ATTENTION DEFICIT HYPERACTIVITY DISORDER IN ADULTS: EVERYTHING YOU NEED TO KNOW!

-Sai Lavanya Patnala, Final year, Apollo Medical college, Hyderabad

What is ADHD?

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),attention deficit–hyperactivity disorder (ADHD) is characterized by symptoms of impulsivity, inattention, and hyperactivity that emerge in childhood. ADHD was initially considered to be solely a childhood disorder, and the diagnosis of adult ADHD was controversial. However, long-term follow-up studies revealed that in 40 to 60% of children with ADHD, the disorder persists into adulthood.[1]

ADHD is characterized by a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development.[2]

The prevalence of adult ADHD is estimated to be around 3.4% worldwide (Fayyad et al., 2007), representing one of the most common psychiatric conditions in adulthood (American Psychiatric Association, 2013).[6]

One of the common features of ADHD are pronounced impairments in multiple aspects of cognition. [6.1] These cognitive impairments were shown to be associated with functional impairments in various domains, such as social functioning, academic achievement, occupational attainment, self-concept, as well as general well-being and quality of life. [6.2] However, because the disruptive outward manifestations of ADHD (eg, hyperactivity) decrease with age, adult ADHD remains somewhat hidden and underdiagnosed.[7]

How is it diagnosed?

To aid physicians and psychologists in the diagnostic process, several validated behavior scales have been developed to help screen, diagnose, evaluate, and track symptoms of ADHD in adults.[3]

According to DSM-5, ADHD occurs when one has inattention or hyperactivity/impulsivity across multiple settings that interferes with one’s life.[2]

All criteria must be met for a diagnosis of ADHD in adults:

1. Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and academic/occupational activities.
2. Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.
3. Several symptoms (inattentive or hyperactive/impulsive) must be present in ≥2 settings (eg, at home, school, or work; with friends or relatives; in other activities).
4. There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
5. Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).

Diagnosis should be based on a complete history and evaluation of the patient.[2]

The DSM-5 criteria also state that in ADHD, symptoms must interfere with or reduce the quality of functioning in such settings. Self-reports of functional impairment are helpful to obtain, but these are vulnerable to deliberate exaggeration (Fuermaier et al., 2018; Suhr et al., 2020).[5] 

Unfortunately, research suggests that although a substantial minority of adults being assessed for ADHD do exaggerate their problems (e.g., Nelson & Lovett, 2019; Sullivan et al., 2007). Conscious exaggeration of symptoms and impairment can be detected through careful assessment. [5]

Who are prone to ADHD?

Young adults who are stressed, anxious, or depressed are more prone to endorsing a wide variety of ADHD symptoms (e.g., A. G. Harrison et al., 2013)

It is estimated that about 30–60% of children diagnosed with attention deficit hyperactivity disorder (ADHD) still suffer from symptoms of ADHD in adulthood (American Psychiatric Association, 2013; Barbaresi et al., 2013; Biederman, Mick, & Faraone, 2000; Mannuzza et al., 1991; Seidman, Valera, & Makris, 2005).[6]

ADHD diagnosis may be masked by other comorbid psychiatric disorders. Prevalence of ADHD among adults with other psychiatric and substance abuse disorders in the past 12 months.

-Any anxiety disorder: 9.5%

-Any mood disorder:13.1%

-Any substance use disorder:10.8%

-Any impulse control disorder:12.3% [8]

In a separate study including adults with ADHD and a comorbid psychiatric disorder,72% retained a diagnosis of ADHD when overlapping symptoms of major depression were subtracted and 75% retained a diagnosis of ADHD when overlapping symptoms of generalized anxiety disorder were subtracted.[9]

ADHD in adults has been found to have high heritability ranging from 75% to 91%.[8,47] There is a 25.6% greater risk in parents, of children with ADHD, and 20.8% greater risk in a sibling.[11]

How is ADHD managed?

The primary goal of an ADHD management plan is to control the core symptoms of inattention and hyperactivity/impulsivity. A multimodal management plan that incorporates a variety of strategies may work best for many patients with ADHD.[10]

The mainstay of ADHD treatment is pharmacotherapy. Randomized trials show clinically significant improvements in ADHD symptoms and in daily functioning with the use of approved medications (stimulants like amphetamine, methylphenidate and nonstimulants like atomoxetine) for ADHD in adults.[1]

Several nonpharmacologic interventions may help with ADHD symptoms. These interventions can be used as part of a management plan that may or may not include medication as a part of therapy.

• Psychoeducation: Education about ADHD is an important starting point in management. The more patients and their families know about the disorder and how it affects them, the better equipped they will be to devise and implement management strategies that target their desired goals.
• Cognitive behavioural therapy: This skills-based approach can help patients change maladaptive behaviours and thought patterns that interfere with daily functioning. Preliminary data support the efficacy of cognitive behavioural therapy as an adjunct to medication in adults with ADHD.
• Coaching/skills training: ADHD coaches can help adults learn practical life skills to manage the daily challenges of the disorder (like being disorganized, forgetful, tardy).
• Managing ADHD at work: The symptoms of ADHD can present many challenges for an adult in the workplace, just as they may for a child in school. Although each adult patient’s challenges are unique, some general strategies may be helpful to adults with ADHD when applied at work.[4]

REFERENCES

1. Volkow ND, Swanson JM. Clinical practice: Adult attention deficit-hyperactivity disorder. N Engl J Med. 2013 Nov 14;369(20):1935-44. doi: 10.1056/NEJMcp1212625. PMID: 24224626; PMCID: PMC4827421.
2. American Psychiatric Association. Attention-deficit and disruptive behavior disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
3. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiat. 2004;65[suppl 3]:12-17.
4. https://www.qandadhd.com/treatment
5. https://www.tandfonline.com/doi/full/10.1080/13803395.2021.1950640
6. tandfonline.com/doi/full/10.1080/23279095.2018.1429441?src=recsys

6.1. Barkley, Murphy, & Fischer, 2007; Kooij et al., 2010

6.2. Agarwal, Goldenberg, Perry, & IsHak, 2012; Canu & Carlson, 2007; Diamantopoulou, Rydell, Thorell, & Bohlin, 2007; Fergusson, Lynskey, & Horwood, 1997; Kok, Groen, Fuermaier, & Tucha, 2016; Kooij et al., 2010

7. Faraone SV, Spencer TJ, Montano CB, Biederman J. Attention-Deficit/Hyperactivity Disorder in Adults: A Survey of Current Practice in Psychiatry and Primary Care. Arch Intern Med. 2004;164(11):1221–1226. doi:10.1001/archinte.164.11.1221

8. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723. doi:10.1176/appi.ajp.163.4.716.

9. Milberger S, Biederman J, Faraone SV, Murphy J, Tsuang MT. Attention deficit hyperactivity disorder and comorbid disorders: issues of overlapping symptoms. Am J Psychiatry. 1995;152:1793-1799.

10. Asherson P, Buitelaar J, Faraone SV, Rohde LA. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatry. 2016;3:568-578.11. Culpepper L, Mattingly G. Challenges in identifying and managing attention-deficit/hyperactivity disorder in adults in the primary care setting: A review of the literature. Prim Care Companion J Clin Psychiatry. 2010;12 PCC.10r00951