ANNE CHILDRESS, M.D. AND LINDA FRANTOM, PH.D.
When one hears the words attention-deficit/ hyperactivity disorder (ADHD), the images of a misbehaving child who is darting in and out of line, climbing inappropriately, interrupting the teacher, and having trouble paying attention may come to mind.
Although these symptoms certainly can describe ADHD, which is often diagnosed during childhood, symptoms can continue into adulthood in up to 65% of cases. In fact, many adults who have ADHD have never been diagnosed or treated. Yet, ADHD is quite common in adults. A recent epidemiologic survey estimated that about 4.4% of all adults have ADHD but only about 25% of those have ever been treated, with only about 11% treated in the past year. Adults with ADHD are twice as likely to be divorced than their peers who don’t have ADHD and less likely to be high school or college graduates.
WHAT IS ADHD?
ADHD is a complex neurobehavioral disorder—meaning that something going on in the brain that is not quite right affects behavior. Some imaging studies have shown differences in the brains of people with ADHD when compared to normal people, but these studies are in their infancy. We do know that people who have had brain damage in specific areas develop symptoms consistent with ADHD. Although it tends to run in families, we don’t have a blood test to diagnose ADHD. The disorder is diagnosed based on a comprehensive medical and behavioral history.
To have ADHD, one must have six or more symptoms of inattention and/or six or more symptoms of hyperactivity and impulsivity. At least some of these symptoms have to have started before age 7 and must have persisted for at least 6 months. The symptoms also have to occur in at least two settings (i.e., home, school, or work) and cause significant problems in social, occupation, or academic functioning.
We’ve all had those days when we’d swear we had ADHD, but for people legitimately affected, these symptoms don’t just come and go. In fact, they cause problems much of the time. Many things can cause decreased concentration such as lack of sleep, medications, and other medical problems. For example, a man who thought that he had ADHD came to our clinic for a research study. However, he was an honor student through high school and had only recently developed problematic inattention. After reviewing a good medical history (with some help from his wife who described him snoring and waking up gasping for air) sleep apnea was suspected. Sure enough, tests confirmed sleep apnea and he was treated appropriately. Folks with sleep apnea can have significant concentration problems.
WHAT ARE THE SYMPTOMS OF ADHD?
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
- Often has difficulty sustaining attention in tasks or play activities
- Often does not seem to listen when spoken to directly
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
- Often has difficulty organizing tasks and activities
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
- Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
- Often is easily distracted by extraneous stimuli
- Is often forgetful in daily activitie
- Often fidgets with hands or feet or squirms in seat
- Often leaves seat in classroom or in other situations in which remaining seated is expected
- Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
- Often has difficulty playing or engaging in leisure activities quietly
- Is often “on the go” or often acts as if “driven by a motor”
- Often talks excessively
- Often blurts out answers before questions have been completed
- Often has difficulty awaiting turn
- Often interrupts or intrudes on others (e.g. butts into conversation or games)
Often patients with adult ADHD aren’t good historians—making it very helpful if parents or partners can give information. An old report card from the first grade describing the patient as having trouble sitting, trouble paying attention, and talking too much can be quite useful. Later academic reports may describe many missing assignments. Teachers may characterize inattentive patients as lazy. Many adults with inattentive ADHD will report that teachers would tell their parents, “if he/she would only try harder.” A history of frequent trips to the emergency room during childhood for lacerations or broken bones due to daredevil activities can also be a clue.
It is not uncommon for parents with ADHD to realize they have the disorder then seek treatment after their children are diagnosed. Sometimes patients are referred by family members or even their employers. When your boss refers you, you know that you have a problem! One patient brought a newspaper ad for one of our adult ADHD studies that she had received from her boss. She hadn’t previously been diagnosed, but with treatment her work performance improved significantly.
In another instance, a principal referred one of her teachers to our clinic. The teacher had been diagnosed with depression, but the only symptoms of depression she displayed were some irritability and poor concentration. Her family doctor had treated her with antidepressants. However, her concentration did not improve. She was chronically late for school and kept an extra set of keys in the office because she so often forgot her own. She was taking evening classes but was restless and had so much trouble sitting that she spent much time outside the classroom. She knew the janitor and security guard better than her teacher. She had accidentally dropped her phone in the pool so many times that insurance would no longer cover replacements. Her antidepressant was stopped and treatment for her ADHD began. She has since received her master’s degree and hasn’t dropped her phone in the pool for several years.
WHAT CAUSES ADHD?
Although the cause of ADHD is unknown, research has shown that ADHD runs in families and genes are involved. Other research indicates that cigarette smoking and alcohol use during pregnancy are linked to ADHD. Patients who have had brain injuries do experience symptoms similar to ADHD. There is a popular notion that sugar contributes to ADHD symptoms, but studies have disproven this theory. However, a recent British study suggested certain food additives may increase activity level, but more research is needed to confirm this.
HOW IS ADHD TREATED?
ADHD is a chronic condition. Effective treatment should be aimed at decreasing symptoms and impairment. Treatment can include psychosocial and medication therapy, either alone or in combination.
