Attention-Deficit Hyperactivity Disorder (ADHD) in Adults

W. Retz, R. G. Klein

• Publisher: S. Karger
• Year: 2009
• ISBN:
  9783805592383
• Topic: Psychologie
• Subtopic: Psychothérapie

Worldwide longitudinal studies performed since the 1970s have clearly shown that ADHD persists into adulthood. These findings have stimulated researchers to develop the therapeutic approaches for adult patients, especially in European countries where scientific and clinical interest in ADHD has increased. In this volume, leading experts from Europe and the United States present their long-term results in order to provide an overview of important aspects of ADHD across the lifespan. These results include epidemiology, neurobiology, psychopathology, longitudinal course, comorbidity and social impairment associated with ADHD. Topics include diagnostic problems and therapeutic options as well as molecular genetic studies. Further, morphological and functional imaging studies in adult ADHD are reviewed, as well as the very important issue of comorbidity.

Chapter 1

Retz W, Klein RG (eds): Attention-Deficit Hyperactivity Disorder (ADHD) in Adults.
Key Issues in Mental Health. Basel, Karger, 2010, vol 176, pp 1–37

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Attention-Deficit Hyperactivity Disorder in Adults: An Overview

Paul H. Wender^a · David A. Tomb^b

^aDepartment of Psychiatry, Harvard Medical School, Boston, Mass., and ^bDepartment of Psychiatry, University of Utah School of Medicine, Salt Lake City, Utah, USA

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Abstract

Attention-deficit hyperactivity disorder (ADHD) is a common, genetically transmitted neurological disorder, with onset in childhood, probably mediated in part by decreased brain dopaminergic functioning. The first author and colleagues were among the earliest (1976) to describe the persistence of symptoms into adulthood and to perform a methylphenidate trial. Prevalence and natural history data suggest that of the 3–10% of children diagnosed with ADHD, one- to two-thirds continue to manifest appreciable ADHD symptoms as adults. This chapter reviews how ADHD in adults can be readily diagnosed and treated using the Wender Utah diagnostic criteria to identify adult characteristics of the disorder. Stringent diagnosis is key to determining effective treatment. This chapter also addresses core hypotheses of etiology and treatment. Dopamine agonist stimulant medications appear to be the most effective in treating ADHD. About 70% of patients receiving stimulant medication have shown moderate to marked improvement, as compared with 20% of those receiving placebo. The core symptoms of hyperactivity, inattention, mood lability, temper, disorganization, stress sensitivity, and impulsivity have been shown to respond to treatment with stimulant medications more than to other drugs. Appropriate management of adult patients with ADHD includes psychoeducation and counseling when necessary while the roles of supportive problem-directed therapy, behavioral intervention, coaching, and couples and family therapy remain to be evaluated.

Copyright © 2010 S. Karger AG, Basel

Attention-deficit hyperactivity disorder (ADHD) is very likely the most common and undiagnosed psychiatric disorder of adult life. Increasingly recognized only since the 1970s, ADHD had previously been believed to diminish in adolescence and disappear in adulthood. About 30 years ago, the senior author noted that the parents of ADHD children described similar problems in their own childhood and for many these problems had continued throughout life. A frequent comment by a spouse was: ‘What do you mean used to have?’ The senior author was then faced with two primary questions: [1] what clinical features characterize ADHD in adults (this work antedated DSM-III) and [2] how does one determine if the adults would have met the criteria for ADHD as children since it is believed that the condition does not appear de novo in adulthood.

With a focus on adults, this chapter outlines the history of the diagnostic concept, its prevalence, clinical medical symptoms, diagnosis and differential diagnosis, presumed etiology and (briefly) treatment. Much of this is based on 30 years of work conducted by Wender and colleagues and their efforts to clarify the two essential questions above. The interested reader is referred to his recent review article or book Attention-Deficit Hyperactivity Disorder in Adults for more detail [1, 2].

History of the ADHD Concept

The names and criteria for the syndrome of ADHD have changed frequently. What is now referred to as ADHD has been variously designated as ‘minimal brain damage’. ‘minimal brain dysfunction’, ‘minimal cerebral dysfunction’, ‘hyperkinesis’. and the ‘hyperactive child syndrome’. The main behavioral and/or cognitive abnormalities contained within the syndrome usually included overactivity, inattentiveness, impulsivity, affective lability and ‘immaturity’. Associated abnormalities included, but were not limited to, poor peer relations, defiance, hostility, ‘acting out’ behaviors and ‘learning problems’. The earliest descriptions of a behavioral condition akin to ADHD were provided by George Still at the turn of the century [3]. He posited an overarching failure in moral control and proposed a biological substrate (either hereditary and/or the result of some acquired encephalopathy). His formulation of underlying CNS damage was reflected in the early diagnostic terms of minimal brain damage or minimal brain dysfunction (both MBD), which prevailed throughout the first half of the 20th century.

Subsequent conceptual shifts are reflected in the several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. A more descriptive view was taken in 1968 such that the second edition called the disorder Hyperkinetic Reaction of Childhood, and stressed abnormally high levels of motor activity as the primary deficit. Later research emphasized deficits in attention and impulse control, as well as hyperactivity [4]. Consequently in 1980 the third revision of the DSM (DSM-III) re-titled it Attention Deficit Disorder (ADD), with two subtypes (with or without hyperactivity) [5]. Debates continued as to the central importance of problems with hyperactivity, and in 1987 the disorder was renamed Attention Deficit/Hyperactivity Disorder (DSM-III-R). ADD without hyperactivity was named Undifferentiated Attention Deficit Disorder, and thought by many to embody a separate disorder of attention [6-8]. The most current DSM-IV (1994) melds the different emphases by titling the disorder ADHD/Primarily Inattentive Type, or ADHD/Primarily Hyperactive-Impulsive Type, or ADHD/Combined Type, depending on the mix of inattentive, hyperactive or impulsive symptoms [9].

