Attention Deficit Hyperactivity Disorder (ADHD), also in adults

Although it is often thought of as a childhood disorder, adhd also occurs in adults.

The ADHD is a behavioral syndrome which affects, according to estimates, between 5% and 10% of the child and adolescent population. The key that is currently used to understand the broad spectrum of manifestations that characterize individuals with ADHD is the concept of deficit in inhibitory response control..

That is, the notorious inability to inhibit impulses and thoughts that interfere in the executive functions, the performance of which allows overcoming distractions, setting goals and planning the sequences of steps necessary to achieve them.

However, this psychological disorder is often spoken of as if it were only a child's thing. Is it so? Does ADHD exist in adults? As we will see, the answer is yes.

ADHD: does it also occur in adults?

For more than 70 years, research on attention deficit hyperactivity disorder has focused on children. But from 1976 onwards, it was shown that this disorder can exist in 60% of adults the symptoms of which already started before the age of seven (Werder PH. te. 2001). This diagnostic gap made the symptoms and treatments of infantile-adolescent ADHD more known and oriented than in adults, despite the fact that the clinical parameters are similar. In addition, in adults, complications, risks and comorbidities are more frequent and nuanced than in children. and more nuanced than in children, with the risk that the symptoms may be confused with another psychiatric condition. (Ramos-Quiroga YA. te. 2006).

A common biological origin allows adults to be diagnosed with the same adapted DSM-IV-TR criteria, but due to the fact that in adults the observer is unique, diagnostic difficulties are encountered, since it facilitates a greater dispersion and bias in opinions.

Although less epistemological data are available in adults, ADHD manifests itself in adults with great frequency. Early work found adult prevalences between 4 and 5%. (Murphy K, Barkley RA, 1996 and Faraone et. al., 2004).

Symptomatology, diagnosis and assessment of ADHD in adults

The diagnostic criteria for ADHD in adults are the same as those for children, as recorded to the DSM-IV-TR. The DSM-III-R formally describes the possibility of diagnosing ADHD in adults.

Signs and symptoms in adults are subjective and subtle, with no biomedical evidence to confirm the diagnosis. In order to diagnose ADHD in an adult, the disorder must have been present since childhood, at least since the age of seven, which is essential for diagnosis, and there must be persistent clinically significant impairment or impairment in more than one important area of activity, such as social, occupational, academic or family functioning. Therefore, it is very important that the clinical history notes the childhood history along with current symptoms and their impact on current life, family, work and social relationships.

Adults with ADHD report mainly inattention and impulsivity symptoms, as hyperactivity symptoms decrease with age. Likewise, the symptoms of hyperactivity in adults often have a slightly different clinical expression from that found in children (Wilens TE, Dodson W, 2004) since it manifests as a subjective feeling of restlessness.

The most common problems of attention deficit hyperactivity disorder in adults are the following: problems with concentration, forgetfulness and poor short-term memory, difficulty with organization, problems with routines, lack of self-discipline, impulsive behavior, depression, low self-esteem, depression, low self-esteem, and poor concentration.The following are some of the symptoms of ADHD in adults: problems with concentration, impulsive behavior, depression, low self-esteem, inner restlessness, poor time management skills, impatience and frustration, poor social skills and a feeling of not achieving goals, among others.

The self-assessment scales are a good diagnostic tool for the most general symptoms (Adler LA, Cohen J. 2003):

Adult self-assessment scale (EAVA): (McCann B. 2004) can be used as a first self-assessment tool to identify adults who may have ADHD. Copeland Symptom Checklist: helps to assess whether an adult has symptoms characteristic of ADHD. Brown Attention Deficit Disorder Scale: explores executive functioning of aspects of cognition that are associated with ADHD. Wender-Reimherr Adult Attention Deficit Disorder Scale: measures the severity of symptoms in adults with ADHD. It is especially useful for assessing mood and lability in ADHD. Conners' Adult ADHD Rating Scale (CAARS): symptoms are assessed with a combination of frequency and severity.

According to Murphy and Gordon (1998), a good assessment of ADHD must take into account whether there is evidence of a relationship between ADHD symptoms during childhood and later significant and chronic impairment in different domains, whether there is a relationship between current ADHD symptoms and substantial and conscious impairment in different domains, whether there is another pathology that justifies the clinical picture better than ADHD, and finally, whether for patients who meet the diagnostic criteria for ADHD, there is any evidence of comorbid conditions.

