Adult ADHD (Attention Deficit/Hyperactivity Disorder)

[David Baxter PhD]

Adult ADHD (Attention Deficit/Hyperactivity Disorder)
By Mayo Clinic Staff
Jan. 28, 2010

Adult attention-deficit/hyperactivity disorder (adult ADHD) is a mental health condition that causes inattention, hyperactivity and impulsive behavior. Adult ADHD symptoms can lead to a number of problems, including unstable relationships, poor work or school performance, and low self-esteem.

ADHD always starts in early childhood, but in some cases it's not diagnosed until later in life. It was once thought that ADHD was limited to childhood. But symptoms can persist into adulthood. For some people, adult ADHD causes significant problems that improve with treatment.

Treatment for adult ADHD is similar to treatment for childhood ADHD, and includes stimulant drugs or other medications, psychological counseling (psychotherapy) and treatment for any mental health conditions that occur along with adult ADHD.

Symptoms
ADHD has been called attention-deficit disorder (ADD) and hyperactivity. But attention-deficit/hyperactivity disorder is the preferred term because it describes both primary aspects of the condition: inattention and hyperactive-impulsive behavior.

Adult ADHD symptoms can include:

• Trouble focusing or concentrating
• Restlessness
• Impulsivity
• Difficulty completing tasks
• Disorganization
• Frequent mood swings
• Hot temper
• Trouble coping with stress
• Unstable relationships

Many adults with ADHD aren't aware they have the disorder ? they just know that everyday tasks can be a real challenge. Many adults with ADHD find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social engagements. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings, outbursts of anger and troubled relationships. Many adults with ADHD have a history of problems at school and at work.

All adults with ADHD had ADHD as children, even if it was never diagnosed. About 1 in 3 people with ADHD grows out of symptoms; about 1 in 3 continues to have symptoms that are less severe as adults; and about 1 in 3 continues to have significant symptoms as adults.

What's normal, and what's ADHD?
At some point in life, virtually everyone has some or all of the symptoms for ADHD. Some people simply have personalities with certain characteristics common with ADHD. But ADHD is diagnosed only when symptoms are severe enough to cause ongoing problems in multiple areas of your life. In adults with ADHD, these persistent and disruptive symptoms can be traced back to early childhood. If your difficulties are recent or occurred only occasionally in the past, you're not considered to have ADHD.

Diagnosis of ADHD in adults can be difficult because certain ADHD symptoms are similar to those caused by other conditions, such as anxiety or mood disorders. To make it even more challenging, half of adults who have ADHD also have at least one other diagnosable mental health condition, such as depression or anxiety.

When to see a doctor
If inattention, hyperactivity or impulsive behavior continually disrupts your life, talk to your doctor about whether you might have ADHD. Because signs of ADHD are similar to those of a number of other mental health conditions, you may not have ADHD ? but you may have another condition that needs treatment.

Causes
While the exact cause of ADHD remains a mystery, it increasingly appears that structural changes in the brain are linked to the disorder. Here are several factors that may play a role in developing ADHD:

• Altered brain function and anatomy. Brain scans have revealed important differences in the structure and brain activity of people with ADHD. For example, people with ADHD appear to have less activity in the area of the brain that controls attention than people who don't have ADHD.
• Inherited traits. ADHD can run in families.
• Maternal smoking, drug use and exposure to toxins. Pregnant women who smoke, drink alcohol or use drugs are at increased risk of having children with ADHD. Likewise, women exposed to environmental poisons during pregnancy ? such as polychlorinated biphenyls (PCBs) ? may be more likely to have children with symptoms of ADHD.
• Childhood exposure to environmental toxins. Preschool children exposed to certain toxins are at increased risk of developmental and behavioral problems. Exposure to lead, which is found mainly in paint and pipes in older buildings, has been linked to disruptive and even violent behavior and to a short attention span.

