This chronic disorder can be mentally exhausting, both to patients and their families
When people hear the term “attention deficit hyperactivity disorder” (ADHD), an image of a young, hyperactive child usually comes to mind. However, ADHD is continuous throughout the lifespan, and the negative consequences that begin in childhood continue to manifest into adulthood.
Our amazing human mind allows for the investigation, synthesizing and integration of all the sensory stimuli encountered, translating it into manageable information. As a result, we are able to read and understand instructions, safely drive vehicles, engage in healthy relationships, and protect ourselves from risky behaviors.
ADHD is a neurodevelopmental psychological disorder that presents with a triad of inattention, impulsivity, and hyperactivity. ADHD affects individuals across the lifespan and is not just a childhood disorder. Undiagnosed and untreated ADHD is a major contributor to the academic, interpersonal, and occupational difficulties that plague patients who have it.
Individuals with ADHD experience hardships with respect to the tasks of reading, processing information, listening and being attentive.1 This chronic disorder can be physically and mentally exhausting, both to patients and their families.
For many ADHD patients, having a lifelong, neurodevelopmental psychological disorder has proven to be socially and psychologically detrimental, greatly reducing an individual’s self-esteem and social acceptance.2 Compared to healthy individuals, 75% of adults with ADHD also have one other mental health disorder, with anxiety, mood, or personality disorders being the most common.3
Epidemiology of ADHD
Various factors influence the epidemiology of ADHD. Prevalence rates in the United States are estimated at 4.4%, and decrease to 4% in the college population.4 Yearly, 4.1% of Americans ages 18 years and older and 9.0% of Americans between the ages of 13 to 18 are diagnosed.5 Frequently, adults with ADHD have other neurodevelopmental disorders like autism, dyslexia, dyscalculia, and dyspraxia.3 Only 15% of patients retain the full diagnosis criteria by age 25; however, 65% fulfill the criteria for ADHD in partial remission.2
The childhood ratio of males to females diagnosed with ADHD is 5:1; this decreases to 3:1 in adults.5 Adults with ADHD are less likely to have completed high school; and individuals that were previously married, are currently or were previously unemployed, and those who are disabled are more frequently diagnosed.7 Higher incidents are seen in non-Hispanic Caucasian populations.8
Who Is Affected?
Scientists are still unraveling the mystery behind the etiology of ADHD. Even though it is not completely understood, a variety of factors have been suggested, including prenatal exposures to lead, premature delivery, low birth weight, genetic factors, psychosocial issues and neurochemical deregulation.3
The following genes have implications in ADHD: D2 dopamine receptor gene, the dopamine beta-hydroxylase gene, the D5 dopamine receptor gene, the D4 dopamine receptor gene, and the dopamine transporter gene.3 Diagnosed individuals carrying one of these genes have thinner brain tissue in the frontal-subcortical networks which are associated with attention.5 The hyperactive and inattentive symptoms are associated with reduced inhibitory functioning of the prefrontal cortex that controls the down regulation of norepinephrine and dopamine.9 Functional reduction of the corpus striatum combined with brain volume reduction and abnormal responses to stimuli result in the characteristic distractibility, elevated emotional response, and decreased sense of motivation.10
As with many disorders, ADHD occurs due to a combination of genetics, environmental and neurobiological features. Moreover, it is important to note that research does not support theories that elevated levels of sugar or increased television viewing cause ADHD.5
Three Hallmark Symptoms
Classification of ADHD is based on symptoms and clinical history. The dynamic nature of this disorder allows symptoms to change over time and can alter the presentation category of the patient.
The DSM-V uses presentation categories that correlate to the three hallmark symptoms: inattention, impulsivity, and hyperactivity.2 Depending on the current symptoms and age of onset, a variety of history and exam findings occur.
