Attention-Deficit/Hyperactivity Disorder (Adult)

Definition
Attention-deficit/hyperactivity disorder is a neurobehavioral disorder characterized by a combination of inattentiveness, distractibility, hyperactivity, and impulsive behavior. AD/HD appears early in life. It is estimated that 3 percent to 7 percent of school-age children are diagnosed with AD/HD; boys are diagnosed more often than girls. Untreated AD/HD has been shown to have long-term adverse affects on academic performance, vocational success, and social-emotional development. AD/HD children have difficulty sitting still and paying attention in class and do not do well at school, even when they have normal or above-normal intelligence. They engage in a broad array of disruptive behaviors and experience peer rejection. As they grow older, children with untreated AD/HD are more prone to drug abuse, antisocial behavior, and injuries of all sorts. More than half the children diagnosed with AD/HD continue to have symptoms during their adolescent years and into adulthood.
Symptoms
Diagnosing an adult with AD/HD is not easy. Many times, when a child is diagnosed with the disorder, a parent will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems is AD/HD. They may have a history of school failures, problems at work, or frequent automobile accidents.
To be diagnosed with AD/HD, an adult must have childhood-onset, persistent, and current symptoms. The accuracy of the diagnosis of adult AD/HD is of utmost importance and should be made by a clinician with expertise in the area of attention dysfunction. For an accurate diagnosis, a history of the patient's childhood behavior, together with an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities, anxiety, or affective disorders.
A correct diagnosis of AD/HD can bring a sense of relief. The individual has brought into adulthood many negative perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and can begin to face them. This may mean, not only treatment for AD/HD but also psychotherapy that can help him cope with the anger he feels about the failure to diagnose the disorder when he was younger.
Causes
Health professionals are still unsure about what causes AD/HD. It may be a genetically determined disorder, as attention disorders often run in families. Studies indicate that 25 percent of close relatives in the families of AD/HD children also have AD/HD, whereas the rate is about 5 percent in the general population. Many studies of twins now show that a strong genetic influence exists in the disorder.
Recent studies show that AD/HD is caused by neurobiological dysfunction. Scientists using neuroimaging and brain scanning tools for studying the brain have demonstrated a link between a person's ability to maintain attention and the level of activity in the brain. For example, scientists have found differences between the frontal lobes of individuals who have AD/HD and those who do not.
Current research is exploring the structure of the brain to determine if there are differences that might indicate a physical basis for attention-deficit/hyperactivity disorder.
There is correlating evidence between the use of cigarettes and alcohol during pregnancy and the risk for developing AD/HD in the unborn child. These substances may endanger the fetus' developing brain. It is best to refrain from smoking, alcohol use, and use of other drugs during pregnancy, as they may distort developing nerve cells and lead to AD/HD.
Toxins in the environment may also disrupt brain development or brain processes, which may lead to AD/HD. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline or paint were once used. It is also present in some older water pipes.
There is, however, little compelling evidence that AD/HD stems from the home environment. Researchers report that not all children from unstable or dysfunctional homes have AD/HD, and not all children with AD/HD come from dysfunctional families. Scientists have also found no real evidence that head injury, undetectable damage to the brain, early infection, or complications at birth cause AD/HD.
Typically, adults with AD/HD are unaware that they have this disorder—they often just feel that it's impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed and ready for the day's work, getting to work on time, and being productive on the job can be major challenges for the AD/HD adult.
Treatment
When adults take a medication for AD/HD, they often start with a stimulant medication. The stimulant medications affect the regulation of two neurotransmitters, norepinephrine and dopamine. The newest medication approved for AD/HD by the FDA, atomoxetine (Strattera®), has been tested in controlled studies in both children and adults and has been found to be effective.
Antidepressants are considered a second choice for treatment of adults with AD/HD. The older antidepressants, the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine. Venlafaxine (Effexor®), a newer antidepressant, is also used for its effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an indirect effect on the neurotransmitter dopamine, has been useful in clinical trials on the treatment of AD/HD in both children and adults. It has the added attraction of being useful in reducing cigarette smoking.
In prescribing for an adult, special considerations are made. The adult may need less of the medication for his weight, or at its regular dosage its effect may last longer in an adult. The adult may take other medications for physical problems, such as diabetes or high blood pressure; often the adult is also taking a medication for anxiety or depression. All of these variables must be taken into account before a medication is prescribed.
Although medication gives needed support, the individual must succeed on his own. To help in this struggle, both AD/HD education and individual psychotherapy can be helpful. The therapist can encourage the AD/HD patient to adjust to changes brought into his life by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting. As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her life, he or she can begin to appreciate the characteristics of AD/HD that are positive—boundless energy, warmth, and enthusiasm.
Treatment plans for adult AD/HD may include:
Consultation with appropriate medical professionals
Education about AD/HD
Medication
Support groups
Psychotherapy for help change a longstanding poor self-image
Coaching in organizational skills
Vocational/educational counseling
Appropriate accommodations for work and school (NIMH, 2006)
Sources:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
Barkley R.A. (2000). Taking Charge of AD/HD. New York: The Guilford Press, p. 21.
Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MF. (1990) Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29(4): 526-533.
Consensus Development Panel (CDP) (1982). Defined Diets and Childhood Hyperactivity. National Institutes of Health Consensus Development Conference Summary, Volume 4(3).
Faraone SV, Biederman J. (1998) Neurobiology of attention-deficit hyperactivity disorder. Biological Psychiatry, 44, 951-958.
Harvard Mental Health Letter (2002). Attention Deficit Disorder in Adults. Vol. 19:5, 3-6.
The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder (AD/HD) (1999). Archives of General Psychiatry, 56:1073-1086.
National Institute of Mental Health (2006). Attention-Deficit/Hyperactivity Disorder. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services. http://www.nimh.nih.gov/publicat/AD/HD.cfm#teen
National Institutes of Health - National Library of Medicine - MedlinePlus, 2007. Attention deficit hyperactivity disorder (AD/HD). http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
US Department of Justice (USDOJ) (2006). A Guide to Disability Rights Laws. Civil Rights Division: Disability Rights Section http://www.usdoj.gov/crt/ada/cguide.htm#anchor62335
U.S. Department of Transportation, National Highway Traffic Safety Administration. State Legislative Fact Sheet, April 2002.
Wilens TC, Faraone, SV, Biederman J, Gunawardene S. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111:1:179-185.
Wilens TE, Biederman J, Spencer TJ. Attention (2002). deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 53:113-131.