Adult Attention Deficit Disorder

Adult attention deficit disorder (AADD) is a psychological condition associated with a disruptive behaviour. It is commonly referred to as an adult attention-deficit hyperactivity disorder (ADHD).

Adult Attention Deficit Disorder is triggered by congenital processes.

Presentation

There are contradictory views on the approach of classifying the short-attention span and high energy stage as a psychiatric disorder. However, attention deficit hyperactivity disorder is associated with different types of symptoms, which are listed below. It is important to note that not all cases of inattention, impulsivity or hyperactivity are associated with an attention disorder, but a repeated or continuous display of these symptoms for more than six months in a child below the age of 7 years may necessitate an investigation.

Broadly, AADD symptoms are classified into three groups. These include impulsivity, hyperactivity and inattention. Common features of inattentiveness may include loss of concentration, distractions, boredom, impatience, inability to fully focus, poor comprehension and listening skills. Patients with symptoms of impulsivity act without instructions and are interruptive and aggressive in response. Characteristics of hyperactivity, on the other hand, include anxiety, inconsistency and disorderliness.

Workup

Effective diagnosis depends on the comprehensive clinical assessment by an experienced health professional. Different factors are important in order to establish the diagnosis. These include the patient's medical history, observed symptoms, and mental examination test. Diagnostic difficulties often arise from the cross-interaction of other comorbid psychiatric symptoms.

Basic patient history may include questions about the effect of the symptoms on behaviors or attitude, temperament control, home or work activities. Also, questions about the overall period of symptom development with other underlying physical or mental problems may be necessary to guide diagnosis.

Treatment

The main therapeutic regimen for treating AADD condition is pharmacotherapy. Most reports focus on children, but many drug schemes have been proven over the years to be safe, appropriate and effective for both children and adults [8] [9]. The use of stimulants is as effective as antidepressants such as bupropion hydrochloride or desipramine, although no current comparative studies about the two drugs exist. Meta-analytical studies carried out recently on the use of stimulant and non-stimulant drugs revealed that there is a significant clinical improvement in the patient when compared with placebo treatment. Clinical guidelines in AADD management recommend that the first line of treatment should consist of stimulants and atomoxetine, followed by an antidepressant medication.The drug regimen involves an initial low dosage of medication, which is then progressively increased to reach a higher therapeutic level in order to prevent or reduce the side effects. Before a change of dosage, a clinical evaluation lasting for 4-6 weeks is important. Often, long-acting or extended-release stimulants are the preferred choice, because about 70% of the patients reported a better response or improvement compared with 40-50% of those placed on immediate-release stimulants.

30% of the patients being managed for AADD are reported to discontinue stimulant treatment due to complications or intolerance to the side effects. Contraindications associated with stimulant treatment include hypertension (HTN), tachycardia, cardiac arrhythmia, psychotic episode, bipolar disorder, anorexia nervosa, and Tourette syndrome. A review study by the U.S. Food and Drug Administration revealed a raised incidence of sudden death cases associated with patients on standard stimulant dosage, having underlying severe heart problems. However, the report from a recent study involving about 150,000 adults showed that the newly formulated stimulant administration for managing patients with AADD carried no risk of severe cardiovascular diseases, such as myocardial infarction, rapid cardiac arrest, stroke or death. Other effective drugs used in ADD include modafinil (INN), clonidine hydrochloride (an alpha agonist) and guanfacine. These drugs are rarely recommended for adults because there no present information about their therapeutic efficacy.

Other additional treatment may include cognitive behavior therapy. The mechanism of action involved is not properly understood, although, it has been proven to be effective and assist in ameliorating the symptoms of patients with AADD. An unproven report indicated that social therapy such as meditation or herbal remedies, such as St John's wort are also effective in managing the condition.

Complications of AADD which result into comorbid psychiatric conditions may be managed symptomatically. Depression is usually treated initially, before AADD. This can then be managed by both antidepressants and stimulants. Drug combination of selective norepinephrine (e.g atomoxetine) and serotonin reuptake inhibitors (e.g fluoxetine) should be avoided because both drugs share the same metabolic pathway (cytochrome P450). Bipolar disorder is managed using atypical antipsychotics and mood stabilizers. The use of stimulants is discouraged in bipolar disorder; however, it is highly recommended as a first-line drug for treating anxiety disorder.

Selective use of serotonin reuptake inhibitors in addition to cognitive therapy is also effective. In cases of patients with AADD and intellectual impairments, no present clinical evidence shows any therapeutic advantage of stimulant use in treating AADD. Also, drugs such as risperidone have been reported as effective in the patient group.

