Adult ADHD

As most parents know ADHD does not “go away” in the majority of children. ADHD persists into adulthood in up to 65% of children with ADHD. It is felt that 4-5% of adults in the US meet criteria for ADHD yet only 25% have been diagnosed and only 10% have been treated. Many adults with ADHD have associated mood, anxiety, sleep and substance misuse issues that complicate diagnosis and intervention.

In adults the primary symptom is inattention rather than hyperactivity. All adults who meet the diagnosis criteria must have a history of ADHD onset in childhood and must meet the established childhood criteria. These criteria include the following: onset of symptoms prior to age 7 years; the presence of at least 6 of 9 possible symptoms in 1 or both of the 2 diagnostic clusters of inattentiveness and hyperactivity; impairment in 2 or more settings (such as home, school and work).

The diagnosis is made by using screening tools in conjunction with a comprehensive patient history and physical examination to evaluate any associated psychiatric disorder. The cognitive and affective symptoms of ADHD are similar to symptoms seen in mood and anxiety disorders. Chronic anxiety issues compounded by stressful events can produce cognitive symptoms that appear similar to ADHD.

Almost 10 million adults in the US have ADHD. It is the second most prevalent disorder behind major depressive disorder which affects almost 7% of the population and generalized anxiety disorder (3%), bipolar disorder (2%) and schizophrenia (1%). 75% of adults with ADHD were not diagnosed as having ADHD during childhood. Adults have fewer symptoms than children and the signs of inattention and hyperactivity in adulthood are somewhat different from those in childhood. In adulthood the inattention symptoms include: difficulty sustaining attention at meeting, with paperwork or with work reading requirements; making careless errors; being forgetful and easily distracted; poor concentration; difficulty finishing tasks; disorganized work habits and frequently misplaced items. Hyperactivity patterns include: inefficiencies at work; internal restlessness; difficulty sitting through meetings; working more than one job; working long hours; very active jobs; feeling of being overwhelmed and talking excessively.

Many adults who are not diagnosed in childhood have developed compensatory strategies to allow them to function in and out of the home and at work. Family members are often able to provide information that is different or not available from the adult who is being evaluated for ADHD.

The treatment of adult ADHD follows the guidelines for the treatment of ADHD in children. A multimodal approach is recommended. Psycho-educational interventions are first and followed by pharmacotherapy for ADHD and any associated psychiatric disorders. Available pharmacologic treatments include short and long acting stimulants and non-stimulant medications. Stimulants are associated with mild elevations in both blood pressure and pulse and need to be monitored in an ongoing basis throughout treatment. Studies have not supported an increased risk for serious cardiovascular risks such as sudden death, myocardial infarction or stroke in children, young adults or middle aged adults.

Although information is limited there is some support for the benefits of using stimulant and non-stimulant therapy to improve executive function impairments that can limit job performance. Executive function involves the ability to organize, sequence, prioritize and maintain information in your working memory while you make decisions. If the executive function disturbance is related to ADHD symptoms including difficulty with selective, shifting and sustained attention then executive function usually improves with medication.

Only about 5% of children diagnosed as having ADHD in childhood continue medication into adulthood. This is felt to be primarily due to the misconception that ADHD symptoms resolve in childhood.

Cognitive behavior therapy approaches that focus on organizational skill development and self-talk/management strategies can also be helpful to develop the compensatory strategies to improve remaining functional impairments. Supportive counseling can also provide motivational support as well as family based mediation and communication benefits.