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FOCUS Adult Attention Deficit Hyperactivity Disorder Volume 9 Number 8 2004 STANLEY P. KUTCHER, M.D., EDITOR FOCUS Adult Attention Deficit Hyperactivity Disorder CONTENTS Richard H. Weisler, MD Focus • Adult Attention Deficit Attention–deficit/hyperactivity disorder (ADHD)—characterized by devel- Hyperactivity Disorder 1 opmentally inappropriate degrees of impulsivity, hyperactivity, and inatten- tion—is one of the most prevalent chronic health conditions in children, af- fecting approximately 10% of school–age youth in the United States. Practitioner Pointer ADHD is a neurobehavioral disorder of childhood onset that frequently • Natural Course of persists into adolescence and adulthood, and although adult onset of ADHD Symptoms and Effect is not thought to occur, clinical presentation may not appear until adulthood. of Treatment 8 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) recognizes 3 subtypes of ADHD: predominantly inattentive, pre- dominantly hyperactive/impulsive, and combined. While hyperactivity and impulsivity may be relatively easy to identify in a child with ADHD, these SUPPLEMENT INCLUDED: symptoms tend to remit with age, leaving inattentive symptoms that may be More overlooked in adults with the disorder. Alternatively, adults may present with New Research inattentive symptoms that were not recognized in childhood or did not meet earlier diagnostic criteria that emphasized motoric symptoms. Consider a sample of 149 clinically referred adults with ADHD, of whom more than 90% reported inattentive symptoms to the clinician investigator. When diag- nosed using DSM–IV criteria, 56% of these patients met the diagnostic crite- ria for ADHD combined subtype, 37% for inattentive subtype, and only 2% met the criteria for hyperactive/impulsive subtype. This profile of ADHD subtypes differs dramatically from that typically observed in children with ADHD. Epidemiologic data collected during an update of the National Comorbidity Survey indicate that the prevalence of adult ADHD according Child & Adolescent Psychopharmacology News to DSM–IV criteria is 4.4% in the United States. As many as 9 million is an independent publication that accepts no advertising or other outside support. CAPN • 1 adults in the US may therefore be af- whereas adulthood tasks involve or- EDITORIAL BOARD Stanley P. Kutcher, M.D., Editor fected by ADHD, making it an impor- ganization, future planning, Dalhousie University, tant public health problem consider- balancing competing demands, and Halifax, NS ing the negative impact on independent thinking. Failure to Normand Carrey Dalhousie University long–term social, emotional, aca- perform academically is the single Mina K. Dulcan demic, driving, and vocational out- most common reason for the initial Northwestern University Medical School, Chicago, IL comes. Feelings of social and aca- referral of children and adolescents Bruce Ferguson demic inadequacy and low with ADHD, and academic difficul- University of Toronto, Toronto, ON David Gardner self–efficacy that develop in child- ties may impact later academic Dalhousie University, hood are often carried through ado- achievement and occupational suc- Halifax, NS lescence and into adulthood, and cess in adulthood. Adults with Barbara Geller Washington University School of Medicine, some adults with ADHD describe an ADHD often have a history of poor St. Louis, MO awareness that they “just don’t seem job performance, academic Laurence Greenhill New York State Psychiatric Institute, to get it.” Adults with ADHD may be underachievement, and chronic New York, NY socially obtuse as well as impulsive, stress associated with a poor ability to Rachel G. Klein New York State Psychiatric Institute, and this translates into turbulent in- manage responsibilities that other New York, NY terpersonal relationships—both ro- adults take for granted. The restless- Lili Kopala Dalhousie University, Halifax, NS mantic and in the workplace. Results ness, distractibility, inattention, and James T. McCracken of a national survey of 500 adults impulsivity inherent to adult ADHD UCLA Neuropsychiatric Institute, Los Angeles, CA with ADHD and 501 age– and gen- underlie the typical functional im- Mark Riddle der–matched adults without ADHD pairments, such as procrastination John Hopkins Medical Institute, Baltimore, MD illustrate the life impairments associ- when facing complex tasks and the Neal Ryan University of Pittsburgh, Pittsburgh, PA ated with the disorder. Significantly inability to finish complicated pro- Jovan Simeon fewer adults with ADHD had at- jects. Yet many adults with ADHD University of Ottawa, Ottawa, ON tended college, twice as many had are able to channel the nov- Child & Adolescent Psychopharmacology News been divorced, and half as many were elty–seeking