The diagnostic procedure is guided by guidelines for performing diagnostic tests according to the clinical situation. This procedure starts with a complete clinical history including a neurological examination. The diagnosis has to be clinical, supported by the self-assessment ladders, discussed above. It is essential to evaluate psychiatric conditions, rule out possible comorbidities and certain medical conditions such as hypertension and rule out substance abuse.

As Biederman and Faraone (2005) point out, in order to make a diagnosis of ADHD in adults it is essential to know which symptoms are specific to the disorder and which are due to another comorbid pathology.

It is very important to take into account that comorbidity is quite common in adult ADHD (Kessler RC, at al. 2006). The most frequent comorbidities are mood disorders such as major depression, dysthymia or bipolar disorder, which has a comorbidity with ADHD ranging from 19% to 37%. For anxiety disorders, comorbidity ranges from 25 to 50%. For alcohol abuse it is 32 to 53% and for other substance abuse such as cocaine it is 8 to 32%. The incidence rate for personality disorders is 10 to 20% and for antisocial behavior 18 to 28% (Barkley RA, Murphy KR. 1998).

Pharmacological treatment

The drugs used to treat this disorder are the same as in childhood. Of the various psychostimulant drugs, methylphenidate and atomoxetine have been shown to be effective in adults with ADHD.

Immediate-release methylphenidate inhibits dopamine uptake; and atomoxetine has the main function of inhibiting noradrenaline uptake. Currently, and thanks to several studies conducted by Faraone (2004), it is known that methylphenidate is more effective than placebo..

The explanatory hypothesis from which ADHD therapy based on psychostimulants such as methylphenidate is based is that this psychological disorder is caused (at least in part) by a constant need to keep the nervous system more activated than it is by default, which results in the repetitive search for external stimuli with which to engage in activities. Thus, methylphenidate and the other similar drugs would activate the nervous system so that the person would not be tempted to look externally for a source of stimulation.

Non-stimulant drugs for the treatment of ADHD in adults include tricyclic antidepressants, amino oxidase inhibitors and nicotinic drugs among others.

Psychological treatment

Despite the high efficacy of psychotropic medication, it is sometimes not sufficient to manage other factors, such as cognitive and disruptive behaviors or other comorbid disorders. (Murphy K. 2005).

Psychoeducational interventions help the patient to gain knowledge about ADHD that allows him/her not only to be aware of the interference of the disorder in his/her daily life, but also to detect his/her own difficulties and define his/her own therapeutic goals (Monastra VJ, 2005). These interventions can be carried out under an individual or group format.

The most effective approach to treat ADHD in adults is the cognitive-behavioral approach, both in an individual and group intervention (Monastra VJ, 2005).The most effective approach to treat ADHD in adults is cognitive-behavioral, both in an individual and group intervention (Brown, 2000; McDermott, 2000; Young, 2002). This type of intervention improves depressive and anxious symptoms. Patients receiving cognitive-behavioral therapy, along with their medications, controlled persistent symptoms better than with the use of medications combined with relaxation exercises.

Psychological treatments can help the patient to cope with the associated emotional, cognitive and behavioral problems, as well as better control of symptomatology refractory to pharmacological treatment. Therefore, multimodal treatments are considered to be the indicated therapeutic strategy (Young S. 2002).

Bibliographic references:

• Franke, B., Faraone, S.V., Asherson, P., Buitelaar, J., Bau, C.H., Ramos-Quiroga, J.A., Mick, E., Grevet, E.H., Johansson, S., Haavik, J., Lesch, K.P., Cormand, B., Reif, A. (2012). The genetics of attention deficit/hyperactivity disorder in adults, a review. Molecular Psychiatry. 17 (10): 960-87.
• Miranda, A., Jarque, S., Soriano, M. (1999) Attention deficit hyperactivity disorder: current controversies about its definition, epidemiology, etiologic basis, and approaches to intervention. REV NEUROL 1999; 28 (Suppl 2): S 182-8.
• Ramos-Quiroga J.A., R. Bosch-Munsó, X. Castells-Cervelló, M. Nogueira-Morais, E. García-Giménez, M. Casas-Brugué (2006) Attention deficit hyperactivity disorder in adults: clinical and therapeutic characterization. REV NEUROL 2006; 42: 600-6.
• Valdizán, J.R., Izaguerri-Gracia A.C. (2009) Attention deficit/hyperactivity disorder in adults. REV NEUROL 2009; 48 (Suppl 2): S95-S99.
• Wilens, T.E., Dodson, W. (2004) A clinical perspective of attention-deficit/hyperactivity disorder into adulthood. J Clin Psychiatry. 2004;65:1301-11.