_____________________________________________________________________ When Children With Attention-Deficit/Hyperactivity Disorder Become Adult
H. Patrick Stern, MD, Asha Garg, MD, Thomas P. Stern, MD
South Med J 95(9):985-991, 2002. © 2002 Southern Medical Association
Historically, attention-deficit/hyperactivity disorder (ADHD) has been viewed as a disorder confined primarily to pediatric patients, with only a small percentage persisting into adulthood. Recently, it has been reported that up to 50% of children with ADHD will continue to have manifestations of this disorder as adults. The sex disparity seen in childhood is much less pronounced than in adults; while the male-to-female ratio of ADHD in childhood is as high as 10:1, the ratio may only be 2:1 in the adult population. Primary care physicians who care for adults must be prepared to assume care of patients previously diagnosed with ADHD as children and to make the diagnosis in adults in whom it has not previously been diagnosed.
Diagnosis and Treatment of ADHD in Children and Adolescents
There are not standard, uniform criteria for diagnosis and management of the child or adolescent with ADHD. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines 3 subtypes of attention-deficit/hyperactivity disorder: combined, predominant inattentive, and predominant hyperactive/impulsive, based upon the predominant symptom pattern over the previous 6 months. Symptoms must be present before age 7 years and there must be some documented impairment of social, academic, or occupational function. More pervasive developmental disorders, schizophrenia, and other psychotic disorders must be excluded. The Classification of Child and Adolescent Mental Diagnosis in Primary Care, Child and Adolescent (DSM-PC) defines ADHD more broadly as a developmental variation, problem, and disorder, with ADHD variation and problem being of lesser severity than the ADHD disorder, which uses DSM-IV criteria. The American Academy of Child and Adolescent Psychiatry,[6,7] the American Academy of Pediatrics,[8,9] and the National Institutes of Health have written practice guidelines for diagnosis and treatment of the child/adolescent with ADHD, and recommend evaluations which include: 1) parent/child interviews, 2) school assessments, 3) a comprehensive physical examination, 4) speech/language evaluations, and 5) occupational/recreational testings. These guidelines for the child with ADHD do not apply to young people with mental retardation, pervasive developmental disorders, moderate to severe sensory deficits, or those taking drug therapies that affect behavior.
Treatment recommendations include medication, particularly stimulants, as well as psychosocial and educational interventions.[6,7,9] Caution is necessary in the use of stimulant medications because they are controlled substances which may be abused by family and patients, particularly adolescents or their peers.[7,8,10] Psychosocial interventions include parent behavior-modification training, support groups, family psychotherapy, social skills training, individual therapy, and day treatment programs. Educational interventions include token economies, time-out procedures, response-cost programs, and homework notebooks. Combined modality treatment is generally recommended (ie, medication and psychosocial interventions). The efficacy of medications, mainly stimulants, in the treatment of ADHD symptoms for up to 14 months has been established. Similarly, the effect of psychosocial interventions on symptoms particularly related to ADHD comorbidity has been established for this time period. There have not been studies to demonstrate long-term efficacy of medication or behavioral interventions. Most research has been performed in structured, academic, clinical settings, but has not been demonstrated in clinical practice. Furthermore, the short-term and long-term improvement in ADHD symptoms, academic/occupational functioning, and social/mental health have not been shown to be sustained if medication and/or psychosocial educational interventions are stopped.[6,9,10]
Some authors recommend that medications be prescribed based upon likely family compliance with psychosocial/educational recommendations and that drug holidays or definite plans to discontinue medication be formulated.[11,12] Behavioral counseling is also recommended in family setting. The primary care physician should seek consultation if there are comorbid mental disorders, a developmental delay, if the child is very young, or if there is not the expected response to given interventions.
Diagnosis and Treatment of ADHD in Adults
The DSM-IV outlines the criteria necessary to make the diagnosis of ADHD in both children and adults. The diagnosis of adult ADHD is usually a difficult one to make, because it requires integration of a broad range of information in the absence of a definitive diagnostic tool. A large differential diagnosis and a high rate of comorbid conditions further complicate making this diagnosis. Attention-deficit/hyperactivity disorder in an adult can only be diagnosed by DSM-IV criteria if the individual had ADHD symptoms as a child. If no diagnosis of ADHD was made in childhood, a retrospective determination of ADHD symptoms is required to make the diagnosis in adulthood. By strict adherence to the requirements of the DSM-IV, symptoms would have had to be present before the age of 7 years, although this specific age-of-onset criterion has been questioned. In order to establish a retrospective diagnosis of ADHD, obtaining a thorough history is paramount. The history should include parental reports of ADHD symptoms in a variety of settings, objective accounts of school conduct and performance, and previous psychiatric therapies.[15,16]
The triad of inattention, impulsivity, and hyperactivity symptoms are usually not present in adults with ADHD. Inattention is the most prominent symptom, seen in over 90% of adults with this disorder, while hyperactivity is less often a problem and is possibly the reason adult ADHD initially went unrecognized. The effects of adult ADHD can be strikingly similar to those seen in children (eg, school failure, occupational failure, legal problems, difficulty with interpersonal relationships). Bresnahan et al compared electroenceophalogram (EEG) findings in children, adolescents, and adults diagnosed with ADHD, and found that the changing symptoms in these age groups correlated with subtle differences in their EEGs.
