Adult attention deficit hyperactivity disorder

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This article is intended to focus on the condition in adults. See also main article, Attention-deficit hyperactivity disorder.

Up to half of children diagnosed with ADHD as young children continue to demonstrate notable ADD symptoms into adolesence and young adulthood.[1]

History

In the 1970s researchers began to realize that the condition now known as ADHD did not always disappear in adolescence, as was once thought.[citation needed] At about the same time, some of the symptoms were also noted in many parents of the children under treatment.[citation needed] The condition was formally recognized as afflicting adults in 1978, often informally called adult ADD, since symptoms associated with hyperactivity are generally less pronounced.[citation needed]

Overview

Adult attention-deficit disorder (also referred to as Adult ADD, Adult ADHD, ADHD, or AADD) is the common term used to describe the neuropsychiatric condition "attention-deficit hyperactivity disorder" (ADHD) when it is present in adults. Current convention refers to this condition as adult ADHD, according to the Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR), 2000 revision. It has been estimated that 5% of the global population has ADHD (including cases not yet diagnosed).[2]

Individuals with ADHD essentially have problems with self-regulation and self-motivation, predominantly due to problems with distractibility, procrastination, organization, and prioritization. The learning potential and overall intelligence of an adult with ADHD, however, are no different from the potential and intelligence of adults who do not have the disorder. ADHD is a chronic condition, beginning in early childhood and persisting throughout a person's lifetime. It is estimated that up to 70% of children with ADHD will continue to have significant ADHD-related symptoms persisting into adulthood, resulting in a significant impact on education, employment, and interpersonal relationships.

Whereas teachers and caregivers responsible for children are often attuned to the symptoms of ADHD, employers and others who interact with adults are far less likely to regard such behaviors as a symptom. In part, this is because symptoms do change with maturity; adults who have ADHD are unlikely to spend much time climbing on the furniture. Research shows that they are far more likely than average to have automobile accidents, however, and less likely to complete their education. Their significantly lower rates of professional employment are not explained by the frequent presence of coexisting psychiatric problems. [3]

Adults with ADHD are often perceived by others as chaotic and disorganized, with a tendency to require high stimulation in order to diminish distractibility and function effectively. As their coping mechanisms become overwhelmed, some individuals may turn to smoking, alcohol, or illicit drugs. As a result, many adults suffer from associated or "co-morbid" psychiatric conditions such as depression, anxiety, or substance abuse.[4] Many with ADHD also have associated learning disabilities, such as dyslexia, which contributes to their difficulties. In 2004, it was estimated that the yearly income loss for adults with ADHD, and the subsequent loss in productivity in the United States was over $77 billion USD.[5]

Many adults with ADHD are aware that "something is wrong," but are unable to find effective solutions for their symptoms. Getting a formal diagnosis of ADHD by a trained professional (usually a psychiatrist, psychologist, or general practitioner) and understanding the disorder as it applies to them, frequently offer adults with ADHD the insight about their own behaviors that they need in order to make changes. Successful treatment of ADHD is usually based on a combination of medication, behavior therapy, cognitive therapy, and skills training.[6] Associated conditions also require treatment.

ADHD in adults, as with children, is recognized as an impairment that may constitute a disability under U.S. federal disability nondiscrimination laws, including such laws as the Rehabilitation Act of 1973 and the Americans With Disabilities Act (ADA, 2008 revision), if the disorder substantially limits one or more of an individual's major life activities. For adults whose ADHD does constitute a disability, workplaces have a duty to provide reasonable accommodations, and educational institutions have a duty to provide appropriate academic adjustments or modifications, to help the individual work more efficiently and productively.[7][8]

Prevalence

In North America and Europe, it is estimated that 3-5% of adults have ADHD, but only about 10% of those have received a formal diagnosis.[9] [10] In the context of the World Health Organization World Mental Health Survey Initiative, researchers screened more than 11,000 people aged 18-44 years in ten countries in the Americas, Europe and the Middle East. On this basis they estimated adult ADHD prevalence to average 3.5% with a range of 1.2% to 7.3%, with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). They said that adult ADHD often co-occurs with other disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for the co-occurring disorders.[11]

Classification

The DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD:

1) An inattentive type
2) A hyperactive/impulsive type
3) A combined type

In order to meet the formal diagnostic criteria of ADHD, an individual must display:

at least six inattentive-type symptoms for the inattentive-type
at least six hyperactive-type symptoms for the hyperactive/impulsive type
all of the above to have the combined-type

The symptoms (see below) need to have been present since before the individual was 7 years old, and must have interfered with at least two spheres of his or her functioning (at home and at school/work, for example) over the last 6 months.

