Adult attention deficit disorder

Adult attention deficit disorder (AADD) is the common terminology for the psychiatric condition currently known as attention-deficit hyperactivity disorder (ADHD), also known as attention deficit disorder (ADD), when it occurs in adulthood. Although the exact prevalence in adults is unknown, epidemiologic studies thus far reveal that the condition, marked by inattentiveness, difficulty getting work done, procrastination, or organization problems, probably exists in about 2-4% of adults. The condition persists to adulthood in about half of children diagnosed with the disorder.

Although most diagnoses of ADHD are made for children, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) definitions of ADHD do not confine the disorder solely to childhood and in fact many adults are also diagnosed. Although the disorder may not have been diagnosed in an individual during childhood, it is also currently thought that all adults with the disorder had it in childhood. There are three subsets of ADHD in the DSM, and one is a form which does not include hyperactivity.

Because symptoms tend to diminish with age, a lesser number of adults are thought to have AADD than children. Current studies indicate that approximately 50% of children diagnosed retain the condition as adults. However, there have been only a few studies, and results varied widely from as low as 9% to as high as 66%. An ADD/ADHD diagnosis is also dependent upon an impairment of functionality. Thus, an individual (adult or child) meeting ADD/ADHD criteria may change through various combinations of maturity, medication, education, and learned behavior to no longer be so diagnosed.

Scientific research strongly indicates that the neurological condition is hereditary. Some adults may discover they have ADHD only after their children are diagnosed with the disorder. It is unknown how many persons have undiagnosed Adult Attention Deficit Disorder. Professionals have noted that adults with ADD/ADHD have often developed coping skills and other forms of adaptive behavior which make symptoms less noticeable to themselves and others. Sometimes also found to be a gift, often accompanied by hyperfocus, the condition is thought to have been a factor for historic figures and persons currently well-known in a wide range of fields. Apparently many of the factors which define the disorder have also been successfully used by individuals to turn a potential problem in their lives into an advantage.

See also main article Attention-deficit hyperactivity disorder

Terminology
There is not yet a naming consensus. Below are listed several terms that have been used, past and present. One challenge in taxonomy is that some patterns of behavior are labeled by experts symptoms or sub-types of ADHD, while other experts label those same patterns as their own disorders, independent of ADHD. For the purposes of this article, the "Terminology" section will be used only to name ADHD and its near equivalents, while the names for its manifestations and subtypes will be listed in 'Symptoms', below.


 * Attention-deficit hyperactivity disorder (ADHD): In 1987, ADD was in effect renamed to ADHD in the DSM-III-R. In it, ADHD was broken down into three subtypes (see 'symptoms' for more details):
 * predominantly inattentive ADHD
 * predominantly hyperactive-impulsive ADHD
 * combined type ADHD


 * Attention deficit disorder (ADD): This term was first introduced in DSM-III, the 1980 edition. Is considered by some to be obsolete, and by others to be a synonym for the predominantly inattentive type of ADHD.

Possibly due to the lesser evidence of hyperactivity symptoms in adults, the stigma attached to hyperactivity, or some combination of the two, many adults prefer the terms ADD or AADD to differentiate adult-related issues.

History
The conditions currently termed under the ADHD designation have only become recognized in the past 100 years, and were first recognized in young children. In 1937, one doctor in Rhode Island gave a stimulant to hyperactive children, and observed that they became calmer, the exact opposite of the response in non-hyperactive children. By the 1950s, research clearly indicated that the hyperactive behavior was not by choice, shifting the study to neurological sources. Professionals learned how to tell ADD apart from conduct disorder or oppositional defiant disorder. It wasn't a matter of volition. ADD is involuntary and spontaneous; the other two are premeditated.

In the 1970&#8217;s, researchers realized that ADHD didn&#8217;t disappear in puberty, and the condition was formally recognized as afflicting adults in 1978. When the invisible attentional component was recognized shortly thereafter, the disorder was renamed attention deficit disorder. Then, the hyperactivity component, so visible especially in boys, was added.

In the 1990&#8217;s, the new tools of MRI, PET and spec scans demonstrated that the brains of ADHD persons are different. Alan Scentian published PET scan studies in which two groups of people with the use of radioactive glucose used by the brain for energy (scan shows brain activity in color) demonstrated that the frontal lobes of ADHD people are smaller, conclusively proving that there are biological differences.

Cause
Psychiatry defines ADD as a set of symptoms, which implies that they are caused by a pathogen. But no systematic cause or causes are known for the characteristics identified as symptoms. Studies of heredity strongly suggest that these characteristics are genetic. The prevailing wisdom is that certain genes contribute to higher dopamine levels in the brain.

A 1990 study at the National Institute of Mental Health correlated ADD with a series of metabolic abnormalities in the brain, providing further evidence that ADD is a neurological disorder. While heredity is often indicated, problems in prenatal development, birth complications, or later neurological damage can contribute to ADD.

The presumed causes under investigation include:


 * brain differences (brain scan technology has revealed differences in the size, symmetry, metabolism, and chemistry of the brain in those who have ADHD; however, it should be noted that there is yet no clear determination of the source of these differences).
 * genetics (children who have one parent with ADHD have a higher incidence of ADHD; current research is examining which genes are involved in ADHD). This investigative path also suggests environmental factors, handed down from generation to generation, that may trigger the symptoms associated with ADD.
 * brain development in utero and during the first year of life (possibly related to drug use during pregnancy or environmental toxins).

