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An exploratory clinical study of adult attention deficit/hyperactivity disorder from India.

Background & objectives: Although adult attention-deficit/hyperactivity disorder (ADHD) is well recognized in western countries, there are no reports of adult ADHD from India. Therefore, this study was planned to identify ADHD in adults in an Indian psychiatry outpatient setting and elicit its phenomenology and co-morbidities.

Methods: A total of 283 adults were screened using Adult ADHD Self-Report Scale-v1.1 (ASRSV1.1) screener. Screen positives were evaluated on ASRSv1.1 symptom checklist, World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) and by clinical assessments. DSM-IV-TR and Wender-Utah criteria were used for diagnosis.

Results: Twenty five men (mean age [+ or -] SD, 23.4 [+ or -] 5.6 yr) were diagnosed as having adult ADHD. The subjects' most common presentations were of losing temper and poor academic performance. The most common ADHD symptoms were difficulty in sustaining attention, easy distractibility, often losing things, and blurting out answers. A majority (80%) of the subjects had one or more psychiatric co-morbidity like oppositional defiant disorder, major depressive disorder and substance abuse/dependence.

Interpretation & conclusion: Adult ADHD can be diagnosed in an Indian psychiatry outpatient setting. ADHD adults infrequently presented with the core symptoms of the disorder and had high psychiatric co-morbidity rates.

Key words Adult ADHD--co-morbidity--phenomenology

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Attention-deficit/hyperactivity disorder (ADHD) was considered primarily a disorder occurring in the childhood and individuals with ADHD inevitably outgrew the disorder (1). However, both longitudinal studies in children with ADHD and retrospective studies in adults with ADHD indicate that the disorder persists in adulthood, often with serious consequences (2,3). ADHD has been largely reconceptualized as a lifespan disorder and adult ADHD is now considered to be a valid disorder, which can be reliably diagnosed and effectively treated (4,5). However, there is scarcity of information/data on adult ADHD from India.

Children are diagnosed with ADHD in routine psychiatry practice in India (6,7). As these children grow, they become adult ADHD patients. Identifying and treating them would reduce the burden of this disorder and may help in better management of the co-morbid conditions in these patients. Therefore, this preliminary study was planned in a psychiatry outpatient setting of a university department of psychiatry in northern India with the aim to identify adult ADHD cases and elicit their phenomenology and co-morbidities.

Material & Methods

This cross-sectional, clinic based study was carried out at the Department of Psychiatry, K.G. Medical University, Lucknow, from September 2004 to March 2006. The inclusion criteria were, (i) age between 18 to 45 yr, (ii) diagnosis of non psychotic psychiatric disorder, and (iii) completion of at least eight years of formal schooling. Exclusion criteria included presence of a severes psychiatric or medical illness, which could impair the subject's capacity to understand the questions in the self-report questionnaires to be used in the assessment process. Patients with psychoactive substance use in severe withdrawal or intoxicated state were also excluded from the study for the same reason. The study protocol was approved by the institutional ethics committee.

A non systematic and purposive sample was collected for the study from four different sources with the aim of identifying the maximum number of adult ADHD patients. The sources were: (i) Up to 5 old or newly registered patients meeting the above criteria were screened from the adult general psychiatric outdoor on Saturday each week (number of patients screened 119), (ii) Based on the assumption that adult ADHD is frequently co-morbid with substance use disorders (8), newly registered patients attending the de-addiction outdoor on two days (Tuesday and Thursday) in a week were also screened (number of patients screened 28), (iii) Considering the high familial risk of ADHD (9), parents and other adult first-degree relatives of all current, old or newly registered, patients of ADHD consulting the child and adolescent psychiatric OPD (Monday, Wednesday and Friday) were screened (number of patients screened 107), and (iv) Referrals of adults suspected of having ADHD by the psychiatrists or the psychiatry residents (number of patients screened 29).

The Adult ADHD Self-Report Scale (ASRSv1.1) (10) screener was translated into Hindi. ASRS v 1.1 screener requires that the first three items to be present at least "sometimes" and the next three to be present "often" to qualify for a screen positive status. Informed consent was taken from all the screen positives for further evaluation, which was subsequently done on mutually convenient appointments.