Diagnosis

The diagnosis of ADHD in adults is almost entirely a clinical one, which contributes to controversy. It requires retrospectively establishing whether the symptoms were also present in childhood, even if not previously recognized. There is no objective "test" that diagnoses ADHD. Rather, it is a combination of a careful history of symptoms up to early childhood, including corroborating evidence from family members, previous report cards, etc. along with a neuropsychiatric evaluation. The neuropsychiatric evaluation often includes a battery of tests to assess overall intelligence and general knowledge, self-reported ADHD symptoms, ADHD symptoms reported by others, and tests to screen for co-morbid conditions. Some of these include, but are not limited to the WAIS, BADDS, and/or WURS tests in order to have some objective evidence of ADHD. The screening tests also seek to rule out other conditions or differential diagnoses such as depression, anxiety, or substance abuse. "Organic" diseases such as hyperthyroidism may also present with symptoms similar to those of ADHD, and it is imperative to rule these out as well.

Generally, medical and mental health professionals follow the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. Periodic updates to the DSM incorporate changes in knowledge and treatments. [12] Under the DSM-IV (published in 1994, with corrections and minor changes in 2000), the diagnostic criteria for ADHD in adults follow the same as in children. Many professionals have speculated that in the next DSM (tentatively DSM-V), ADHD in adults may be differentiated from the syndrome as it occurs in children.

It should be noted that every normal individual exhibits ADHD-like symptoms occasionally (when tired or stressed, for example) but in order to have the diagnosis, the symptoms should be present from childhood and persistently interfere with functioning in multiple spheres of an individual's life - work, school, and interpersonal relationships. The symptoms that individuals exhibit as children are still present in adulthood, but manifest differently as most adults develop some form of compensatory mechanisms in order to adapt to their particular environment.

Symptoms

Inattentive-type

In childhood:

Forgetful during daily activities
Easily distracted by extraneous stimuli
Losing important items (e.g. pencils, homework, toys, etc.)
Not listening and not responding to name being called out
Unable to focus on tasks at hand, cannot sustain attention in activities
Avoids or dislikes tasks requiring sustained mental effort
Makes careless mistakes by failing to pay attention to details
Difficulty organizing tasks and activities
Fails to follow-through on complex instructions and tasks (e.g. homework, chores, etc.)

In adults, these evolve into:[13]

Procrastination
Indecision, difficulty recalling and organizing details required for a task
Poor time management, losing track of time
Avoiding tasks or jobs that require sustained attention
Difficulty initiating tasks
Difficulty completing and following through on tasks
Difficulty multitasking
Difficulty shifting attention from one task to another

Hyperactive/Impulsive-type

In children:

Squirms and fidgets (with hands and/or feet)
Cannot sit still
Cannot play quietly or engage in leisurely activities
Talks excessively
Runs and climbs excessively
Always on the go, as if "driven by a motor"
Cannot wait for their turn
Blurts out answers
Intrudes on others and interrupts conversations

In adults:

Chooses highly active, stimulating jobs
Avoids situations with low physical activity or sedentary work
May choose to work long hours or two jobs
Seeks constant activity
Easily bored
Impatient
Intolerant to frustration, easily irritated
Impulsive, snap decisions and irresponsible behaviors
Loses temper easily, angers quickly

Most adults have the inattentive-type, but men exhibit a tendency towards the hyperactive/impulsive-type symptoms and have predominantly the combined-type (??ref). Symptoms of ADHD can vary widely between individuals and throughout the lifetime of an individual. As the neurobiology of ADHD is becoming increasingly understood, it is becoming evident that difficulties exhibited by individuals with ADHD are due to problems with the brain known as executive functioning (see below, neurobiology). These result in problems with sustaining attention, planning, organizing, prioritizing, and impulsive thinking/decision making. These symptoms are independent of an individual's overall intelligence.

The difficulties generated by these symptoms can range from moderate to extreme. Inability to effectively structure their lives, plan simple daily tasks, or think of consequences results in various difficulties: poor performance in school & work leading to academic underachievement or getting fired, poor driving record with traffic violations and accidents, multiple relationships or marriages, legal problems, STDs, unplanned pregnancies, smoking, alcoholism, substance abuse. As problems accumulate, a negativistic self-view becomes established and a vicious circle of failure is set up. Up to 80% of adults may have some form of psychiatric comorbidity.[14] The difficulty is often due to the ADHD person's observed behaviour (e.g the impulsive types, who may insult their boss for instance, resulting in dismissal), despite genuinely trying to avoid these and knowing that it can get them in trouble. Often, the ADHD person will miss things that an adult of similar age and experience should catch onto or know. These lapses can lead others to label the individuals with ADHD as "lazy" or "stupid" or "inconsiderate".

