Diagnosing ADHD in Adults

Approximately 50-percent of children with ADHD become ADHD adults. Find out about diagnosis and treatment of ADHD in adults.

ADHD or Attention Deficit Hyperactivity Disorder affects thirty to fifty percent of adults who had ADHD in childhood. Accurate diagnosis of ADHD in adults is challenging and requires attention to early development, and symptoms of inattention, distractibility, impulsivity and emotional lability.

Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse. While stimulants are a common treatment for adult patients with ADHD, antidepressants may also be effective.

ADHD receives considerable attention in both medical literature and the lay media. Historically, ADHD was considered to be primarily a childhood condition. However, recent data suggest that symptoms of ADHD continue into adulthood in up to fifty percent of persons with childhood ADHD.

Since ADHD is such a well-known disorder, adults with both objective and subjective symptoms of poor concentration and inattention have got the probabilities for evaluation. While the symptoms of ADHD have been extended developmentally upward to adults, most of the information about the etiology, symptoms and treatment of this disorder comes from observations of, and studies in, children (Weiss, 2001).

Diagnosis of Adult ADHD

For several reasons, family physicians may be uncomfortable evaluating and treating adult patients with symptoms of ADHD, particularly those without a previously established ADHD diagnosis. First, the criteria for ADHD are not objectively verifiable and require reliance on the patient's subjective report of symptoms. Second, the criteria for ADHD do not describe the subtle cognitive-behavioral symptoms that may affect adults more than children.

The family physician's role as diagnostician is further complicated by the high rates of self-diagnosis of ADHD in adults. Many of these persons are influenced by the popular press. Studies of self-referral suggest that only one third to one half of adults who believe they have ADHD actually meet formal diagnostic criteria.

Even as family physicians are knowledgeable about childhood ADHD, there is a noticeable absence of guidelines for primary care evaluation and treatment of adults with symptoms of the disorder (Goldstein and Ellison, 2002).

The diagnostic criteria describe the disorder in three subtypes. The first is the predominantly hyperactive, the second is the predominantly inattentive, and the third is a mixed type with symptoms of the first and the second.

Symptoms should be persistently present since age seven. While a longstanding symptom history is often difficult to elicit clearly in adults, it is a key feature of the disorder.

The following are the symptoms:

Inattention: where a person often fails to give close attention to details or makes careless mistakes, often has difficulty sustaining attention in tasks, often does not seem to listen when spoken to directly, or often does not follow through on instructions.

Tasks: Where a person often has difficulty organizing tasks and activities, often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort, often loses things necessary for tasks or activities, often easily gets distracted by extraneous stimuli, or is often forgetful in daily activities.

Hyperactivity: Where a person often fidgets with hands or feet or squirms in seat, often feels restless, often has difficulty engaging in leisure activities quietly, or often talks excessively.

Impulsivity: Where a person often blurts out answers before questions have been completed, or often interrupts or intrudes on others.

There is a growing consensus that the central feature of ADHD is disinhibition. Patients are unable to stop themselves from immediately responding, and they have deficits in their capacity for monitoring their own behavior. Hyperactivity, while a common feature among children, is likely to be less overt in adults. Utah criteria may be called the imperative criteria for this. For adults, it is used like this: What is the childhood history consistent with ADHD? What are the adult symptoms? Does the adult have hyperactivity and poor concentration? Is there any affective lability or hot temper? Is there the inability to complete tasks and disorganization? Is there any stress intolerance, or impulsivity? (Wender, 1998)

Wender developed these ADHD criteria, known as the Utah criteria, which reflect the distinct features of the disorder in adults. The diagnosis of ADHD in an adult requires a longstanding history of ADHD symptoms, dating back to at least age seven. In the absence of treatment, such symptoms should have been consistently present without remission. In addition, hyperactivity and poor concentration should be present in adulthood, along with two of the five additional symptoms: affective lability; hot temper; inability to complete tasks and disorganization; stress intolerance; and impulsivity.

The Utah criteria include the emotional aspects of the syndrome. Affective lability is characterized by brief, intense affective outbursts ranging from euphoria to despair to anger, and is experienced by the ADHD adult as being out of control. Under conditions of increased emotional arousal from external demands, the patient becomes more disorganized and distractible.

Treatment of Adult ADHD

Some treatments for ADHD in adults are as follows:

Stimulants: Stimulants work by increasing both blood flow and the levels of Dopamine in the brain, especially the frontal lobes where the brain's Executive Functions take place. Stimulants will increase the brain's ability to inhibit itself. This allows the brain to focus on the right thing at the right time, and to be less distracted, and less impulsive. Stimulants increase the "signal to noise ratio" in the brain.

Antidepressants: Antidepressants are considered a second choice for treatment of adults with ADHD. The older antidepressants, the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine.

Other Medications: Sympatholytics have also been used in the management of ADHD as well as the non-stimulant ADHD medication, Strattera.

Self-Management Strategies: Adults with ADHD benefit considerably from direct education about the disorder. They can use information about their deficits to develop compensatory strategies. Planning and organization can be improved by encouraging patients to make lists and use methodically written schedules.

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References

Wender, Paul (1998). Attention-Deficit Hyperactivity Disorder in Adults . Oxford University Press.

Weiss, Margaret (2001). Adhd in Adulthood: A Guide to Current Theory, Diagnosis, and Treatment . Johns Hopkins University Press.

Goldstein, Sam; Ellison, Anne (2002). Clinicians' Guide to Adult ADHD: Assessment and Intervention. Academic Press.