Clinical Subtypes of ADHD
MAY 22, 2020
Theresa Cerulli, MD: Hello, and welcome to this HCPLive® Peer Exchange® on the treatment landscape for the management of ADHD, attention deficit hyperactivity disorder. I’m Dr Theresa Cerulli, from Beth Israel Deaconess Medical Center in Boston. I’m excited to announce that I’m being joined today in this discussion by 4 of my esteemed colleagues and ADHD experts: Dr Ann Childress, from the Center for Psychiatry and Behavioral Medicine in Las Vegas, Nevada; Dr Andrew Cutler, from SUNY Upstate Medical University, Lakewood Ranch, Florida. We also have Dr David Goodman, from Johns Hopkins University School of Medicine. And finally, please welcome Dr Timothy Wilens, from Massachusetts General Hospital in Boston, Massachusetts.
Our discussion today will focus on currently available therapeutic options to treat adult ADHD as well as newer agents in the pipeline with novel mechanisms of action. Let’s get started.
David, it would be great if you could get our group rolling. Tell us, what is ADHD? Is it different from ADD [attention deficit disorder]?
David W. Goodman, MD: ADHD is the formal diagnosis. Without hyperactivity and impulsivity in adults, the general public will call that ADD, but ADHD is the formal diagnosis. It breaks out into 3 flavors, as I like to call them. You have the inattentive, you have the hyperactive and impulsive, and then you have the combined type. What’s interesting is that from DSM-IV to DSM-5, we’ve gone from subtypes to presentations.
That’s because the children who might have had hyperactivity and impulsivity and would have been a combined type as a child may now be an adult with less hyperactivity and impulsivity. They don’t reach the symptom threshold for a combined type, and they get diagnosed as inattentive. We now go on presentation of presenting symptoms when you see the patient for a comprehensive psychiatric evaluation.
Theresa Cerulli, MD: And those presenting symptoms are a little different for adults, in terms of diagnostic criteria and changes from DSM-IV to DSM-5?
David W. Goodman, MD: Well, there are several changes. The DSM-IV criteria had a threshold of age 7. We’ve increased that to age 12, because a lot of the inattentive children weren’t being diagnosed. A lot of the focus was on disruptive behavior. However, as the children age, the inattention and disorganization become the source of the impairments, along with executive function.
And so, the evolution from childhood to adulthood. And my area of expertise is in older adults, looking at the trajectory of the symptoms over the course of time. But coming back to DSM-5, you have the symptoms. The symptom threshold has changed for children and adults. For children, it’s 6 of 9 inattention or 6 of 9 hyperactive impulsive symptoms. For adults, it’s 5 of 9 in either of the 2 categories.
So you have the symptoms, you have the impairments that they need to cause. Because you can interview somebody who says, “I have occasional inattention and distractibility,” that doesn’t mean you have a case of ADHD. Remember, the hallmark of ADHD is the foundation of symptoms in childhood and early adolescence that evolve relatively unchanged over the course of time.
Transcript Edited for Clarity