A total of three to four appointments, each of about two hours duration, were given to each of the screen positive adults and their family members. Information regarding details of identification, socio-demographic details, chief complaints, history of present illness, history of past illness, family history, personal history and premorbid personality was obtained and recorded on a semi-structured proforma along with the findings of physical examination. Wherever possible, a time-line was made to assess functioning of the screen positives in the various phases of their lives. Special attention was paid to the progression of the symptoms of ADHD from childhood to adult life. The parents of the screen positives, if available, were contacted to get details about their childhood period. Mental status examination was done by administering the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI)--Hindi version (11). WMH-CIDI has been translated in Hindi and back translated in English by independent translators. Then both the original English version and English back translation were compared and found comparable. The Hindi version was used in Hindi speaking areas in a multicenter epidemiological study of WHO. Disorders not included in the WMH-CIDI were assessed clinically (e.g., schizophrenia, antisocial personality disorder, somatoform disorders, dissociative disorders). ASRSv1.1 Symptom Checklist (10) was used for further detailed assessment of ADHD phenomenology. Subjects were referred to a clinical psychologist for assessment of intelligence when deemed necessary. Mental status examination for ADHD (12) was carried out by giving all the subjects age appropriate tasks. Global Assessment of Functioning scale (GAF) (13) was applied to assess the global functioning of the subjects.

The diagnosis of adult ADHD, various co-morbid disorders, and the differential diagnosis were made using Diagnostic and Statistical Manual of Mental Disorders--4th edition text revision (DSM-IV-TR) criteria (13). Wender-Utah criteria (4) for adult ADHD were also applied to all adult ADHD subjects because their clinical descriptions of adult ADHD are much more appropriate. IQ assessment was done using Raven's Standard Progressive Matrices (14).

Results

A total of 283 eligible persons were screened. Of these, 225 (77%) were males; 35 persons were found screen positive. Of these 35, 25 were diagnosed with adult ADHD after detailed evaluation, and 10 were kept in the differential diagnosis group (persons presenting with symptoms of inattention or hyperactivity or impulsivity who were not diagnosed with adult ADHD).

All 25 adult ADHD subjects were men (mean age [+ or -] SD, 23.4 [+ or -] 5.6 yr), a majority unmarried (18, 72%) and urban (17, 68%). Fourteen (56%) subjects were not directly involved in academic tasks and only 10 (40%) were employed. IQ assessment was done in 9 subjects (14). Their mean IQ was 100.6 [+ or -] 6.2.

Only 6 (24%) subjects presented with the core symptoms of ADHD i.e., problems of inattention, hyperactivity and impulsivity. Most common presenting complaints were losing temper and problem in studies in 13 (52%) and 10 (40%) subjects respectively. Over 90 per cent of the subjects were screen positive on items relating to inattention and disorganization, 64 and 8 per cent were screened positive for 'fidgeting or squirming when asked to wait' and 'feeling overactive and almost compelled to do things as if driven by a motor' respectively (Table I).

A majority of the subjects or their parents 16 (64%) could recall the onset of symptoms of ADHD before 7 yr of age. This number increased to 22 (88%) for a childhood onset prior to 12 yr of age. All the subjects had onset of ADHD symptoms before the age of 16 yr.

The most common symptoms as per the DSM-IV-TR were 'difficulty in sustaining attention' in 23 (92%), 'easy distractibility' in 22 (88%), 'often loosing things' in 20 (80%), and 'blurting out answers' in 20 (80%) subjects. The most common symptoms of hyperactivity in the adult ADHD subjects were of "fidgeting or squirming excessively" in 16 (64%) and "feeling of inner-restlessness" in 15 (60%) subjects. "Blurting out answers" was the most common symptom of impulsivity in 20 (80%) subjects (Table II). Overall, the subjects had more symptoms of inattention than those of hyperactivity/impulsivity.

