Attention Deficit Hyperactivity Disorder (ADHD), also in adults
The ADHD is a behavioral syndrome which affects, according to estimates, between 5% and 10% of the child and adolescent population. The key that is currently used to understand the wide spectrum of manifestations that characterize individuals with ADHD is the concept of deficit in the inhibitory control of the response . That is, the notorious inability to inhibit the impulses and thoughts that interfere in the executive functions the performance of which allows to overcome the distractions, set goals and plan the sequences of steps necessary to achieve them.
For more than 70 years, investigations of attention deficit hyperactivity disorder have focused on the child population. But starting in 1976, it was shown that this disorder can exist in 60% of adults, the symptoms of which have already begun before the age of seven (Werder PH, 2001). This diagnostic mismatch made the symptoms and treatments of childhood-juvenile ADHD more known and oriented than in adults, even though the clinical parameters are similar. Further, in adults, complications, risks and comorbidities are more frequent and nuanced that in children, with the risk that the symptoms are confused with other psychiatric symptoms. (Ramos-Quiroga, A., 2006).
A common biological origin allows adults to be diagnosed with the same criteria adapted from the DSM-IV-TR, but due to the fact that in the adult the observer is only unique diagnostic difficulties are found, since it facilitates a larger dispersion and bias in the opinions.
Although in adults there is less epistemological data available, ADHD manifests itself as an adult person with great frequency. The first works found prevalences in adults between 4 and 5%. (Murphy K, Barkley RA, 1996 and Faraone et al., 2004)
Symptomatology, diagnosis and evaluation of ADHD in adults
The diagnostic criteria for ADHD in adults are the same as for children, registered at DSM-IV-TR . The DSM-III-R formally describes the possibility of diagnosing them.
The signs and symptoms in adults are subjective and subtle, without biomedical evidence that can confirm their diagnosis. In order to diagnose ADHD in an adult person, it is necessary that the disorder be present from childhood, at least from seven years old, an essential data for the diagnosis, and there must persist a clinically significant alteration or deterioration in more than one area. important of its activity, such as social, work, academic or family functioning. For this reason, it is very important that the child's medical history is recorded in the clinical history along with the current symptoms and their repercussions on current life, family, work and social relationships.
Adults with ADHD mainly report symptoms of inattention and impulsivity, since the symptoms of hyperactivity decrease with age. Likewise, the symptoms of hyperactivity in adults usually have a slightly different clinical expression of the encounter in children (Wilens TE, Dodson W, 2004) since it manifests as a subjective feeling of restlessness.
The most common problems of attention deficit hyperactivity disorder in adults are the following: problems for concentration, lack of memory and poor short-term memory, difficulty organizing, problems with routines, lack of self-discipline , impulsive behavior, depression, low self-esteem, inner restlessness, poor ability to manage time, impatience and frustration, poor social skills and a sense of not achieving goals, among others.
Self-assessment stairs are a good diagnostic tool for more general symptoms (Adler LA, Cohen J. 2003):
Adult Self-Assessment Ladder (EAVA): (McCann B. 2004) can be used as a first self-assessment tool to identify adults who may have ADHD. Copeland Symptom Checklist: help to assess if an adult has characteristic symptoms of ADHD. Brown Attention Deficit Disorder Scale: explores the executive functioning of aspects of cognition that are associated with ADHD. Wender-Reimherr Adult Attention Deficit Disorder Scale: measures the severity of the symptoms of adults with ADHD. It is especially useful for assessing the mood and lability of ADHD. Conners'Adult Rating Rating Scale (CAARS): symptoms are evaluated with a combination of frequency and severity.
According to Murphy and Gordon (1998), in order to make a good assessment of ADHD, one must take into account if there is evidence about the relationship between the symptoms of ADHD during childhood and a significant and chronic subsequent deterioration in different areas, if there is a relationship between the symptoms of current ADHD and a substantial and conscious deterioration in different areas, if there is another pathology that justifies the clinical picture better than ADHD, and finally, if for patients who meet the diagnostic criteria for ADHD, there is some evidence that there are comorbid conditions.