Ultimately, this constellation of symptoms can be summarized as a deficiency in self-regulation and self-motivation, especially for the impulsive/hyperactive types. Assessment of adult patients seeking a possible diagnosis can be better than in children due to the adult's greater ability to provide their own history, input, and insight. However, it has been noted that many individuals, particularly those with high intelligence, develop coping strategies that mask ADHD impairments and therefore they do not present for diagnosis and treatment. [15]

Pathophysiology of ADHD

Over the last 10 years, research into ADHD has greatly accelerated. There is no single, unified theory that explains the cause of ADHD and research is ongoing.

It is becoming increasingly accepted that individuals with ADHD have difficulty with what neuropsychologists term "executive functioning". In higher organisms, such as humans, these functions are thought to reside in the frontal lobes. They enable us to recall tasks that need accomplishing, organize ourselves to accomplish these tasks, assess the consequences of actions, prioritize thoughts and actions, keep track of time, be aware of our interaction with our surroundings, sort out competing stimuli, and adapt to changing situations. They also enable us to judge what is "right" or "correct" as opposed to what is "wrong" or "incorrect".

(Phineas Gage, a railroad worker who in 1848 survived a large iron rod being accidentally driven through his head, is often cited as a demonstration that executive function resides in the frontal lobes, because at least one of those lobes was destroyed in Gage by the accident, after which his behavior and personality were markedly changed. However, while Gage's case certainly stimulated 19th-century thinking about the brain and the localization of its functions, most specific uses of Gage to illustrate theoretical ideas about the brain employ greatly exaggerated descriptions of his behavioral changes.)[16]

The executive functions of the brain in the frontal lobes are thought to be linked to the rest of the brain by way of the prefrontal cortex. This part of the brain is involved in working memory and linked to the limbic system, which controls our basic emotions of fear, anger, pleasure and also plays an important role in the formation of long-term memories. The nucleus accumbens is a part of the brain that is involved in our internal reward system and allows us to feel pleasure, success, or accomplishments in response to certain stimuli. Many of these interconnections are via dopaminergic pathways. For example, cocaine and amphetamines act directly on this part of the brain to stimulate dopamine release, giving users a euphoric feeling.

Several lines of research based on structural and/or functional imaging techniques, stimulant drugs, psychological interventions have identified alterations in the dopaminergic and adrenergic pathways of individuals with ADHD. In particular, areas of the prefrontal cortex appear to be the most affected. Dopamine and norepinephrine are neurotransmitters playing an important role in brain function. The receptors for dopamine and norepinephrine are overly active and clear these neurotransmitters from the synapse a lot faster than in normal individuals. This is thought to increase processing latency, diminishes working memory, and affects salience. To make an analogy, individuals with ADHD have a problem with the search engine of their brain—the "raw" data (knowledge) is all stored in the cortex, but accessing it, prioritizing it, synthesizing it, and keeping it all in mind is problematic.

Stimulants, such as methylphenidate and amphetamine act on these neurons to increase the availability of dopamine and norepinephrine for neurotransmission. They act to correct the problem with the "wiring". Methylphenidate acts by blocking an enzyme called monoamine oxidase, which neutralizes these neurotransmitters, and the receptors on the presynaptic neuron which take them back into the cell. Amphetamine acts in the same fashion, but also increases the release of these neurotransmitters into the synaptic cleft.

Treatment

Stimulant medication is an effective treatment[17] for Adult ADHD [18][19] although the response rate may be lower for adults than children.[20] Atomoxetine is an effective treatment for adult ADHD which does not have abuse potential.[21] Some physicians may recommend antidepressant drugs as the first line treatment instead of stimulants[22] although antidepressants have lower treatment effect sizes than stimulant medication. [23]

The cornerstone of treatment for adult ADHD lies in a combination of medications and behavioural, cognitive, or vocational interventions. Treatment often begins with medication selected to address the symptoms of ADHD, along with any comorbid conditions that may be present. Medications alone however are generally insufficient as they only aid in correcting the symptoms of ADHD, but do not correct the lack of "life" skills that many of these adults failed to acquire because of their ADHD. The therapeutic process itself and learning about the illness provides much benefit in adults because these can be designed more collaboratively with mature individuals. For example, being able to focus better does not automatically make one a better organizer or prioritizer, or improve their communication skills. These need to be learned once the underlying symptoms are treated. But becoming aware that a particular individual needs a quiet, distraction-free place to study for an exam, at a certain time of day, with the aid of a stimulant to help sustain attention and minimize internal distractions may be a recipe for success.

