Family physicians get tool to tune in to adult ADHD

CrossCurrents

Kim Goggins

When Denise Difede was in high school, she could never understand why her notebooks weren’t as neat as the other girls’, why her locker was a disaster, why every plan to start a project early inevitably fell through. “I’ve always felt not quite in with the rest of the world,” says the 45-year-old receptionist. “As I matured, I still had problems with organization and procrastination – starting a project and never finishing it, missing appointments, not writing things down. I was completely disorganized.”

It wasn’t until four years ago, when her three children were diagnosed with attention deficit/hyperactivity disorder (ADHD), that Denise realized she might also have the condition, characterized by hyperactivity, impulsivity and concentration difficulties. An assessment by a psychiatrist confirmed her suspicion.

Difede is one of the “lucky” ones, because her children’s psychiatrist agreed to treat her, and her family doctor became involved. Dr. Umesh Jain, chair of the Canadian ADHD Resource Alliance (CADDRA) in Toronto, says the situation for most adults with ADHD is critical because few psychiatrists and family physicians are prepared to diagnose and treat them. Yet about four per cent of adults have ADHD, according to a study published in a 2006 issue of the American Journal of Psychiatry.

To combat the problem, CADDRA recently released the 2007/2008 Canadian ADHD Practice Guidelines (CAP-G), which help family doctors diagnose and treat ADHD and monitor progress.

While males are frequently linked to the hyperactive, impulsive symptoms of ADHD, females, like Difede, tend to be quiet daydreamers and often go undiagnosed because they are not disruptive. As teens become adults, hyperactivity and impulsivity decrease, but problems related to concentration and organization may become more debilitating as the demands of adult life increase. “Many adults feel an internal restlessness all the time versus outward hyperactivity,” says Heidi Bernhardt, national director of CADDRA and the Centre for ADD/ADHD Advocacy, Canada.

The lack of resources for those with ADHD is a serious problem. “There are not enough child psychiatrists to see the children, let alone this huge population of adults,” says Dr. Derryck Smith, former head of psychiatry at B.C.’s Children’s Hospital in Vancouver. “Until about five years ago, adult psychiatrists did not even recognize that adult ADHD exists, even though they were seeing these patients.”

Detecting and treating adult ADHD can also be challenging because it is often accompanied by comorbid conditions. In fact, research has found that between 80 and 90 per cent of adults with ADHD have comorbid conditions such as depression, anxiety or substance use problems, which can translate into misdiagnosis and ineffective treatment if ADHD isn’t worked into the equation. “I get many calls from adults who have been seeing psychiatrists or family doctors or psychologists for years to treat their anxiety or depression,” says Bernhardt. “Frequently, these people have years of therapy or medication with no success because the underlying cause isn’t being treated.”

“People with ADHD should be primarily treated by their family doctors, but the problem is that family doctors are very poorly trained,” says Smith, who is now in private practice. “Many family doctors don’t feel comfortable managing children with ADHD, and feel out of their depth treating adults.”

That’s where CAP-G comes in. CADDRA’s aim for 2008 is to train more physicians to use the guidelines. More emphasis on adult ADHD in medical school curricula is another goal, as well as educating other people who commonly see adults with the condition, such as teachers, who often consult with parents about their children’s behaviour.

Through the development of a national continuing medical education project, 200 more psychiatrists will also be trained in adult ADHD so they can then teach physicians. “If you don’t train more psychiatrists, you can’t then train the family doctors,” says Jain, who is a psychiatrist at the Centre for Addiction and Mental Health in Toronto. “If psychiatrists make better diagnoses, family doctors will accept the diagnoses and continue the medication and lifestyle strategies for dealing with ADHD. As doctors get familiar with ADHD, they’ll start making their own diagnoses.”

As director of the Toronto-based Attention Deficit Resource Network, Difede knows she is fortunate to have help. She recalls many times she has witnessed clients in tears because they have nowhere to turn.

“The most frustrating thing is that treatment will turn people’s lives around,” says Jain. “If you give them the right medications, the right intervention strategy, it makes a profound difference. You can help people in a very short period of time.”

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