Treatment Controversies in Adult ADHD.

Prospective Follow-up Studies of ADHD: Helping Establish a Valid Diagnosis in Adults

FIGURE 1. Changes in cortical thickness provide one measure of brain maturation. A large longitudinal study found that for most areas of cortex, children with attention deficit hyperactivity disorder (ADHD) reach peak cortical thickness several years later than typically developing children, supporting presence of developmental delay. The rate of cortical thinning also differed between the group who continued to meet diagnostic criteria into adulthood (persistent ADHD) and those who did not (remitted ADHD). Areas of cortex in which the rate of thinning correlated with adult symptom level (green, more symptoms associated with more thinning) are approximated on medial and lateral simplified representations of cortex. An earlier study also identified multiple areas in which cortex was thinner in adults with persistent ADHD compared with controls (orange). In addition, this study noted some areas of thicker cortex in remitted ADHD when compared with persistent ADHD (blue).

National Variation of ADHD Diagnostic Prevalence and Medication Use: Health Care Providers and Education Policies

Can Guidelines Help Reduce the Medicalization of Early Childhood?

Few studies have examined the impact of childhood attention deficit hyperactivity disorder (ADHD) symptoms on adult ADHD functional outcomes. To address this issue dimensionally, ADHD symptoms in childhood and adulthood and their relation to educational deficits and work disability are studied in a clinical sample of adult patients with previously untreated ADHD. About 250 adults diagnosed systematically with ADHD according to DSM-IV were prospectively recruited. Primary outcomes were high school dropout and being out of the work last year. Childhood ADHD symptoms, sex differences, comorbidities of other mental disorders, and adult ADHD symptoms were examined by historical data, clinician interviews, and questionnaires. High levels of ADHD symptom severity in childhood were related to dropping out of high school [odds ratio (OR) = 3.0], as were higher numbers of hyperactive–impulsive symptoms in childhood. Significantly, more women than men were long-term work disabled (OR = 2.0). After adjusting for age and gender, persisting high levels of ADHD inattention symptoms in adulthood (OR = 2.5), number of comorbid disorders, and particularly anxiety disorders were significantly related to long-term work disability. Childhood hyperactive–impulsive symptoms and overall severity of childhood ADHD symptoms were associated with high school dropout rates; however, persisting ADHD inattention symptoms and comorbid mental disorders in adulthood were more correlated to occupational impairment. These findings underline proposals for studies on early recognition and interventions for ADHD and psychiatric comorbidity. They further suggest that inattentive symptoms be a focus of adult ADHD treatment and that workplace interventions be considered to prevent long-term work disability.

We still need to know more about adolescents with attention deficit hyperactivity disorder who undergo surgery for severe obesity

BackgroundAttention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.MethodsThe European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.ResultsBesides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?ConclusionsADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults

Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults.

