult population. Moreover, research indicates that objective measures of ADHD decrease with age, even though significant impairments (e.g., clinical and psychosocial) continue to exist (Asherson et al., 2012).
Life span developmental and functional impairments It is important to illustrate how some of the life span developmental and functional impairment factors appear and impact the lives of those who have undiagnosed and untreated ADHD. These challenges may be demonstrated in the home setting, at work, and in social interactions (Barkley, Fischer, Smallish, & Fletcher, 2006). Compared to those without ADHD, these individuals often fail to graduate from school and are more likely to have been fired from a job or to have quit a job (Barkley et al., 2006; Biederman et al., 2006; de Graff et al., 2008). They may have had more sexual partners, higher risks for pregnancy, and more sexually transmitted diseases, and/or have had overall poorer quality in relationships than non-ADHD peers (Barkley et al., 2006; Biederman et al., 2006). Compared to those without ADHD, adults with ADHD often have poorer driving records and have more accidents and citations; they are also more likely to have been arrested or abused drugs (Biederman et al., 2006). Adults with untreated ADHD often lack skills for appropriate money management and have more problems with making impulsive purchases, saving money, and paying bills than their non-ADHD peers. One clearly sees how unrecognized and untreated ADHD is associated with significant functional impairments that are not only a burden on patients, but also on families. Furthermore, the effects on the workforce and on public safety also make ADHD a public health concern. When one considers the multiple impairments affecting multiple life domains, why does adult ADHD go undiagnosed and untreated? The child with ADHD is in close, direct contact with parents and teachers who observe behavior in a variety of contexts throughout much of the day. Beginning in adolescence, the consistency of observation may be lost, as students visit multiple classrooms and spend increasing time with peers rather than parents. Also, 303
Recognizing adult ADHD
adolescents may not have a sole clinician responsible for primary healthcare. PCPs who traditionally serve adults may be unfamiliar with a patient’s pediatric history and with adult ADHD in general (Hechtman, 2011). The adult provider is often more familiar with anxiety, depression, and perhaps conduct disorder and substance abuse disorder. These conditions are often comorbid with ADHD and have an overlapping symptom profile (Biederman, 2004; Spencer, Biederman, & Mick, 2007). PCPs, including NPs, are more likely to be trained to diagnose these comorbidities and may fail to identify subtle differences in symptom characteristics that would suggest an alternative diagnosis of ADHD (Hechtman, 2011; Heiligenstein & Keeling, 1995). Thus, unrecognized ADHD may contribute to the person’s experiences of failure and selfblame and poor career choices and career functioning, all of which increase the person’s social problems and perpetuate his or her socioeconomic disadvantage (Painter, Prevatt, & Welles, 2008; Rucklidge, Brown, Crawford, & Kaplan, 2007).
Assessment measures Most primary healthcare visits (70%) are actually psychosocial in nature rather than being strictly related to a physical problem (Robinson & Reiter, 2007). While it may be difficult for the PCP to look beyond the presenting physical problem during a visit, it is important because of the reported 4.4% prevalence of ADHD among adults, of which
