Understanding the Full Clinical Presentation of ADHD

In this chapter, experts examine the broader clinical presentation of attention-deficit/hyperactivity disorder (ADHD) and the need for comprehensive assessments to inform treatment planning. After watching the video, test your knowledge with the quiz in the sidebar. 

To learn more, view the full series: ADHD Beyond The Core – What We’re Missing and Why It Matters. 

Mattingly: Welcome, friends and colleagues, to this session on Understanding the Full Clinical Presentation of ADHD. ADHD is a chronic neurodevelopmental disorder characterized by symptoms of inattention and/or hyperactivity, impulsivity, as well as multiple associated features and comorbidities. Core symptoms of ADHD, as defined by DSM-5, include problems with inattention, hyperactivity, impulsivity that interfere with daily function or development. While the core symptoms are a key diagnostic feature, that's not the full flavor of ADHD. ADHD is frequently associated with associated features such as emotional dysregulation, impulsivity, frustration tolerance that correlate with the underlying neurologic abnormalities of ADHD. When we think about some of the emotional dysregulation, we've probably all dealt with a child, an adolescent, or adult who has difficulty modulating their emotions and response to stress, difficulty adapting to stressful events, shifts of behavior, goal-oriented settings, frustration. And this can manifest such as mood swings, irritability, impulsive anger, low frustration tolerance, reduced motivation, procrastination, and emotional overactivity.  

Nearly half and two-thirds of adults with ADHD are affected by emotional dysregulation. We know that emotional regulation plays a key role in ADHD symptom domain, such as inattentiveness, impulsivity, hyperactivity, and underlying executive function. An often overlooked area is the role of executive function deficits. Executive function refers to impairments in interconnected cognitive processes that support goal-directed behavior and problem-solving, mainly involving memory, inhibitory control, and set shifting from a preferred to a non-preferred task. We know that executive dysfunction may be a core symptom that's associated with inattention, hyperactivity, and impulsivity in both adults and children with ADHD. And we know that adults with ADHD and executive function tend to have greater emotional dysregulation than those that just have ADHD alone. In addition to these associated features, ADHD frequently doesn't come in the door by itself. Frequently, it brings in a lot of other friends, and those friends sometimes aren't as wanted as others.  

So, some of the friends that come in the door can be anxiety, can be depression, can be sleep disorders, and unfortunately can be concomitant substance use disorders. Having at least 1 coexisting psychiatric disorder is common, with nearly 50% of adults and one-third of children having multiple comorbid conditions, including anxiety. Symptom overlap between ADHD and comorbidities such as anxiety can lead to misdiagnosis, a delay in diagnosis. We pick up the anxiety and the stress, and we miss the underlying ADHD, which is driving the emotional frustration and sense of anxiety. We know that patient burden tends to build over time. Emotional dysregulation can cause difficulties at school, work, and relationships, friendships, diminished self-esteem and is a common comorbidity of ADHD. It contributes, unfortunately, to increased suicide rates, with studies showing that adults with ADHD have a 50% to doubling the rates of suicide as compared to those without ADHD.  

Executive function deficits also impact everyday functioning—the ability to manage things in social environments, task completion, financial regards, social and emotional regulations with others. When we think about comorbidities, probably the one that comes to the forefront is anxiety. Anxiety is linked to lower occupational achievement, poor occupational outcomes, reduced quality of life, more frequent hospitalizations, and greater risk of psychotic symptoms, suicidal behavior, and increased irritability. Another unwanted friend sometimes is that of depression. Depression demoralization is almost as common as anxiety in adults. Nearly 50% will have a comorbid depression. Substance use tends to build over time. When people are living illnesses of despair, frustration, they tend to start self-medicating. We know this can be especially difficult because, quite often, our treatments we're using for ADHD are also themselves Schedule II controlled substances. In children, behavioral disorders such as oppositional defiant disorder and conduct disorder can co-occur with ADHD.  

And often, these situations do not respond well to our basic stimulant medications used to treat ADHD. Another condition that I deal with quite a bit is the world of tics and twitches. Tourette’s syndrome associated with ADHD, that can worsen with many of our common medications such as stimulant medications. Finally, we want to talk about chronic health conditions such as obesity, cardiovascular disease, diabetes, that have all been linked both genetically and as an associated risk with ADHD. When we think about the overall risk of these, we want to talk about mortality rates. Mortality rates such as suicide, accidental trauma, natural causes, and cardiovascular disease are all linked to untreated ADHD. So, let's open it up to a little bit of a discussion here. It's kind of the good news, bad news of ADHD. There's a lot of associations here, Desiree, when you think through your patients, how do you think about these associated features, these associated comorbid health and mental health conditions that also come in the door with ADHD?  

Matthews: Absolutely. It's not always an easy picture or sometimes to discern. So, really, I do a thorough assessment when we walk through the door, whether it's a complaint of depression or anxiety—"I can't sleep”—because these are nonspecific symptoms. And, as you mentioned, comorbidities really common with ADHD. I recall a case where an individual, she actually was going to college and flunked out. And she was treated for general anxiety disorder, panic disorder. They thought that she had really run the gamut of medications. She wasn't getting better with our standard of care. And I dug a little bit deeper and come to find out it was really the ADHD, the emotional dysregulation, the executive dysfunction that was driving this anxiety. And she had a good outcome. We treated her. She was able to return to school and actually graduate with proper treatment for her ADHD.  

