Recognizing and managing ADHD in adults
Symptoms tend to evolve and attenuate with age, but may still require treatment.
Many children with attention deficit hyperactivity disorder (ADHD) continue to experience symptoms after reaching adulthood. One study based on a nationally representative survey estimated that slightly more than 4% of U.S. adults meet the diagnostic criteria for ADHD listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
However, symptoms of ADHD tend to evolve and become more subtle with age. If overtly hyperactive behavior is part of the picture — for example, running around or having trouble sitting still — it usually emerges in childhood and is most noticeable during elementary school. By adolescence, hyperactivity often subsides or is manifested in less obvious ways, such as fidgeting or restlessness. By adulthood, the primary difficulty is with memory and attention (see "Diagnosing ADHD in adults") — causing problems not only at work, but also with personal relationships and finances.
Although most of the research on ADHD has been done in children, detailed guidance has emerged for adults who experience symptoms of the disorder. As is the case with children, combination treatment — medication plus psychotherapy — seems to offer the best chance at symptom relief for adults.
Symptoms and diagnosis
ADHD probably does not arise spontaneously in previously unaffected individuals, so patients usually recall a history of symptoms as children. There may be documentation of a childhood ADHD diagnosis, but medical records are usually hard to come by — or the diagnosis may have been missed earlier in life. In the worst case, symptoms may be severe enough to cause impairment in different areas of a person's life, such as losing a job because of inability to follow directions and falling into debt because of failure to pay bills. Individuals with milder symptoms of ADHD may be able to compensate well enough to meet their responsibilities, but nonetheless may be helped by treatment.
ADHD symptoms often overlap with symptoms of other psychiatric disorders. Two studies of adults with ADHD found that more than four in five met the criteria for at least one other psychiatric disorder. The most common co-occurring disorders were anxiety, major depression, dysthymia, conduct disorder, oppositional defiant disorder, and substance abuse.
When multiple mental health problems affect an adult with ADHD, it's important to determine which problems need to be addressed first. The Texas Treatment Algorithm provides guidance for treating children with ADHD who also have other psychiatric diagnoses, and the consensus is that the same advice is valid for adults: manage substance abuse and severe mood or anxiety disorders before treating ADHD.
Diagnosing ADHD in adults
The criteria for attention deficit hyperactivity disorder (ADHD) listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) are:
NOTE: Symptoms of inattention tend to predominate in adults with ADHD, and may show up as procrastination, forgetfulness, losing things, lack of organization, and problems with jobs and relationships.
Stimulants are considered first-line medications for adults with ADHD, as they are for children, because these drugs are effective and work quickly. But other medication options exist for adults who cannot take stimulants.
Although side effects from ADHD medications are usually mild, adults are at greater risk than children for heart problems — mainly because risk of cardiovascular disease increases with age. Therefore, it makes sense to do a complete medical workup and take heart disease and other conditions into account before prescribing medicines.
Stimulants. The two categories of stimulants most often used to treat adults with ADHD are amphetamines and methylphenidate. Both help improve attention by modulating the action of two neurotransmitters — dopamine and norepinephrine — albeit in slightly different ways, which helps explain why individual patients may respond better to one or the other. These drugs typically take effect in one to three hours.
The most common side effects of stimulants are insomnia, anxiety, and headache. These medications may also raise blood pressure or heart rate, so regular blood pressure checks are essential.
Nonstimulant. The drug atomoxetine (Strattera) selectively targets norepinephrine, although it indirectly increases levels of dopamine. It takes longer to work than stimulants — typically about two weeks.
Although it does not work quickly, atomoxetine provides an alternative for patients who have not responded to stimulants. It may also be a good first choice when a patient with ADHD suffers from another disorder that may be aggravated by stimulants, such as anxiety or tics.
Doses should start low and be increased gradually over several weeks to one month. The most common side effects are gastrointestinal upset, slight increases in blood pressure or heart rate, and sexual dysfunction in men.
Antidepressants. Randomized controlled studies have reported that two antidepressants that affect norepinephrine levels — bupropion (Wellbutrin) and desipramine (Norpramin) — may offer some relief to patients who have not responded to other drugs. Generally speaking, however, neither drug is as effective at treating adult ADHD as stimulants or atomoxetine.
Side effects are another concern. Bupropion may increase the risk of seizures. Desipramine, which is a tricyclic antidepressant, can cause cardiac problems, and an overdose may even cause death.