Medication therapy is considered a first- line treatment. All medications approved by the U.S. Food and Drug Administration (FDA) to treat ADHD increase the availability of the neurotransmitters for dopamine and /or norepinephrine in the brain. The effectiveness and safety of both stimulants (amphetamines including Adderall XR® and Vyvanse® methylphenidates including Concerta® and Focalin XR®) and of the non-stimulant atomoxetine (Strattera®) have been demonstrated in multiple clinical studies in adults.
What are the differences between stimulants and non-stimulants? Stimulants are controlled substances that the Drug Enforcement Administration has determined have potential for abuse. A written prescription is necessary for stimulants, with physicians only able to write one for a one-month supply and refills cannot be called into the pharmacy. Stimulants are generally more effective than non-stimulants and amphetamines work a little better than methylphenidates. All of the stimulants approved by the FDA for the treatment of ADHD are long- acting formulations that can last up to 14 hours after dosing. However, almost one-half of adults received a short-acting stimulant for treatment of their ADHD in 2008. This is important because the short acting stimulants haven’t been systematically evaluated in clinical studies and are more likely to be misused and abused than the long-acting stimulants.
What are the differences between the long-acting stimulant medications? Concerta® (osmotic-release oral system-methylphenidate) effectively is a combination of short and long- acting methyphenidate. The outer shell of the capsule has a coating of immediate-release methylphenidate. A laser-drilled hole in the capsule allows the short-acting methylphenidate contained within to be gradually pushed out as liquids flow into the inner core, thus making it behave as a long-acting medication. No data exists on exactly how long this medication lasts when given to adults. However, when given to children in one simulated classroom study, attention and behavior began to improve within 45 minutes and the changes lasted through the final measurement at 12.5 hours.
Focalin XR® (dexmethylphenidate extended- release) uses a coated bead technology where 50% of the medication contained in the capsule is released immediately and the other 50% is released about four hours later. Also, it can be opened up and sprinkled for patients who have difficulty swallowing capsules, whereas the Concerta® capsule must be swallowed whole. Again, there is not good information regarding how long Focalin XR® works in adults, but in children it has been shown to start working within 30 minutes of dosing and the effect on ADHD symptoms can last up to 12 hours.
Adderall XR® (mixed amphetamine salts extended release) also employs a beaded technology. Half of the content is released immediately and the other half is released about four hours later. Effects on ADHD symptoms in children were shown to start at about 1.5 hours after a dose was taken and lasted up to 12 hours.
Vyvanse® (lisdexamfetamine dimesylate) is formulated by adding the amino acid lysine to short-acting amphetamine. (Remember amino acids from science? They are the building blocks of proteins in our diet.) After this compound is taken, enzymes break off the lysine portion and the amphetamine is gradually released into the blood stream. It is known how long this medication lasts in adults. A study was done in which patients took a math test before taking the medication then several times after the Vyvanse was taken. The results showed it begins working at most two hours after a dose is taken and lasts up to 14 hours. In a study using children, the improvement in attention and behavior began by 1.5 hours after it was taken and lasted for 13 hours after dosing.
Strattera® (atomoxetine) is the only non- stimulant that is approved by the FDA for the treatment of ADHD in adults. The compound is contained in a capsule that should be swallowed whole. Unlike stimulants that start working within hours of taking the first dose, it may take days or weeks for patients to achieve optimal improvement in their ADHD symptoms with this medication.
WHAT ABOUT SIDE EFFECTS?
All medications can cause side effects. When patients are prescribed stimulants or atomoxetine, the pharmacist should provide a medication guide. Although it consists of several pages, it is important to read the information about expectations and side effects contained in the guide.
Common side effects listed for stimulants include: upper abdominal pain, decreased appetite, headaches, dizziness, dry mouth, irritability, trouble sleeping, nausea, vomiting, and weight loss. These medications may not be appropriate for patients who have heart problems or high blood pressure. In addition, people who have narrowing of their gastrointestinal tract may not be able to take Concerta®, as the tablet does not dissolve after it is ingested.
Adults taking Strattera® may experience common side effects that include: constipation, dry mouth, nausea, decreased appetite, dizziness, trouble sleeping, sexual side effects, menstrual cramps, and problems passing urine.
A common misconception in the treatment of adult ADHD is that there really is no effective treatment apart from pharmacological treatment. Although medication has been shown to be the most effective option for treating the core symptoms of ADHD, studies have shown that many of the symptoms can be effectively treated with psychosocial and behavioral treatments. Psychoeducation, or educating patients on the symptoms and practical implications of living with adult ADHD, is the first step of psychosocial intervention. This is typically accomplished both by direct feedback/instruction from mental health practitioners, as well as literature in the form of books, workbooks, and various educational sources such as handouts or magazines. Books can provide broad overviews of strategies or can be targeted to special considerations such as addressing young adults and college needs or difficulties with social and marital relationships. Books such as Delivered from Distraction (2005, Hallowell and Raley), Succeeding with Adult ADHD: Daily Strategies to Help You Achieve Your Goals and Manage Your Life (Levrini and Prevatt, 2012), and Taking Charge of Adult ADHD (Barkley, 2010) are some of the current literature specifically geared towards adults.