Risk factors
You're at increased risk of ADHD if:

• Your mother was exposed to toxins during pregnancy
• Your mother smoked, drank alcohol or used drugs during pregnancy
• You have blood relatives (such as a parent or sibling) with ADHD or another mental health disorder
• You were born prematurely
• You were exposed to environmental toxins as a child

Complications
ADHD has been linked to:

• Poor school performance
• Trouble with the law
• Problems at work
• Alcohol or drug abuse
• Frequent car accidents or other accidents
• Unstable relationships

Although ADHD doesn't cause other psychological or developmental conditions, a number of other disorders frequently occur along with ADHD. These include:

• Mood disorders. Many adults with ADHD also have depression, bipolar disorder or another other mood disorder. While mood problems aren't necessarily due directly to ADHD, a repeated pattern of failures and frustrations due to ADHD can worsen depression.
• Anxiety disorders. Anxiety disorders occur fairly often in adults with ADHD. Anxiety disorder may cause overwhelming worry, nervousness and other symptoms. Anxiety can be made worse by the challenges and setbacks caused by ADHD.
• Personality disorders. Adults with ADHD are at increased risk of personality disorders, such as borderline personality disorder or antisocial personality disorder.

Tests and diagnosis
The following chart from the National Institute of Mental Health lists the types of doctors who are qualified to diagnose and supervise treatment for ADHD, although not all may have specific training in the disorder.

Specialist | Can diagnose ADHD? | Can prescribe medications, if needed? | Provides counseling or training?
Psychiatrist | Yes | Yes | Yes
Psychologist | Yes | Usually No | Yes
Family doctor | Yes | Yes | Usually No
Neurologist | Yes | Yes | No

Diagnosing ADHD in adults
It can be more challenging to identify ADHD in adults than in children. The signs and symptoms in adults can be hard to spot. No single test can confirm the diagnosis. Your doctor will likely start by doing a physical exam and asking you a number of questions.

Ruling out other conditions
Your doctor or mental health provider will consider whether your symptoms may be caused by something other than ADHD. Conditions that can cause symptoms similar to those caused by ADHD include:

• Mental health disorders. A number of other mental health conditions can mimic ADHD both in children and in adults, including anxiety disorders, mood disorders, adjustment disorders, learning and language deficits, and psychotic disorders.
• Other health problems. Your doctor may consider a different diagnosis or refer you to a specialist if you have a history of a developmental disorder, seizures, sleep apnea, hearing or vision problems, a thyroid disorder, lead poisoning or low blood sugar (hypoglycemia).
• Drugs and medications. Alcohol or drug abuse and certain medications can cause ADHD-like symptoms.

Evaluating signs and symptoms that you had ADHD as a child
A persistent pattern of signs and symptoms, beginning no later than age 7, is essential for a diagnosis of adult ADHD. You may have a hard time remembering whether your problems date back to childhood. For that reason, your doctor may ask for your old school records and gather information from teachers, parents and anyone else who knew you when you were young. Your doctor will also want to hear from your spouse, a parent, close friend or someone else who knows you well.

Diagnostic criteria for ADHD
To be diagnosed with ADHD, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association.

The DSM assessment was developed primarily for children, but uses the same criteria to diagnose adults. When considering your symptoms, your doctor or mental health provider will consider what symptoms you had as a child, as well as which symptoms you still have as an adult.

For a diagnosis of ADHD, you must have six or more signs and symptoms from one or both of the two categories below:

Inattention

• Often fails to give close attention to details or makes careless mistakes in work or other activities
• Often has difficulty sustaining attention in tasks
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish work or other duties (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
• Often loses things necessary for tasks or activities
• Is often easily distracted
• Is often forgetful in daily activities

Hyperactivity and impulsivity

• Often fidgets with hands or feet or squirms in seat
• Often leaves the room in situations in which remaining seated is expected
• Often physically active in situations in which it is inappropriate
• Often has difficulty 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 (for example, butts into conversations or games)

In addition to having at least six symptoms from one of the two categories, someone with adult ADHD:

• Has inattentive or hyperactive-impulsive signs and symptoms that caused impairment and were present before age 7
• Had behaviors that weren't normal for children the same age who didn't have ADHD
• Has symptoms for at least six months
• Has symptoms that hurt school, work, home life or relationships in more than one setting

Other criteria for diagnosing ADHD in adults
Because symptoms of ADHD will differ in adults from those in the DSM criteria ? especially those listed for symptoms of hyperactive behavior ? other criteria more specific to adults are generally used to help confirm a diagnosis.

A number of questionnaires and expanded lists of signs and symptoms have been developed to check for signs of adult ADHD. Your doctor may have you answer the questions on one of these to help determine whether you have ADHD.

In addition, your doctor will carefully examine the impact of your core symptoms on your current life ? your performance at work or in school and your relationships with friends and family.