Treatment of adults also generally includes forms of stress or anxiety management. Because of a tendency to get frustrated and overwhelmed easily, and also because of the sheer amount of energy many ADHD individuals expend to live their daily lives, it is important to achieve balance between the mind and body. Regular, physical exercise is an important component of treatment for individuals with ADHD. The benefits of exercise are too numerous to list here. Various forms of meditation and biofeedback may also be of benefit.

Medications

Stimulant medications are often the 1st line treatment and are usually effective in ~80% of individuals.[24] When stimulants are prescribed low doses are generally recommended for adults with ADHD. High doses of stimulants offer no benefit and increase adverse effects.[25] Stimulants are formulated in short-acting, immediate-acting, or long-acting formulations. There is always abuse potential, especially with the short-acting forms which can potentially be injected or snorted which is why long-acting formulations are recommended. Many of these long-acting formulations prevent them from being injected or snorted. In adults, stimulants may increase the risk of adverse cardiovascular events such as myocardial infarctions (heart attacks) or hypertension (high blood pressure). Judicious use and careful, regular follow-up with a physician are therefore critically important.

Methylphenidate is often the first line therapy. In the short term, methylphenidate is well tolerated however long term safety has not been determined in adults and there are concerns about increases in blood pressure in those treated.[26]Again, careful discussion with the treating physician and good clinical judgment are important to decide on the most appropriate therapy.

Amphetamines and their derivatives are also effective in the treatment of adult ADHD. They not only block the uptake of dopamine and norepinephrine, but increase the release of these from the pre-synaptic neuron. They may have a better side-effect profile than methylphenidate, especially in terms of cardiovascular events, and are potentially better tolerated.[27]

Non-stimulant medication, such as atomoxetine, acts by inhibiting the norepinephrine transporter. It is often prescribed in adults who cannot tolerate the side-effects of amphetamines or methylphenidate. It is also effective and approved by the FDA (Food and Drug Administration). A rare but potentially severe side-effect includes liver damage and increased suicidal ideation. These should be discussed with the prescribing physician.

Research has also shown that brief psychological interventions in adults also play an important role in therapy.[28] ADHD coaching also plays an important role in enabling people with ADHD to develop structure and get things done.

