Adult attention-deficit disorder
Encyclopedia
Adult attention deficit hyperactivity disorder (also referred to as Adult ADHD, Adult ADD) is the common term used to describe the neuropsychiatric condition attention-deficit hyperactivity disorder
(ADHD) when it is present in adult
s. Up to 60% of children diagnosed
with ADHD in early childhood
continue to demonstrate notable ADHD symptom
s as 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 15% of the global population
has ADHD (including cases not yet diagnosed).
Successful treatment
of ADHD is usually based on a combination of medication
, behavior therapy, cognitive therapy
, and skill
s training
.
, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD:
To meet the formal diagnostic criteria of ADHD, an individual must display:
The symptom
s (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.
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 relationship
s.
Whereas teachers and caregivers responsible for children are often attuned to the symptom
s 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. Research shows that adults with ADHD are more likely than their non-ADHD counterparts to experience automobile accidents and less likely to complete their education. ADHD adults have significantly lower rates of professional
employment, even controlling for confounding
psychiatric problems.
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. As their 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
. Many with ADHD also have associated learning disabilities, such as dyslexia
, which contributes to their difficulties.
Most adults with ADHD have the inattentive-type, but men exhibit a tendency towards the hyperactive/impulsive
-type symptoms and have predominantly the combined-type. 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 and work leading to academic underachievement or getting fired, poor driving
record with traffic violations and accidents, multiple relationships or serial marriage
s, legal problems
, sexually-transmitted diseases, unplanned pregnancies, and 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
. 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 present for diagnosis and treatment.
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, 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
.
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. 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. The proposed revision for the DSM-5 differentiates the presentation of ADHD for children and adults for several symptoms DSM-5 ADHD.
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.
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.)
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 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
. 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 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.
s than stimulant medication.
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).
or stress management
.
Research has shown that, alongside medication, psychological interventions in adults can be effective in reducing symptomatic deficiencies. Although cognitive behavioral therapy has not proven effective in children with ADHD, it may be helpful in adults.
which is why long-acting formulations are recommended. Many of these long-acting formulations prevent them from being injected or insufflated. In adults, stimulants may increase the risk of adverse cardiovascular events such as myocardial infarction
s (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.
Amphetamine
s 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 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.
in treating attention
al deficit in adults has been demonstrated in an outcome study. Research has also shown that neurofeedback outcomes compare favorably to those of stimulant medications.
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.
(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 for drug abuse are $58 billion; for alcohol abuse are $85 billion; and for depression are $43 billion.
Attention-deficit hyperactivity disorder
Attention deficit hyperactivity disorder is a developmental disorder. It is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age.ADHD is the most commonly studied and...
(ADHD) when it is present in adult
Adult
An adult is a human being or living organism that is of relatively mature age, typically associated with sexual maturity and the attainment of reproductive age....
s. Up to 60% of children diagnosed
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
with ADHD in early childhood
Early childhood
For the video game rating with a similar age group see ESRBEarly childhood is a stage in human development. It generally includes toddlerhood and some time afterwards. Play age is an unspecific designation approximately within the scope of early childhood.-Education:Infants and toddlers experience...
continue to demonstrate notable ADHD symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s as 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 15% of the global population
World population
The world population is the total number of living humans on the planet Earth. As of today, it is estimated to be billion by the United States Census Bureau...
has ADHD (including cases not yet diagnosed).
Successful treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
of ADHD is usually based on a combination of medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
, behavior therapy, cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...
, and skill
Skill
A skill is the learned capacity to carry out pre-determined results often with the minimum outlay of time, energy, or both. Skills can often be divided into domain-general and domain-specific skills...
s training
Training
The term training refers to the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relate to specific useful competencies. It forms the core of apprenticeships and provides the backbone of content at institutes of...
.
Classification
The DSM-IVDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
, or Diagnostic and Statistical Manual of Mental Disorders, 2000 edition, defines three types of ADHD:
- 1) An inattentiveADHD predominantly inattentiveADHD predominantly inattentive is one of the three subtypes of Attention-deficit hyperactivity disorder . While ADHD-PI is sometimes still called "attention deficit disorder" by the general public, these older terms were formally changed in 1994 in the new Diagnostic and Statistical Manual of...
type - 2) A hyperactive/impulsiveImpulsiveImpulsive may refer to:*Impulsive *Impulsivity*Impulsion*Impulse function...
type - 3) A combined type
To meet the formal 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 symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s (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.
