ADHD and the Stages of Life

NYU Langone Psychiatrists Are Leading the Efforts to Diagnose and Treat ADHD through the Life Span

Psychiatrists at NYU Langone helped create the World Health Organization ADHD Self-Report Scale Screener to better identify at-risk adults in the general population.

Age-appropriate screens and psychosocial interventions for attention deficit hyperactivity disorder (ADHD) developed by psychiatrists at NYU Langone Medical Center are helping physicians to better diagnose ADHD across the life span.

“The charge is to make an appropriate ADHD diagnosis, use appropriate treatments for the patients, and measure symptoms at baseline and throughout the course of treatment to document any changes,” explains Lenard A. Adler, MD, professor of psychiatry and child and adolescent psychiatry, and director of the Adult ADHD Program at NYU Langone.

The minimum threshold of successful treatment is a 30 percent improvement in the full spectrum of ADHD symptoms, but the goal should be as high as 50 percent, he says. If the patient is not improving, options may include adding a new medication, tweaking dosing of existing medication, and/or implementing another treatment modality.

“All of medicine is driven by outcome measures. That is where our symptom checklist comes in,” he says. “We can’t just say patients are better. We have to show it.”The clinical instruments developed by the adult and child psychiatrists at NYU Langone are increasingly helping others in the field do just that.Dr. Adler helped create the World Health Organization Adult ADHD Self-Report Scale (ASRS-v1) Screener to better identify at-risk adults in the general population. This six-question prescreening tool, which identifies six symptoms of ADHD, is now translated into 22 languages. A patient who screens positive on the ASRS-v1 has a 53 to 94 percent chance of having ADHD, he says. The next step is a longer, 18-item symptom checklist (ASRS-v1.1), which is designed to pick up any of the additional symptoms. “If you don’t know the symptoms, you can’t assess impairment, which is another critical aspect of making the diagnosis,” Dr. Adler says.

On the pediatric side, Howard Abikoff, PhD, the Pevaroff Cohn Professor of Child and Adolescent Psychiatry and director of the Institute for Attention Deficit Hyperactivity and Behavior Disorders at the Child Study Center at NYU Langone, pioneered with his colleague Richard Gallagher, PhD, the Children’s Organizational Skills Scale (COSS), which can identify problems with organization, time management, and planning. About 50 percent of children with ADHD have organizational deficits that affect their school performance. “We are not just looking at symptoms. We are looking to see what type of functional impairments they cause,” Dr. Abikoff says.

Making the correct diagnosis also involves clinical evaluation. For example, as many as 50 percent of adults with ADHD have one or more comorbidities, such as severe depression or bipolar disorder. “ADHD is present throughout the patient’s whole life, whereas the comorbidities tend to be episodic, so we must look for symptoms that start before the onset of the comorbidity or that persist after the comorbidity is quiescent,” Dr. Adler says. “The clinician has to take a longitudinal retrospective history because the routes of ADHD lie in childhood.”

Collateral information can also help doctors sift through layers of comorbidities and make a definitive diagnosis of ADHD. “A good clinician, if they obtain the right information from the right sources, is better able to make the differential diagnosis,” says Dr. Abikoff. 

Once ADHD is properly diagnosed, medication is only one part of an effective treatment strategy. “Medications can take care of the symptoms of inattention, distraction, and restlessness, but they are often not as effective for treating executive dysfunction,” says Dr. Adler. He is now validating the adult correlate of a skills training psychosocial intervention that seeks to improve higher-level cognitive function, working memory, time management, emotional control, and other markers of executive function. “We are trying to create an easier-access, five-session manual based on some of the principles of cognitive behavioral therapy that can be utilized by all healthcare providers, not just psychiatrists.”

Dr. Abikoff’s group is field testing an organizational skills training (OST) program that he and Dr. Gallagher developed and that can be used by therapists across multiple settings. The OST program uses task analysis and behavioral skills training to teach effective organizational strategies to help third-, fourth-, and fifth-graders diagnosed with ADHD who are experiencing difficulties with organization, time management, and planning tasks. Results from a large study funded by the National Institute of Mental Health indicated that about 60 percent of children treated with the OST program improved to the point that their organizational functioning was no longer impaired, and this led to improvements in academic performance. Patients who participated in a contingency management program also showed marked improvement. The next step is to determine which method works best in which children and why.

“The field of healthcare is moving toward personalized medicine. Our approach to children and families is highly individualized care based on evidence-based practice,” says Glenn S. Hirsch, MD, assistant professor of child and adolescent psychiatry and vice chair for clinical affairs at NYU Langone’s Child Study Center. “At every step of the way, we take into account all aspects of the patient’s symptoms and the symptoms’ impact on their world, and we carefully tailor our treatment to the needs of the individual and their family.”