Michele G. Sulliva

Up to 70% of children who have been diagnosed with attention-deficit hyperactivity disorder continue to experience symptoms into adulthood, and as a result, as many as 8 million adults are affected. That figure may come as a surprise to clinicians who still think of ADHD as a childhood disorder.

Studies suggest that only 20% of adults with ADHD are diagnosed and treated for the disorder. And there are a number of possible reasons for this treatment gap. First, the adult form of the illness was not recognized as a diagnostic entity until the late 1980s. Second, patients who were never diagnosed may have accepted their symptoms as personality flaws or developed ways to compensate. Finally, others are regulars in the psychiatrist's office and are being treated unsuccessfully for comorbid conditions such as depression or anxiety.

Diagnosis

Most adults diagnosed with ADHD are self-referred. One of the most frequent stimuli for seeking help is that their own child has been diagnosed with the disorder. A combination of hyperactivity and inattention forms the most common subtype of the disorder; 70% of adult patients manifest that combination. A largely inattentive subtype occurs in 25%, and about 5% show the hyperactive/impulsive subtype.

Adults with ADHD are likely to display poor tolerance for frustration, temper outbursts, lack of social judgment, inability to organize daily tasks, lack of motivation, procrastination, risk-taking, and low stimulation. They are poor listeners, tending to interrupt. They frequently misplace items or forget appointments.

Adults with ADHD are highly likely to have comorbid depression, anxiety, or bipolar disorder. If untreated, they also have an increased risk of substance abuse, which many researchers believe is an attempt to self-medicate.

Several screening tools are available to assess the likelihood of ADHD. One of these includes a six-question patient self-report that can be supplemented with a longer physician screen. The screening tool identifies individuals at risk for ADHD so that they can be evaluated by their doctors. It's important to use a screen designed for adults, with questions that pinpoint very specific areas of impairment an adult is likely to encounter. One such screen and a self-assessment tool are available at

www.med.nyu.edu/psych/training/adhd.html

Management

Adults with ADHD respond readily to the same medications used to treat childhood ADHD. Stimulants (methylphenidate and amphetamine products) are very highly studied in children, producing a robust, prompt response and a significant decrease in symptoms. But until recently, amphetamines had not been well studied in adults.

As a result, most adults were significantly underdosed. Additionally, the short-term action of the drugs made them a less-than-ideal choice.

In 2004, the Food and Drug Administration approved a mixed salts preparation of a single-entity amphetamine (Adderall XR) as a once-daily treatment for adults with ADHD. With the approval of this extended-release formulation, stimulant therapy became more appropriate for adults.

Atomoxetine (Strattera) is the first nonstimulant therapy for adult ADHD. A selective norepinephrine reuptake inhibitor, atomoxetine relieves symptoms for as long as 12 hours and does not exacerbate comorbid tics or mood disorders. The drug is not a controlled substance, as are amphetamines. This is an advantage when treating a patient with a history of serious drug abuse. Some improvement may be noted in 5-7 days, but the full effect usually takes about 2 weeks to appear. The FDA recently stated that patients should discontinue the drug if they develop jaundice or have laboratory evidence of liver injury. Atomoxetine has been linked to two cases of severe liver injury.

Both classes of drug should be started at a low dosage and titrated upward until the patient achieves good symptom relief with minimum side effects. Most patients benefit from some form of adjunctive psychosocial therapy.

Medication compliance can be challenging in patients who have trouble remembering. Patients piggyback their medication onto another daily task, preferably one that is habitual. Segmented medication organizers can be helpful, especially if a family member or roommate can ensure the doses are taken at the correct times.

Sources: LENARD A. ADLER, M.D., head of the adult ADHD program at New York University, New York; RICHARD H. WEISLER, M.D., department of psychiatry, University of North Carolina, Chapel Hill, and Duke University, Durham, N.C.

Up to 70% of children who have been diagnosed with attention-deficit hyperactivity disorder continue to experience symptoms into adulthood, and as a result, as many as 8 million adults are affected. That figure may come as a surprise to clinicians who still think of ADHD as a childhood disorder.

Studies suggest that only 20% of adults with ADHD are diagnosed and treated for the disorder. And there are a number of possible reasons for this treatment gap. First, the adult form of the illness was not recognized as a diagnostic entity until the late 1980s. Second, patients who were never diagnosed may have accepted their symptoms as personality flaws or developed ways to compensate. Finally, others are regulars in the psychiatrist's office and are being treated unsuccessfully for comorbid conditions such as depression or anxiety.

Diagnosis

Most adults diagnosed with ADHD are self-referred. One of the most frequent stimuli for seeking help is that their own child has been diagnosed with the disorder. A combination of hyperactivity and inattention forms the most common subtype of the disorder; 70% of adult patients manifest that combination. A largely inattentive subtype occurs in 25%, and about 5% show the hyperactive/impulsive subtype.

Adults with ADHD are likely to display poor tolerance for frustration, temper outbursts, lack of social judgment, inability to organize daily tasks, lack of motivation, procrastination, risk-taking, and low stimulation. They are poor listeners, tending to interrupt. They frequently misplace items or forget appointments.

Adults with ADHD are highly likely to have comorbid depression, anxiety, or bipolar disorder. If untreated, they also have an increased risk of substance abuse, which many researchers believe is an attempt to self-medicate.

Several screening tools are available to assess the likelihood of ADHD. One of these includes a six-question patient self-report that can be supplemented with a longer physician screen. The screening tool identifies individuals at risk for ADHD so that they can be evaluated by their doctors. It's important to use a screen designed for adults, with questions that pinpoint very specific areas of impairment an adult is likely to encounter. One such screen and a self-assessment tool are available at

www.med.nyu.edu/psych/training/adhd.html

Management

Adults with ADHD respond readily to the same medications used to treat childhood ADHD. Stimulants (methylphenidate and amphetamine products) are very highly studied in children, producing a robust, prompt response and a significant decrease in symptoms. But until recently, amphetamines had not been well studied in adults.