There are several self-reporting tools used to screen for adult ADHD. Examples of these scales include the Wender Utah Rating Scale and the Copeland Symptom Checklist for Adult Attention Deficit Disorders. Although use of self-reporting scales in adults has been shown to accurately describe ADHD symptomatology, the scales lack specificity. Additional measures are needed to assist in making the diagnosis of adult ADHD.[19,20] Rating scales may aid in monitoring the symptoms and course of the disease.
The differential diagnosis of ADHD must exclude comorbid psychiatric conditions, such as major depression and substance abuse. Medical conditions in the differential diagnosis include hyperthyroidism, hepatic disease, intoxications, and sleep-disordered breathing. A thorough medical evaluation, including a thyroid panel, serum lead level, and urine drug screen, are indicated to rule out these disorders. No specific neuropsychologic testing is recommended for the diagnosis of ADHD, but it may be useful when the diagnosis is uncertain. The testing should be individualized for each patient.
Personality traits have been associated with adults who have ADHD, particularly an increased incidence of mild histrionic traits. Adults with ADHD and comorbid disorders demonstrated avoidant and dependent personality styles. When oppositional defiant disorder occurs with ADHD, avoidant, narcissistic, antisocial, aggressive-sadistic, and negativistic traits are often found.
Adults with ADHD frequently have comorbid disorders, including substance abuse, depression, oppositional defiant disorder, and panic disorder. Whether incidence of substance abuse is increased in adults with ADHD is unclear. Biederman et al[23,24] have published several articles implicating ADHD as a risk factor, but Lynskey et al question this association without a concomitant diagnosis of a conduct disorder.
Treatment for adults includes medication and psychosocial interventions. Medication continues to be the mainstay of treatment in adults because of its demonstrated short-term benefits; however, medication has not been shown to improve the long-term outcome of ADHD. Stimulant medications, such as methylphenidate hydrochloride, amphetamine, and pemoline, have been the most popular. Weight-adjusted doses of methylphenidate hydrochloride had a 74% efficacy in adults, similar to what has been found in children. Treatment with desipramine hydrochloride, a tricyclic antidepressant, showed a similar efficacy of 68%, and may be a good alternative for adults who cannot tolerate or have a contraindication to stimulants.[28,29] Buproprion hydrochloride therapy showed good efficacy in adults with ADHD in a randomized, double-blind, placebo-controlled trial.
The role of psychosocial interventions in adults is less clearly defined. The main form of therapy used in adults with ADHD is cognitive behavioral therapy, which includes problem-solving strategies, self-monitoring, self-reinforcement, and skills training. The goal of these therapies is to improve self-control. Psychosocial interventions, like medication, have not been shown to improve the long-term outcome of ADHD.
Hechtman describes 3 outcomes of adult ADHD. Thirty percent of adults with this disorder function well and are not different from adults who do not have ADHD. The majority of adults with ADHD continue to have problems with concentration, impulsivity, and social interactions, resulting in educational, occupational, and social problems. The third group consists of a minority (10%-15%) of adult ADHD patients with frequent hyperactivity who have concomitant significant psychiatric or antisocial symptoms. Peer-controlled, prospective follow-up studies on ADHD in adolescents and adults confirmed the above findings.
Transition of Care of ADHD Patients from Pediatricians to Primary Physicians Who Care for Adults
There are 2 circumstances in which primary care physicians of adults may encounter a patient who presents with adult ADHD. The patient may have been previously diagnosed in his youth or never have been previously diagnosed but have the disorder. A primary care physician may also have cared for the pediatric patient and may continue care for that patient in adulthood.
Diagnosing ADHD is challenging because of the large differential diagnosis, the many possible comorbidities, and the lack of a definitive diagnostic test.[4-6,8,10] Since the majority of children who are diagnosed with ADHD show no evidence of any mental disorder in adulthood, those who continue to have the disorder are a select group. Some possible explanations are that an incorrect diagnosis of ADHD was made, a comorbid diagnosis was missed or has subsequently occurred, treatment has been ineffective (possibly because of poor compliance), and/or the patient has a more complicated form of ADHD with persistent morbidity.
The physician who assumes care of an adult with a previous diagnosis of ADHD should determine how the initial diagnosis was made. Careful review of the record is necessary to determine the presenting symptoms, the evaluators, physical examination findings, medication use, prior medical disorders, and family history. The background of the diagnostician(s) must also be determined. Results of diagnostic tests (particularly psychoeducational testing and speech and language testing) should be reviewed. Records should also be reviewed to determine what medications and psychosocial and educational interventions have been tried, and what impact the interventions had.
A comprehensive medical and psychosocial history, as well as a complete physical examination, should be performed. An attempt should be made to obtain a medical history from a spouse or significant other, parents, other close relatives, teachers, employers, and/or friends. The updated assessment will likely take 2 or 3 visits to complete. Based upon the expertise of the primary care physician and the complexity of the case, consultation with a behavioral subspecialist should be considered. The primary care physician who is maintaining care of an adult with ADHD should also review how the diagnosis was made and examine previous treatment effects. An updated history, including sources other than the patient, should be taken and physical examination should be done.
