Today’s article is a follow up to last week’s newsletter that address the patterns of persistence of ADHD symptomatology through late adolescence and into early adulthood. The results of that study are strongly suggestive that ongoing monitoring is warranted for many of these individuals throughout their teen years and into their early adult years as the course of the condition has been noted to have waxing and waning profiles for many and ongoing and/or intermittent treatment can thus be both appropriate and beneficial for patients with ADHD.
Today’s newsletter discusses the findings of the same research group as regards the validity of the notion of “late onset ADHD”. The group’s data was developed from psychiatric assessments administered longitudinally to a normative comparison group involved in the seminal Multimodal Treatment Study of ADHD. The concept of “late onset” ADHD has been an area of interest and concern, in part, in consequence of the modification of the age of onset criteria in DSM 5 for diagnosing ADHD in children – now with an extension of the required date of onset from mid-elementary school years (~age 7, as per DSM IV) out to the middle school years (~ age 12). Does a broader age range make sense?
The question of “late onset” ADHD is of practical concern as data suggests an increasing number of older adolescents and young adults are presenting with complaints of inattentiveness beyond the new DSM cutoff age. Some estimates of the prevalence of this later onset presentation have been reported to range from 2.5% up to 10% of the population. The majority of these individuals do not have a history of childhood onset of symptoms.
Findings from the referenced study suggest that a number of factors are involved in the relatively high prevalence data. The following subgroups bear consideration:
1) Some of these patents may represent individuals with undetected childhood ADHD– i.e., they are “identified” late but have had some signs or symptoms since earlier in childhood. Others in this group may have been high functioning in spite of their handicap— only running into performance challenges as they advance to higher grades in school or face more demanding work challenges. For this population, with appropriate confirmation of a past history from the patient and family and, as feasible, from prior providers (educational and medical), and, with a clear presentation of relevant symptomatology and no evidence of contraindications (i.e., no current substance use issues and a clean CURES check), judicious initiation of treatment, with close follow up with the patient and relevant collaterals, may be indicated and appropriate. Concurrent participation in psychotherapy and/or other support activities (tutoring, psycho-education, etc.) would be clearly appropriate for most of these “late-identified” individuals.
2) Another group, accounting for the majority of the “late-onset” cohort, are described in the study as typically-developing individuals without core ADHD symptoms who seek stimulant medication for cognitive enhancement during their late high school, college and post graduate first years in the workforce. Requests for treatment may come from parents or the young adult patients themselves. In general, this is not the type of patient for whom prescribing would be recommended. While it may be difficult to ‘just say no’ to those presenting in this manner, saying ‘yes’ presents an ethical dilemma — artificially supporting the achievement of someone seeking credentialing as a lawyer, physician or ‘whatever’ thru medication that offers short term cognitive enhancement is ultimately not fair to the individual nor to their prospective clients or patients. The risk of harm to the individual if they continue to take a medication that is not needed is one concern and the possibility that they will not be fully capable of performing their work adequately after credentialing is another concern.
3) Finally, and perhaps the most challenging patients are those who have developed an ADHD profile consequent to a health or psychosocial condition occurring during their childhood or adolescence. Individuals in these categories would not typically be appropriate for treatment within a primary care setting, though once evaluated and if well stabilized and supported, some might be able to be maintained on appropriate medication regimens in primary care with availability for consultation as needed.
a) For example, individuals who’ve suffered a significant traumatic brain injury or other major medical or neurological insult may present with a secondary form of ADHD for which medication may be of great benefit.
b) Even more complex may be those who have had significant substance abuse exposure but who are now in recovery status with strong support systems and oversight. These individuals may sometimes need treatment, but clearly would need to be monitored and tracked intensively with multimodal therapeutic interventions and ongoing drug screening activities beyond the capacity of a primary care provider.
c) Also quite complex, are those with other psychiatric conditions who may present with significant impairment in their cognitive and executive functioning as might be seen in an individual with ADHD. Individuals in this category would most appropriately be treated by a psychiatrist or psychiatric team to address all aspects of their illness(es) so that any and all co-morbidities and risk could be addressed.
The bottom line take home message from the data is that “late-onset ADHD” is not a valid diagnostic category but that for a small minority of individuals other considerations may support initiation of treatment for ADHD. Careful assessment and management of such individuals by specialty mental health providers with close monitoring of treatment interventions would be the most appropriate approach to care.
The following SmartCare newsletters contain further information relevant to treatment of ADHD.
Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25; Margaret H. Sibley, Ph.D., et al.; American Journal of Psychiatry; Published Online: 20 Oct 2017 https://doi.org/10.1176/appi.ajp.2017.17030298