Attention deficit hyperactivity disorder in adults: review of an article.

It has long been thought that adult attention deficit/hyperactivity disorder did not continue beyond adolescence, but it is now known that this condition persists into adulthood and, in fact, exists in 3-9 percent of children and 4 percent of adults worldwide.

Studies of patients with ADHD over their lifespan do show a decrease in hyperactivity in adults but with persistence of symptoms of attentional syndromes. Not unlike some children with ADHD, adults with ADHD tend to have "executive function" defects, which include organizational problems as well as difficulties with problem solving. Adults with ADHD tend to have difficulties with educational achievement and do best if their curriculum is structured. Academic problems continue to manifest themselves as underachievement in college. Frequently, there is a history of suspension of driver's licenses for DUI and other violations.

Although the diagnostic criteria may seem unduly cumbersome and numerous, it is important that they be adhered to because of the many different etiologies of this syndrome and actual misdiagnosis because of similarities to other diagnostic etiologies.

Diagnosis of ADHD requires a minimum of six symptoms listed in Section A1 (inattention) and Section A2 (hyperactivity and impulsivity) as well as all the symptoms listed in Sections B through E, according to DSM-IV.

Diagnostic Criteria for ADHD

Section A:

For inattention, those symptoms are:

a. Often fails to give close attention to details or makes careless mistakes in school or other work

b. Often has difficulty paying close attention in games or other tasks

c. Often does not listen carefully

d. Often fails to complete schoolwork or other tasks

e. Has difficulty organizing tasks

f. Often has difficulty with tasks that require sustained activity

g. Often loses things necessary for activities or tasks

h. Is easily distracted

i. Is often forgetful in daily activities

For hyperactivity, those symptoms are:

a. Often fidgets with hands or feet

b. Often leaves seat in situations where remaining seating is expected

c. Often runs about where remaining still would be expected (or in adults excessive feelings of restlessness)

d. Often has difficulty engaging in leisure activities quietly

e. Often constantly "on the go"

f. Talks excessively

For impulsivity, those symptoms are:

a. Often blurts out answers before questions have been completed

b Often has difficulty awaiting one's turn

c. Often interrupts

Section B. Some hyperactive or inattentive criteria must have been present before age seven.

Section C. Some impairment from the symptoms must be present in at least two settings (e.g. school, home, work).

Section D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

Section E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, or schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder or a personality disorder).

General Points Regarding Diagnosis

In determining the correct diagnosis, particularly in adults where ADHD may not be suspected, 15-20 percent of adults with substance abuse disorders, anxiety, depressive disorders, and bipolar disorders have ADHD. Conversely, in primary depression, anxiety, and dementia, cognitive defects which exist as part of the disorder might be misinterpreted as being secondary to ADHD. In the reviewer's experience, however (as well as the authors), the diagnosis of ADHD may be missed more often in the context of symptoms suggesting major depression, bipolar disorder, panic, and substance abuse.

Because of the difficulty in establishing the diagnosis of autism, a variety of scales and tests have been developed. Many of these are presented on this internet site: http://www.neurodiversity.com/diagnostic_instruments.html and can be utilized to improve diagnostic accuracy.

Genetic Susceptibility to ADHD in Adults

The genetic susceptibility to ADHD is about 70 percent in all age groups and is thought to be somewhat higher in adults with ADHD (reviewers note: this means that 70 percent of patients diagnosed with ADHD will have a positive family history and emphasizes the importance of a family history in adults who have ADHD as a possible basis of their symptoms as discussed above). Genetic studies of children and adults with ADHD have found evidence for the involvement of the D2 dopamine-receptor gene, the SNAP-25 and the D4 dopamine receptor gene. The D4 receptor gene associated with ADHD is important because of its association with the blunted response to norepinephrine and dopamine. Such a blunted response is part of the putative cause of ADHD.

The Influence of Perinatal Factors in the Incidence of ADHD

Since the publication of the article under review, a review published in the Mayo Clinic Proceedings (St. Sauver-2004) investigated the relationship between the characteristics of labor and delivery on the incidence of ADHD. The investigators found there was no relationship between such factors as length of labor, breech presentation, and breech delivery. In addition, they investigated the relationship between twinning and ADHD and found that none existed.

Brain Anomalies in Adults with ADHD

It has been known for some time that defects in tasks requiring vigilance, motoric inhibition, organization, planning, complex problem solving ability, verbal learning, and memory exist in children with ADHD. Recent studies have shown similar problems in adults with ADHD. The following points representing the current neurophysiological and neurological thinking underlying the above findings are as follows:

* defects in the cingulate cortex, which plays a role in motivational aspects of attention and in response selection and inhibition.

