What is ADHD?

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Attention deficit / hyperactivity disorder (ADHD) is common in school children (2 to 5%). It is marked by concentration difficulties and can be accompanied by hyperactivity and impulsiveness. The cause lies in changes in brain functioning.

In the past, it was believed that the disorder disappeared in adulthood, but since the 1970’s science publications have described the persistence of adhd into adulthood in 30 to 50% of children. That means that 1 to 3% of adults suffer ADHD.

Adult ADHD

In adulthood the most common symptoms are impaired concentration, day dreaming, forgetfulness and frequent changes in activity. In adults, hyperactivity and restlessness are rarer; however ADHD is often associated with other problems such as boredom, chronic conflicts and social adjustment difficulties, leading to problems at work and home. Furthermore, alcohol or drug abuse, anxiety and depression are frequent complaints.

More and more often practitioners are confronted with patients’ questions about the diagnosis and treatment of ADHD. Professionals in the adult psychiatric sector may struggle to respond, professional training and traditional thinking often ill prepares them for this problem. A brief overview of the subject is of topical interest.

A little known pathology

The diagnosis of ADHD (attention deficit / hyperactivity disorder) has been generally recognized for many years in child psychiatry, and, according to the DSM-IV affects 2-5% of all children. The diagnostic term ADHD is of American origin and includes the non-hyperactive subtype, in contrast to Europe’s much more restrictive concept of hyper-kinetic syndrome in the ICD-10. In 30-50% of children with ADHD the origin is genetic. If ADHD persists into adulthood, the genetic contribution is greater; an adult with ADHD has an 84% chance that at least one of his children will have ADHD. It is known that 30 to 50 % of the children continue to have adhd related problems in adulthood.
However, in the adult psychiatric health sector a lack of familiarity with this disorder persists. Several factors may explain this:

1 In adults motor hyperactivity decreases and attention and organisational difficulties come to the fore, so one thinks less of it

2 In adults ADHD is often associated with mood instability and emotional reactivity, often interpreted as manifestations of a personality disorder.

3 Under the restrictive criteria of the ICD-10 diagnosis of hyper-kinetic syndrome cannot be made if there is a comorbidity such as depression

4 In the DSM-IV, ADHD is listed in the chapter about childhood disturbances; consequently adult psychiatry is less familiar with ADHD.

5 Child psychiatrists and adult psychiatrists have little or no contact, either in training or in practice, so that children reaching adulthood with ADHD are not automatically referred to adult services.

6 It is easier for people to accept and understand a disorder of self control in children then in adults.

Diagnosis

As with children, a patient history is the cornerstone of diagnosis. It is necessary to establish if the difficulties existed since childhood. The clinician should be aware of the possibility of ADHD and take a focused history; care should be taken to avoid colouring the childhood history with a priori psychodynamic or system theoretical perspectives. In adults it may be difficult to obtain an accurate retrospective view of childhood functioning. Additionally, adult life may be complicated by many factors, differential diagnoses, co morbidities, so that getting a clear perspective on adult problems is not always easy.

The diagnostic criteria listed in the DSM_IV are also applicable in adulthood. Several authors have suggested that the minimum criteria for adults should be four or five of the nine symptoms of hyperactivity/impulsivity (instead of six as stipulated in the DSM-IV for children) and four of five of the nine symptoms of inattention, because the severity of symptoms in adults is less marked.

The Utah criteria for ADHD in adults are the best validated (although drawn up solely for the hyperactive subtype):

· The symptoms must be present from childhood onwards.

· There should be clear mild difficulties with attention and motor unrest.

· At least two of the following five criteria should be met: mood swings, organizational problems, irascibility, emotional reactivity, impulsiveness.

Further, an EEG study of the cognitive evoked brain potential can be useful for an objective neuropsychological examination of the attentional and frontal lobe functions. The specificity and sensitivity of these tests have their limitations. However, against the background of these test results ,the patient can better understand and accept that there exist objective reasons for his difficulties, especially as the personal history data obtained is often questionable and subjective.

Differential diagnosis and comorbidity

1) Depression and Dysthimia (depressive neurosis): depression is present in 20-30% of patients with ADHD (in the general population it is 15%). The differential diagnosis can be difficult: Dysthymia can also express with chronic attention difficulties, however negative self-perception with an inability to experience pleasure are clearly central.

2) Addictions occur in 10-40% of patients with ADHD.

3) Borderline, antisocial and histrionic personality disorder: the differential diagnosis can be difficult. In borderline personality disorder a more markedly contorted personality exists , coupled with feelings of emptiness, more manipulative behaviour, suicidal behaviour , self mutilation, abandonment fears with attachment problems, and identity disorders. The impulsiveness in borderline personality disorder is more driven and often self-destructive (whilst the impulsiveness of ADHD is short-lived and more thoughtless). One needs to take in account the possibility of the combination of the 2 disorders with a more targeted patient history.

Treatment

1. Psycho-education: the provision and explanation of the diagnosis is in itself therapeutic. Often the patient has had many years of personal troubles and (troubles adapting to their environment) without understanding the reasons. Often the patient has had years of psychotherapy without success, often only resulting in further disappointments and misunderstandings However, the diagnosis should not be used as an excuse for every continuing problem: correct diagnosis should lead to measures for finding solutions. Any comorbidities must be explained, where a diagnosis of adhd does not cover all the problems. It is important that the practitioner not only knows the symptom lists, but is familiar with the current explanatory neuropsychological models- such as Barkley’s, in order to consider the broader picture. Also, the practitioner must be familiar with the impact of ADHD problems in the entire daily life, working life and partner relationships.

2. Medication: Although traditionally doctors in Europe are reluctant to prescribe psycho-stimulants (especially Ritalin, but also some stimulant antidepressants), in the United States it might be seen as a serious medical error not to offer medication. The recommended course is to offer a months trial (Ritalin 3 times a day, every 4 hours, at constructive dosages). In 25-78% of cases there is a positive result, although still often residual problems persist. This result is reflected in all areas: not just attention, hyperactivity and impulsiveness, but also self control over mood swings, motivation and emotional over reactivity and organizing functions. If this medication is clearly indicated and properly prescribed, under supervision, there is no reason to fear for addiction.

3. Psychotherapy, coaching: Coaching and organization skill learning is important , one should, however, be aware that a finished plan, practical tips and good intentions often still lead to failures because often patients with ADHD know, by definition,’ what they should do, but do not do what they know’. Psychotherapy is only useful if there are difficulties; handling past failures, or adapting to new patterns of functioning under medication, or difficulties with comorbidities or relationships. But one should be careful of explaining ADHD symptoms in a psychodynamic or system theoretical manner.

4. Contact with Fellow-Sufferers: Regional Support Groups for adults with ADHD in Flanders started an organization ("Aandacht"), with its own website (www.adhd-volwassenen.be). The mutual recognition and validation is frequently a revelation and support for many participants. The exchange of experiences, tips and information, and the experience of seeking solutions jointly often has a major significance for group members and their surroundings.

Dr. W. Van den Bergh (Leuven)
De Agenda Psychiatrie Nr. 19, Mei 2001, p. 8-9

Thank you to Dr Van Den Bergh for permission to translate this article.

Stephanie Clark. With help from Anne.