Signs and symptoms
Individuals with ADHD have deficiencies with self-regulationSelf control
Self control is the ability to control one's emotions, behavior and desires in order to obtain some reward later. In psychology it is sometimes called self-regulation...
and self-motivation, that cause problems with distractibility
Distraction
Distraction is the divided attention of an individual or group from the chosen object of attention onto the source of distraction. Distraction is caused by: the lack of ability to pay attention; lack of interest in the object of attention; or the great intensity, novelty or attractiveness of...
, procrastination
Procrastination
In psychology, procrastination refers to the act of replacing high-priority actions with tasks of low-priority, and thus putting off important tasks to a later time...
, organization
Organizing
Organizing is the act of rearranging elements following one or more rules.Anything is commonly considered organized when it looks like everything has a correct order or placement. But it's only ultimately organized if any element has no difference on time taken to find it...
, 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
Chronic
Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre...
condition, beginning in early childhood
Early childhood
For the video game rating with a similar age group see ESRBEarly childhood is a stage in human development. It generally includes toddlerhood and some time afterwards. Play age is an unspecific designation approximately within the scope of early childhood.-Education:Infants and toddlers experience...
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
Education
Education in its broadest, general sense is the means through which the aims and habits of a group of people lives on from one generation to the next. Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts...
, employment
Employment
Employment is a contract between two parties, one being the employer and the other being the employee. An employee may be defined as:- Employee :...
, and interpersonal relationship
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
s.
Whereas teachers and caregivers responsible for children are often attuned to the symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s 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
Maturity (psychological)
Maturity is a psychological term used to indicate how a person responds to the circumstances or environment in an appropriate manner. This response is generally learned rather than instinctive, and is not determined by one's age...
; adults who have ADHD are less likely to exhibit obvious hyperactive behaviors. Research shows that adults with ADHD are more likely than their non-ADHD counterparts to experience automobile accidents and less likely to complete their education. ADHD adults have significantly lower rates of professional
Professional
A professional is a person who is paid to undertake a specialised set of tasks and to complete them for a fee. The traditional professions were doctors, lawyers, clergymen, and commissioned military officers. Today, the term is applied to estate agents, surveyors , environmental scientists,...
employment, even controlling for confounding
Confounding
In statistics, a confounding variable is an extraneous variable in a statistical model that correlates with both the dependent variable and the independent variable...
psychiatric problems.
Adults with ADHD are often perceived by others as chaotic and disorganized, with a tendency to need high stimulation
Stimulation
Stimulation is the action of various agents on nerves, muscles, or a sensory end organ, by which activity is evoked; especially, the nervous impulse produced by various agents on nerves, or a sensory end organ, by which the part connected with the nerve is thrown into a state of activity.The word...
to be less distracted and function effectively. As their coping mechanisms become overwhelmed, some individuals may turn to smoking
Smoking
Smoking is a practice in which a substance, most commonly tobacco or cannabis, is burned and the smoke is tasted or inhaled. This is primarily practised as a route of administration for recreational drug use, as combustion releases the active substances in drugs such as nicotine and makes them...
, alcohol
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
, or illicit drugs. As a result, many adults suffer from associated or "co-morbid" psychiatric conditions such as depression, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, or substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
. Many with ADHD also have associated learning disabilities, such as dyslexia
Dyslexia
Dyslexia is a very broad term defining a learning disability that impairs a person's fluency or comprehension accuracy in being able to read, and which can manifest itself as a difficulty with phonological awareness, phonological decoding, orthographic coding, auditory short-term memory, or rapid...
, which contributes to their difficulties.
| Inattentive-type (ADHD-I) | Hyperactive/Impulsive-type (ADHD-H) |
|---|---|
In children:
|
In children:
|
| In adults, these evolve into:
Procrastination In psychology, procrastination refers to the act of replacing high-priority actions with tasks of low-priority, and thus putting off important tasks to a later time... Human multitasking Human multitasking is the best performance by an individual of appearing to handle more than one task at the same time. The term is derived from computer multitasking. An example of multitasking is taking phone calls while typing an email... |
In adults:
|
Most adults with ADHD have the inattentive-type, but men exhibit a tendency towards the hyperactive/impulsive
Impulsive
Impulsive may refer to:*Impulsive *Impulsivity*Impulsion*Impulse function...
-type symptoms and have predominantly the combined-type. 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
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
known as executive functioning (see below, neurobiology). These result in problems with sustaining attention
Attention
Attention is the cognitive process of paying attention to one aspect of the environment while ignoring others. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience....
, planning
Planning
Planning in organizations and public policy is both the organizational process of creating and maintaining a plan; and the psychological process of thinking about the activities required to create a desired goal on some scale. As such, it is a fundamental property of intelligent behavior...
