Attention-deficit/hyperactivity disorder (ADHD) was once thought to be limited to overactive or inattentive children. Yet recent studies have shown that ADHD has a 50% to 60% persistence rate into adulthood and may affect as many as seven million adults in the United States today, impairing the ability of many to function productively.1,2 A significant number of adolescents previously diagnosed with ADHD but not currently receiving treatment are emerging into young adulthood. Some patients are prompted to seek help when their ADHD symptoms interfere with daily functioning; in others, ADHD is identified when they seek treatment for other conditions.
Most older ADHD patients initially present in the primary care setting,3 where practitioners may be reluctant to treat them because:
(1) The diagnosis of ADHD is subjective and purely clinical.
(2) It is unclear how the presently published diagnostic criteria should be applied to adults.
(3) The ADHD treatments proven most effective are schedule II psychostimulants, which have a certain potential for abuse.4
This article summarizes a review of currently accepted practice in primary care for recognizing and treating ADHD in the young adult patient.
Background
Between 1990 and 1998, the number of school-age children diagnosed with ADHD reportedly increased by 700%.5 The accompanying increase in use of schedule II stimulants6 (primarily methylphenidate and dexamphetamine) aroused some controversy, even though these medications were shown to be effective in reducing the inattentiveness, impulsivity, and hyperactivity associated with ADHD.7,8
Concerns regarding the indicated medications—possible abuse, associated adverse effects, inconvenience, stigma—prompted many parents of affected children to decline pharmacologic treatment.9 Among treated children, a large proportion discontinued their medications because they did not have a response or experienced intolerable adverse effects.10,11 Still others were never diagnosed. As a result, a significant number of adolescents with untreated or undertreated ADHD are now entering adulthood. Without treatment now, perhaps half of them will experience lifelong impairment resulting from ADHD and associated comorbidities (ie, conduct and oppositional-defiant disorder, antisocial personality disorder, substance abuse disorder, anxiety disorders, and depression).1,2,9,10,12
ADHD is believed to have a solid neurobiologic basis, but the condition has no known objective markers. Its diagnosis remains subjective and clinical, depending primarily on structured interviews conducted by trained practitioners.13 Unlike most behavioral disorders, which are first understood in adults, then extrapolated to children,14 ADHD has been recognized and treated in children since the late 1930s15 but has only recently been identified among significant numbers of adults.1 Thus, ADHD is currently best understood in children.14
The classic symptoms and signs of ADHD and its subtypes undergo subtle alterations as the patient matures.2,12,16 Hyperactivity wanes in adolescence and may be replaced by a restlessness that prompts the adult patient to change jobs and/or living quarters frequently, leading to an unstable lifestyle.12 Although impulsivity and inattention may persist through adolescence into adulthood, they are often obscured by both coping mechanisms (eg, choice of employment, conscious efforts by high achievers to overcome their disorganization)1 and behavioral comorbidities (depression, self-medication/substance abuse, personality disorders) that the patient may have developed.10,16 These developments may significantly complicate identification of the disorder in older patients.2,12,10,16
The adult with ADHD often exhibits low self-esteem, anxiety, depression, sleep disturbances,17 difficulties with personal relationships and jobs, and impulsivity, which can lead to trouble with the law.18 The costs to adult ADHD patients, their families, and the community are enormous, making it all the more important for health care professionals to understand this condition.
Diagnostic Criteria
The diagnosis of ADHD is based on criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition7,19(DSM-IV; see www.cdc gov/ncbddd/adhd/symptom.htm). ADHD may be widely acknowledged to affect adults, but only recently has an attempt been made to modify the DSM-IV criteria to accommodate the adult patient; changes so far have been limited to minor rewording. As the DSM-IV undergoes significant change at a conservative pace, individual practitioners must decide how best to apply the current criteria to adult patients.
Modifying the DSM-IV Criteria
Adult ADHD is a relatively new diagnostic category. Creating such categories to account for the symptoms of less impaired patients incurs the risk of ascribing pathology to conditions that lie at the margins of normality; hence the reluctance of DSM-IV editors to engage in rapid change. Weighed against their conservative approach, however, is the opportunity to treat individuals whose lives would benefit as a result. Thus, the editors of DSM-IV encourage its use as a guideline rather than a “cookbook.”20 The further practitioners move away from the comorbidities of mental health toward the merging of “soft” morbidity with normality, the more flexibility is required in applying the DSM-IV criteria.