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Pearls


5 fundamentals of managing adult ADHD

Vol. 2, No. 7 / July 2003

As a psychiatrist specializing in college health, I see 40 to 50 young adults yearly with undiagnosed attention-deficit/hyperactivity disorder (ADHD). I have found that understanding five fundamentals of ADHD is key to recognizing this disorder in adults.

  1. There is no “adult onset” ADHD. Although ADHD may manifest itself differently in adults than in children, studies indicate that the disorder is a continuation of childhood ADHD rather than a discrete adult disorder. Clinicians thus need to establish that adult patients exhibited symptomatic and functional impairment before age 7 (as per DSM-IV), although some experts suggest preadolescence as a cutoff. 1
  2. Most people do not “outgrow” ADHD. We once assumed that most patients with ADHD became asymptomatic as they matured from adolescence into adulthood. Research reveals that hyperactivity and impulsivity decline over time but inattention and executive dysfunction usually persist into adulthood. 2 These residual deficits cause continued vocational, academic, and interpersonal difficulties.
  3. ADHD can mimic other psychiatric disorders. The hyperkinesis, impulsivity, and inattention that are the essence of ADHD are also commonly observed in adults with anxiety disorders, mood disorders, substance abuse problems, and learning disorders. Patients who present with atypical affective or anxiety symptoms or learning problems, or who do not respond to conventional treatments, should be screened for ADHD.
  4. The genetic apple does not fall far from the tree in ADHD. Many adults with ADHD are identified in middle age after their children are diagnosed. Adoption data and multiple twin studies have placed the heritability of ADHD at approximately 75%, 3 putting first-degree relatives at fairly high predisposition.
  5. Stimulant medications do not promote substance abuse in ADHD patients. Stimulant medication is more likely to reduce the risk of substance abuse in ADHD than enhance it.4 For patients at high-risk for substance abuse disorders, however, atomoxetine and bupropion offer nonstimulant alternatives. Also, the newer, longer-acting dextroamphetamine/amphetamine and methylphenidate preparations are more difficult to abuse because of their slow-release mechanisms.

References

1. Barkley RA, Biederman J. Toward a broader definition of the age-of-onset criteria for attention deficit disorder. J Am Acad Child Adolesc Psychiatry 1997;36:1204-10.

2. Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into adulthood as a function of reporting sources and definition of disorder. J Abnorm Psychol 2002;111:279-89.

3. Sprich S, Biederman J, Crawford MH, et al. Adoptive and biological families of children and adolescents with ADHD. J Am Acad. Child Adolesc Psychiatry 2000;143:1432-7.

4. Biederman J, Wilens T, Mick E, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104:e20.-

Dr. Anders is clinical assistant professor of psychiatry, University Health Services, University of Wisconsin, Madison.

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