, 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 and work leading to academic underachievement or getting fired, poor driving
Driving
Driving is the controlled operation and movement of a land vehicle, such as a car, truck or bus.Although direct operation of a bicycle and a mounted animal are commonly referred to as riding, such operators are legally considered drivers and are required to obey the rules of the road...
record with traffic violations and accidents, multiple relationships or serial marriage
Marriage
Marriage is a social union or legal contract between people that creates kinship. It is an institution in which interpersonal relationships, usually intimate and sexual, are acknowledged in a variety of ways, depending on the culture or subculture in which it is found...
s, legal problems
Crime
Crime is the breach of rules or laws for which some governing authority can ultimately prescribe a conviction...
, sexually-transmitted diseases, unplanned pregnancies, and 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
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
. 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 present for diagnosis and treatment.
Diagnosis
The diagnosis of ADHD in adults is 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 neuropsychiatricNeuropsychological test
Neuropsychological tests are specifically designed tasks used to measure a psychological function known to be linked to a particular brain structure or pathway. Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the...
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
Wechsler Adult Intelligence Scale
The Wechsler Adult Intelligence Scale intelligence quotient tests are the primary clinical instruments used to measure adult and adolescent intelligence. The original WAIS was published in February 1955 by David Wechsler, as a revision of the Wechsler-Bellevue Intelligence Scale...
, 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
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
such as depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, or substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
. "Organic" diseases such as hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
may exhibit symptoms similar to those of ADHD, and it is imperative to rule these out as well. Asperger syndrome
Asperger syndrome
Asperger's syndrome that is characterized by significant difficulties in social interaction, alongside restricted and repetitive patterns of behavior and interests. It differs from other autism spectrum disorders by its relative preservation of linguistic and cognitive development...
, a condition on the autism spectrum
Autism spectrum
The term "autism spectrum" is often used to describe disorders that are currently classified as pervasive developmental disorders. Pervasive developmental disorders include autism, Asperger syndrome, Childhood disintegrative disorder, Rett syndrome and Pervasive Developmental Disorder Not Otherwise...
, 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
Sensory integration
Sensory integration is defined as the neurological process that organizes sensation from one’s own body and the environment, thus making it possible to use the body effectively within the environment. Specifically, it deals with how the brain processes multiple sensory modality inputs into usable...
, including hypersensitivity
Hypersensitivity
Hypersensitivity refers to undesirable reactions produced by the normal immune system, including allergies and autoimmunity. These reactions may be damaging, uncomfortable, or occasionally fatal. Hypersensitivity reactions require a pre-sensitized state of the host. The four-group classification...
.
Generally, medical and mental health professionals follow the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM) of the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
. Periodic updates to the DSM incorporate changes in knowledge and treatments. 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. The proposed revision for the DSM-5 differentiates the presentation of ADHD for children and adults for several symptoms DSM-5 ADHD.
It should be noted that every normal individual exhibits ADHD-like symptoms occasionally (when tired
Tired
Tired may refer to:* Fatigue , a feeling of exhaustion* "Tired", a song by Rollins Band on Weight from 1994* "Tired", a song by Willa Ford on Willa Was Here from 2001* "Tired", a song by LCD Soundsystem on LCD Soundsystem from 2005...
or stressed
Stress (biology)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
, 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.
Pathophysiology
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
Phineas Gage
Phineas P. Gage was an American railroad construction foreman now remembered for his improbablesurvival of an accident in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and...
, 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.)
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
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
. This part of the brain is involved in working memory
Working memory
Working memory has been defined as the system which actively holds information in the mind to do verbal and nonverbal tasks such as reasoning and comprehension, and to make it available for further information processing...
and linked to the limbic system
Limbic system
The limbic system is a set of brain structures including the hippocampus, amygdala, anterior thalamic nuclei, septum, limbic cortex and fornix, which seemingly support a variety of functions including emotion, behavior, long term memory, and olfaction. The term "limbic" comes from the Latin...
, 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
Nucleus accumbens
The nucleus accumbens , also known as the accumbens nucleus or as the nucleus accumbens septi , is a collection of neurons and forms the main part of the ventral striatum...
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
Dopaminergic
Dopaminergic means related to the neurotransmitter dopamine. For example, certain proteins such as the dopamine transporter , vesicular monoamine transporter 2 , and dopamine receptors can be classified as dopaminergic, and neurons which synthesize or contain dopamine and synapses with dopamine...
