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Attention-Deficit Hyperactivity Disorder

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of ADHD.

Alternative Names

Oppositional Defiant Disorder

Risk Factors

In the US, the diagnosis of ADHD in children increased from 1.1% of office visits in 1990 to 3.6% in 1996, or from nearly 950,000 to over 2,400,000 children. Estimates of prevalence of the disorder range from 2% to 18% depending on where and how the studies were conducted. ADHD is a genuine disorder, but it should be strongly noted that the US accounts for 90% of worldwide prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in ADHD or a better ability to recognize it. Or it may be an indication of a culture that places excessive value on normalcy and academic achievement at the expense of more frequent diagnoses.

Gender and ADHD

ADHD is most often diagnosed in boys, but there is some evidence that it is underdiagnosed in girls because they may be less likely to exhibit aggressive behaviors and so go unnoticed. Until recently, all major studies were conducted using boys as subjects. Important studies on girls with ADHD are now underway and to date, a major study is reporting that girls with the condition experience the same multiple impairments as boys do.

Adults with ADHD

Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are definitely on the rise. It was estimated that methylphenidate (Ritalin) was prescribed in nearly 800,000 adults in the US in 1997, nearly three times the number in 1992.

Attention Deficit Disorder In Adults

How Is Attention Deficit Disorder Identified in Adults?

Some research suggests that ADHD affects between 2% and 6% of the adult population, assuming that one- to two-thirds of cases persist into adulthood. ADHD in adults always occurs as a continuum of the childhood condition. Adult-onset symptoms are likely to be due to other factors. Diagnosing adult ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while attention and organizational problems may develop in older people. Some experts believe, then, that the number of adults with ADHD is underestimated.

A rating scale using four factors has been developed that may prove to be useful in identifying adults with ADHD:

  • Inattention and memory problems. (Examples: losing or forgetting things, being absent-minded, not finishing things, misjudging time, depending on others for order, having trouble getting started, changing jobs or projects in the middle.)
  • Hyperactivity and restlessness. (Examples: always being on the go, fidgety, easily bored, taking risks, liking active and fast paced jobs and activities, such as being a sales representative or stockbroker.)
  • Impulsivity and emotional instability. (Examples: saying things without thinking first, interrupting others, being annoying to others, easily frustrated, easily angered, having unpredictable moods, driving recklessly, having high relationship and job turnover.)
  • Problems with self worth. (Examples: Avoids new challenges, appears confident to others but not to oneself.)

Physicians can use adult reports of their childhood behaviors and experiences when searching for clues for a diagnosis. Interestingly, the disorder seems to be distributed equally between women and men in adulthood, with women having twice the reported incidence in young adulthood. Such findings suggest that ADHD may be underestimated in girls.

How Serious Is Attention Deficit Disorder in Adults?

Accompanying Emotional, Personality, and Learning Disorders. Between 19% and 37% of adults with ADHD have depression or bipolar disorder and between 25% and 50% have anxiety disorder. Bipolar disorder plus ADHD, in fact, may be very difficult to differentiate from ADHD alone in adults.

Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders, usually dyslexia and auditory processing problems. These problems should be considered in any treatment plan.

Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower educational levels and to be fired more often. In fact, one article reported that by the time they are in their 30s, about 35% of ADHD adults are self-employed.

Substance Abuse and Risky Behavior. According to a 2003 study, the incidence in ADHD is five to 10 times higher among alcoholics than in the general public. Other studies have reported that between 32% and 53% of adults with ADHD abuse alcohol and between 8% and 32% smoke marijuana or take cocaine. Self-medication with nicotine and coffee is also common. Notably, deficiencies in the brain chemical dopamine may create a more intense need for "reward" seeking. Substance abuse, then, is a way of self-medicating. Nicotine, in particular, may act as a medication that improves ADHD symptoms. An important 2003 study suggested that young people and adults with the highest risk for substance abuse were those whose ADHD symptoms during childhood were primarily inattention and those with conduct disorders. Adults with ADHD also take more sexual risks and have a higher risk for sexually transmitted disease.

Accidents and Driving. Of concern is a significantly higher risk for injury-producing automobile accidents in older adolescents and adult drivers. The major factors contributing to this higher risk were higher rates of drunken driving, street racing, and traffic violations. Those with more severe ADHD symptoms were more likely to be in danger. Whether ADHD traits, such as inattentiveness or hyperactivity, were involved with the risk is not known.

Sleep Disorders. Sleep disorders, especially restless legs syndrome and sleep apnea, are common in adults, as they are in children, with ADHD. Sleep apnea is a disorder in which a person stops breathing during the night, perhaps hundreds of times. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath. It is usually accompanied by snoring. One report suggested that treating sleep apnea in adults with both conditions may help reduce ADHD symptoms. [See Well-Connected Report # 65 Sleep Apnea.]

How Is Adult Attention Deficit Disorder Treated?

Atomoxetine (Strattera). Atomoxetine (Strattera) is the first agent approved for adults with ADHD. It is not a stimulant but acts on the neurotransmitters dopamine and norepinephrine. In two well-conducted 2003 studies, atomoxetine significantly reduced symptoms of inattention, hyperactivity, and impulsivity in adult patients. Side effects were mild. The drug does not appear to pose a risk for abuse.

Antidepressants. Specific antidepressants, such as bupropion (Wellbutrin) and venlafaxine (Effexor), may be useful for adults with ADHD. Studies to date report response rates with these agents of 50% to 78%. Bupropion may be a particularly good choice for certain ADHD adults, including those who also have bipolar disorder or a history of substance abuse. Tricyclic antidepressants, such as desipramine may also be very effective, particularly in adults with both ADHD and depression.

Psychostimulants. The standard psychostimulants, methylphenidate (Ritalin) and Adderall, are also effective in adults. The newer, longer acting forms of methylphenidate (Concerta, Ritalin-LA, Metadate CD) and Adderall (Adderall XR) may offer specific advantages for this group. Some adults, however, might still need a mid-day boost of the medications.

Nicotine Replacement. Nicotine improves ADHD symptoms and appears to have effects in the brain that are similar to those of stimulants. Although such findings should certainly not encourage anyone to smoke, some studies are focusing on benefits of nicotine therapy in adults with ADHD.

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