Attention Deficit Hyperactivity Disorder (ADHD), 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 currently used to understand the broad spectrum of manifestations that characterize individuals with ADHD is the concept of deficit in inhibitory control of the response.

That is, the notorious inability to inhibit impulses and thoughts that interfere with executive functions, the performance of which allows you to overcome distractions, set goals and plan the sequences of steps necessary to achieve them.

Now, many times this psychological alteration is spoken of as if it were only a children's thing. Is that so? Is there ADHD in adults? As we will see, the answer is yes.

• Related article: "Types of ADHD (characteristics, causes and symptoms)"

ADHD: Does it also occur in adults?

For more than 70 years, research on attention deficit hyperactivity disorder has focused on the child population. But as of 1976, it was shown that this disorder may exist in 60% of adults, the symptoms of which already began before the age of seven (Werder PH. tea. 2001). This diagnostic gap made the symptoms and treatments of child-adolescent ADHD more known and oriented than in adults, despite the fact that the clinical parameters are similar. What's more,

in adults, complications, risks and comorbidities are more frequent and nuanced than in children, with the risk that the symptoms are confused with other psychiatric conditions. (Ramos-Quiroga YA. tea. 2006).

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

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

Symptoms, diagnosis and evaluation of ADHD in adults

The diagnostic criteria for ADHD in adults are the same as for children, registered at DSM-IV-TR. Starting with the DSM-III-R, the possibility of diagnosing these is formally described.

Signs and symptoms in adults are subjective and subtle, with no biomedical test to confirm their diagnosis. In order to diagnose ADHD in an adult, the disorder must be present from childhood, at least from the age of seven, essential data for the diagnosis, and has to persist a clinically significant alteration or deterioration in more than one important area of ​​their activity, such as social, work, academic or family. For this reason, it is very important that the medical history of the child is recorded together with with current symptoms and their impact on current life, family, work and relationships social.

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

The most common problems with attention deficit hyperactivity disorder in adults are: trouble concentrating, forgetfulness and poor short-term memory, difficulty organizing, trouble with routines, lack of self-discipline, impulsive behavior, depression, low self-esteem, inner restlessness, poor ability to manage time, impatience and frustration, poor social skills and a feeling of not achieving goals, among others.

Self-assessment ladders are a good diagnostic tool for more general symptoms (Adler LA, Cohen J. 2003):

Adult Self-Assessment Ladder (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 characteristic ADHD symptoms. 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 helpful in assessing ADHD mood and lability. Conners´Adult ADHD Rating Scale (CAARS): Symptoms are assessed with a combination of frequency and severity.

According to Murphy and Gordon (1998), in order to make a good evaluation of ADHD, it is necessary to take into account whether there is evidence on the relationship between ADHD symptoms during childhood and a significant and chronic subsequent decline in different settings, if there is a relationship between current ADHD symptoms and substantial and conscious decline in different settings, if there is another pathology that justifies the clinical picture better than ADHD, and finally, if for patients who meet the diagnostic criteria for ADHD, there is any evidence that conditions exist comorbid.

The diagnostic procedure is guided by guidelines for performing diagnostic tests according to the clinical situation. This procedure begins with a complete medical 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.

How Biederman and Faraone (2005) highlight very well, to be able to make a diagnosis of ADHD in adults it is essential to know which symptoms are typical of the disorder and which are due to another pathology comorbid.

It is very important to note 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 that ranges from 19 to 37%. For anxiety disorders, comorbidity ranges from 25% to 50%. In the case of alcohol abuse it is from 32 to 53% and in other types of substance abuse such as cocaine it is from 8 to 32%. The incidence rate for personality disorders is 10-20% and for antisocial behavior 18-28% (Barkley RA, Murphy KR. 1998).

Pharmacotherapy

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

Immediate-release methylphenidate inhibits dopamine collection; and atomoxetine, its main function is to inhibit the collection of norepinephrine. Currently, and thanks to several studies carried out by Faraone (2004), methylphenidate is known to be more effective than placebo.

The explanatory hypothesis from which ADHD therapy based on psychostimulants such as methylphenidate starts is that this psychological disorder is caused (at least in part) by a need constant effort to keep the nervous system more activated than it is by default, which has as a consequence the repetitive search for extensive stimuli with which to engage in activities. Thus, methylphenidate and other similar drugs would activate the nervous system so that the person is not tempted to seek externally 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 drugs, on certain occasions it is not enough to time to manage other factors, such as disruptive cognitions and behaviors or other disorders comorbid. (Murphy K. 2005).

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

The most effective approach to treating ADHD in adults is cognitive-behavioral, both in an individual and in a 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 cope with emotional, cognitive, and associated behavioral disorders, as well as better control of refractory symptoms to treatment pharmacological. For this reason, multimodal treatments are considered the indicated therapeutic strategy (Young S. 2002).

Bibliographic references:

• Franke, B., Faraone, SV, Asherson, P., Buitelaar, J., Bau, CH, Ramos-Quiroga, JA, Mick, E., Grevet, EH, Johansson, S., Haavik, J., Lesch, KP, 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, etiological bases and intervention approaches. 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