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
Dopaminergic
Dopaminergic means related to the neurotransmitter dopamine. For example, certain proteins such as the dopamine transporter , vesicular monoamine transporter 2 , and dopamine receptors can be classified as dopaminergic, and neurons which synthesize or contain dopamine and synapses with dopamine...
and adrenergic
Adrenergic
An adrenergic agent is a drug, or other substance, which has effects similar to, or the same as, epinephrine . Thus, it is a kind of sympathomimetic agent...
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
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
and norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
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
Working memory
Working memory has been defined as the system which actively holds information in the mind to do verbal and nonverbal tasks such as reasoning and comprehension, and to make it available for further information processing...
, and affects salience
Salience (neuroscience)
The salience of an item – be it an object, a person, a pixel, etc – is the state or quality by which it stands out relative to its neighbours...
. 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
Methylphenidate
Methylphenidate is a psychostimulant drug approved for treatment of attention-deficit hyperactivity disorder, postural orthostatic tachycardia syndrome and narcolepsy. It may also be prescribed for off-label use in treatment-resistant cases of lethargy, depression, neural insult and obesity...
and amphetamine
Amphetamine
Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...
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.
Treatment
Stimulant medication is a common and effective treatment for Adult ADHD although the response rate may be lower for adults than children. The non-stimulant Atomoxetine is also an effective treatment for adult ADHD, without the abuse potential of stimulant medication and has been associated with increased incidence of suicidal thoughts. Some physicians may recommend antidepressant drugs instead of stimulants, though antidepressants have lower treatment effect sizeEffect size
In statistics, an effect size is a measure of the strength of the relationship between two variables in a statistical population, or a sample-based estimate of that quantity...
s than stimulant medication.
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).
Psychosocial therapy
Treatment of adult ADHD may also include forms of anxietyAnxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
or stress management
Stress management
Stress management is the alteration of stress and especially chronic stress often for the purpose of improving everyday functioning.Stress produces numerous symptoms which vary according to persons, situations, and severity. These can include physical health decline as well as depression. According...
.
Research has shown that, alongside medication, psychological interventions in adults can be effective in reducing symptomatic deficiencies. Although cognitive behavioral therapy has not proven effective in children with ADHD, it may be helpful in adults.
Medications
Stimulant medications are often the first line of treatment and are effective in approximately 80% of individuals. When stimulants are prescribed, low doses are generally recommended for adults with ADHD. High doses of stimulants were generally thought to offer no additional benefit and increase adverse effects, but more recent studies have shown that this may not be true, and in adults with ADHD higher doses (on average 1.1 mg/kg/day) may be most effective. 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 insufflatedInsufflation (medicine)
Insufflation is the practice of inhaling a substance. Insufflation has limited medical use, but is a common route of administration with many respiratory drugs used to treat conditions in the lungs and paranasal sinus .The technique is common for many recreational drugs and is also used for some...
which is why long-acting formulations are recommended. Many of these long-acting formulations prevent them from being injected or insufflated. In adults, stimulants may increase the risk of adverse cardiovascular events such as myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
s (heart attacks) or hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
(high blood pressure). Judicious use and careful, regular follow-up with a physician are therefore critically important.
The stimulant methylphenidate
Methylphenidate
Methylphenidate is a psychostimulant drug approved for treatment of attention-deficit hyperactivity disorder, postural orthostatic tachycardia syndrome and narcolepsy. It may also be prescribed for off-label use in treatment-resistant cases of lethargy, depression, neural insult and obesity...
(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.
Amphetamine
Amphetamine
Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...
s and their derivatives are also effective in the treatment of adult ADHD. They not only block the uptake of dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
and norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
, 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
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
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
Suicidal ideation
Suicidal ideation is a common medical term for thoughts about suicide, which may be as detailed as a formulated plan, without the suicidal act itself. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts...
. These should be discussed with the prescribing physician.
Neurofeedback
Efficacy of neurofeedbackNeurofeedback
Neurofeedback , also called neurotherapy, neurobiofeedback or EEG biofeedback is a type of biofeedback that uses realtime displays of electroencephalography or functional magnetic resonance imaging to illustrate brain activity, often with a goal of controlling central nervous system activity...
in treating attention
Attention
Attention is the cognitive process of paying attention to one aspect of the environment while ignoring others. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience....
al deficit in adults has been demonstrated in an outcome study. Research has also shown that neurofeedback outcomes compare favorably to those of stimulant medications.
Epidemiology
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.In the context of the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
World Mental Health Survey Initiative, researchers screened more than 11,000 people aged 18 to 44 years in ten countries in the Americas, Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...
and the Middle East
Middle East
The Middle East is a region that encompasses Western Asia and Northern Africa. It is often used as a synonym for Near East, in opposition to Far 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.