As a result, most adults were significantly underdosed. Additionally, the short-term action of the drugs made them a less-than-ideal choice.

In 2004, the Food and Drug Administration approved a mixed salts preparation of a single-entity amphetamine (Adderall XR) as a once-daily treatment for adults with ADHD. With the approval of this extended-release formulation, stimulant therapy became more appropriate for adults.

Atomoxetine (Strattera) is the first nonstimulant therapy for adult ADHD. A selective norepinephrine reuptake inhibitor, atomoxetine relieves symptoms for as long as 12 hours and does not exacerbate comorbid tics or mood disorders. The drug is not a controlled substance, as are amphetamines. This is an advantage when treating a patient with a history of serious drug abuse. Some improvement may be noted in 5-7 days, but the full effect usually takes about 2 weeks to appear. The FDA recently stated that patients should discontinue the drug if they develop jaundice or have laboratory evidence of liver injury. Atomoxetine has been linked to two cases of severe liver injury.

Both classes of drug should be started at a low dosage and titrated upward until the patient achieves good symptom relief with minimum side effects. Most patients benefit from some form of adjunctive psychosocial therapy.

Medication compliance can be challenging in patients who have trouble remembering. Patients piggyback their medication onto another daily task, preferably one that is habitual. Segmented medication organizers can be helpful, especially if a family member or roommate can ensure the doses are taken at the correct times.

Sources: LENARD A. ADLER, M.D., head of the adult ADHD program at New York University, New York; RICHARD H. WEISLER, M.D., department of psychiatry, University of North Carolina, Chapel Hill, and Duke University, Durham, N.C.

Up to 70% of children who have been diagnosed with attention-deficit hyperactivity disorder continue to experience symptoms into adulthood, and as a result, as many as 8 million adults are affected. That figure may come as a surprise to clinicians who still think of ADHD as a childhood disorder.

Studies suggest that only 20% of adults with ADHD are diagnosed and treated for the disorder. And there are a number of possible reasons for this treatment gap. First, the adult form of the illness was not recognized as a diagnostic entity until the late 1980s. Second, patients who were never diagnosed may have accepted their symptoms as personality flaws or developed ways to compensate. Finally, others are regulars in the psychiatrist's office and are being treated unsuccessfully for comorbid conditions such as depression or anxiety.

Diagnosis

Most adults diagnosed with ADHD are self-referred. One of the most frequent stimuli for seeking help is that their own child has been diagnosed with the disorder. A combination of hyperactivity and inattention forms the most common subtype of the disorder; 70% of adult patients manifest that combination. A largely inattentive subtype occurs in 25%, and about 5% show the hyperactive/impulsive subtype.

Adults with ADHD are likely to display poor tolerance for frustration, temper outbursts, lack of social judgment, inability to organize daily tasks, lack of motivation, procrastination, risk-taking, and low stimulation. They are poor listeners, tending to interrupt. They frequently misplace items or forget appointments.

Adults with ADHD are highly likely to have comorbid depression, anxiety, or bipolar disorder. If untreated, they also have an increased risk of substance abuse, which many researchers believe is an attempt to self-medicate.

Several screening tools are available to assess the likelihood of ADHD. One of these includes a six-question patient self-report that can be supplemented with a longer physician screen. The screening tool identifies individuals at risk for ADHD so that they can be evaluated by their doctors. It's important to use a screen designed for adults, with questions that pinpoint very specific areas of impairment an adult is likely to encounter. One such screen and a self-assessment tool are available at

www.med.nyu.edu/psych/training/adhd.html

Management

Adults with ADHD respond readily to the same medications used to treat childhood ADHD. Stimulants (methylphenidate and amphetamine products) are very highly studied in children, producing a robust, prompt response and a significant decrease in symptoms. But until recently, amphetamines had not been well studied in adults.

As a result, most adults were significantly underdosed. Additionally, the short-term action of the drugs made them a less-than-ideal choice.

In 2004, the Food and Drug Administration approved a mixed salts preparation of a single-entity amphetamine (Adderall XR) as a once-daily treatment for adults with ADHD. With the approval of this extended-release formulation, stimulant therapy became more appropriate for adults.

Atomoxetine (Strattera) is the first nonstimulant therapy for adult ADHD. A selective norepinephrine reuptake inhibitor, atomoxetine relieves symptoms for as long as 12 hours and does not exacerbate comorbid tics or mood disorders. The drug is not a controlled substance, as are amphetamines. This is an advantage when treating a patient with a history of serious drug abuse. Some improvement may be noted in 5-7 days, but the full effect usually takes about 2 weeks to appear. The FDA recently stated that patients should discontinue the drug if they develop jaundice or have laboratory evidence of liver injury. Atomoxetine has been linked to two cases of severe liver injury.

Both classes of drug should be started at a low dosage and titrated upward until the patient achieves good symptom relief with minimum side effects. Most patients benefit from some form of adjunctive psychosocial therapy.

Medication compliance can be challenging in patients who have trouble remembering. Patients piggyback their medication onto another daily task, preferably one that is habitual. Segmented medication organizers can be helpful, especially if a family member or roommate can ensure the doses are taken at the correct times.

Sources: LENARD A. ADLER, M.D., head of the adult ADHD program at New York University, New York; RICHARD H. WEISLER, M.D., department of psychiatry, University of North Carolina, Chapel Hill, and Duke University, Durham, N.C.