This article will be focused on ADHD in adults.

Introduction

It is estimated that in any given year, ADHD affects 4.1 percent of adults, ages 18-44. Although everyone has occasional lapses in attention and concentration, people with ADHD have symptoms that significantly affects their ability to function in school, work, home, and social settings.

Symptoms:

ADHD in adults can be conceptualize as a disorder of our brain’s “executive functions”. The executive functions include planning, initiating and inhibiting actions, selecting relevant sensory information to focus on, etc. Impairment of the executive functions can result in many of the following symptoms:

Inattentiveness as displayed in:

-Difficulty paying attention to details, or careless mistakes in schoolwork, work, or other activities.

-Difficulty keeping attention on tasks or activities

-Difficulty following instructions on tasks despite understanding instructions

-Difficulty focusing on the current conversation because of distracting background noises or conversations

-Difficulty organizing activities

-Difficulty focusing on tasks for a long period of time

-Often misplacing or losing belongings

-Often easily distracted

-Often forgetful in daily activities

Hyperactivity as displayed in:

-Often feeling fidgety during meetings, resulting in fidgeting with hands or feet, shifting positions in seat, or standing up from seat when remaining in the seat is expected.

-Often feeling restless, feeling “driven by a motor”, or always “on the go”

-Often talking excessively

Impulsivity as displayed in:

-Often blurting out answers before questions have been finished, interrupting others as they are speaking, or intruding on others’ conversations

-Difficulty waiting one’s turn

Diagnosis

Diagnosis of ADHD in an adult is dependent on a history of ADHD symptoms in childhood before age 7. If ADHD-like symptoms suddenly emerge in adulthood without a childhood history, it is likely that a different disorder with overlapping symptoms is responsible. Major depression and bipolar disorder, among others, can mimic different aspects of ADHD.

There must also be clear evidence of significant impairment of functioning from ADHD symptoms in more than one realm (e.g. home, school, work and social settings).

There are three major types of ADHD:

1. ADHD Predominantly Inattentive Type: formerly known as “Attention Deficit Disorder”, or ADD.
2. ADHD, Predominantly Hyperactive-Impulsive Type
3. ADHD, Combined Type: ADHD combined type is a combination of the symptoms of inattentive type and hyperactive-impulsive type.

Of note, many still use the term “Attention Deficit Disorder” or “ADD” to refer to ADHD – Inattentive Type. This is because the term “ADD” was used until 1987 when it was changed to ADHD – Inattentive Type with the DSM-III-R.

ADHD is diagnosed clinically, based on history. Oftentimes, information from parents or teachers is helpful. Psychological testing is sometimes used to help diagnose unclear cases of ADHD. There is no blood test or imaging test that is diagnostic for ADHD. However, if there are clinical signs that suggest a medical problem may be contributing to ADHD symptoms, your doctor may order blood tests or brain imaging tests to see if there are any other factors contributing to the ADHD symptoms.

Treatment

Treatment can involve therapy, medications, or combined treatment, depending on patient preference and severity of symptoms.

• Therapy: Behavior therapy has been shown to be effective in children with ADHD. In adults, elements of cognitive behavioral therapy (CBT) and cognitive rehabilitation including compensatory strategies can be helpful to cope more effectively with the disorder.
• Medications: The most commonly used medications for treating ADHD are stimulants. These medications are controlled substances and are generally prescribed by a psychiatrist or neurologist.
  • There are two major classes of stimulants: amphetamine class stimulants and methylphenidate class stimulants. There are also other types of ADHD medications that do not fall into the amphetamine or methylphenidate classes.
    • Amphetamine Class Stimulants
      • Mechanism of Action: Amphetamines act by increasing the release of norepinephrine and dopamine and blocking their reuptake.
      • Examples:
        • Adderall (amphetamine/dextroamphetamine) – Duration 3-5 hours Adderall XR (amphetamine/dextroamphetamine) – Duration 8-12 hours
        • Dextroamphetamine (generic) – Duration 3-5 hours for immediate release version, duration 4-8 hours for extended release version
        • Vyvanse (lisdexamfetamine) – a pro-drug that is converted to dextroamphetamine by the liver, duration 9-13 hours
    • Methylphenidate Class Stimulants:
      • Mechanism of Action: Methylphenidate class stimulants act by increasing the release of norepinephrine and dopamine and blocking their reuptake.
      • Examples:
        • Methylphenidate (generic) – Duration 3-5 hours for immediate release version, duration 4-8 hours for extended release version Ritalin (methylphenidate) – Duration 3-5 hours Ritalin SR (methylphenidate) – Duration 4-8 hours Ritalin LA (methylphenidate) – Duration 8-12 hours Methylin (methylphenidate) – Duration 3-5 hours Methylin ER (methylphenidate) – Duration 4-8 hours Metadate ER (methylphenidate) – Duration 4-8 hours Metadate CD (methylphenidate) – Duration 8-12 hours Concerta (methylphenidate) – Duration 8-12 hours Daytrana (methylphenidate transdermal) – Duration 2 hours after application until up to 5 hours after removal Focalin (dexmethylphenidate) – Duration 3-5 hours Focalin XR (dexmethylphenidate) – Duration 8-12 hours
    • Non-Stimulant ADHD Medications:
      • Mechanism of Action: Whereas medications in the methylphenidate and amphetamine classes all act by increasing the release of norepinephrine and dopamine and blocking their reuptake, the following ADHD medications act in different ways.
      • Examples:
        • Bupropion (generic) – Inhibits norepinephrine and dopamine reuptake. Also used as an antidepressant and smoking cessation aid. Available as generic or as brand-name Wellbutrin.
        • Strattera (atomoxetine) – Inhibits norepinephrine reuptake. Unique in that it does not become therapeutic until 4-8 weeks after initiation.
        • Intuniv (guanfacine) – Stimulates alpha2-adrenergic receptors. Not to be confused with guaifenesin (an over the counter cough medicine).
        • Provigil (modafinil) – exact mechanism of action unknown, but affects the dopamine system. Used in the military to prolong alertness. Not officially FDA approved for the treatment of ADHD, but at times prescribed “off-label”.

  • Treatment with stimulants needs to be carefully monitored. Your physician will need to know about any personal or family history of cardiac problems including heart attacks, high blood pressure, arrthymias, etc. You may need to undergo an electrocardiogram (EKG) or further testing prior to initiating treatment if there is the possibility of cardiac problems. Your physician will want to monitor your blood pressure and heart rate periodically, as those can be increased by stimulants. Common side effects that will also need to be monitored is possible weight loss because of appetite suppression, and slowed growth in children.

• Combined Treatment: The combination of therapy and medications can be the most effective form of treatment for some patients.

For Further Information: See the Wikipedia entry on ADHD, or contact a qualified mental health professional.

Article written 12/19/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.