King Grub
2017-10-20, 09:33
Objective:
Adolescents and young adults without childhood attention deficit hyperactivity disorder (ADHD) often present to clinics seeking stimulant medication for late-onset ADHD symptoms. Recent birth-cohort studies support the notion of late-onset ADHD, but these investigations are limited by relying on screening instruments to assess ADHD, not considering alternative causes of symptoms, or failing to obtain complete psychiatric histories. The authors address these limitations by examining psychiatric assessments administered longitudinally to the local normative comparison group of the Multimodal Treatment Study of ADHD.
Method:
Individuals without childhood ADHD (N=239) were administered eight assessments from comparison baseline (mean age=9.89 years) to young adulthood (mean age=24.40 years). Diagnostic procedures utilized parent, teacher, and self-reports of ADHD symptoms, impairment, substance use, and other mental disorders, with consideration of symptom context and timing.
Results:
Approximately 95% of individuals who initially screened positive on symptom checklists were excluded from late-onset ADHD diagnosis. Among individuals with impairing late-onset ADHD symptoms, the most common reason for diagnostic exclusion was symptoms or impairment occurring exclusively in the context of heavy substance use. Most late-onset cases displayed onset in adolescence and an adolescence-limited presentation. There was no evidence for adult-onset ADHD independent of a complex psychiatric history.
Conclusions:
Individuals seeking treatment for late-onset ADHD may be valid cases; however, more commonly, symptoms represent nonimpairing cognitive fluctuations, a comorbid disorder, or the cognitive effects of substance use. False positive late-onset ADHD cases are common without careful assessment. Clinicians should carefully assess impairment, psychiatric history, and substance use before treating potential late-onset cases.
The Multimodal Treatment Study of ADHD comparison group did not support adult-onset ADHD independent of a complex psychiatric history. The two case subjects identified as adult-onset both possessed a variety of past or current mental health symptoms. In both cases, it was difficult to disentangle the etiology of these individuals’ symptoms, and thus the panel conservatively voted to retain the cases. In line with the false-positive paradox, the vast majority of case subjects who initially met late-onset symptom and impairment criteria were excluded from diagnosis because of clear evidence that heavy substance use or another mental disorder better accounted for symptoms or impairment. In fact, the majority of impairing late-onset ADHD symptoms in young adulthood could be traced to heavy substance use. There are still other potential causes of late-onset symptoms, such as brain injury, illness, or trauma, that should also be considered in future investigations. Without clear exclusionary guidelines for ADHD in adolescents and adults, there is risk that ADHD may become a catchall diagnosis for executive dysfunction stemming from any source.
Some adolescents and young adults who present for first timeADHD diagnoses may represent valid late-onset cases. However, the most common source of impairing late-onset ADHD symptoms in adolescence and young adulthood was substance use. Prior to diagnosing or treating ADHD in late onset cases, clinicians should carefully assess and treat substance use and comorbid mental health disorders as a potential source of symptoms. The majority of adolescent onset cases possessed transient symptoms. Thus, it may be appropriate to give provisional first-time ADHD diagnoses in adolescence and to monitor symptoms over time, as remission may occur within a few years. Further research is needed to understand how cognitive immaturity or adolescent neurocognitive changes might mimic or facilitate emerging ADHD symptoms.
Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. The American Journal of Psychiatry, October 20, 2017.
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2017.17030298
Adolescents and young adults without childhood attention deficit hyperactivity disorder (ADHD) often present to clinics seeking stimulant medication for late-onset ADHD symptoms. Recent birth-cohort studies support the notion of late-onset ADHD, but these investigations are limited by relying on screening instruments to assess ADHD, not considering alternative causes of symptoms, or failing to obtain complete psychiatric histories. The authors address these limitations by examining psychiatric assessments administered longitudinally to the local normative comparison group of the Multimodal Treatment Study of ADHD.
Method:
Individuals without childhood ADHD (N=239) were administered eight assessments from comparison baseline (mean age=9.89 years) to young adulthood (mean age=24.40 years). Diagnostic procedures utilized parent, teacher, and self-reports of ADHD symptoms, impairment, substance use, and other mental disorders, with consideration of symptom context and timing.
Results:
Approximately 95% of individuals who initially screened positive on symptom checklists were excluded from late-onset ADHD diagnosis. Among individuals with impairing late-onset ADHD symptoms, the most common reason for diagnostic exclusion was symptoms or impairment occurring exclusively in the context of heavy substance use. Most late-onset cases displayed onset in adolescence and an adolescence-limited presentation. There was no evidence for adult-onset ADHD independent of a complex psychiatric history.
Conclusions:
Individuals seeking treatment for late-onset ADHD may be valid cases; however, more commonly, symptoms represent nonimpairing cognitive fluctuations, a comorbid disorder, or the cognitive effects of substance use. False positive late-onset ADHD cases are common without careful assessment. Clinicians should carefully assess impairment, psychiatric history, and substance use before treating potential late-onset cases.
The Multimodal Treatment Study of ADHD comparison group did not support adult-onset ADHD independent of a complex psychiatric history. The two case subjects identified as adult-onset both possessed a variety of past or current mental health symptoms. In both cases, it was difficult to disentangle the etiology of these individuals’ symptoms, and thus the panel conservatively voted to retain the cases. In line with the false-positive paradox, the vast majority of case subjects who initially met late-onset symptom and impairment criteria were excluded from diagnosis because of clear evidence that heavy substance use or another mental disorder better accounted for symptoms or impairment. In fact, the majority of impairing late-onset ADHD symptoms in young adulthood could be traced to heavy substance use. There are still other potential causes of late-onset symptoms, such as brain injury, illness, or trauma, that should also be considered in future investigations. Without clear exclusionary guidelines for ADHD in adolescents and adults, there is risk that ADHD may become a catchall diagnosis for executive dysfunction stemming from any source.
Some adolescents and young adults who present for first timeADHD diagnoses may represent valid late-onset cases. However, the most common source of impairing late-onset ADHD symptoms in adolescence and young adulthood was substance use. Prior to diagnosing or treating ADHD in late onset cases, clinicians should carefully assess and treat substance use and comorbid mental health disorders as a potential source of symptoms. The majority of adolescent onset cases possessed transient symptoms. Thus, it may be appropriate to give provisional first-time ADHD diagnoses in adolescence and to monitor symptoms over time, as remission may occur within a few years. Further research is needed to understand how cognitive immaturity or adolescent neurocognitive changes might mimic or facilitate emerging ADHD symptoms.
Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. The American Journal of Psychiatry, October 20, 2017.
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2017.17030298