Inattention and hyperactivity/impulsivity are the domains that the DSM-V utilizes to diagnose ADHD. Individuals with ADHD have an overall pattern of inattention and/or hyperactivity-impulsivity that interferes with function or development.11 Some common findings include: academic/occupational dysfunction, problems with authority, relationship dysfunction, risky sexual behaviors, drug/alcohol abuse, thrill-seeking actions, failure to pay attention, careless mistakes, difficulty maintaining attention, incompletion of tasks, organizational difficulties, frequently losing things, restlessness, excessive talking and frequent interruptions.2
Adult presentations are characterized primarily by increased internal restlessness (rather than hyperactivity and impulsivity) with functional impairment, underachievement in occupational endeavors and disorganization.5
Diagnosis Based on Clinical History
Psychological testing is currently not available; and there are no diagnostic tests that allow clinicians to definitively diagnose a patient with ADHD. Diagnosis is based purely on clinical history and the evaluation of the patient based on the DSM-V criteria.
Investigation of the patient’s clinical history is very important when ADHD is suspected. History of childhood behaviors, performance in school, and parent accounts are critical for creating a diagnosis timeline. ADHD rating scales can help a clinician identify the level of attention impairment that a patient is experiencing, but these are not diagnostic.12
The Conners Adult ADHD Rating Scale (Connors scale) or the Brown Attention Deficit Disorder Scale (Brown scale) are examples of ancillary measures. These rating scales are used to evaluate for other psychiatric diagnoses that may mimic ADHD. In individuals suspected of having ADHD who report cognitive problems or executive functioning issues, neuropsychological testing should also be conducted.
Every Patients’ Plight Is Unique
ADHD is dynamic and presents in a variety of ways. Each patient experiences the disorder differently and has symptoms that are associated with their presentation category. ADHD has no definitive cure and the goal of treatment is to control symptoms, maximize quality of life, and improve functioning.
Just as one individual may be more hyperactive while another may be more inattentive, therapy regimens must be tailored for each patient. Not every patient will need adjunct therapy with antidepressants or sleep aids. Combination therapy allows for adjustments to target the symptoms that cause the most hardship.
Frequent assessment of medication side effects and treatment benefits allows progress to be tracked. The fluctuating intensity of symptoms makes re-evaluation and re-screening prudent in ADHD management. Since this disorder persist throughout the lifespan, various treatment modalities exist which can be individualized based on current stressors and concomitant disorders that are present.
Examples of treatments include: medications (stimulant and non-stimulant), psychotherapy and education, and combination approaches. The Conners Scale and Brown Scale are designed to track severity of symptoms and are used to evaluate treatment success.2
Challenges with ADHD come into play when the diagnosis is delayed or treatment is not promptly initiated or continued. Without proper diagnosis or treatment, patients may experience higher rates of substance abuse, and negative experiences (such as car accidents) due to increased risky behaviors.3
Obstructive sleep apnea is another issue that providers must be aware of when evaluating for co-morbid conditions.13 Suicidal ideation is a severe and potentially deadly issue that many individuals with ADHD face.7 Patients’ feelings toward their condition seem to worsen as the severity of symptoms increase, especially when medication tolerance develops or occupational dysfunction inclines.4
Furthermore, ADHD patients are subjected to social stigma from having a psychological disorder, which stems from the societal misconceptions regarding the etiology of ADHD and suspicions about pharmacological treatment abuse. These factors, combined with a lack of emotional support, make dealing with ADHD all the more challenging for the individuals who are diagnosed with it.
Proper Diagnosis Leads to Good Prognosis
The overall prognosis for patients diagnosed with ADHD is good, and with proper medical and pharmacological interventions, most patients experience a high quality of life. All presentations of ADHD will benefit from adjunctive psychotherapy and training in organization and time-management skills.2 Psychotherapy provides coping and emotional strategies that can enhance the ADHD medication benefits. In addition, comorbid mood and anxiety disorders that present with ADHD are also highly treatable.
The good news is, the CDC reports that 60% of patients treated with stimulant medication have the same job satisfaction and quality-of-life rating as individuals without a diagnosis of ADHD.12 Healthcare providers that are proactive in the clinical setting provide the best means for diagnosing and treating adults with ADHD, which can combat the negative effects of delayed diagnosis (or misdiagnosis).
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