Adult Attention Deficit Hyperactivity Disorder: The European Perspective

ADHDThe prevalence of Adult Attention Deficit Hyperactivity Disorder is between 1 and 5%.  Both DSM-IV and ICD-10 criteria recognise that symptoms of Attention Deficit Hyperactivity Disorder and Hyperkinetic disorder persist beyond childhood into adulthood. However neither classification gives fixed thresholds for the number of symptoms required to make a diagnosis in adults.  DSM-IV criteria suggests that adults with only some of the symptoms of Attention Deficit Hyperactivity Disorder should be given a diagnosis of Attention Deficit Hyperactivity Disorder in partial remission; however, this diagnosis seems to underplay the significant impairments seen in adults no longer meeting the full DSM-IV criteria.  There is no doubt that symptoms of adult Attention Deficit Hyperactivity Disorder should be judged with reference to developmentally appropriate norms. The expression of Attention Deficit Hyperactivity Disorder in adults is different from that in children and the diagnostic descriptions of symptoms are not easily applicable to adults.  For example physical activity in children is replaced by constant mental activity, feelings of restlessness and difficulty engaging in quiet sedentary activities in adults. Compared to the diagnosis in children, a diagnosis of Attention Deficit Hyperactivity Disorder in adults is also heavily dependent on self-reporting symptoms. For that reason an independent informant particularly one who had knowledge of the adult in childhood is particularly important. In addition school reports can be most helpful.  Girls particularly with Attention Deficit Disorder without the hyperactivity tend to be under diagnosed and under treated.  In Adult Psychiatry Attention Deficit Hyperactivity Disorder is probably one of the commonest missed diagnosis, the second most commonly missed diagnosis being Asperger’s syndrome.  What is treated is the comorbid anxiety, depression, or drug abuse and the underlying Attention Deficit Hyperactivity Disorder is left untreated with serious consequences.

 

The key element in diagnosis is the lifetime and persistent history of symptoms with impairment in either school, work, home, or interpersonal relationships.  This was emphasised at a recent meeting of the European Network for Attention Deficit Hyperactivity Disorder in Frankfurt.

 

Treatment should focus on psychoeducation for persons with Attention Deficit Hyperactivity Disorder, as well as pharmacotherapy, and in addition the treatment of comorbid disorders.  Stimulants like Methylphenidate are used in the treatment of adults. Long acting Methylphenidate for example Concerta is being used off label for adult Attention Deficit Hyperactivity Disorder.  Atomoxetine (Strattera) which is licensed for adults in the United States and is available in Ireland on a named patient basis is being used for the treatment of Attention Deficit Hyperactivity Disorder.  It is the first non-stimulant medication for Attention Deficit Hyperactivity Disorder.  I have found that the tricyclic antidepressants are unfortunately rather ineffective. The core symptoms of Attention Deficit Hyperactivity Disorder require pharmacological treatment.  The other behavioural associated problems or disorders can benefit from psychotherapy, cognitive, supportive, etc..

 

It is possible that Adult Attention Deficit Hyperactivity Disorder may belong to a more severe and more genetically effected condition. Morbidity and mortality are both increased in adults with Attention Deficit Hyperactivity Disorder. It appears that Attention Deficit Hyperactivity Disorder can result in more accidents including traffic accidents and alcohol and drug abuse.  There is evidence that where Attention Deficit Hyperactivity Disorder has been adequately treated the rate of substance abuse was less.  It is important to reiterate that in adulthood the features of Attention Deficit Hyperactivity Disorder that are most common are inattention, impulsivity, poor organisation, and restlessness. Attention Deficit Hyperactivity Disorder can be associated with creativity for example Kurt Cobain who had diagnosed Attention Deficit Hyperactivity Disorder in childhood, Oscar Wilde, Lord Byron, Ernest Shakleton, and Richard Brinsley Sheridan.

 

Adult Attention Deficit Hyperactivity Disorder is of critical importance in services treating drug problems, personality disorders, and forensic services.  The rate of Attention Deficit Hyperactivity Disorder in Mountjoy Prison is much higher than in a non-prison population.  A recent edition of the Journal (2003) Drugs:  Education Prevention and Policy emphasised the association of adult Attention Deficit Hyperactivity Disorder, Antisocial Personality Disorder and substance misuse.  Despite this clinicians have a reluctance to take Attention Deficit Hyperactivity Disorder into account at the diagnostic and therapeutic level.  The reluctance to accept the diagnosis is even more puzzling because of its very high heritability which is higher than many conditions psychiatrists treat.  There should be regional centres for the treatment of adult Attention Deficit Hyperactivity Disorder but this is not possible with the catchment area arrangement. Therefore one Consultant Psychiatrist in each catchment area should take a special interest in adult Attention Deficit Hyperactivity Disorder.