behavior and intellec- (ISSN 1085-0295) is published eight times per year (Feb, Mar, May, June, Aug, Sept, Nov, and Dec) by completely satisfied with their tual curiosity into high–energy, de- The Guilford Press, 72 Spring Street, New York, NY 10012. Periodicals postage paid at New York, NY, and professional life and career track. manding careers as physicians, at additional mailing offices. lawyers, stockbrokers, sales people, SUBSCRIPTION PRICE: Volume 9, 2004 (eight issues) Individuals $150.00 ($160.00, Canada and for- Neurobiology of Adult ADHD and entrepreneurs. eign) and Institutions, $225.00 ($235.00, Canada and foreign). Orders by MasterCard, VISA, or American Express can be placed by phone at 800-365-7006, Fax Although the neurobiologic basis of Adult ADHD: A Valid 212-966-6708, or E-mail [email protected]; in New ADHD has not been completely de- York, 212-431-9800. Payment must be made in U.S. Psychiatric Diagnosis? dollars through a U.S. bank. All prices quoted in U.S. fined, dysfunction of dopaminergic dollars. Pro forma invoices issued upon request. Visit our website at www.guilford.com. and noradrenergic pathways and ab- Faraone and colleagues reviewed the va- Guilford’s GST registration number: 137401014 CHANGE OF ADDRESS: Please inform publisher normalities in frontal networks or lidity of adult ADHD based on the at least six weeks prior to move. Enclose mailing label frontal–striatal dysfunction are premise that validity of any psychiatric with change of address. Claims for lost issues cannot be honored four months after mailing date. Duplicate among the factors implicated. It is diagnosis is derived from a pattern of copies cannot be sent to replace issues not delivered because of failure to notify publisher of change of ad- well established that the stimulant consistent data, with standard valida- dress. Postmaster: Send address changes to Child & Adolescent Psychopharmacology News, Guilford medications potentiate the actions of tion criteria including family history, Press, 72 Spring Street, New York, NY 10012. both dopamine and norepinephrine treatment response, laboratory studies, Photocopying of this newsletter is not permitted. Inquire for bulk rates. in the synapse. Neuropsychologic clinical course, and outcome. Clinical models of ADHD stress impairment symptoms of adult ADHD are not unlike IMPORTANT NOTICE in executive function as a fundamen- those of children, though the intensity This publication is intended to provide accurate and tal deficit in ADHD. Impaired execu- of various symptoms may change with authoritative information regarding the subject matter covered. It is sold with the understanding that the pub- tive function includes deficits in age. Hyperactivity may not be problem- lisher is not engaged in rendering medical, psychologi- working memory (verbal and nonver- atic in adults, but impulsivity, cal, financial, legal, or other professional services. The recommended doses of medications cited in bal), self–regulations (affect, motiva- distractibility, and restlessness can lead this newsletter are not meant to serve as a guide for prescribing of medications. tion, and arousal) and the ability to to significant impairments when jug- Physicians, please check the manufacturer’s product analyze behavior and synthesize novel gling the complexities of daily life. information sheet or the PHYSICIAN’S DESK REF- ERENCE for further information and contraindica- responses. As in children with ADHD, these tions. Childhood tasks typically require functional impairments occur in multi- Copyright © 2004 by The Guilford Press simple responses to the specific de- ple domains, often including poor edu- Printed in the United States of America mands of parents or teachers, cational performance, occupational CAPN • 2 problems, and relationship difficulties. academic and test records that provide sion of a patients’ clinical history. A Adults with ADHD have increased support for an ADHD diagnosis that survey of primary care and psychiatry rates of mood, anxiety, substance use, was frequently missed. practices revealed that more than 90% and antisocial personality disorders. The reliability and validity of of adults with undiagnosed ADHD were The validity of ADHD is strongly sup- self–ratings of symptoms associated self–referred in both practice settings ported by family studies, which have with other types of psychiatric diagno- and more than 50% of previously demonstrated that adult relatives of ses have been demonstrated, and the undiagnosed adults had complained ADHD children are at increased risk same is true for adult ADHD. Studies about ADHD symptoms to other health for ADHD as are the child relatives of have shown that adults with ADHD professionals in the past, so a quick ADHD adults. Twin studies
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