Thinning of the Cerebral Cortex During Development: A Dimension of ADHD

Back to table of contents Previous article Next article LetterFull AccessADHD in Adult Psychiatric OutpatientsBen Lomas, M.D., and Peter Gartside, M.S., Ph.D.Ben LomasSearch for more papers by this author, M.D., and Peter GartsideSearch for more papers by this author, M.S., Ph.D.Published Online:1 May 1999https://doi.org/10.1176/ps.50.5.705AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Anxiety and depression are two of the most common complaints of psychiatric outpatients, and anxiety and mood disorders are among the most common psychiatric disorders in the United States (1). These disorders are also frequently associated with attention-deficit hyperactivity disorder (ADHD) in both children and adults (2).ADHD is a chronic psychiatric disorder characterized by early childhood onset of motor overactivity (hyperactivity), distractibility (inattentiveness), and impulsivity that often persists into adulthood (3). ADHD affects 3 to 5 percent of all classroom children, and clinically significant signs and symptoms of ADHD may persist into adulthood in 60 to 70 percent of the cases. Therefore, one would expect to find a disproportionately large number of psychiatric patients with ADHD.This report describes a study that attempted to measure the frequency of ADHD in a cross-sectional sample of 212 randomly assigned adult psychiatric outpatients, none of whom were referred for or were being treated for ADHD. The sample consisted of 130 veterans being treated in a Veterans Affairs mental hygiene clinic, 42 outpatients at a community mental health center, and 40 consecutive private psychiatric outpatients first seen by the first author in 1993 and followed for 24 to 36 months.Of the 212 outpatients, only 114, or 54 percent, received a complete ADHD assessment. Ninety-eight patients (46 percent) were excluded because of psychosis or evidence of structural brain damage. The average age of the 114 patients was 43 years, 68 percent were male, and 97 percent were Caucasian. Sixty-one percent were married, and 21 percent were divorced. Fifty-one percent were employed; the remainder were partly or total disabled or retired.Formal ADHD evaluation consisted of a review of family and childhood history and a review of grade-school report cards and school records whenever possible. Patients were also evaluated by DSM-III-R criteria for ADHD. They were scored on the Wender Utah Rating Scale (WURS) and Wender's suggested 25 items (WURS-25), which measure recollected early grade school problems (4), and on Hallowell and Ratey's 20-item Suggested Adult ADHD Criteria (5). The first author interviewed significant others and first-degree relatives using Wender's ten-item Parental Rating Scale (WPRS), which measures observations of motor overactivity, distractibility, and impulsivity, or relied on professional staff's observations.To receive a diagnosis of ADHD, a subject had to meet eight or more of the DSM-III-R criteria and have a score of 46 or more on the WURS-25, 12 or more on the Hallowell-Ratey criteria, or 10 or more on the WPRS. The subject also had to be found positive for ADHD by clinical observation, by observation of a significant other, or according to childhood school records.Fifty-seven of the 114 patients, or 50 percent, received a diagnosis of ADHD. Patients who were diagnosed with ADHD met a mean±SD of 10.3±2.5 DSM-III-R criteria. WPRS scores were obtained for 40 patients; the mean score was 15.9±3.8. The mean score on the Hallowell-Ratey scale was 17.2±1.6; on the WURS-25 it was 58.9±14.1; and on the WURS it was 113.8±28.3. Childhood school records indicated ADHD in 27 of 30 cases in which records were available.Seventeen cases of panic disorder were found in the ADHD group, but only four cases in the group without ADHD. A total of 29 cases of anxiety disorder were found in the ADHD group, compared with 11 in the other group.Fifteen of the 18 outpatients, or 83 percent, who were assessed from the community mental health center received a diagnosis of ADHD. This disproportionately high figure might be related to a higher incidence of poverty among these patients, but further study is needed.This preliminary study of ADHD in adults relied primarily on clinical observations over comparatively long time periods, ranging from 24 to 36 months. Future studies will require separating the processes of diagnosis, ADHD assessment, and treatment into controlled segments for the sake of believability and accuracy. However, the fact that the patients in the study were observed over a substantial period increases the likelihood that they did in fact have ADHD.Dr. Lomas is a staff psychiatrist at the Veterans Affairs Medical Center in Cincinnati and associate professor of psychiatry at the University of Cincinnati Medical Center. Dr. Gartside is associate professor of biostatistics and epidemiology in the department of enviromental health at the University of Cincinnati College of Medicine.

We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children. We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms. Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis. Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.

Although previously considered a disorder of childhood, studies in the last decade have demonstrated that attention-deficit hyperactivity disorder (ADHD) continues to impair function into adulthood and responds to pharmacotherapy. Due to age-specific changes in roles and challenges, it is possible that presentation and response to intervention may differ between older and younger adults. A literature search for papers that identified older adults with ADHD, including papers describing its epidemiology, manifestation, and treatment, was the basis for this paper. There is a paucity of data on ADHD in older adults; however, small observational studies have characterized the presence, impact, and treatment of ADHD in adults over the age of 50years, and larger epidemiologic studies have demonstrated that ADHD symptoms exist in older adulthood. Optimal criteria for diagnosis of ADHD and methods of treating ADHD in older individuals have not been systematically explored. In light of the limited data, this review discusses considerations for differential diagnosis and safe pharmacotherapy of ADHD in older adults.

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder that frequently persists into adulthood, with significant levels of inattentive, hyperactive and impulsive behavior. Impairments associated with adult ADHD include distress from the symptoms, impaired ability to function in work and academic settings, and problems sustaining stable relationships. The disorder is commonly associated with volatile moods, antisocial behavior, and drug and alcohol misuse. There is an increased risk of developing comorbid anxiety, depression, personality disorders, and drug and alcohol dependence. Despite the proven effectiveness of drugs such as methylphenidate, dexamphetamine and atomoxetine, few cases of ADHD are recognized and treated in the UK. The reasons for this are unclear, since most psychiatrists working with children and adolescents are aware that ADHD commonly persists into adult life and they also see the disorder affecting parents of children with ADHD. Issues of transition from the care of child to adult psychiatry and the need to refer adult relatives of children with ADHD to suitable psychiatric services are a major concern. Furthermore, many cases of adult ADHD go unrecognized or are seen by mental health teams that are not familiar with the subtleties of the adult presentation. As a result, misdiagnosis and treatment for conditions such as atypical depression, mixed affective disorder, cyclothymia, and borderline and unstable emotional personality disorders is not uncommon. There is therefore a requirement for further training in this area. This review will describe the common clinical presentation and provide guidelines for the diagnosis and treatment of ADHD in adults. Any psychiatrically trained physician using standard psychiatric assessment procedures can perform clinical evaluations for adult ADHD. As with other psychiatric disorders in adulthood, ADHD has its own characteristic onset, course and psychopathology. Symptoms of ADHD are trait-like, being stable characteristics from early childhood, and commonly co-occur with affective instability. Stimulants are the mainstay of treatment and are effective in around 70% of cases. Psychotherapeutic interventions also have an important role. These guidelines will assist psychiatrists and other adult mental health workers in identifying and treating individuals with adult ADHD.