Cognitive behavioral therapy (CBT) typically addresses faulty thoughts or cognitions associated with ADHD that tend to impede achievement as well as behaviors that can be modified or improved. CBT can help patients learn to restructure their environments at work and home so that they become more organized and less distracted. Cognitive strategies include identifying and modifying core beliefs that arise from the frustration of dealing with problems commonly associated with adult ADHD, such as poor work performance, underachievement, interpersonal difficulties, and general failure experiences. The behavioral component helps patients develop strategies related to time management, organization, planning, managing procrastination, and improving inattention and distractibility. Oftentimes, depression and anxiety can co-exist with ADHD, and the core symptoms of these disorders can likewise be addressed with CBT, which can be delivered as individual therapy or group therapy.
Recent studies have also shown some promising results with the use of dialectical behavior therapy (DBT), a type of CBT that involves skills training in various areas, including interpersonal effectiveness, self-regulation, distress tolerance, and mindfulness. The skills training portion of DBT is administered in a group format. Other types of group therapy demonstrating positive results include group mindfulness training, in which adults learn and practice mindfulness-based exercises to improve attention, decrease distractibility, and improve expression of emotions. Mindfulness, originally rooted in Eastern Buddhist tradition, is now being applied to Western medicine and involves learning how to pay attention to one thing at a time, effectively, and preferably without judgment.SOURCES FOR MORE INFORMATION ON ADHD
Patrick McKenna and Rick Green made a helpful video about ADHD called ADD and Loving It?! It is a humorous look at ADHD in which McKenna does a good job of describing symptoms, impairment, and treatment. This video aired on PBS a few months ago and can be purchased on Amazon.com.
The National Institute of Mental Health website (www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-dis…) contains information about ADHD in children, adolescents and adults. Children and Adults with Attention Deficit / Hyperactivity Disorder (CHADD; www.chadd.org) is a national non-profit organization providing support, advocacy, and education for people with ADHD. Many cities have a local chapter and support groups.
COACHES AND PROFESSIONAL ORGANIZERS
In addition to therapy or medication treatment, other professionals can help people with ADHD make lifestyle changes.
ADHD coaches help clients identify and break down problems—developing definable goals to deal with the problem behaviors. ADHD coaches are not therapists. They do not diagnose ADHD or treat the disorder. The psychcentral website lists some helpful tips when looking for an ADHD coach.
Professional organizers are valuable resources that can work with patients and can even be hired to come to one’s home or workplace. Susan Pinsky, a professional organizer, wrote a book called Organizing Solutions for People with ADD (Fair Winds Press) that contains many tips to help with organization—and they are useful not only for people with ADHD. She discusses recycling plastic bottles from the bathroom. Since many folks with ADHD have trouble getting the recyclables to the recycle bin, she recommended being a bit less green, keeping a big trash can in the bathroom and throwing the bottles away when empty.
Another tip Pinsky gave was to keep things simple and reduce inventory. She recommended ditching most of the Tupperware and keeping only a few containers for leftovers. When there aren’t enough dishes for leftovers, there are fewer leftovers in the fridge to become toxic waste. Check out her website www.organizationallyours.com for some additional tips and advice.
In summary, ADHD isn’t just for kids. It can be a lifelong disorder resulting in significant distress and disability. Although no one is sure exactly what causes ADHD, the good news is that it is a treatable problem. Both psychotherapy and medication treatments been studied and shown to be effective. If you think that you have ADHD, what is the next step? Start with your primary care physician to discuss your concerns and symptoms. If your primary care provider doesn’t treat ADHD, he/she may be able to refer you to a psychiatrist, who will recommend medication, psychotherapy, or both. Often patients will see a physician for medication management and psychologist for psychotherapy.
ABOUT THE AUTHORS
Ann C. Childress, MD is Psychiatrist and President at the Center for Psychiatry and Behavioral Medicine in Las Vegas, Nevada. She is also an adjunct assistant professor at the University of Nevada School of Medicine, Dr. Childress has published numerous articles in such publications as Journal of Child and Adolescent Psychopharmacology, CNS Spectrums, Journal of Attention Disorders and the Journal of the American Academy of Child and Adolescent Psychiatry. She has been an investigator for more than 80 studies of major depressive disorder, schizophrenia, and ADHD, among others.
Dr. Frantom obtained her M.A. and Ph. D. in clinical psychology from the University of Nevada, Las Vegas. She has been affiliated with Center for Psychiatry and Behavioral Medicine since 2001, initially as a behavioral rater in clinical trials and as of 2005 as a sub- investigator and rater. She has been in private practice as Comprehensive Psychological Services since 2007, where she specializes in treating adults and adolescents with mood and anxiety disorders, with a special interest in treating individuals with bipolar disorder and ADHD.