History
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.Societal Impact
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 ActADA Amendments Act of 2008
The ADA Amendments Act of 2008 is an Act of Congress, effective January 1, 2009, that amended the Americans with Disabilities Act of 1990 and other disability nondiscrimination laws at the Federal level of the United States. Passed on September 17, 2008, and signed into law by President George W...
(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 for drug abuse are $58 billion; for alcohol abuse are $85 billion; and for depression are $43 billion.
Further reading
- [Gabor MAte]], " Sacttered Minds"
- Russell BarkleyRussell BarkleyRussell A. Barkley, Ph.D., is a Research Professor in the Department of Psychiatry at the State University of New York Upstate Medical University...
, Kevin R. Murphy, and Mariellen Fischer. ADHD in Adults: What the Science Says ISBN 978-1-59385-586-4 - Hallowell MD, Edward M.Edward Hallowell (psychiatrist)Edward M. Hallowell is a child and adult psychiatrist who specialises in ADD/ADHD and who also has ADD. He is the co-author of the books Driven to Distraction and Delivered From Distraction .-Biography:...
, and Ratey, John J., Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder, 2005. ISBN 978-0-345-44230-7. ISBN 978-0-345-44230-7. - Hartmann, Thom, Attention Deficit Disorder: A New Perspective
- Lara Honos-WebbLara Honos-WebbLara Honos-Webb, Ph.D., is the author of several books on ADHD. She is a practicing clinical psychologist, licensed in California. She is well known for her distinctive reframing of mental illnesses that are commonly conceived as detrimental, into gifts that offer exceptional strengths. She is...
. (2008)The Gift of Adult ADD. ISBN 978-1-57224-565-5. - Matlen MSW,ACSW, Terry.Terry MatlenTerry Matlen, M.S.W.,A.C.S.W., is a clinical social worker/psychotherapist. She is the author of Survival Tips for Women with ADHD, which offers solutions to women struggling with the symptoms of ADHD....
(2005) Survival Tips for Women with ADHD. ISBN 978-1-886941-59-5 - Pera, Gina. (2008). Is It You, Me, or Adult A.D.D.?: Stopping the Roller Coaster When Someone You Love Has Attention Deficit Disorder ISBN 978-0-9815487-0-8
- Ratey, Nancy. (2008) The Disorganized Mind: Coaching Your ADHD Brain to Take Control of Your Time, Tasks, and Talents. ISBN 978-0-312-35533-3
- Stephanie Moulton SarkisStephanie Moulton SarkisStephanie Moulton Sarkis is a specialist in the treatment of ADD/ADHD and the author of four books on adult ADHD. She is a practicing Licensed Mental Health Counselor and National Certified Counselor based in Boca Raton, FL. She specializes in ADHD and its impact on college performance and...
. (2011) Adult ADD: A Guide for the Newly Diagnosed. ISBN 978-1-60882-005-4 - Stephanie Moulton SarkisStephanie Moulton SarkisStephanie Moulton Sarkis is a specialist in the treatment of ADD/ADHD and the author of four books on adult ADHD. She is a practicing Licensed Mental Health Counselor and National Certified Counselor based in Boca Raton, FL. She specializes in ADHD and its impact on college performance and...
, and Klein, Karl. (2009) ADD and Your Money: A Guide to Personal Finance for Adults with Attention-Deficit Disorder. ISBN 978-1-57224-707-9 - Stephanie Moulton SarkisStephanie Moulton SarkisStephanie Moulton Sarkis is a specialist in the treatment of ADD/ADHD and the author of four books on adult ADHD. She is a practicing Licensed Mental Health Counselor and National Certified Counselor based in Boca Raton, FL. She specializes in ADHD and its impact on college performance and...
. (2006) 10 Simple Solutions to Adult ADD: How to Overcome Chronic Distraction & Accomplish Your Goals. ISBN 978-1-57224-434-4 - Tuckman, Ari. (2009) More Attention, Less Deficit: Success Strategies for Adults with ADHD ISBN 978-1-886941-74-8
- Weiss, Lynn. (2005) Attention Deficit Disorder in Adults, 4th Edition: A Different Way of Thinking ISBN 978-1-58979-237-1
External links
- National Institute for Mental Health official website
- National Mental Health association, AADD webspage
- National Attention Deficit Disorder Association
- www.add.org.au ADDults with ADHD (NSW) Inc. (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
- ADDA-SR Resource network, support groups, referrals, educational events
- Mungo's Adult ADHD blog - 40 year old diagnosed with Adult ADHD, documents his journey to discovery.