Adult attention deficit hyperactivity disorder
Adult attention deficit hyperactivity disorder (also referred to as Adult ADHD, Adult ADD or simply ADHD in adults) is the neurobiological condition of attention-deficit hyperactivity disorder (ADHD) in adults. About one-third to two-thirdsp. 87 of children with symptoms from early childhood continue to demonstrate notable ADHD symptoms throughout life.
Three subtypes of ADHD are identified in the DSM-IV (inattentive, hyperactive/impulsive, and combined). In later life, the hyperactive/impulsive subtype manifests more frequently.p44 Symptoms include distractibility, impulsivity and restlessness, which impair executive functions – management of memory and approach to tasks, causing persistent and significant impairment among different areas of life.
Diagnosis of the condition includes assessment by clinicians, with examination of personal history, observational evidence from family members and report cards going back to school years etc., and neuropsychological tests as well as evaluation to rule out other possibilities or diagnose co-morbid (coincident) conditions.
The condition is highly heritable,p32 and while its exact causes are not fully known, genetic and environmental factors are understood to play a part. ADHD is a childhood-onset condition, usually requiring symptoms to have been present before age seven for a diagnosis. Children under treatment will migrate to adult health services if necessary as they transit into adulthood, while diagnosis of adults involves full examination of their history.
Successful treatment of ADHD is usually based on a combination of medication, cognitive behavioral therapy, and coaching or skills training. Within school and work, reasonable accommodations may be put in place to help the individual work more efficiently and productively.
Early work on disorders of attention was conducted by Alexander Crichton in 1798 writing about "mental restlessness". The underlying condition came to be recognized from the early 1900s by Sir George Still.p. 6 Efficacy of medications on symptoms was discovered during the 1930s and research continued throughout the twentieth century. ADHD in adults began to be studied from the early 1970s and research has increased as worldwide interest in the condition has grown.
The DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD:
To meet the 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 seven years old, and must have interfered with at least two spheres of his or her functioning (at home and at school or work, for example) over the last six months. The DSM-IV criteria for ADHD are, however, tailored towards the type of symptoms that children would show, and might therefore underestimate the prevalence of ADHD in adults.
Signs and symptoms
Individuals with ADHD have deficiencies with self-regulation and self-motivation, that cause 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 60% 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 less likely to exhibit obvious hyperactive behaviors.
Adults with ADHD are often perceived by others as chaotic and disorganized, with a tendency to need high stimulation to be less distracted and function effectively. Additionally, many adults suffer from associated or "co-morbid" psychiatric conditions such as depression or anxiety. Many with ADHD also have associated learning disabilities, such as dyslexia, which contributes to their difficulties.
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 parts of the brain responsible for executive functions (see below: Pathophysiology). These result in problems with sustaining attention, planning, organizing, prioritizing, and impulsive thinking/decision making.
The difficulties generated by these symptoms can range from moderate to extreme. Inability to effectively structure their lives, plan daily tasks, or think of consequences results in various difficulties: poor performance in school and work leading to underachievement in these areas, in young adults poor driving record with traffic violations, as well as histories of alcoholism or 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. 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 seek diagnosis and treatment.
|Inattentive-type (ADHD-I)||Hyperactive/Impulsive-type (ADHD-H)|
|In adults, these evolve into:
The diagnosis of ADHD in adults is a clinical one, which contributes to controversy. It requires retrospectively establishing whether the symptoms were also present in childhood, even if not previously recognized. As with other mental disorders such as schizophrenia 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, Connors 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 exhibit symptoms similar to those of ADHD, and it is imperative to rule these out as well. Asperger syndrome, a condition on the autism spectrum, is sometimes mistaken for ADHD, due to impairments in executive functioning found in some people with Asperger syndrome. However, Asperger syndrome also typically involves difficulties in social interaction, restricted and repetitive patterns of behavior and interests, and problems with sensory integration, including hypersensitivity.
United States medical and mental health professionals follow the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association; the International Classification of Diseases (ICD) published by the World Health Organisation (WHO) is often used by health professionals elsewhere. Periodic updates incorporate changes in knowledge and treatments. For example, under DSM-IV (published in 1994, with corrections and minor changes in 2000), the diagnostic criteria for ADHD in adults broadly follow the same as in children, but the proposed revision for the DSM-5 differentiates the presentation of ADHD for children and adults for several symptoms.