Medication and psychosocial interventions continue to be the treatment options in adult ADHD. Unfortunately, no intervention has been shown to improve the long-term outcome of ADHD.[7,9,10] Stimulant medications, particularly methylphenidate hydrochloride and amphetamine, the primary treatment for adult ADHD, are controlled substances. Other kinds of medications, such as desipramine hydrochloride and buproprion hydrochloride, have been found to provide effective treatment in adults.[28-30] Prescribing these medications eliminates the possibility of stimulant abuse. Referral of adults for psychosocial interventions not offered by the primary care physician should be made. Consultation with or referral to a behavioral specialist should occur if increasing doses of stimulant medications are required, if multiple psychoactive drugs are needed, or if social, academic, or occupational functioning does not improve with optimization of pharmacologic and psychosocial interventions.
Although ADHD is the mental health disorder in the DSM-IV that has been most extensively studied in children, it continues to generate a great deal of controversy associated with diagnosis and treatment.[10,34] This is true, in part, because the number of symptoms required by the diagnostic criteria for ADHD has never been empirically validated, generally being defined as "often", which makes judgment of the existence of symptoms subjective. Treatment with stimulant medication is controversial because it has long been known that clinical response is the same in normal children and children with the ADHD diagnosis. It is also known that the diagnosis and treatment of ADHD in clinical practice may not reflect what is done in optimal, research-type settings.
A recent commentary in a supplement to Developmental and Behavioral Pediatrics highlights the controversy surrounding the diagnosis and treatment of ADHD in early childhood. An increase of more than 700% in the production of methylphenidate hydrochloride and of more than 2,500% in amphetamine production occurred in the United States between 1991 and 2000. Although guidelines for diagnosis and treatment of ADHD are available, it has been found that the use of methylphenidate hydrochloride (Ritalin) in primary care and community medicine is inconsistently linked to the ADHD diagnosis. The use of methylphenidate hydrochloride, which has escalated in the last decade, varies widely in different communities throughout the United States. Government policy may have affected the diagnosis and treatment of ADHD; the Individuals With Disabilities Act in 1991 made ADHD a covered diagnosis for education disability services, which correlated with the increase in both ADHD diagnosis and stimulant use.
The National Institute of Mental Health multimodal treatment study for ADHD has been touted as the gold standard for research in mental health disorders of children. The detailed analysis of this study by Pelham raises questions about the design of this research and the validity of the authors' conclusion that medication alone is the preferred treatment for childhood ADHD. The multimodal treatment study had 4 treatment groups: 1) medication alone (38 mg/day of methylphenidate hydrochloride); 2) intensive behavioral treatment (including parent training, a summer treatment program, and a school intervention with a short-term classroom aide); 3) a combination of behavioral interventions with medication; and 4) a community control group that received a mean prescribed dose of 23 mg/day of methylphenidate hydrochloride. Nineteen outcome measures were assessed over a 14-month period. It is noteworthy that the intensive behavioral interventions were reduced 4 to 5 months before the end of this period, while medication doses remained at maximally tolerable levels throughout the study.
All 4 treatment groups showed striking improvement from the time of baseline measurements to completion of the study 14 months later. Behavioral treatment was as effective as medication alone on 16 of 19 outcome measures, and was generally equivalent to community treatments. The results of combined treatment did not differ appreciably from those of medication management, but were generally superior to those of behavioral treatment. Both medication management and combined treatment were generally superior to community treatments. Although other authors have concluded that medication alone is the preferred treatment for ADHD, Pelham concludes that combined treatment, which "normalized" a higher rate of children than either medication or behavioral intervention alone, is the preferred treatment. He also notes that behavioral improvement is sustained after interventions are withdrawn, whereas medication effects stop. The persistence of improved symptoms may be one of the reasons that parents prefer the inclusion of behavioral treatment in the care of their children, rather than the use of medication alone.
The fact that stimulants are controlled substances with known abuse potential results in middle and high school students being approached to sell or trade their ADHD medications. Although research has indicated that children with ADHD treated with stimulant medication are less likely to abuse drugs than those who were not medicated, these patients are nevertheless using a controlled substance with the potential for abuse. The primary use of a controlled substance to treat ADHD raises philosophic questions, especially in children who may require lifelong treatment, which may explain why this disorder continues to generate heated controversy.
The diagnosis and treatment of ADHD are very complex and controversial. Although there is consensus that this disorder exists, professionals continue to struggle to make an accurate diagnosis and prescribe treatments with established long-term efficacy. Thoughtful, comprehensive care, both diagnostically and therapeutically, needs to be provided for patients who present with ADHD symptoms. A thorough reassessment should be done when a patient previously diagnosed with ADHD transitions from pediatric to adult primary care. Physicians must vigilantly monitor the evolving research related to this complex disorder to ensure that they continue to provide the quality of care that children and adults with ADHD symptoms need.
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