The risk of drug abuse associated with AADD medication is high, so there is a need for strategic planning and proper monitoring of the drug administration by the patient's family and clinicians to prevent abuse or noncompliance to drugs such as stimulants particularly for patients with AADD [10]. These may include signed drug dependence contact document, laboratory investigations (drug of abuse urine screening) to evaluate the compliance of the patient to drug instructions and also screening for the unprescribed drugs. This can also assist in periodic follow-up, monitoring and evaluation of the therapeutic effectiveness of the drugs.

Prognosis

Generally about 30% of the children diagnosed with attention deficit hyperactivity disorder recover from the condition and remarkably progress into adulthood without any residual problems. However, the remaining percentage may either have some or all of the symptoms, which may be a highly significant problem. These negative responses are associated with severe and recurrent symptoms. Previous studies revealed that there are similarities in the symptoms exhibited both in childhood and adult years, although, the daily effect of the symptoms differ distinctly. Proper management of the condition with appropriate drug regimen may significantly change the outcome of AADD in an affected patient. As an example, an effective management of the symptoms with the appropriate medication may play a key role in preventing the development of other psychiatric problems or improve low academic performance.

Moreover, other important studies involving the outcome of adults with AADD showed that about 11% of affected adults receive therapeutic aid, while about 50% suffer from anxiety disorder [6]. Also, about 40% and 15% develop another form of co-occurring mood or substance-abuse disorder [7]. Newly emerging reports suggested that a combination therapy involving a drug regimen, cognitive therapy, life coaching or mentoring is effective and significantly increases the prognosis.

Etiology

AADD is a clinical condition with a significant genetic influence. Few cases of AADD may result from drinking or smoking in pregnancy, ante- or postnatal complications. Also, it may be caused by an exposure to lead poisoning, toxins, brain injury or trauma. Although the major known cause of AADD is presently not known, results from brain imaging techniques revealed the different parts of the brain involved with AADD. Also, research studies reported the role of impaired neurotransmission in the pathogenesis of the condition. These neurotransmitters include dopamine (DA), norepinephrine (NE) and epinephrine.

Epidemiology

Previously, it was generally believed that ADD resolves with age but was later confirmed that about 60% of affected children still exhibit the symptoms until adulthood. Sometimes, adults presenting with AADD may have previously been diagnosed and managed for the condition during childhood, while others become aware of their condition after diagnosis, following various social problems. The known estimated prevalence rate of the adult population with AADD is 4%. AADD is a global health problem and more commonly reported among male than female individuals [4].

Sex distribution
Age distribution

Pathophysiology

Different types of neurotransmitter and neuroanatomic impairment are related to AADD. With the aid of structural neuroimaging, it has been shown that individuals with AADD lack the frontal lobe asymmetrical arrangement which is commonly seen in normal subjects. Anatomically, the right side of the brain frontal lobe is usually larger than the left side. Also, neuroimaging studies revealed structural and functional changes in the brain. Most commonly, the affected part is the right side and more specifically the prefrontal cortex and anterior cingulate. Also, other parts such as the caudate nucleus, and sometimes cerebellar vermis may be affected.

Genetic studies are designed based on the scientific hypothesis that reduced levels of dopamine influence AADD development. Genetic base sequences which are translated to dopamine proteins are well studied, including the enzymes involved in the synthesis (dopa decarboxylase, which converts l-dopa to dopamine), inactivating pathway (involving dopamine or norepinephrine transporters), as well as degradation. The receptor involved in dopamine activity is also affected (particularly the D4 receptor). The results showed that no single genetic sequence or translated protein has been repeatedly found in AADD, a fact which indicates polygenetic activities [5].

Prevention

There are no known prevention methods to control ADD development in children but the stages of the condition can be monitored. Most adults affected with AADD often do not receive the diagnosis of the condition in time, which may often result in other psychological problems. Therefore, early, appropriate, effective treatment is important to reduce the risk or complications, such as psychosocial morbidity, which is related to AADD. Common complex morbidities include depression, social anxiety and drug abuse, which often necessitate diagnostic request and sometimes make the detection difficult, because of the similarities with other psychotic disorder. Reports suggested that AADD patients under treatment usually respond well with better social habits and lifestyle. These include the reduction in drug abuse, improvement in work or academic performance, with better productivity generally when compared with untreated cases.

Proper evaluation and assessment of patients with AADD or suspected individuals may be done using a three-scaled, validated, auto-report computer program. This may help to guide clinicians in managing the patient properly.

Summary

Attention-deficit hyperactivity disorder (ADHD) or attention-deficit disorder (ADD) was previously considered a disorder that exclusively affected children, due to the reduction of external behaviors. However, reports from longitudinal studies revealed that clinically, the symptoms are still significantly relevant in most of the patients as they progress into adulthood. Recent studies reported that at least one adult attention deficit disorder (AADD) symptom, which causes clinically relevant impairment in adulthood, develops in about 66% of patients earlier diagnosed during childhood with ADD.