Treatments and drugs
The best treatment for ADHD is still a matter of debate. Current treatments typically involve medication, psychological counseling or both. A combination of therapy and medication is often the most effective treatment.

Medications
Stimulants (psychostimulants) are the most commonly prescribed medications for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters.

These ADHD medications help treat the core signs and symptoms of inattention and hyperactivity ? sometimes dramatically. However, effects of the drugs can wear off quickly, especially if you take a short-acting type rather than a long-acting type of stimulant. The right dose varies between individuals, so it may take some time in the beginning to find the dose that's right for you. Stimulants used to treat ADHD include:

• Methylphenidate (Ritalin, Concerta, Daytrana, Metadate)
• Dextroamphetamine-amphetamine (Adderall)
• Dextroamphetamine (Dexedrine)
• Lisdexamfetamine (Vyvanse)

Stimulant drugs are available in short-acting and long-acting forms.

• The short-acting forms last about four hours, while the long-acting preparations last between six and 12 hours.
• Methylphenidate is available in a long-acting patch that can be worn on the hip (Daytrana). It delivers medication for about nine hours. While the long-lasting effects mean you won't need to take medication as often, it can take up to three hours to start working.

Side effects of stimulants can include insomnia, anorexia, nausea, decreased appetite, weight loss, headache, increased blood pressure, faster pulse, abdominal pain and shifting moods. In some people, stimulants may cause involuntary muscle movements of the face or body (tics). Rarely, they cause seizures, high blood pressure (hypertension), delusions (psychosis) or liver problems. For most people, these medications are considered a safe long-term treatment for adult ADHD. If you have certain conditions, including high blood pressure, heart disease, or problems with alcohol or drug use, your doctor may start your treatment with a nonstimulant medication.

Other medications sometimes used to treat ADHD include:

• Atomoxetine (Strattera)
• Antidepressants such as bupropion (Wellbutrin) and venlafaxine (Effexor)

Atomoxetine and antidepressants work more slowly than stimulants and may take several weeks before they take full effect. These medications may be a good option if you can't take stimulants because of health problems, have a history of substance abuse or have a tic disorder or if stimulants cause severe side effects. Bupropion or venlafaxine may be a good choice if you have a mood disorder along with ADHD.

• Side effects of atomoxetine can include nausea, decreased appetite, insomnia, slightly increased blood pressure and heart rate, decreased sex drive (libido), sweating, and painful urination.
• Side effects of bupropion can include headache, nausea, dry mouth, insomnia, sweating, anxiety and constipation. These side effects may improve as your body adjusts to the medication. In rare cases, bupropion can cause seizures. Bupropion causes fewer sexual side effects than atomoxetine and most other antidepressants. Higher doses of bupropion have been associated with seizures.
• Side effects of venlafaxine and other commonly prescribed antidepressants can include nausea, loose bowel movements, headache and insomnia. These will likely improve as your body adjusts to the medication. For many people the most bothersome side effect is a decrease in sexual desire or ability, which may not improve. High doses of venlafaxine can increase blood pressure.

Psychological counseling
Adults with ADHD often benefit from counseling. Counseling for adult ADHD also generally includes psychological counseling (psychotherapy) and education about the disorder (psychoeducation). Counseling can help you and your family members understand why ADHD occurs, how it affects your life and relationships, and how treatment works.

Psychotherapy for adults with ADHD is often focused on helping develop skills to resolve specific issues. It can help you:

• Improve your time management and organizational skills
• Learn how to reduce your impulsive behavior
• Develop better problem-solving skills
• Cope with past academic and social failures
• Improve your self-esteem
• Learn ways to have better relationships with your family, co-workers and friends
• Develop strategies for controlling your temper

Common types of psychotherapy for ADHD include:

• Cognitive behavioral therapy. This is a structured type of counseling that teaches specific skills to control your behavior and change negative thinking patterns into positive ones. It can be helpful in dealing with specific life challenges, such as school, work or relationship problems, and is also helpful in addressing other mental health conditions such as depression or substance abuse. This type of therapy can be done one-on-one or in a group setting.
• Marital counseling and family therapy. This type of therapy can help loved ones cope with the stress of living with someone who has ADHD and learn what they can do to help. Problems linked to ADHD can put a lot of stress on your relationships. Your spouse or other family members may feel like you're unreliable, messy, a poor listener or not contributing equally to family responsibilities. Understanding that your faults aren't due to not making an effort to change your behavior can relieve tension and help you avoid blaming one another.