* a system mainly involving the right prefrontal and parietal cortex which is activated during sustained attention across different modalities is thought to be defective.

* the inferior parietal lobe and superior temporal sulcus, areas that provide a representation of extrapersonal space which plays an important role in focusing on a target stimulus, has been thought to be a factor.

* the reticular activating system and the reticular thalamic nuclei have also been implicated since they regulate attention (it is important, in the reviewer's opinion, to be familiar with the pathophysiology of ADHD because future therapeutic advances may be dependent on such knowledge, but the authors fail to provide information about whether such information is based on gross or micropathology, neuropsychological, or neurophysiological studies)

Neuroimaging Studies

Neuroimaging studies, which are again compatible with a diagnosis of ADHD but not conclusively diagnostic, are as follows:

* smaller volumes in the frontal cortex, cerebellum, and subcortical structures.

* functional imaging systems suggest that fronto-cortical systems are part of the pathophysiology of ADHD. If the readers of this review (as does the reviewer) suggest that neuroimaging studies are compatible with ADHD but not diagnostic, these studies may be of value in determining the pathophysiology and future treatment possibilities for ADHD. Structures such as the caudate, putamen, and globus pallidus serve as inhibitors or modulators of behavior and have found to be abnormal. Such studies may also provide a means of determining the proper diagnosis of such patients. They (the functional varieties of MRI scans at any rate) are quite expensive, and the proper diagnosis may often be made in adults by at least considering it based on clinical criteria rather than resorting to an MRI. (reviewer's comment).

Treatment of ADHD

For accurate details regarding dosage and treatment alternatives, it is suggested that the reader refer to the original article. In general, the medications used to treat ADHD affect neurotransmission of catecholamines, including dopamine and norepinephrine. The categories of medications approved for adult use only include mixed amphetamine compounds and the noradrenergic specific reuptake inhibitor, atomoxetine. Other types of agents that have been approved for all age groups include antidepressants and cholinergic agents. The stimulant agents--amphetamine, methylphenidate, and pemoline--block the presynaptic reuptake of dopamine and norepinephrine in the synaptic cleft. Amphetamine releases dopamine and norepinephrine directly.

Comments

This is a valuable paper for clinicians (or their patients) interested in developmental disabilities primarily for two reasons: a) ADHD, which has been thought until recently to occur almost exclusively in children has now been shown to occur in a substantial number of adults. b) behavioral problems occur frequently in the context of developmental disabilities in adults and may occasionally be due to ADHD resulting from another developmental disability. Alternatively, the cause of the behavioral problems may actually be due to the "primary" developmental disability of unknown etiology as described above (or one of the other causes, such as drug abuse, as described in the article).

The clinical characteristics of ADHD in adults are somewhat different. The principal difference seems to be that a greater percentage of adults have the inattentive variety.

To what extent imaging is useful in actually making the diagnosis (except to rule out other causes of the patient's developmental disorder) is problematical except in the hands of an expert neuroradiologist. My personal opinion is that the patient's history is extremely valuable, particularly since there is a family history in 70 percent of patients.

It goes without saying that the value of a proper diagnosis to the patient is great since a proper diagnosis may require the use of a different category of medication (i.e stimulants) than would ordinarily be considered. Furthermore, dramatic results can be anticipated in a significant number of cases. It is particularly important to graph the patients daily progress based on objective parameters (such as the number of instances of inattentiveness or the degree of restlessness based on an objective scale).

Recent literature has emphasized an increase in the number of cases of ADHD in both children and adults, probably based on increased knowledge of diagnostic criteria. It is very important to rule out other conditions when making the diagnosis, whether it is a problem of a mistaken diagnosis or a comorbid condition. Examples include hyperthyroidism, central nervous system problems, and manic depressive or borderline conditions. It cannot be stressed too highly that since this is a disorder of eclectic etiology, patients may respond to different groups of medication so there may be some therapeutic trial and error involved.

REFERENCE

Wilens T., Faraone S., Biederman J: Attention Deficit-Hyperactivity Disorder in Adults. JAMA 2004; 292:619-623.

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Upon completion of the reading of this article the learner will be able to:

1. Appreciate the influence of family history in making the diagnosis of ADHD in adults.

2. Describe the criteria for making a DSM-IV-tr diagnosis of ADHD.

3. Describe the comorbid conditions, which complicate the diagnosis of ADHD in an adult.

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NEDD RAPP, M.D, PENN VALLEY, PENNSYLVANIA