It should be noted that every normal individual exhibits ADHD-like symptoms occasionally (when tired or stressed, for example) but 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 compensatory mechanisms to adapt to their environment.
Over the last 30 years, research into ADHD has greatly accelerated. There is no single, unified theory that explains the cause of ADHD and research is ongoing. Genetic and environmental factors are thought to play a part.
It is becoming increasingly accepted that individuals with ADHD have difficulty with what neuropsychologists call "executive functioning". In higher organisms, such as humans, these functions are thought to reside in the frontal lobes. They enable recall of tasks that need accomplishing, organization to accomplish these tasks, assessment of consequences of actions, prioritization of thoughts and actions, keeping track of time, awareness of interactions with surroundings, the ability to focus despite competing stimuli, and adaptation to changing situations. They are also required for the ability 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, or completely counterfactual, descriptions of his behavioral changes.
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 the 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 the internal reward system and allows the feeling of pleasure, success, or accomplishment 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 uptake transporters 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.
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 the dopamine and norepinephrine transporters, thus slowing the pace at which these neurotransmitters are cleared from the synapse. Amphetamine acts in a similar fashion, but also increases the release of these neurotransmitters into the synaptic cleft by temporarily reversing the uptake process.
Stimulant medication is the first-line treatment for Adult ADHD. The non-stimulant Atomoxetine is also an effective treatment for adult ADHD, without the abuse potential of stimulant medication. Some physicians may recommend certain antidepressant drugs instead of stimulants, though antidepressants have lower treatment effect sizes than stimulant medication. Moclobemide, desipramine and buproprion are antidepressants that have demonstrated evidence of effectiveness in the management of ADHD especially when there is comorbid major depression.
Treatment for adult ADHD may combine medication and behavioral, 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. Medication alone, while effective in correcting the physiological symptoms of ADHD, will not address the paucity of skills which many adults will have failed to acquire because of their ADHD (e.g., one might regain ability to focus with medication, but skills such as organizing, prioritizing and effectively communicating have taken others time to cultivate).
Stimulants are formulated in short-acting, immediate-acting, or long-acting formulations. While many of the long-acting formulations prevent them from being injected or insufflated, the short-acting forms carry a higher abuse potential, as they can potentially be injected or insufflated. 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.
The stimulant methylphenidate (or MPH) 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. 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.
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 US 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.
Treatment of adult ADHD may also include forms of stress management or relaxation training.
Research has shown that, alongside medication, psychological interventions in adults can be effective in reducing symptomatic deficiencies. Emerging evidence suggests a possible role for cognitive behavioral therapy (CBT) alongside medication in the treatment of adult ADHD.
Efficacy of neurofeedback in treating attentional deficit in adults has been demonstrated in an outcome study. Research has also shown that neurofeedback outcomes compare favorably to those of stimulant medications. The UK National Institute for Clinical Excellence reviewing their guidelines for ADHD in late 2011 determined new trials research on its use was interesting although further evidence was needed before recommendations could be made for its NHS use in ADHD.
In North America and Europe, it is estimated that three to five percent of adults have ADHD, but only about ten percent of those have received a formal diagnosis. It has been estimated that 5% of the global population has ADHD (including cases not yet diagnosed). In the context of the World Health Organization World Mental Health Survey Initiative, researchers screened more than 11,000 people aged 18 to 44 years in ten countries in the Americas, Europe and the Middle East. On this basis they estimated the adult ADHD proportion of the population to average 3.5 percent with a range of 1.2 to 7.3 percent, with a significantly lower prevalence in low-income countries (1.9%) compared to high-income countries (4.2%). The researchers concluded that adult ADHD often co-occurs with other disorders, and that it is associated with considerable role disability. Although they found that few adults are treated for ADHD itself, in many instances treatment is given for the co-occurring disorders.
In the 1970s researchers began to realize that the condition now known as ADHD did not always disappear in adolescence, as was once thought. At about the same time, some of the symptoms were also noted in many parents of the children under treatment. The condition was formally recognized as afflicting adults in 1978, often informally called adult ADD, since symptoms associated with hyperactivity are generally less pronounced.
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.
In a 2004 study it was estimated that the yearly income discrepancy for adults with ADHD was $10,791 less per year than high school graduate counterparts and $4,334 lower for college graduate counterparts. The study estimates a total loss in productivity in the United States of over $77 billion USD. By contrast, loss estimations are $58 billion for drug abuse, $85 billion for alcohol abuse, and $43 billion for depression.
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