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.

Attention Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic condition and frequently coexists with other emotional, behavioral, developmental and physical conditions. This problem causes major academic and social issues for your child and stress for your family. Children who are having difficulty with attention span, distractibility, impulsivity, motor restlessness and work completion need to be evaluated for ADHD.

Children, teens and adults can all have ADHD. No one is certain what causes ADHD. It likely comes from a combination of things including genes, exposure to lead, smoking and alcohol, certain brain injuries and other environmental exposures.

Children with ADHD get distracted easily and have difficulty listening to and following directions. They move from one activity to another too quickly and seem to fidget and squirm. They are often easily distracted and unable to finish tasks. They tend to be active and prefer to run around a lot. They climb on furniture and in or out of cabinets. They have trouble keeping their hands to themselves. They may be very impatient and have trouble controlling their emotions. Some children with ADHD have the inattentive type. In this type of ADHD the child is not hyperactive. Their primary issue is with attention and being easily distracted. These children are more often girls than boys and can be easily missed because they do not stand out due to not having a high activity level.

Most evaluations occur between the ages of 4 and 18 years. Your first discussion of your concerns will be with your child’s pediatrician. Depending on your child’s age and symptoms, initial interventions including parent and teacher directed behavior therapy and medication intervention. The primary focus must always be on appropriate social, emotional, educational and behavioral accommodations as well as a physical examination to make certain there is no underlying medical condition causing the ADHD symptoms. If symptoms warrant a referral to a specialist who deals with ADHD may be arranged.

When seeking a specialty evaluation for your child with possible ADHD it is important you seek a professional trained in the diagnosis and management of ADHD. A thorough history will be obtained and a comprehensive physical and neurological examination will be performed. The evaluation may also include psychological and educational assessments and a review of prior evaluations and teacher reports. Further information including classroom observations and parent/teacher questionnaires may also be required.

Intervention options are targeted to your specific needs and the needs of your child. A collaborative multimodal treatment plan tailored to the short and long term behavioral and academic needs of your child is the goal. Children, teens and adults with ADHD do get better with the right treatment, guidance and understanding.

The Use of Stimulant Medication in Healthy Children and Adults

The use of prescription stimulants or psychotropic medication to improve cognition or overall functioning in a healthy individual who does not have an underlying medical condition is called neuroenhancement.  The prevalence of such treatment is increasing for children and adults.

The premise behind the use of stimulant medication or anxiolytic medication is to improve overall functioning and achievement in an otherwise normal individual.  A parent or child’s willingness and interest to pursue neuroenhancement are dependent on numerous cultural, social, religious, psychological, personal and ethical considerations.

The use of stimulant medication has been increasing and so has the diagnosis of ADHD.  Recent reports estimate an increase in the diagnosis of ADHD by over 40% for teens.  At least part of this increase is due to a “softening” in the diagnostic criteria to allow stimulant medication to be prescribed.  In these situations the stimulant is prescribed for social or psycho-educational motivations rather than medical. With such prescriptive treatment the benefits of treatment often do not justify the risk for side effects and the potential misuse of the stimulant medication.

The most common side effects include nervousness, tachycardia, hypertension, motor or vocal tics, appetite suppression and insomnia.  Potential neurodevelopmental effects are unknown as are the effects on the development of individual autonomy and the sense of internal control of one’s own decision making.

Parents and doctors play a vital role in both providing information and decision-making. The use of these medications to provide a competitive academic edge is becoming increasingly common in our era where academic achievement and success are increasingly important for long term economic success and job or academic advancement.  This is not a new question.  Caffeine has been used for productivity enhancement for many decades. The risk to drift in this direction with stimulant medications has already begun.

In the end the decision to use stimulant medication comes down to what is and what is not appropriate. What price is a parent or child willing to pay to excel?  Honest two way communication and evidence based advice are critical. This decision needs to be discussed in an open and honest forum with appropriate documentation of the criteria that justify treatment rather than allowing the decision to be based solely on a consumer-provider relationship where the parent or student wants and the physician provides the medication.