On Wender-Utah criteria the subjects were commonly found to have problems of attention deficit (25,100%), impulsivity (24, 96%), and explosive temper outbursts (23, 92%) (Table III). Ten (40%) subjects had the symptoms of "academic and vocational success below that expected on the basis of intelligence and education". This group included the subjects who did not have occupational success inspite of being qualified or those subjects who had poor scholastic performance inspite of above average intelligence. Overall, 14 (56%) subjects had repeated at least one grade.

Though all the 25 subjects could be diagnosed with ADHD using the DSM-IV-TR criteria, only 16 (64%) could be diagnosed with the disorder if only the validated DSM-IV-TR categories of ADHD-Inattentive type and ADHD-Combined type were considered. All the subjects diagnosed with ADHD-not otherwise specified (NOS; 9, 36%) were the ones where a definite childhood history (onset before 7 yr of age) of symptoms of inattention, hyperactivity, and impulsivity were not available.

Eighteen (72%) subjects with DSM-IV-TR diagnosis of ADHD could be diagnosed having adult ADHD using the Wender-Utah criteria. Four of the remaining seven were diagnosed ADHD-NOS, two ADHD-Inattentive type and one ADHD-Combined type.

The co-morbidity rates of the subjects in the study included both cross-sectional and longitudinal co-morbidities (Table IV); 20 (80%) and 15 (60%) subjects had one or more life time and current co-morbid psychiatric disorder respectively, and 14 (56%) subjects had multiple psychiatric co-morbidities. In these subjects co-morbid psychiatric disorder(s) could not explain their pervasive long-standing symptoms of inattention, hyperactivity, and impulsivity. There was a definite and distinct impairment because of the various co-morbidities; 12 (48%) subjects had either a mood disorder or an anxiety disorder. Of the five subjects grouped in the substance abuse/dependence group, one each was diagnosed with alcohol dependence, cannabis dependence and inhalant substance abuse respectively, two were dependent on nicotine. Anti-social personality disorder was diagnosed in one subject. Three subjects had a family history of bipolar affective disorder, eight had the symptoms of DSM-IV-TR diagnosis of intermittent explosive disorder. However, the presence of ADHD excluded this diagnosis as the symptom of impulsive anger could be explained on the basis of ADHD.

Most of the subjects had moderate difficulty in functioning (GAF rating 58.8 [+ or -] 6.2). The subjects historically had impairments in the area of occupational functioning (like trouble finding and keeping jobs, performance below the level of competence and problems with co-workers 5, 20%), educational functioning (poor school performance, frequent change of school and use of unfair means in examinations 10, 40%), inter-personal relationships (problems with spouse, relatives and peers 14, 56%), driving (problem in waiting for green signal, taking unnecessary risk while driving and loosing temper on fellow motorist 7, 28%) and in other commitments of adult life like handling finances (2, 8%).

Discussion

There are no studies reported from Asia except a recent one from Lebanon (15). This implies that adult ADHD has been inadequately documented cross-culturally. We were able to diagnose 25 cases of adult ADHD using validated tools. We could clinically systematically evaluate and diagnose adult ADHD in India.

All the diagnosed 25 adult ADHD subjects in our study were men. Biederman et al (16) pointed out that the male to female ratio of adults with attention deficit/ hyperactivity disorder is much narrower than that in childhood population. The absence of women in our study could be because of the design of the study and the small purposive sample.

In our study, only six subjects presented with the core symptoms of ADHD. The majority presented with the complaints not specific to ADHD. The routine use of a screener for adult ADHD or inclusion of items for core symptoms of the disorder in the clinical interview would help in diagnosing such patients. Adler and Cohen (5) also pointed out that adults with ADHD are less likely to exhibit the symptoms of the disorder described in the DSM-IV-TR, which are more applicable to children. Adjustments made by the patients due to the disorder and high rates of co-morbidities can often obscure the symptoms of adult ADHD.

In our study, emotional dysregulation was a prominent symptom. Losing temper was the commonest presenting complaint. This symptom can possibly be a result of impaction of the ADHD symptom of impulsivity on the problem of anger, leading to the characteristic short outbursts of explosive anger. The co-morbidity of oppositional defiant disorder in the current study could be another reason for the common occurrence of this symptom. Wender (4) asserts that mood symptoms of adult ADHD are an integral part of its phenomenology and affective lability and emotional over-reactivity are highly suggestive of ADHD in adults.

