The 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.

Kurt Cobain was wrong – the treatment of Attention Deficit Hyperactivity Disorder with Methylphenidate does not predispose to substance misuse indeed precisely the opposite is true.  Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area with Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.

Kurt Cobain had Attention Deficit Hyperactivity Disorder, and was prescribed Methylphenidate when he was at school. Unfortunately he only took it for three months.  The impression was given later that this was a factor in his developing substance abuse. Indeed precisely the opposite is the truth.  Persons who are treated for Attention Deficit Hyperactivity Disorder on a continuous basis with Methylphenidate are less likely to abuse substances as they get older. The abuse of drugs like cannabis or cocaine is often a feature of self-medication for Attention Deficit Hyperactivity Disorder.  The increased use of cigarettes by persons with Attention Deficit Hyperactivity Disorder may also be done for the same reason.  There is no doubt that persons with Attention Deficit Hyperactivity Disorder have an earlier onset of cigarette smoking and a greater use of it. There is no evidence for long term risks for substance use disorders in persons prescribed Methylphenidate. Indeed there is a reduced likelihood of substance misuse if Attention Deficit Hyperactivity Disorder is properly treated with stimulants.  This doesn’t mean that there aren’t some risks from stimulants i.e. through diversion. A new medication for Attention Deficit Hyperactivity Disorder Atomoxetine has been shown to have no greater abuse liability than Desipramine an antidepressant or placebo. Unfortunately Attention Deficit Hyperactivity Disorder is a serious condition which requires early intervention and the misinformation about it is preventing some children from getting the treatment that they need.

Children with Attention Deficit Hyperactivity Disorder are at risk of increasing complications as they get older.  They start in childhood with Attention Deficit Hyperactivity Disorder alone and then can develop disruptive behaviour disorders, oppositional disorders, challenging behaviour, and later from about 14 years onwards they experience often school exclusion, substance abuse, mood disorder, conduct disorder, and finally antisocial personality disorder and often get involved with the law at the same time.  Of course this trajectory only occurs in those with severe Attention Deficit Hyperactivity Disorder and severe complications.  Comorbid Oppositional Defiant Disorder occurs in over 40%, Conduct Disorder in 20 to 56%, delinquent and antisocial activities in 18 to 30%. Many continue their problems into adulthood and they are more likely to enter the workforce at unskilled or semi skilled level. They are twice as likely to be dismissed from their employment, tend to have many more jobs than the average, and to show much lower work performance than the average.

In examining motor vehicle driving risks persons with Adult Attention Deficit Hyperactivity Disorder are 60% more likely to have a crash with injuries as compared to 17% of the general population. As well as having much more accidents they tend to have worse accidents.  They have four times higher risk of having sexually transmitted diseases because of their earlier onset of sexual activity and their increased number of sexual partners.  In addition they are less likely to employ contraception and spend less time with each partner than the average population.  Girls with Attention Deficit Hyperactivity Disorder are over 9 times more likely to have a teen pregnancy than those without Attention Deficit Hyperactivity Disorder.  The judicial costs of having Attention Deficit Hyperactivity Disorder are vastly increased as compared to people without Attention Deficit Hyperactivity Disorder. In America it has been estimated that the total criminal costs for persons with Attention Deficit Hyperactivity Disorder and Conduct Disorder combined are 37,830 dollars.

Unfortunately Adult Attention Deficit Hyperactivity Disorder is largely missed as a diagnosis.  It appears to me that the  next most missed diagnosis in adults is Asperger’s syndrome which nowadays tends to misdiagnosed as Mild Bipolar disorder.  It tended in the past (and this still occurs in the present) to be misdiagnosed as Personality disorder or Schizophrenia.  This meant they didn’t get the treatment they needed and got inappropriate treatment.  A typical example is the novelist who was nominated for a Nobel Prize Janet Frame who was diagnosed with Schizophrenia outside Europe.  She was put on a list for lobotomy in 1952.  She was told by the Maudsley Hospital later that she did not have Schizophrenia.  She died in 2004.  In actual fact she had Asperger’s syndrome.  There may be thousands in a similar situation throughout the world with misdiagnosis of psychiatric disorder.  Hopefully the Irish College of Psychiatrists, Irish Psychiatric Association and those responsible for C.M.E. will take up this issue.

Going back to Kurt Cobain he would have a much greater chance of having survived if he persisted taking his Methylphenidate on a regular basis and had intensive multimodal treatment for his Attention Deficit Hyperactivity Disorder and associated problems.  He showed the majority of comorbidities that one can get with Attention Deficit Hyperactivity Disorder.  It was not surprising that he completed suicide.

Automobile crashes are one of the leading causes of deaths in adolescents.  Accidents are three to four times more frequent in persons with Attention Deficit Hyperactivity Disorder.  The Attention Deficit Hyperactivity Disorder driver is three to four times more likely to be at fault.  The Attention Deficit Hyperactivity Disorder driver is six to eight times more likely to loose their license.  The treatment of Attention Deficit Hyperactivity Disorder with stimulants improves the performance of the driver.  There is a serious lack of attention being given to the impact of Attention Deficit Hyperactivity Disorder on driver’s performance in relation to accidents in Ireland.  Unfortunately adult Attention Deficit Hyperactivity Disorder is not uncommonly missed as a psychiatric diagnosis.

Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area of Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.  Doctors can also have adult Attention Deficit Hyperactivity Disorder and the following questions are often worth considering:

(1)       Do you have difficulty concentrating or focussing your attention on one thing?

(2)       Do you often start multiple projects at the same time, but rarely finish them?

(3)       Do you have trouble with organisation?

(4)       Do you procrastinate on projects that take a lot of attention to detail?

(5)       Do you have problems remembering appointments or obligations?

(6)       Do you have trouble staying seated during meetings or other activities?

(7)       Are you restless or fidgety?

(8)       Do you often loose or misplace things?

In terms of driving behaviour Methylphenidate (Ritalin / Ritalin LA) significantly reduces inattentive driving errors.  It would appear that for those driving in the early evening including during the day Concerta XL (Methylphenidate) which lasts for 12 hours would be more relevant.  This is also a form of slow release Methylphenidate and is off label in Ireland for adults.  Of course accidents do occur in the evening and so good attention is particularly required at this time.  There is also a new medication the first non-stimulant medication available in Ireland for Attention Deficit Hyperactivity Disorder on a named patient basis called Atomoxetine (Strattera) which is active over the 24 hours. This has slow onset and has to be taken seven days a week. This would seem to have a place when you are particularly focussing on wanting to have a person on continuous treatment as it does not wear off.  It would particularly appear to be important for late evening / night, the time of maximum danger for accidents.  Adolescents with Attention Deficit Hyperactivity Disorder also benefit from cognitive / behavioural therapy which focuses on the inhibition of impulses, time management, organisational skills, problem solving skills, anger management, decision-making skills, social skills training, and improved social perception.  Persons with Attention Deficit Hyperactivity Disorder need to be educated about it.  Once the diagnosis is given to them it can suddenly make sense of their lives and sometimes of the chaos of their lives.  It is difficult to get a chaotic life into order if one doesn’t understand what the problem is.  Genetic factors play a major role in Attention Deficit Hyperactivity Disorder.  The problem of adult Attention Deficit Hyperactivity Disorder and accidents is a matter that should be taken up by professional psychiatric bodies and by consultants in Accident and Emergency Departments who are often on the receiving end of problems with Attention Deficit Hyperactivity Disorder.  Organisations involved in road safety should also examine this issue.