Ask Dr. Hallberg: What are the issues with diagnosing ADHD in adults?

For years, Attention Deficit Hyperactivity Disorder has been thought of as a condition that affects children, but there's been a recent effort to diagnose and treat adults as well.

At the American Psychiatric Association meeting this month, there was a proposal to make it easier to diagnose ADHD in adults. Medical providers have also discussed whether to redefine the disorder in the next version of the DSM, the textbook for diagnosing mental illnesses.

Medical analyst Dr, Jon Hallberg spoke with MPR's Tom Crann about the challenges of diagnosing and treating adults with the disorder.

Tom Crann: Let's back up and define it. Do we define it the same way for adults as we do for children, ADHD?

Dr. Jon Hallberg: We do. We still use the broad umbrella Attention Deficit Hyperactivity Disorder, although as adults we see much less of the squirminess, the inability to sit still that we do with kids. But still we use the same broad definition

Crann: So until recently it was a diagnosis for children only. Still in this DSM, it's only listed for children. Why is that?

Hallberg: It's important to remember that this entire huge book consists of diagnoses that, simply, people have put together. It's a committee that gets together and decides this stuff. So the condition can certainly exist in some demonstrable way. It's just that it hasn't been sort of codified or put together in a book. So that's simply the reason for this.

Crann: For adults, will it be diagnosed in the same way, a series of questions or a checklist?

Hallberg: That's right, and I think it's important to know that many of us in primary care, for example, feel very uncomfortable diagnosing this in children or adults. I think it's just because there's so much baggage attached to it. I can't think of any other diagnosable condition that is as controversial or as difficult to decide what to do with. Some of my colleagues won't touch it with a ten-foot pole.

Crann: Why? Is it because of the stigma attached to it?

Hallberg: No, I think it's because the treatment has historically been using a very potent medication, a Schedule II stimulant. And basically it's speed, and giving speed to kids or adults is a little scary. It's not that different than prescribing a narcotic pain medication to somebody. They are often in the same category, and because of that, some providers just will not go there.

Crann: Tell me why a stimulant would be indicated here, because you'd think if people especially are given to distraction and hyperactivity, that's not what you'd think of.

Hallberg: That's right. There's something very interesting going on, and that is that there's a part of the brain that needs to be stimulated that allows us to focus. And I should point out, too, and many young people know this, and many adults know this, that if people take one and they shouldn't be taking it, but they do, and they've got a test or they've got something they need to complete, I mean almost everybody feels better. They can get the task done. So that's part of the problem with this diagnosis and the condition is that many of us would benefit from taking a stimulant like that.

Crann: Last time you told us that some forty percent of cases that are diagnosed in children move on to adulthood or stay with. Can it also appear in adults who maybe had no signs of it as kids?

Hallberg: Well that's an interesting point, and I'm not sure we know the answer to that yet. I think that most of the adults that come to me and ask me if they have that diagnosis were never diagnosed as kids. And I've got people in their sixties and seventies who are asking me. And it gets tricky because many times they've been very successful people. It would look, in looking back on their lives, that they were not adversely affected by this diagnosis. And that's one of the criteria &emdash; that you really have to have adverse effects in your life because of this. So I think it's possible, but it's tricky.

Crann: And what are some of those adverse effects in more serious cases?

Hallberg: People, they tried to go to college. They couldn't complete it.

Crann: Couldn't finish.

Hallberg: They were failing classes. They simply couldn't get assignments done, so that their whole life may have been altered because of that. It's also interesting because Major League Baseball, for example, is dealing very much with this right now, that men are claiming that they have ADHD. They can no longer get quietly stimulants or speed. So they're looking for this diagnosis, and Major League Baseball has been really hard about this diagnosis.

Crann: Is there a risk here of medicalizing what people might call, for lack of a better term, quirky behavior or even disorganization? Are we almost too willing to give everything a syndrome now for just differences in personalities?

Hallberg: Well, this is sort of the problem I think we face with modern life in some ways. We are medicalizing processes of aging. For example, bones that are thin, it's low bone density or osteopenia. Is that really a medical disease process, or is that just called aging?

And I think this, too, are we trying to create a medical condition around something that's a quirk or that's a little disorganization or modern life? So this particular diagnosis, more than just about anything, I think has that element of philosophy and medicine intimately interwoven.

Crann: But that said, there can be a stigma for adults who are dealing with this in that the rest of the world just thinks they're slackers.

Hallberg: Certainly, and it's really hard. And I've gotten some patients, who frankly we've just decided to try some medication, and they do, and they tell me that their lives have completely changed. And my goodness, when we're in medicine and we're trying to relieve suffering and help people, and you get that kind of a response, and it's used reasonably and people take drug holidays, they don't take it every day, but yet it can make that kind of a difference? That's a pretty compelling reason to treat people.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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