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

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). ^[1]

Individuals with ADHD essentially have problems with self-regulation and self-motivation, predominantly due to problems with distractibility, procrastination, organization, and prioritization. The individual's learning potential and overall intelligence, however, is no different from those without 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.

Adults with ADHD are often perceived as chaotic and disorganized, with a tendency to require high stimulation in order to diminish distractibility and function effectively. As 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. ^[2] 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.^[3]

Many adults are aware that "something is wrong", but are unable to find effective solutions. 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 offers an adult insight into their own behaviors in order to effect the changes they need. Successful treatment of ADHD is usually based on a combination of medication, behavior therapy, cognitive therapy, and skills training.^[4] Associated conditions also require treatment.

ADHD in adults, as with children, is recognized as a disability under U.S. federal legislation including the Rehabilitation Act of 1973 and the Americans With Disabilities Act (ADA). Appropriate and reasonable accommodations are sometimes made in the workplace or educational institutions for adults with ADHD, which help the individual work more efficiently and productively.

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.^[5] ^[6] 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.^[7]

Classification

The DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition defines 3 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 meet:

at least 6 inattentive-type symptoms for the inattentive-type

at least 6 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 age of 7 and interfere with at least 2 spheres of 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 comorbid 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. ^[8] 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 we are 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 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:^[9]

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.^[10] 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, these 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. ^[11]

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.)^[12]

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 and enzyme called monoamine oxidase, which neutralizes these neurotransmitters, and the receptors on the presynpatic 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

There have been a number of clinical trials of stimulants for ADHD. Some studies have shown benefit whereas others have produced conflicting results. More research is needed to determine whether adult ADHD responds to stimulants.^[13] Atomoxetine is an effective treatment for adult ADHD which does not have abuse potential.^[14] Certain treatments have proven effective, whereas others have not, and some treatments may in fact be deleterious.

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. Mindfulness, a form of meditation, can also help with ADHD.^[15]

Medications

Stimulant medications are often the 1st line treatment and are usually effective in ~80% of individuals.^[16] When stimulants are prescribed low doses are generally recommended for adults with ADHD. High doses of stimulants offer no benefit and increase adverse effects.^[17] 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.^[18] 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.^[19]

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.^[20] ADHD coaching also plays an important role in enabling people with ADHD to develop structure and get things done.

References

^ http://ajp.psychiatryonline.org/cgi/content/abstract/164/6/942
^ http://www.psychiatrymmc.com/displayArticle.cfm?articleID=article218
^ http://news.healingwell.com/index.php?p=news1&id=521145
^ You've Got Adult ADD… Now What?, ADDitude magazine, 2007
^ 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
^ The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication
^ 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
^ http://kadi.myweb.uga.edu/The_Development_of_the_DSM.html
^ Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and AdultsSreenivas, Prim Care Clin Office Pract 34:317–341, 2007
^ Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and Adults. Prim Care Clin Office Pract 34:317–341, 2007
^ http://www.neuropsychiatryreviews.com/feb00/npr_feb00_ADHD.html
^ 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)
^ Maidment ID (2003). "Efficacy of stimulants in adult ADHD". Ann Pharmacother. 37 (12): 1884–90. doi:10.1345/aph.1D028. PMID 14632541. {{cite journal}}: Unknown parameter |month= ignored (help)
^ Simpson D, Plosker GL (2004). "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs. 18 (6): 397–401. PMID 15089111.
^ http://marc.ucla.edu/body.cfm?id=16
^ 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.
^ 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)
^ 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)
^ Kolar D, et al. Treatment of adults with attention deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment 2008:4(2)389–403
^ 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

External links

National Institute for Mental Health official website
National Mental Health association, AADD webspage
National Attention Deficit Disorder Association
CHADD Support groups, national education devoted to helping and supporting people with ADD and ADHD
Living with ADD/ADHD
ADDults with ADHD (Australian)
Today Show segment on adult ADHD, June 5, 2008
www.aadd.org.uk Adults with Attention Deficit Disorder UK
ADDitude magazine Adult ADHD Information
www.lbctnz.co.nz Complete informational guide to add/adhd and dyxlexia. NZ

[The_Worldwide_prevalance_of_ADHD-1] ttp://ajp.psychiatryonline.org/cgi/content/abstract/164/6/942

[psychiatrymmc.com-2] ttp://www.psychiatrymmc.com/displayArticle.cfm?articleID=article218

[3] ttp://news.healingwell.com/index.php?p=news1&id=521145

[additudemag.com-4] You've Got Adult ADD… Now What?, ADDitude magazine, 2007

[5] 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

[6] The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication

[7] 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

[8] ttp://kadi.myweb.uga.edu/The_Development_of_the_DSM.html

[9] Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and AdultsSreenivas, Prim Care Clin Office Pract 34:317–341, 2007

[10] Katragadda S. and Schubiner H. ADHD in Children, Adolescents, and Adults. Prim Care Clin Office Pract 34:317–341, 2007

[neuropsychiatryreviews.com-11] ttp://www.neuropsychiatryreviews.com/feb00/npr_feb00_ADHD.html

[12] 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)

[13] Maidment ID (2003). "Efficacy of stimulants in adult ADHD". Ann Pharmacother. 37 (12): 1884–90. doi:10.1345/aph.1D028. PMID 14632541. {{cite journal}}: Unknown parameter |month= ignored (help)

[14] Simpson D, Plosker GL (2004). "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs. 18 (6): 397–401. PMID 15089111.

[15] ttp://marc.ucla.edu/body.cfm?id=16

[16] 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.

[17] 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)

[18] 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)

[19] Kolar D, et al. Treatment of adults with attention deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment 2008:4(2)389–403

[20] 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

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 ==Treatment==
-There have been a number of clinical trials of stimulants for ADHD. Some studies have shown benefit whereas others have produced conflicting results. More research is needed to determine whether adult ADHD responds to stimulants.<ref>{{cite journal |author=Maidment ID |title=Efficacy of stimulants in adult ADHD |journal=Ann Pharmacother |volume=37 |issue=12 |pages=1884–90 |year=2003 |month=December |pmid=14632541 |doi=10.1345/aph.1D028 |url=}}</ref> Certain treatments have proven effective, whereas others have not, and some treatments may in fact be deleterious.
+There have been a number of clinical trials of stimulants for ADHD. Some studies have shown benefit whereas others have produced conflicting results. More research is needed to determine whether adult ADHD responds to stimulants.<ref>{{cite journal |author=Maidment ID |title=Efficacy of stimulants in adult ADHD |journal=Ann Pharmacother |volume=37 |issue=12 |pages=1884–90 |year=2003 |month=December |pmid=14632541 |doi=10.1345/aph.1D028 |url=}}</ref> [[Atomoxetine]] is an effective treatment for adult ADHD which does not have abuse potential.<ref>{{cite journal |author=Simpson D, Plosker GL |title=Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder |journal=CNS Drugs |volume=18 |issue=6 |pages=397–401 |year=2004 |pmid=15089111 |doi= |url=}}</ref> Certain treatments have proven effective, whereas others have not, and some treatments may in fact be deleterious.
 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.