See also

References

  1. ^ Karande S (2005). "Attention deficit hyperactivity disorder--a review for family physicians". Indian J Med Sci. 59 (12): 546–55. PMID 16385176. {{cite journal}}: Unknown parameter |month= ignored (help)
  2. ^ http://ajp.psychiatryonline.org/cgi/content/abstract/164/6/942
  3. ^ Anthshel, Kevin; Faraone, Steven; Kunwar, Arun (November 2008), "ADHD in Adults: How to Recognize and Treat", Psychiatric Times, 48 (12){{citation}}: CS1 maint: date and year (link)
  4. ^ http://www.psychiatrymmc.com/displayArticle.cfm?articleID=article218
  5. ^ http://news.healingwell.com/index.php?p=news1&id=521145
  6. ^ You've Got Adult ADD… Now What?, ADDitude magazine, 2007
  7. ^ U.S. Equal Employment Opportunity Commission, Enforcement Guidance: Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act
  8. ^ U.S. Department of Education, Office of Civil Rights, Questions and Answers on Disability Discrimination under Section 504 and Title II
  9. ^ The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative
  10. ^ The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication
  11. ^ Fayyad J., De Graaf R., Kessler R., Alonso J., Angermeyer M., Demyttenaere K., De Girolamo G., Haro J.M., Karam E.G., Lara C., Lepine J.-P., Ormel J., Posada-Villa J., Zaslavsky A.M., Jin R., "Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder" British Journal of Psychiatry 190, May 2007, pp402-409
  12. ^ http://kadi.myweb.uga.edu/The_Development_of_the_DSM.html
  13. ^ Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and AdultsSreenivas, Prim Care Clin Office Pract 34:317–341, 2007
  14. ^ Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and Adults. Prim Care Clin Office Pract 34:317–341, 2007
  15. ^ http://www.neuropsychiatryreviews.com/feb00/npr_feb00_ADHD.html
  16. ^ Macmillan, M. (2008). "Phineas Gage – Unravelling the myth The Psychologist ([[British Psychological Society]]), 21(9): 828-831" (PDF). {{cite web}}: URL–wikilink conflict (help)CS1 maint: numeric names: authors list (link)
  17. ^ Dusan Kolar, Amanda Keller, Maria Golfinopoulos, Lucy Cumyn, Cassidy Syer, and Lily Hechtman (2008). "Treatment of adults with attention-deficit/hyperactivity disorder". Neuropsychiatr Dis Treat. 4 (1): 107–121. PMID 18728812. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  18. ^ Spencer TJ. (2007). "Pharmacology of adult ADHD with stimulants". CNS Spectr. 12 (4(supplement 6)): 8–11. PMID 17715564. {{cite journal}}: Unknown parameter |month= ignored (help)
  19. ^ Rostain, Anthony L. (2008). "ADHD in Adults: Attention-Deficit/Hyperactivity Disorder in Adults: Evidence-Based Recommendations for Management". Postgraduate Medicine. 120 (3): 27–38. doi:10.3810/pgm.2008.09.1905. PMID 18824823. {{cite journal}}: Unknown parameter |month= ignored (help)
  20. ^ Spencer, Thomas. Biederman, Joseph. Wilens, Timothy (2004). "Stimulant treatment of adult attention-deficit/hyperactivity disorder". Psychiatric Clinics of North America. 27 (2). {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  21. ^ Simpson D, Plosker GL (2004). "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs. 18 (6): 397–401. PMID 15089111.
  22. ^ Higgins ES (1999). "A comparative analysis of antidepressants and stimulants for the treatment of adults with attention-deficit hyperactivity disorder". J Fam Pract. 48 (1): 15–20. PMID 9934377. {{cite journal}}: Unknown parameter |month= ignored (help)
  23. ^ Verbeeck W, Tuinier S, Bekkering GE. (2009). "Antidepressants in the treatment of adult attention-deficit hyperactivity disorder: a systematic review" (PDF). Adv Ther. 26 (2): 170–184. doi:10.1007/s12325-009-0008-7. PMID 19238340. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  24. ^ Spencer T, Biederman J, Wilens T, et al. 2005. A large, double-blind, randomized clinical trial of methylphenidate in the treatment of adults with attention deficit/hyperactivity disorder. Biol Psychiatry, 57:456–63.
  25. ^ Sachdev PS, Trollor JN (2000). "How high a dose of stimulant medication in adult attention deficit hyperactivity disorder?". Aust N Z J Psychiatry. 34 (4): 645–50. PMID 10954396. {{cite journal}}: Unknown parameter |month= ignored (help)
  26. ^ Godfrey J (2008). "Safety of therapeutic methylphenidate in adults: a systematic review of the evidence". J. Psychopharmacol. (Oxford). doi:10.1177/0269881108089809. PMID 18515459. {{cite journal}}: Unknown parameter |month= ignored (help)
  27. ^ Kolar D, et al. Treatment of adults with attention deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment 2008:4(2)389–403
  28. ^ Weiss M., et al. Research Forum on Psychological Treatment of Adults With ADHD. J of Att Dis 2008; 11(6) 642-651.http://jad.sagepub.com/cgi/content/abstract/11/6/642

Further reading

  • Amen, Dr. Daniel G., Healing ADD: The Breakthrough Program That Allows You to See and Heal the Six Types of ADD
  • Doyle, Dr. Brian B, Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder
  • Hallowell MD, Edward M., and Ratey, John J., Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood to Adulthood, 1994. ISBN 0684801280. ISBN 978-0684801285.
  • Hallowell MD, Edward M., and Ratey, John J., Answers to Distraction, 1995. ISBN 055337821X. ISBN 978-0553378214.
  • Hallowell MD, Edward M., and Ratey, John J., Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder, 2005. ISBN 034544230X. ISBN 978-0345442307.
  • Hartmann, Thom, Attention Deficit Disorder: A New Perspective
  • Hersey, Jane, Why Can't My Child Behave?
  • Lawlis, Frank, The ADD Answer
  • Matlen, Terry. (2005) "Survival Tips for Women with AD/HD". ISBN 1886941599
  • Solden, Sari, Women with Attention Deficit Disorder
  • Solden, Sari, "Journeys Through ADDulthood"
  • Mate, Dr. Gabor, "Scattered Minds"
  • Brown, Dr Thomas E. "Attention Deficit Disorder: The Unfocused Mind in Children and Adults", Yale University Press, Sep 2005.

External links

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