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Attention Deficit Hyperactivity Disorder in Adults

LukeNotes, November/December 2005

Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder primarily characterized by developmentally inappropriate levels of sustained attention, and/or hyperactivity/impulsivity. Symptoms commonly reported by individuals with ADHD include: difficulty staying attentive and focused, especially while reading; trouble sustaining alertness, effort, and motivation; difficulty with getting organized, prioritizing, and activating tasks; difficulty inhibiting impulses and modulating emotions (e.g.,anger getting out of control); deficits in working memory (i.e. ,the ability to hold something in mind while doing something else) and in prospective memory (i.e.,remembering to do a task in the future); and difficulty flexibly addressing problems and pursuing long-term goals. Subtypes of ADHD include the predominantly inattentive type (approximately 90% of diagnosed adults,) the predominantly hyperactive/impulsive type, and the combined type.

Situational variables can have a major determining effect on the symptoms that will be displayed. Typically, individuals with ADHD function better in one-on-one situations, when engaged in activities that they enjoy or find interesting, when there is a pay off for behaving well, when they are supervised, and when their work is done earlier rather than later in the day.

The onset of ADHD occurs in childhood (usually prior to the age of seven) and occurs in about 3%-9% of children and adolescents, with  boys outnumbering girls approximately 3:1. The gender ratio among adults is 2:1 or lower. Approximately 30%-70% of children with ADHD will continue to have symptoms throughout adulthood. Several conditions tend to co-occur with ADHD. Among untreated adults with ADHD, 33% suffer from depression, 33% have significant anxiety, 50% have a substance abuse disorder, 31% display evidence of problems with temper, affective lability and emotional over-reactivity, 25-45% have learning disabilities, and 10% suffer from bipolar disorder. It is noteworthy that as many as 40% of adults who believe they have ADHD and seek professional services are not diagnosed with ADHD after extensive evaluation. This finding highlights the fact that there are numerous reasons why a person may be inattentive, distractible, impulsive, disorganized, or forgetful, only one of which is ADHD. Consequently, a diagnostic evaluation of an adult with suspected ADHD should be comprehensive enough to rule out alternative causes of ADHD-like symptoms.

Causes of ADHD

There is a strong genetic contribution to ADHD. Approximately 80% of the primary ADHD traits-inattention, hyperactivity, and impulsivity-are due to genetic factors. Environmental factors account for only about 6%. Non-hereditary factors that can contribute to the risk of having ADHD include difficulties during pregnancy, prenatal exposure to alcohol and tobacco smoke, premature delivery, excessive low birth weight, excessive high body lead levels, and postnatal injury to the prefrontal regions of the brain.

Impact of ADHD

Russell Barkley describes individuals with ADHD as having problems in four areas: 1) difficulty with hindsight and foresight, 2) problems separating the emotional aspects of a situation from the informational content, 3) decreased ability to use internal language or thought to guide their behavior, and 4) difficulty analyzing problem situations, breaking them down into component parts, and difficulty recombining them to develop creative solutions to their problems. Individuals with ADHD are frequently unable to withhold a reaction; there is little or no delay between an event and their response to it. Several research studies have characterized ADHD as a disorder arising from deficits in executive functioning, primarily mediated by the frontal lobes of the brain, and some connections with structures  deep in the brain. A broad range of abilities falls under the heading of executive functions, including working memory, planning, foresight, initiation, inhibition, organization, resistance to distraction, problem solving, future-directed behavior, flexibility, and strategy development.

Diagnosis and Treatment

There is no single test or test battery that can definitively determine whether an adult has ADHD. The evaluation process is further complicated by the fact that most adults, at one time or another, experience ADHD-like symptoms. A typical evaluation for ADHD includes a detailed developmental history and diagnostic interview, completion of ADHD symptoms rating scales by the individual being evaluated and by a collateral source, collateral interviews, and administration of a computerized continuous performance test. As many as 75% of adults with ADHD experience a  marked reduction in problematic symptoms when treated with stimulant medications such as Ritalin, Dexedrine, Concerta, or Adderall. Strattera, a recently developed non-stimulant ADHD medication, is effective in treating ADHD. Certain antidepressants, namely Desipramine and Wellbutrin, may be effective in managing ADHD-related symptoms. Effective treatment of adults with ADHD requires simultaneous focus on multiple levels. In addition to medication, psychotherapy is needed to deal with low self-esteem, shame and self-blame, demoralization, developing life management skills, organizational techniques and coping strategies, relationship and workplace problems and poor time management. Depression, anxiety, learning disorders and other conditions that have a high frequency of co-occurrence with ADHD must also be addressed.