Manifestation of Adult Attention-Deficit/Hyperactivity Disorder
For many years, attention-deficit/hyperactivity disorder (ADHD) was considered a neuropsychological condition occurring strictly during childhood and adolescence. However, approximately 30% to 70% of children with ADHD continue to have symptoms into adulthood. The estimated U.S. prevalence of adult ADHD is 1% to 7%. In the last few years, the manifestation of the condition in adults has garnered increased attention, and the body of evidence supporting treatment modalities for this population is growing.
In this article, we aim to identify medications that have been studied in the treatment of adult ADHD and to present the evidence regarding their effectiveness. We conducted a MEDLINE literature search from 1995 to the present, using various combinations of the key words “ADHD,” “ADD,” “attention,” “deficit,” “hyperactivity,” “disorder,” and “adults.” We then performed a “snowball search” from the references of the relevant articles to identify additional studies published before 1995. Although the evaluation of measurement tools is outside the scope of this article, it is important for readers to bear in mind the complexity of comparing studies that use different outcome measures.
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Diagnosis and Clinical Features
Only about 20% of adults with ADHD have been given the proper diagnosis. Adults without a previous diagnosis of ADHD sometimes present to their primary care provider with
self-reported symptoms suggestive of ADHD. The diagnosis of adult ADHD can be challenging because these self-reported symptoms are not objectively verifiable.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), emphasizes both inattention and impulsivity/hyperactivity, but these symptoms may be subtle and difficult to elicit in adults. Symptoms are usually longstanding, and the growing consensus is that disinhibition may be a cardinal feature. Disinhibition may be manifested as poor self-regulation and difficulty with focused attention and goal-directed thought and action.
Although children with symptoms of ADHD are characterized as being constantly “on the go,” adults with these symptoms are considered to be “on edge.” Patients may have difficulty completing tasks or relaxing, and they are generally disorganized. Impulsivity may take the form of socially inappropriate behavior, such as interrupting or intruding on conversations.
ADHD can coexist with many psychiatric conditions such as depression, Generalized Anxiety Disorder (GAD), and bipolar disorder. The symptomatology of many of these conditions mirrors those of ADHD, making it difficult to “tease out” which condition is causing the range of symptoms described by family members or the patient. online pharmacy uk
In a study of 56 adults who met the DSM-IV criteria for ADHD, the majority had additional psychiatric diagnoses; only seven subjects had a diagnosis of ADHD alone. Additional diagnoses included GAD (53%), dysthymic disorder (25%), and cyclothymic disorder (25%). Antisocial personality features were found in one fifth of adults with ADHD.
Adults with ADHD are more likely to be unemployed or underemployed, to be smokers, and to have substance abuse and marital problems. These factors underscore the importance of proper diagnosis and treatment. In the attempt to extend the DSM-IV criteria to adult patients, problems may arise, because the criteria were specifically developed for the diagnosis of ADHD in children. Although they are not free from inherent limitations of their own, the Utah Criteria for ADHD in Adults, on the other hand, were developed to reflect the distinct features of ADHD in adults.
The first Utah criterion is a childhood history of ADHD. Patients must also experience symptoms of hyperactivity with poor concentration and at least two of the following:
- affective lability
- hot temper
- an inability to complete tasks and disorganization
- stress intolerance
Before evaluating the patient’s presenting symptoms, the physician should establish a continuous developmental history of inattention and hyperactivity dating to at least age seven years. The evaluation of adult ADHD should also include an assessment of the impact of core ADHD symptoms on current functioning in the patient’s occupation, schooling, and relationships. Clinicians may also consider obtaining information on attention, concentration, distractibility, and short-term memory, as well as other psychiatric disorders and substance abuse. If the results are equivocal upon this assessment, the patient should be referred for psychological evaluation.