AADD is usually characterized by symptoms of behavioral and cognitive change which include hyperactivity, absent-mindedness, impulsiveness, and disorganization. For an effective diagnosis to be made, the symptoms usually need to be severe, persistent and causing significant defect clinically in multiple facets of the patient's life. Most commonly, during childhood, the most disturbing symptoms include hyperactivity, impulsiveness, and inattention. These constitute social problems, causing a disruptive attitude in every place, including home and school, that usually lead to clinical referral for proper management. Hyperactivity may reduce in adulthood but other symptoms (such as impulsiveness, disorganization, etc.) may affect both home and work life. Most commonly, patients complain about difficulties in performing, organizing and undertaking a given task associated with employment or higher learning. Cases of low academic performance, job loss, reduced turnover, social incompetence and divorce are commonly observed among the adult patients with AADD. Also, previous studies reported a higher incidence of social misbehavior including depression, fear, drug addiction or abuse among the adult population diagnosed with AADD [1] [2] [3].

Patient Information

Attention-deficit hyperactivity disorder (ADHD) which was previously referred to as attention-deficit disorder (ADD) is a psychological condition associated with disruptive behavior, characterized by three main features: inattention, impulsivity and hyperactivity. ADHD may affect both male and female individuals. Often, adults are unaware of their condition because of the pressure or stress of daily activities. However, children with the symptoms may be diagnosed early and monitored until adulthood. Common signs of ADD in adult patients include lack of concentration, restlessness, inattention, emotional imbalance, social instability, impulsivity, stress or pressure, intolerance and hyperactivity. Patients have difficulties in performing academically and socially. Some of the symptoms may persist from childhood to adulthood. Complications resulting from AADD which is not well managed may result in depression, anxiety, bipolar disorder and death.

The symptoms observed in AADD are similar to other psychological disorders; therefore the diagnosis is difficult. From the noticeable symptoms, the diagnosis will be made by an experienced physician who will use guided protocols to evaluate the patient. These may include patient history, noticeable symptoms and mental assessment tests. Personal lifestyle questions may be required including the influence of the symptoms on performance, change in attitude, duration of presentation, etc.

Most of the symptoms may be observed by any individual at times, which does not necessarily indicate AADD. However, if the symptoms persist and affect performance (academic, social etc.) or other parts of the patient's lifestyle, there may be a need to be examined by a clinician. The condition can be managed and it is better when discovered early. Various medications are available to alleviate the symptoms with significant improvement following post-management therapy. These drugs include antidepressant and stimulants. Also, patients may benefit from cognitive behavior therapy, including counseling and reassurance from the care giver or patient relatives.

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References

  1. Ginsberg Y, Quintero J, Anand E, Casillas M, Upadhyaya HP. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord. 2014; 16(3). pii: PCC.13r01600
  2. Paris J, Bhat V, Thombs B. Is Adult Attention-Deficit Hyperactivity Disorder Being Overdiagnosed? Can J Psychiatry. 2015; 60(7): 324-8
  3. Brus MJ, Solanto MV, Goldberg JF. Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians.J Psychiatr Pract. 2014; 20(6): 428-37
  4. Williamson D, Johnston C. Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review. Clin Psychol Rev. 2015; 40:15-27.
  5. Brikell I, Kuja-Halkola R, Larsson H. Heritability of attention-deficit hyperactivity disorder in adults Am J Med Genet B Neuropsychiatr Genet. 2015, Jun 30
  6. Young S, Sedgwick O, Fridman M, et al. Co-morbid psychiatric disorders among incarcerated ADHD populations: a meta-analysis. Psychol Med. 2015; 45(12): 2499-510
  7. Knecht C, de Alvaro R, Martinez-Raga J, Balanza-Martinez V. Attention-deficit hyperactivity disorder (ADHD), substance use disorders, and criminality: a difficult problem with complex solutions. Int J Adolesc Med Health. 2015; 27(2): 163-75
  8. Mattingly G, Culpepper L, Babcock T, Arnold V. Aiming for remission in adults with attention-deficit/hyperactivity disorder: The primary care goal. Postgrad Med. 2015; 127(3): 323-9
  9. Simon N, Rolland B, Karila L. Methylphenidate in Adults with Attention Deficit Hyperactivity Disorder and Substance Use Disorders. Curr Pharm Des. 2015;21(23):3359-66
  10. Modesto-Lowe V, Chaplin M, Sinha S, Woodard K. Universal precautions to reduce stimulant misuse in treating adult ADHD. Cleve Clin J Med. 2015; 82(8): 506-12

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