Problem in studies was one of the presenting problems in 40 per cent subjects of our study. It is known that adult with ADHD are more likely to experience grade retention and suspension from educational institutes (17). The dropout rate from school of such individuals is thus higher and they are likely to have lower class rankings than their peers. In the study by Biederma (18) 32 per cent of men and 17 per cent of women with ADHD had repeated a grade and most had to be placed in special classes and required extra help because of their academic difficulties.

The most common symptoms in our subjects as per the DSM-IV-TR were those of inattention i.e., difficulty in sustaining attention and easy distractibility. None of the subjects in the current study could be diagnosed with ADHD-hyperactive/impulsive type. Various other investigators also pointed out the prominence of inattention symptoms in adult ADHD subjects (19). There is an age associated decline in all the core ADHD symptoms (20). However, the symptoms of inattention remit in fewer patients than those of hyperactivity or impulsivity. Moreover, adult symptoms of hyperactivity are more likely to be subtle than in their paediatric counterparts.

In our study, 60 per cent subjects had problems of "inner restlessness". This is in contrast to 24 per cent reporting the DSM-IV-TR hyperactivity symptom of "Leaves seats in situations in which remaining seated is expected" or "Driven by a motor". Increased demands of planning in adulthood often lead to an increase in the "overt" symptoms of in attention in this age group (21). In contrast to hyperactivity, difficulties of attention and concentration persist and may be even more evident in adults than in children.

We had difficulty in diagnosing adult ADHD by using DSM IV TR as well as Wender-Utah criteria. But the description of adult ADHD in Wender-Utah criteria is much more appropriate than that in DSM IV TR. If one compares the diagnostic criteria of ADHD as given in DSM IV TR and Wender-Utah criteria, it is obvious that the examples given to describe hyperactivity, inattention and impulsivity in the former are more applicable to school age children while the latter are developmentally appropriate for adult life situations. In our study "Hot temper, explosive, short-lived outbursts", "Affective labiality", "Emotional over-reactivity", "Academic and vocational success below than that expected on the basis of intelligence and education" in 10 (40%), "Alcohol or drug abuse" and "Marital instability" were seen. These symptoms are not described in DSM IV TR. These symptoms were present in subjects who were diagnosed by us as ADHD or ADHD NOS using DSM IV TR criteria showing that adult ADHD subjects do have Wender-Utah symptoms. We suggest that newer criteria for adult ADHD should be developed keeping in mind the age appropriate changes in ADHD symptoms.

ADHD at any age is frequently co-morbid with other psychiatric disorders. In our study, 80 per cent patients had a comorbid psychiatric disorder, and 56 per cent had multiple psychiatric co-morbidities. McGough et al (22) reported that 87 per cent subjects had at least 1 and 56 per cent had at least 2 other psychiatric disorders. Similarly, other studies have also reported high rates of lifetime co-morbidity in clinic referred adult ADHD subjects, like generalized anxiety disorder, drug abuse or dependence, major depressive disorder and personality disorders (23,24). The high co-morbidity rates in our study illustrate the difficulty in diagnosing such patients with ADHD as it requires a structured and detailed evaluation in order to delineate the symptoms of ADHD from those of the co-morbid disorders. Approximately a third of adults with ADHD may have a lifetime diagnosis of conduct or oppositional defiant disorder (18,22). In our study, 28 per cent subjects had a lifetime diagnosis of oppositional defiant disorder and only one was diagnosed with antisocial personality disorder.

In our study 5 (20%) subjects had a substance use disorder as one of their co-morbidities. ADHD is recognised as a risk factor for substance abuse in adults with lifetime prevalence rates of up to 50 per cent of substance use disorders in such patients (8,23). Flory and Lyman (25) showed that the presence of ADHD predicts a shorter duration from abuse to dependence, an earlier age of onset of substance abuse and a rapid progression from alcohol abuse to other more serious substance abuse disorders.