Mattingly: Desiree is pointing out that ADHD isn't just boys and girls anymore. It's not just adult men anymore. But the role of women, quite often missed when they were younger. So, the impact of hormones, the impact of emotional dysregulation, masking of symptoms where we treat the chief complaint, which is anxiety, stress, being overwhelmed. But we miss the underlying ADHD. So, Rakesh, talk a little bit about the role of women, the role of women in ADHD, and this, in particular, anxiety in women. What do we see there? 

Jain: Yeah, yeah. Oh my gosh. Such an important topic, isn't it? For decades, we have ignored the plight of females, but particularly young adult women. And I think we've done so because of our own biases. We have too often seen hyperactivity and impulsivity as the major driver. But, as you said, the major driver of ADHD in women, besides obvious inattention, is low self-esteem, low self-confidence, low wellness, emotional dysregulation. And that leads to a whole host of problems. It's a cascade of events. As I was listening to your beautiful introduction, my heart dropped. And then, with every passing minute, my heart dropped further because it reminds me that I can't just think about ADHD in my patients. I’ve got to think about ADHD and its associated features.  

Mattingly: Yeah, well said, Rakesh. Andy, we know we live in a world where many patients don't get diagnosed until adulthood. In particular, women. We have new data that came out of the CDC that about two-thirds of women were missed in childhood and don't get diagnosed until adulthood. So, when you think about living with ADHD, living with untreated ADHD, how do some of these associated features and things start to stack over time when we're not receiving treatment?  

Cutler: And that's very well said. They do stack up and there's almost a logarithmic relationship. It's just not 1 plus 1 equals 2. It's 1 plus 1 equals 4 when you're talking about these things. And I think what happens, I see all ages, as I know you do too, and you do as well as a child psychiatrist. I find that with children, it's kind of obvious that it's ADHD when they come in, right? They're having trouble with school or behavior, but adults is much harder. And very often, like Desiree's case, it's the comorbidity that presents, and you have to dig deeper to find the underlying ADHD. But also, it can be the executive function or emotional dysregulation. I've seen some older adults who came in saying, I think I have dementia because they were having so much trouble with organization and memory. And, of course, as we get older, we can have some normal aging kinds of things. I also very well remember a man who came in because his wife was afraid to leave the children with him because he had so much trouble with emotional dysregulation. He would blow up, and he always felt guilty afterward and he just could not control himself. And even when I put him on a stimulant, it just didn't really fully address that. And then, of course, what happens? To your point, he became super anxious and getting depressed, and it just all snowballed.  

Mattingly: Thank you all for just a wonderful discussion of the world of ADHD. The real world, which is ADHD doesn't typically come in by itself—80% or more of our patients are going to have an associated health condition. Those associated features may be emotional frustration, impulsivity, executive function, or it may be associated health conditions such as anxiety disorders, sleep disorders, or other associated features. Thank you to the audience, as always, for joining us in this wonderful discussion, and we look forward to hearing you in future discussions.  

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Andrew Cutler, MD 
Dr Andrew J. Cutler is a clinical associate professor of psychiatry at SUNY Upstate Medical University in New York, and he serves as the chief medical officer of the Neuroscience Education Institute. He received his MD from the University of Virginia School of Medicine, where he was also elected to the Alpha Omega Alpha honor medical society and received the Merck Award for outstanding medical scholarship. He completed his medical internship, internal medicine residency, and psychiatry residency at the University of Virginia Medical Center, where he served as chief resident of psychiatric medicine and did research on dopamine receptor pharmacology.  Dr Cutler then served as the first assistant professor and director of psychiatric medicine at the University of Chicago.  He is board certified in both internal medicine and psychiatry. Dr Cutler has also been the principal investigator on over 400 psychiatric and medical clinical trials.   

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Rakesh Jain, MD, MPH
Dr Rakesh Jain is a clinical professor at the Texas Tech University School of Medicine. He attended medical school at the University of Calcutta in India. He then attended graduate school at the University of Texas School of Public Health in Houston, where he was awarded a “National Institute/Center for Disease Control Competitive Traineeship.” His research thesis focused on the impact of substance abuse. He graduated from the School of Public Health in 1987 with a Master of Public Health degree. Dr Jain served a 3-year residency in Psychiatry at the Department of Psychiatry and Behavioral Sciences at the University of Texas Medical School at Houston. He then obtained further specialty training, undergoing a 2-year fellowship in child and adolescent psychiatry. In addition, Dr Jain completed a postdoctoral fellowship in research psychiatry at the University of Texas Mental Sciences Institute in Houston. He was awarded the “National Research Service Award” for the support of this postdoctoral fellowship. 

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Desiree Matthews, PMHNP-BC 
Desiree Matthews is a board-certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal patient outcomes and elevating healthcare provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible, precision-focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company. 

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Greg Mattingly, MD 
Dr Greg Mattingly is a physician and principal investigator in clinical trials for Midwest Research Group. He is also a founding partner of St Charles Psychiatric Associates and an associate clinical professor at Washington University. A St Louis native, he earned his medical degree and received a Fulbright scholarship while attending Washington University. Dr Mattingly is board certified in adult and adolescent psychiatry and is a diplomat of the National Board of Medical Examiners. Dr Mattingly has been a principal investigator in over 400 clinical trials focusing on ADHD, anxiety disorders, major depression, bipolar disorder and schizophrenia. Having served on numerous national and international advisory panels, Dr Mattingly has received awards and distinctions for clinical leadership and neuroscience research. Dr Mattingly is also the President for the American Professional Society of ADHD and Related Disorders and is on the Scientific Advisory Board for the World Federation of ADHD.  

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