Combinations. Some clinicians recommend combining atomoxetine with stimulants to boost symptom relief. Although in theory this strategy should be helpful, it has not yet been proven effective in clinical trials.
About 20% to 50% of adults with ADHD do not respond to drug treatment. Even in those who do respond to medication, psychotherapy is often an essential adjunct, helping patients to gain the skills necessary to compensate for the disorder and improve their ability to function at home and work, and in social activities.
Although the research on ADHD has mainly focused on children, a review of studies in adults identified several types of psychotherapy that might be worth considering. Generally speaking, these therapies emphasize acquiring and practicing new skills that help patients compensate for attention problems.
The authors of the review note, however, that most studies have been small and conducted by the same researchers who developed the intervention being evaluated. Studies also usually follow patients for a short time, so the longer-term benefits are not clear.
Education. Often easy to overlook, education about ADHD can help patients, spouses, and family members keep expectations realistic, find sensible treatment options, and establish achievable goals.
Cognitive behavioral therapy. This standby of psychotherapy can help patients break the self-defeating cycle of failure, anxiety, blame, and additional failure. This treatment emphasizes practical skills: time management, organizational skills, and compensatory strategies, such as setting up a reminder system to counteract forgetfulness.
The structured nature of cognitive behavioral therapy — it provides a concrete framework for identifying problems and brainstorming solutions — may enable adults with ADHD to handle challenges more productively. Cognitive behavioral therapy requires a significant commitment of time by both patient and therapist.
Dialectical behavioral therapy. In this variation of cognitive behavioral therapy, patients learn to enhance mindfulness and modulate emotional distress. The goal is to improve self-esteem and gain control over emotions.
Metacognitive therapy. Another variation of cognitive behavioral therapy, this intervention aims to help patients better plan and manage their time.
Coaching. This approach has multiple roots outside of the clinical-psychotherapy community, and draws on many influences — for example, human resources development, philosophies of personal enhancement, organizational and social psychology, and theories of education and leadership. This explicitly action-oriented approach has particular appeal in fields, such as business and sports, where achievement can be measured in quantitative terms.
A personal coach can help someone with ADHD set goals, develop strategies to achieve them, and then monitor progress. Although coaching shares some elements in common with cognitive behavioral therapy, it focuses on solving specific problems or achieving particular goals, rather than developing a more general problem-solving approach. One advantage to coaching, for working people, is that coaches often purposely intervene in the actual context of the client's life, using telephone or even e-mail contact to provide "real-time" support and guidance.
Little research has evaluated how useful coaching is for adults with ADHD. Preliminary evidence suggests that coaching is most helpful when combined with other types of psychosocial treatment.
Information and resources
Books about treatment
Barkley, R.A. Attention Deficit Hyperactivity Disorder in Adults: The Latest Assessment and Treatment Strategies (Jones and Bartlett Publishers, 2010).
Goldstein, S., et al., eds. Clinician's Guide to Adult ADHD: Assessment and Intervention (Academic Press, 2002).
Hallowell E.M., et al. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood (Simon and Schuster, 1995).
Hallowell E.M., et al. Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder (Random House, 2005).
Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD)
National Resource Center on ADHD: A Program of CHADD
Finding other options
Although adults with ADHD face significant challenges, researchers and clinicians have become increasingly aware of adult ADHD and its treatment. Patients themselves have become more vocal about what they need. New options and resources are becoming available to guide care (see "Information and resources"). With the right mix of therapies, adults with ADHD can now become more productive and feel more satisfied with their accomplishments at work and at home.
Antai-Otong D. "The Art of Prescribing Pharmacological Management of Adult ADHD: Implications for Psychiatric Care," Perspectives on Psychiatric Care (July 2008): Vol. 44, No. 3, pp. 196–201.
Feifel D, et al. "Attention Deficit/Hyperactivity Disorder in Adults: Recognition and Diagnosis of This Often-Overlooked Condition," Postgraduate Medicine (Sept. 2008): Vol. 120, No. 3, pp. 39–47.
Knouse LE, et al. "Recent Developments in the Psychosocial Treatment of Adult ADHD," Expert Review of Neurotherapeutics (Oct. 2008): Vol. 8, No. 10, pp. 1537–48.
For more references, please see www.health.harvard.edu/mentalextra.
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