Lifestyle and home remedies
Because ADHD is a complex disorder and each person with ADHD is unique, it's hard to make recommendations that are right for every adult. But some of the following suggestions may help:

• Make a list of tasks to be accomplished each day. Make sure you're not trying to do too much.
• Use sticky pads to write notes to yourself. Put them on the fridge, on the bathroom mirror, in the car or in other places where you will benefit from having a reminder or information.
• Keep an appointment book or planning calendar to track appointments and deadlines. You may want to use an electronic personal digital assistant (PDA).
• Carry a notebook with you so you can write down ideas or things you'll need to remember.
• Take time to set up systems to file and organize information, both on the computer and for paper documents. Get in the habit of using these systems consistently.
• Break down tasks into smaller, more manageable steps.
• Ask for help from family members or loved ones.
• Follow a routine that's consistent from day to day.

Relationships
If you're like many adults with ADHD, you may be unpredictable and difficult to get along with. Forgotten appointments, missed deadlines, impulsive or irrational decisions, and angry outbursts can strain the patience of the most forgiving co-worker, friend or partner.

Therapy that focuses on these issues and helps you better monitor your behavior can be very helpful. So can classes to improve communication skills, conflict resolution and problem solving. Couples therapy and classes in which family members learn more about ADHD may significantly improve your relationships.

Alternative medicine
While more research is needed, there's some evidence that alternative medicine treatments can reduce ADHD symptoms. Some alternative treatments for ADHD include:

• Yoga. Doing regular yoga routines may help treat symptoms of ADHD.
• Special diets. Most diets for ADHD involve eliminating foods thought to increase hyperactivity, such as sugar and caffeine, and common allergens such as wheat, milk and eggs. Some diets recommend eliminating artificial food colorings and additives. If you notice that a certain food causes a change in your symptoms, you may want to try eliminating it from your diet to see if it makes a difference. However, consult with your doctor before starting a limited diet. A diet that eliminates too many foods can be unhealthy because it may lack necessary vitamins and nutrients.
• Vitamin or mineral supplements. While certain vitamins and minerals are necessary for good health, there's no evidence that supplemental vitamins or minerals can reduce symptoms of ADHD. "Megadoses" of vitamins ? doses that far exceed the Recommended Dietary Allowance (RDA) ? can be harmful.
• Herbal supplements. It's unknown whether taking hypericum, ginseng, ginkgo, traditional Chinese medicine formulas or other herbal remedies help with ADHD, although some people claim they do.
• Essential fatty acids. These fats, which include omega-3 oils, are necessary for the brain to function properly. It's too soon to say whether they may improve ADHD symptoms.
• Glyconutrients. The term "glyconutrients" refers to eight specific sugars that theoretically reduce symptoms by helping form important compounds called glycoproteins. While sugars are necessary for brain function, it isn't clear whether glyconutrient supplements have any effect on ADHD.
• Neurofeedback training. Also called electroencephalographic biofeedback, this treatment involves regular sessions in which you focus on certain tasks while using a machine that shows brain wave patterns. Theoretically, you can learn to keep brain wave patterns active in the front of the brain ? improving symptoms of ADHD. More research is needed to see whether this treatment works.

Coping and support
While medication can make a big difference with ADHD, taking other steps can help you understand ADHD and learn to manage it. Some resources that may help you include:

• Support groups. Support groups allow you to meet other people with ADHD so you can share experiences, information and coping strategies. Support groups are available in person in many communities and also online.
• Social support. Involve your spouse, close relatives and friends in your ADHD treatment. You may feel reluctant to let people know you have ADHD, but letting others know what's going on can help them understand you better and improve your relationships.
• Colleagues, supervisors and teachers. ADHD can make work and school a challenge. You may feel embarrassed telling your boss or your professor you have ADHD, but most likely they'll be happy to make small accommodations to help you succeed. Ask for what you need to improve your performance at work or at school (such as more in-depth explanations or more time on certain tasks).

Prevention
Once you have your ADHD under control, you can take steps to prevent it from getting worse.

• Take your medications exactly as prescribed. Call your doctor before you make any changes.
• Be diligent about using skills you've learned. Stay organized, manage stress and keep a positive attitude.
• Don't hesitate to ask for help. From the outset, let people close know you're coping with a disability. Their support can make a big difference.

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