Inside the Mind of an Adult ADHD Specialist – Interview with Dr Mahendra Perera

CAN YOU GIVE OUR READERS A BRIEF IDEA OF YOUR EXPERIENCES IN TREATING PATIENTS WITH ADULT ADHD?

Sanil, I would like to thank you for asking me to talk about a topic which I am very interested in. Before going on to my experiences, I think it’s best to briefly outline how I got interested in the field. Since I worked in addiction psychiatry and then did some child psychiatry work in the early 1990s, I must say the penny dropped, regarding ADHD. Subsequently, as an adult general psychiatrist, I think the first patient I diagnosed with ADHD had various dependencies both alcohol and opioids due to a chronic pain syndrome. I treated her albeit with some trepidation, with stimulants. The one redeeming feature was that the stimulants were never abused. They were always used in the manner prescribed or less.

Since then the number of people I saw with ADHD gradually increased until I stopped private practice a couple of years ago when I had almost 80% of my practice with ADHD patients.

I think treating people with the condition is very rewarding but also demanding. You need to separate the wheat from the chaff (otherwise there are those who will approach you for stimulants) as well as strictly adhere to the rules and regulations of the state in which you practice as well as our licensing requirements.

Once you set up your practice in a carefully considered manner, you are less likely to come across those who are seeking substances for hedonistic purposes. The difficulty, however, is that patients do not read a textbook and may have comorbid conditions which need to be dealt with. The most problematic of these being substance use disorders.

 

WHY IS ADULT ADHD SO IMPORTANT TO RECOGNISE IN CLINICAL PRACTICE?

ADHD is a neurodevelopmental disorder that begins in childhood, and according to most of the current literature, about 50% remain symptomatic even in adulthood.

The problem is that the hyperactivity may not be present in adults, but they have various other problems stemming from the core illness. There are some who believe that even if diagnosed in childhood by the time they are adults the disorder disappears.

If on the other hand, they were not diagnosed in childhood, then, there is a bigger problem because those adults who for whatever reason got through their childhood without a diagnosis continue to have problems or have greater problems as an adult. The condition when dealt with appropriately, as I have mentioned earlier, is rewarding for the practitioner but much more so for the adult sufferer.

 

ADULT ADHD IS CONSIDERED A CONTROVERSIAL DIAGNOSIS BY SOME. WHAT IS YOUR VIEW ON THE DIAGNOSIS??

In answer to part one of your question, there will always be the naysayers of any illness or condition. Secondly and I hypothesise here that it could be a lack of knowledge or information regarding the condition.

Another reason could be that since more and more people are coming out of the woodwork with a presumptive diagnosis of ADHD, some may be of the view that colleagues are over diagnosing the condition or indeed to use the cliche to someone with a hammer everything is a nail.

This need not be controversial at all as the research clearly bears out that the condition persists into adulthood and prevalence rates have been well documented. 

However, as with the other so-called functional diagnoses, we make in psychiatry, we do not have clearly demonstrable pathological or biochemical markers.

My view is that it exists, it needs to be properly managed, and we need to educate our colleagues as well as the public that it is a disorder like any other condition such as depression, OCD et cetera.

Of course, each psychiatrist may not wish to treat (especially) the more challenging clients with ADHD. Each of us does have a subspecialty niche.  However, that does not negate the fact that ADHD exists in the adult.

 

WHAT ARE THE CORE FEATURES THAT ONE SHOULD FOCUS ON IN DIAGNOSIS?

ADHD is diagnosed by hyperactivity, inattentiveness and impulsivity. These need to be present or have been demonstrably present in childhood. The DSM 5 has subsumed impulsivity under hyperactivity.

However, when dealing with adults, the impulsivity and inattentiveness are more prominent than hyperactivity per se.

The hyperactivity itself is characterised by a sense of restlessness e.g. inability to sit for a long period of time or have difficulty staying through a lecture.

Since the symptoms of ADHD have been well noted in the DSM and on many other websites I shall not detail these here.

 

WHAT ARE THE COMMON CLINICAL PRESENTATIONS OF ADHD AND WHAT INDICATORS SHOULD RAISE OUR SUSPICION?

This gets down to the core business of a clinician. There are several calling cards, and I shall briefly outline them here.

The first – they have been diagnosed by a paediatrician and now as an adult would like to continue with treatment OR the paediatrician is looking for a psychiatrist to refer them on to for continuing therapy.

I have received several such requests from my paediatrician colleagues.  There are others who have had lifelong problems and either through friends or self-reading would suspect they have ADHD and request an assessment.

One caveat here is that the child with ADHD who did not have any other difficulties may as an adult develop other physical or psychological problems and hence re-evaluating or clarifying our role in the management is important.

One of the common features seen in the hitherto undiagnosed patient is that they may present as what I would loosely call a treatment resistant depression or anxiety state which may well be due to underlying ADHD.

Impulsive behaviours (above and beyond normal or societal bounds) and substance use disorders may be due to underlying ADHD. More recently people have even thought of ADHD underpinning some personality disorders.

It is always good to suspect ADHD as a probable diagnosis amongst the other psychological diagnoses where it could be relevant. The axiom here is that if we do not suspect we are not likely to diagnose.

 

WHAT ARE THE KEY FEATURES IN THE DIAGNOSTIC ASSESSMENT?

Once more we need to suspect a condition, without which we would not be likely to look for it. For me as a practising clinician, the key feature is the narrative offered by the individual and collateral history to ascertain the veracity of the story.