The diagnostic procedure is guided by guidelines to perform diagnostic tests according to the clinical situation. This procedure begins with a complete medical history including a neurological examination. The diagnosis has to be clinical, supported by the self-assessment stairs, discussed above. It is essential to evaluate psychiatric conditions, rule out possible comorbidities and certain medical conditions such as hypertension and rule out substance abuse.
As Biederman and Faraone (2005) point out very well, in order to diagnose ADHD in adults, it is essential to know which symptoms are specific to the disorder and which are due to another comorbid pathology.
It is very important to bear in mind that comorbidity in adult ADHD is quite common (Kessler RC, at al 2006). The most frequent comorbidities are mood disorders such as major depression, dysthymia or bipolar disorder, which has a comorbidity with ADHD ranging from 19% to 37%. For anxiety disorders, the comorbidity ranges between 25 and 50%. In the case of alcohol abuse is 32 to 53% and in another type of abuse of substances such as cocaine is 8 to 32%. The incidence rate of personality disorders is 10 to 20% and for antisocial behavior 18 to 28% (Barkley RA, Murphy KR, 1998).
Pharmacological treatment of ADHD in adults
The drugs used to treat this disorder are the same as in childhood. Of the different psychostimulant drugs, efficacy has been demonstrated in adults with ADHD of methylphenidate and atomoxetine.
Immediate-release methylphenidate inhibits the collection of dopamine; and atomoxetine, whose main function is to inhibit the collection of noradrenaline. Currently, and thanks to several studies conducted by Faraone (2004), It is known that methylphenidate is more effective than placebo . Non-stimulant drugs for the treatment of ADHD in adults include tricyclic antidepressants, aminooxidase inhibitors and nicotinic drugs, among others.
Psychological treatment of ADHD in adults
In spite of the high efficacy of psychotropic drugs, in certain occasions it is not enough when handling other factors, such as cognitions and disruptive behaviors or other comorbid disorders. (Murphy K. 2005).
Psychoeducational interventions help to ensure that the patient obtains knowledge about ADHD that allows him not only to be aware of the interference of the disorder in his daily life, but also that the same subject detects his difficulties and defines his own therapeutic objectives (Monastra VJ , 2005). These interventions can be carried out in an individual or group format.
The most effective approach to treating ADHD in adults is cognitive-behavioral, both in an individual and group intervention (Brown, 2000, McDermott, 2000, Young, 2002). This type of intervention improves depressive and anxious symptoms. Patients receiving cognitive-behavioral therapy, along with their medications, controlled persistent symptoms better than with the use of medications combined with relaxation exercises.
Psychological treatments can help the patient to confront the associated emotional, cognitive and behavioral problems, as well as a better control of the symptomatology refractory to the pharmacological treatment. For this reason, multimodal treatments are considered to be the indicated therapeutic strategy (Young S. 2002).
Bibliographic references:
- Miranda, A., Jarque, S., Soriano, M. (1999) Hyperactivity disorder with attention deficit: current controversies about its definition, epidemiology, etiological bases and approaches to intervention. REV NEUROL 1999; 28 (Suppl 2): S 182-8.
- Ramos-Quiroga JA, R. Bosch-Munsó, X. Castells-Cervelló, M. Nogueira-Morais, E. García-Giménez, M. Casas-Brugué (2006) Attention deficit disorder with hyperactivity in adults: clinical characterization and therapy. REV NEUROL 2006; 42: 600-6.
- Valdizán, J.R., Izaguerri-Gracia A.C. (2009) Attention deficit / hyperactivity disorder in adults. REV NEUROL 2009; 48 (Suppl 2): S95-S99.
- Wilens, T.E., Dodson, W. (2004) A clinical perspective of attention-deficit / hyperactivity disorder into adulthood. J Clin Psychiatry. 2004; 65: 1301-11
