Evaluation and Treatment in Family Medicine

Attention-deficit/hyperactivity disorder (ADHD) affects 30 to 50 percent of adults who had ADHD in childhood. Accurate diagnosis of ADHD in adults is challenging and requires attention to early development and symptoms of inattention, distractibility, impulsivity and emotional lability. Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse. While stimulants are a common treatment for adult patients with ADHD, antidepressants may also be effective. Cognitive-behavioral skills training and psychotherapy are useful adjuncts to pharmacotherapy. (Am Fam Physician 2000;62:2077-86,2091-2.)

Attention-deficit/hyperactivity disorder (ADHD) receives considerable attention in both medical literature and the lay media. Historically, ADHD was considered to be primarily a childhood condition. However, recent data suggest that symptoms of ADHD continue into adulthood in up to 50 percent of persons with childhood ADHD.(1,2)(pp41-75) Because ADHD is such a well-known disorder, adults with both objective and subjective symptoms of poor concentration and inattention are likely to present to family physicians for evaluation. While the symptoms of ADHD have been extended developmentally upward to adults, most of the information about the etiology, symptoms and treatment of this disorder comes from observations of and studies in children. Research on adult ADHD is in an early stage. The criteria for ADHD emphasize a childhood presentation, and there is growing evidence that the diagnostic features of ADHD take a different form in adults.

For several reasons, family physicians may be uncomfortable evaluating and treating patients with symptoms of ADHD, particularly adults without a previously established ADHD diagnosis. First, the criteria for ADHD are not objectively verifiable and require reliance on the patient’s subjective report of symptoms. Second, the criteria for ADHD do not describe the subtle cognitive-behavioral symptoms that may affect adults more than children. Third, the most effective treatment is long-term use of a schedule II drug with potential for abuse.(3)

The family physician’s role as diagnostician is further complicated by the high rates of self-diagnosis of ADHD in adults. Many of these persons are influenced by the popular press. Studies of self-referral suggest that only one third to one half of adults who believe they have ADHD actually meet formal diagnostic criteria.(4) While family physicians are knowledgeable about childhood ADHD, there is a noticeable absence of guidelines for primary care evaluation and treatment of adults with symptoms of the disorder.

Diagnostic Criteria and Symptoms

The criteria for ADHD as specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), are described in Table 1.5 DSM-IV describes three subtypes of the disorder: predominantly hyperactive, predominantly inattentive and a mixed type with symptoms of the other two forms. Symptoms should be persistently present since age seven. While a longstanding symptom history is often difficult to elicit clearly in adults, it is a key feature of the disorder.

Adults who have retained some, but not all, of the symptoms of childhood ADHD may be best diagnosed as having ADHD in partial remission.(5,6) While the DSM-IV criteria for ADHD may be applied to adults, these dimensions tend to reflect presentations in children. The subtlety of ADHD symptoms among adults has led to several modifications of existing criteria. Rather than requiring six DSM-IV symptoms of inattention or hyperactivity, some investigators propose requiring only five such behaviors for older patients.(7) In addition, the symptoms take different forms in adults.

There is growing consensus that the central feature of ADHD is disinhibition.(8) Patients are unable to stop themselves from immediately responding, and they have deficits in their capacity for monitoring their own behavior. Hyperactivity, while a common feature among children, is likely to be less overt in adults. The “on the go” drivenness seen in many ADHD children is replaced in adults with restlessness, difficulty relaxing and a feeling of being chronically “on edge.”(1)

Deficits in sustained attention and concentration are likely to remain and may become more apparent in late adolescence and early adulthood as responsibilities increase. Appointments, social commitments and deadlines are frequently forgotten. Impulsivity often takes the form of socially inappropriate behavior, such as blurting out thoughts that are rude or insulting. While many of the symptoms are reported by others in the patient’s life, the problem often expressed by adults with ADHD is frustration over the inability to be organized.(1) Prioritizing is another common source of frustration. Important tasks are not completed while trivial distractions receive inordinate time and attention.

Wender developed a set of ADHD criteria, referred to as the Utah criteria, that reflect the distinct features of the disorder in adults (Table 2).(2)(pp122-43) The diagnosis of ADHD in an adult requires a longstanding history of ADHD symptoms, dating back to at least age seven. In the absence of treatment, such symptoms should have been consistently present without remission. In addition, hyperactivity and poor concentration should be present in adulthood, along with two of five additional symptoms: affective lability; hot temper; inability to complete tasks and disorganization; stress intolerance; and impulsivity.

The Utah criteria include the emotional aspects of the syndrome. The episodes of hot temper, typified by frequent angry eruptions out of proportion to the precipitants, often “blow over” more quickly for the patient than for coworkers and family members. Affective lability is characterized by brief, intense affective outbursts ranging from euphoria to despair to anger, and is experienced by the ADHD adult as being out of control. Under conditions of increased emotional arousal from external demands, the patient becomes more disorganized and distractible.2(pp122-43)

Another model of adult ADHD diverges from DSM-IV but overlaps with Wender’s criteria and includes five areas.(9) In this model, the five core ADHD dimensions include the following: activation and organization; sustained attention; sustained energy and effort; managing affective interference; and working memory and accessing recall. Activation refers to difficulties initiating and organizing daily tasks. Sustained attention includes such aspects as distractibility, daydreaming and having to reread material to understand it. Sustained energy and effort refers to drowsiness, inconsistent performance and poor task completion. Managing affective interference includes difficulty managing criticism as well as being easily frustrated, irritable and poorly motivated. Memory difficulties encompass recent and remote memory for daily activities and task-related materials.(9)

Another model, which serves as the basis for the Copeland symptom checklist for ADHD in adults, includes eight dimensions: inattention and distractibility; impulsivity; activity level problems; noncompliance; underachievement, disorganization and learning problems; emotional difficulties; poor peer relations; and impaired family relationships.(10)

Evaluation

The subtlety and subjectivity of ADHD symptoms in adults, together with the absence of a single “gold standard” for confirming the diagnosis, make assessment particularly challenging. Evaluation of adults with symptoms of ADHD requires weighing and integrating a range of data, including the patient’s history, the patient’s self-report of symptoms and mental status testing (Table 3). A thorough history should include an emphasis on past school performance and conduct, previous and current psychiatric therapies, and reports of specific symptoms of inattention, distractibility and disorganization. ADHD is currently understood as a neurobehavioral condition that is typically apparent in preschool years and becomes more pronounced in the early elementary grades.

An extended, consistent pattern of ADHD symptoms, dating back to early childhood, should be uncovered during history taking. Patients with ADHD may have difficulty accurately recalling relevant history.11Adult patients should be asked to provide any available school records and gather information from parents and other adults who knew them as children. Because adults with ADHD may not appreciate their symptoms, the patient’s spouse or another significant person in the patient’s life should ideally be included in the interview. The recent onset of symptoms or sporadic episodes of symptoms should raise concern about the appropriateness of the diagnosis of ADHD.