Personally, I would not diagnose ADHD in the absence of childhood history suggestive of the condition. This information can be obtained in many ways. Other than the individual account, I find that the school reports at least the ones I have seen are usually indicative. 

Comments such as – “could do better if he only tried” is a constant theme. Collateral information from parents or significant others is the another source of information.

 I tend to use a couple of questionnaires. I use the World Health Organisation (WHO) Adult ADHD Self-Report Scale (ASRSv1.1), which is an 18 item questionnaire and is available freely on the web. This is a self-administered questionnaire. I have been using the DSM items which have been typed onto a Word document, and I use it as an interviewer-administered questionnaire writing my comments. 

DIVA is another questionnaire, and that is useful. There are many other questionnaires, and it is useful for the clinician to become familiar with one or two to be able to quantify the assessment.

 There are various biological investigations. However, as far as I’m aware none of them is specific for ADHD although  EEG’s, scanning techniques have demonstrated statistically significant differences in those with ADHD compared with those who do not have it.

Although I have not used it personally, a commercially available tool is the Global Mind Screen. This is a broad instrument which the patient completes and offers a profile for probable diagnoses including ADHD.

 

WHAT ARE THE KEY STEPS IN MANAGEMENT?

For me, the most important thing is to arrive at a firm diagnosis and also assess for any co-morbid conditions. I would then explain my view to the individual patient and preferably a significant other due to the contentious nature of the condition.

I would discuss management options. They are, learning behavioural techniques, medication (stimulant and non-stimulant) and advocating for the patient if they are facing difficulties.

I always make it manifestly clear that ADHD is not an excuse for bad behaviour. e.g., I would write a letter on behalf of a student who was having difficulty with handing in an assignment on time. Once more I make it very clear that once they are adequately treated, they should have no excuse for further delay.

 

CAN YOU GIVE US A BRIEF OVERVIEW OF MEDICATIONS?

Stimulants have been the cornerstone of medication management. One of the very early studies dates back to 1930s when Benzedrine was used. Currently, the two stimulants in vogue are dexamphetamine and methylphenidate.

For both of these substances, the slow-release or long-acting versions are available in Australia. However, there are certain restrictions regarding pharmaceutical benefits scheme (PBS) subsidies for the long-acting medicine.

I have listed some medicines that are used in ADHD. I think it is important the clinician become familiar with the medicines they are using and also be aware of cost and availability.

Stimulant

• Dexamphetamine 5 mg tablets (immediate release- duration of action ~ 4hrs)
• Lisdexamfetamine (Vyvanse) 30, 50 and 70 mg capsules
• Methylphenidate 10 mg tablets
• Ritalin LA  10, 20, 30, 40 and 60 mg (PBS restrictions apply)
• Concerta 18, 27, 36 and 54 mg (PBS restrictions apply)
• Has been used although not product licensed for ADHD [Modafanil (Provigil) 100 and 200 mg] – No PBS subsidy for ADHD

Non-Stimulant

• Atomoxetine (Strattera) 10, 18, 25, 40, 60, 80 and 100 mg (PBS restrictions apply)
• Clonidine – has been used especially with children – I have not personally used
• Guanfacine – Used in ADHD but I do not have any further information
• Bupropion – mainly in the states available here as Zyban for smoking cessation.

 Since sleep is a problem for some, they could either use a smaller dose of a stimulant if they are on one or melatonin 2 – 4 mg.

 

HOW DOES ONE CHOOSE SPECIFIC STIMULANTS OR NON-STIMULANTS?

I would say this is an art as well as a science and the prescriber/clinician needs to be aware of this and be able to individualise the drug treatment regime.

For medical practitioners, these are vital questions which we need to grapple with on a regular basis. If a patient has psychosis or is substance dependent, I would be reluctant to use stimulants (but would not exclude such use if essential or necessary).

In a straightforward situation, I will discuss the pros and cons of medicines in general and offer them a choice of dexamphetamine or methylphenidate because, for me, either of the stimulants is much of a muchness.

A key principle for me is the go low go slow approach to medication.

If they do have other comorbid conditions that too would need appropriate medication management.

My recommendation: always begin with the straightforward patients with ADHD, get comfortable with prescribing medication and then go on to more complex situations.

A peer review group and/or collaboration with the experienced clinician is helpful and necessary. Even those of us who regularly do this work consult with our colleagues as and when necessary.

 

ANY FINAL WORDS?

Although I have dealt with medication and the diagnosis it is only briefly that I have mentioned about behavioural techniques that could be used to help these people.

We are aware of neuronal plasticity, and it is important that an individual with the condition be aware that medicine is only part of the answer if they choose to use the medicines.

There are many behavioural methods that will also help and need to be applied concurrently with medication.

Make sure that your permits are up to date and prescribing is within the guidelines.

There are many who would say that ADHD is a new diagnosis or a condition that has suddenly erupted in the 20th and 21st centuries. Actually, there are records of similar conditions been described over hundreds of years.

Certainly, the condition does give an evolutionary advantage, and since the gene pool does not turn over that fast, it is likely that the condition existed for many centuries or millennia.

The question of it being brought to light more recently could be looked at in many different ways. The social and cultural pressure to achieve and especially in an academic sense maybe one reason, another reason is the increase of environmental pollutants could be contributing to the unmasking of certain characteristics (epigenetic phenomena).

Furthermore, the availability of knowledge freely on the Internet may be another reason people are becoming more aware of the condition and reaching out for help.

I do not have one answer to this, but I do realise that ADHD is a condition that we need to recognise and manage and when properly approached is rewarding to both the clinician and most importantly to the patient.