All of the above terminology reflects evolving theories of etiology or key symptoms. Future advances in understanding the biology and pathophysiology of the disorder may yet lead us to further nosological shifts [see, for example, Retz and Freitag, Baehne and Fallgatter, and Schneider et al., chapters 3, 4 and 5].

Core Symptoms

Although a former version of the DSM included the category of ‘ADHD-residual type’, there are no specific criteria for ADHD in adults. The DSM-IV’s symptomatic criteria were developed for children and, not surprisingly, many of them are age-limited and look exclusively at behavior. In this category are behaviors such as ‘often runs about or climbs excessively…’ or ‘often has difficulty playing or engaging in leisure activities quietly’. These criteria are not applicable to adulthood, which makes defining relevant and age-appropriate symptoms a critical issue. Versions of DSM-III (1980-1994) upon which much research has been based was even more inappropriate by using descriptions such as: ‘has difficulty waiting turn in games or group situations.’ Moreover, the DSM criteria focus on only three symptoms/behaviors of adult ADHD: inattention, hyperactivity, and impulsivity. There is no effort to assess the variety of broader problems that appear to accompany ADHD in adults. Accordingly, since 1976, the senior author has been developing tentative operational criteria for ADHD in an attempt to better specify characteristics more directly relevant to adults.

Childhood Status

By definition, ADHD begins in childhood. Thus the first task of the clinician is to determine the psychiatric status of the patient as a child and to make a retrospective diagnosis of childhood ADHD. Some patients may have been evaluated or treated as children. For others we inquire about the presence or absence of DSM-IV ADHD symptoms during childhood. However, many ADHD adults’ memories of their childhood are cloudy and inaccurate and we lack a measure of reliability. In 2002, Mannuzza interviewed ADHD subjects and controls as children and then again about their childhood symptoms when they were adults and found that retrospective diagnoses of ADHD in childhood, based on the subjects’ adult memories, were inaccurate in 73% of cases. As a screening procedure one can seek to obtain a history of the more macro (and presumably better recalled) behavioral characterizations (see below). To further circumvent a memory problem we have also employed the three approaches outlined below. Parental interview is the first and preferred method of obtaining childhood symptoms. If this is not possible, a useful second approach is for the patient’s parents to rate their (now) adult offspring as he or she had been in childhood, using the ‘Parents Rating Scale’ (PRS) (see appendix A). The PRS is a 10-item adaptation of the Conner’s Rating Scale popularly used for childhood ADHD assessment, and yields an index of the magnitude of an adult’s hyperactivity during childhood [10]. The PRS has been normed and a score of 12 or greater (0-3/item) places the adult patient in the 95th percentile for childhood ‘hyperactivity’ within the United States population. Other populations will require further standardization. The third technique is to administer the Wender Utah Rating Scale (WURS). It is a patient self-rating scale for childhood behavior and symptoms of 61 items consistent with ADHD/Combined Type (see appendix B).

The 25 most discriminating items are scored in a 0-4 rating scale [11]. This scale has been standardized in normal adults, adults with a major depressive disorder, and adults with ADHD and has been translated into and standardized in German [12].

Utah Criteria

The senior author and his collaborators have developed a set of characteristics to specify both necessary childhood criteria and current ADHD symptoms in the adult. These ‘Utah Criteria’ are as follows:

I. Childhood Characteristics

A childhood history consistent with ADHD is established through the methods discussed above.

The ‘Utah Criteria’ require that a patient must have met either the ‘narrow’ or the ‘broad’ criteria as a child measured by either the PRS and/or the WURS. The following are those necessary standards for ADD in childhood.

A. Narrow Criteria (DSM-IV)

That the individual meet full DSM-IV criteria for ADHD in childhood.

B. Broad Criteria

Both characteristics 1 and 2, and at least one characteristic from 3 through 6 below:

1 Hyperactivity: more active than other children, unable to sit still, fidgetiness, restlessness, always on the go, talking excessively

2 Attention deficits: sometimes described as a ‘short attention span,’ distractibility, unable to finish schoolwork

3 Behavior problems in school

4 Impulsivity

5 Overexcitability

6 Temper outbursts

II. Adult Characteristics

The Utah scheme requires that ADHD patients have both symptoms A and B below, plus two of the remaining symptoms (e.g., must be ADHD/Combined Type). At the time of the development of these criteria, Inattentive and the Hyperactive-Impulsive subtypes were not well validated (see above and below). Even now, more work needs to be completed to validate the existence of exclusively Inattentive or Hyperactive-Impulsive subtypes in adults. The reader should also be aware that the Utah criteria are not based exclusively on the behavioral criteria outlined in the DSM because ADHD is viewed as a polythetic condition, consisting of several diverse, non-overlapping features. Thus the criteria also include associated features and subjective symptoms (e.g., low frustration tolerance, temper outbursts, etc.) which the adult undergoing evaluation and his/her partner report [13, 14]. Exactly which symptoms were chosen for inclusion was based upon the best judgment of the senior author. Likewise, the ‘cutting point’ where a difficulty becomes a symptom was similarly decided. Since this is a reflection of the probable polythetic nature of adult ADHD, it will only become clarified through experience and research which attempts to define a ‘pure culture’ or ‘gold standard’ picture of adult ADHD.

A. Motor Hyperactivity

Manifested by restlessness, inability to relax; ‘nervousness’ (meaning inability to settle down, not anticipatory anxiety); inability to persist in sedentary activities (e.g., watching movies or TV, reading the newspaper); always on the go, dysphoric when inactive.

B. ...