In summary, our study showed that adult ADHD can be clinically diagnosed in India. The phenomenology and co-morbidities of adult ADHD were similar to those seen in the western countries. A larger sample size and use of semi-structured diagnostic interview schedules for adult ADHD and rating scales for retrospective childhood diagnosis would have made our study more comprehensive and robust.

Received July 11, 2007

References

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Reprint requests: Dr Vivek Agarwal, B-1-10/69, Sector K, Aliganj, Lucknow 226 024, India e-mail: drvivekagarwa106@gmail.com

Prabhat Sitholey, Vivek Agarwal & Swapnil Sharma *

Department of Psychiatry, C.S.M. Medical University U.P. (Formerly King George's Medical University) Lucknow, India & * St. George Hospital, NSW, Australia
Table I. Adult ADHD self-report scale (ASRSv1.1.) screen positive
symptoms * of adult ADHD subjects (N=25)

Item N (%)

1. Troubles wrapping final details of project, 24 (96)
 once the challenging parts have been done

2. Difficulty in getting things in order in tasks 24 (96)
 requiring organization

3. Problems in remembering obligations and 23 (92)
 appointments

4. Avoiding tasks requiring a lot of thought 23 (92)

5. Fidgeting or squirming when asked to wait 16 (64)

6. Feeling overactive and almost compelled to do 2 (8)
 things as if driven by a motor

* Not mutually exclusive

Table II. Frequency of DSM-IV-TR symptoms * in the adult ADHD
subjects (N=25)

DSM-IV-TR symptoms N (%)

1. Difficulty in sustaining attention 23 (92)
2. Easily distracted 22 (88)
3. Loses things 20 (80)
4. Blurts out answers 20 (80)
5. Difficulty in organization 19 (76)
6. Fails to give attention to detail or makes 19 (76)
 careless mistakes
7. Avoids/dislikes tasks requiring sustained 18 (72)
 mental effort
8. Does not seem to listen when spoken directly 16 (64)
9. Fidgets/squirms 16 (64)
10. Inner restlessness 15 (60)
11. Difficulty waiting in turn 15 (60)
12. Forgetful 14 (56)
13. Fails to finish work 10 (40)
14. Talks excessively 8 (32)
15. Difficulty engaging in leisure activities 6 (24)
 quietly
16. Leaves seats in situations in which remaining 6 (24)
 seated is expected
17. Interrupts or intrudes 5 (20)
18. "On the go" or "Driven by a motor" 2 (8)

* Not mutually exclusive

Table III. Frequency of Wender-Utah symptoms * in the adult
ADHD subjects (N=25)

Wender-Utah criteria N (%)

1. Attention deficits 25 (100)
2. Impulsivity 24 (96)
3. Hot temper, explosive, short-lived outbursts 23 (92)
4. Motor hyperactivity 20 (80)
5. Disorganization, inability to complete tasks 19 (76)
6. Affective labiality 11 (44)
7. Emotional over-reactivity 5 (20)
8. Associated features
Academic and vocational success below than that 10 (40)
expected on the basis of intelligence and education
Alcohol or drug abuse 5 (20)
Marital instability 2 (8)
Family histories of ADHD 1 (4)

* Not mutually exclusive

Table IV. Co-morbid psychiatric disorders * in adult ADHD
subjects (N=25)

Co-morbidities Current Lifetime
 N (%) N (%)
Oppositional defiant disorder 6 (24) 1 (4)
Major depressive disorder 6 (24)
Substance abuse/dependence 5 (20)
Social phobia 2 (8)
Specific phobia 2 (8)
Undifferentiated somatoform disorder 2 (8)
Bipolar affective disorder 2 (8)
Obsessive compulsive disorder 2 (8)
Pain disorder due to psychological causes 1 (4)
Male erectile disorder 1 (4)
Generalized anxiety disorder 1 (4)
Anti-social personality disorder 1 (4)
Multiple co-morbidities 6 (24) 8 (32)

* Not mutually exclusive
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Author:Sitholey, Prabhat; Agarwal, Vivek; Sharma, Swapnil
Publication:Indian Journal of Medical Research
Article Type:Report
Geographic Code:9INDI
Date:Jan 1, 2009
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