There is increasing evidence that variants in the gene for the dopamine transporter are related to the development of ADHD (Roman et al., 2004, Am J Pharmacogenomics 4:83-92). This makes sense, as according to other recent studies, people with ADHD usually have abnormally high dopamine transporter levels which reclaim the dopamine emitted by a presynaptic neuron before the postsynaptic neuron can fully make use of it. The stimulant medications used to treat the disorder are all capable of blocking dopamine transporters. Therefore, it is theorized that stimulant medication allows the brain to use its natural supply of dopamine more efficiently by blocking the dopamine transporters. Currently this theory is the most widely accepted in the scientific and medical community.

New studies consider the possibility that norepinephrine also plays a role. (see Krause, Dresel, Krause in Psycho 26/2000 p.199ff).

Controversy
While ADD/ADHD is a known psychiatric condition, there are various theories about the cause and some controversy over the number of persons diagnosed and the cost of medications.

Hunter-versus-farmer theory
A broad theory, not necessarily in conflict with the current medical research findings, is the hunter vs. farmer theory, which holds that in some ways, some ADD attributes in some humans may be a form of environment adaption, or specialty. Under the theory, as civilized society evolved, the attributes of a hunter gave way to those of a farmer for most people as the survival skills needed changed. The hunter vs. farmer theory was first presented by Thom Hartmann, whose website describes him as "an internationally-known speaker on culture and communications, an author, and an innovator in the fields of psychiatry, ecology, and economics." 

ADD/ADHD a hoax?
There are some claims that ADD/ADHD is a hoax. Some have charged there has been a conspiracy between medical and counseling professionals and the pharmaceutical companies, or that the former have been misled by the latter, which have profited greatly from the sale of medication such as Ritalin and Adderall, and have advertised their products extensively. Further, since medications became available there has been an increased number of persons diagnosed, though this might be explained by increased awareness.

It has also been suggested that ADD/ADHD is actually a result of poor diet and other factors, rather than something inherent in sufferers. The study of changes in diets of children provide anecdotal and scientific evidence for this.

However, the results achieved in clinical tests with medication and anecdotal evidence of parents, teachers, and both child and adult sufferers suggest there is both a condition, and a treatment for at least some. Differences between the brains of people with and without ADD have been observed using MRI testing.

A further problem is that ADD and ADHD are syndromes, associations of symptoms. There is no well-established cause for the condition. This means that it may actually be a blanket term covering a multitude of conditions with a variety of causes.

Nevertheless, science is slowly uncovering biological clues. Children with ADHD lose zinc (and develop behavioral abnormalities) when exposed to Tartrazine (Yellow #5). Those without ADHD don't. (Ward 1990) Their sulfur oxidation appears to be abnormal. (Breakey 2004) They do not appear to use water in the same way as others - drinking more but excreting less, yet often appearing dehydrated. (Oades 1999)

Confusion may also arise from the fact that ADD/ADHD symptoms vary with each individual, and some mimic those of other causes. A known fact is that, as the body matures and grows, the symptoms and adaptability of the individual also change. Many children diagnosed with ADD/ADHD seem to outgrow it as they mature, but other individuals experience the symptoms their entire lives.

Symptoms and hallmarks
Adults are more likely than children to realize that they might have ADD/ADHD. However, because the very nature of the condition makes a person likely to be poor at self-observation, it is important to seek a professional diagnosis. In Driven To Distraction Edward M. Hallowell describes the disorder from the patient's perspective:


 * ... It's like being super-charged all the time. You get one idea and you have to act on it, and then, what do you know, but you've got another idea before you've finished up with the first one, and so you go for that one, but of course a third idea intercepts the second, and you just have to follow that one, and pretty soon people are calling you disorganized and impulsive and all sorts of impolite words that miss the point completely. Because you're trying really hard. It's just that you have all these invisible vectors pulling you this way and that, which makes it really hard to stay on task.

The behavior of people with ADHD goes beyond occasional fidgeting, disorganization, and procrastination. For them, performing tasks can be so hard that it interferes with their ability to function at work, at home, at school, and socially. 


 * In children the disorder is characterized by inattentiveness to external direction, impulsive behavior and restlessness. However, children with the inattentive type are actually often sluggish and hypo-active.
 * In adults the problem is often an inability to structure their lives and plan simple daily tasks. Thus, inattentiveness and restlessness often become secondary problems.

Symptoms or hallmarks of ADD/ADHD vary widely between individuals, just as no two human brains are exactly alike. They also vary throughout a lifetime as the individual matures, and are affected by life experiences and learned behavior. However, the ADD/ADHD diagnosis is defined by multiple factors.

ADD with hyperactivity (ADHD) is characterized by symptoms of inattention, impulsivity and/or hyperactivity which have an onset during childhood, although the condition may have been undiagnosed. Some hyperactivity symptoms are less noticeable in adults. One subset of the current ADHD criteria does not require hyperactivity at all. This was formerly known as simply ADD.

An adult with ADHD or ADD has a different complex of symptoms than a child does. Often the most prominent characteristic in ADHD adults is difficulty with executive functioning, which is the brain activity that oversees the ability to monitor one's own behavior, to plan, and to organize. Other symptoms observed in adults include inattention, impulsivity, over-activity, behavioral, learning, and emotional problems.

Hyperactive and impulsive with ADD adults feel restless, are constantly "on the go," and try to do multiple tasks at once. They are often perceived as not thinking before they act or speak.

"In adults, it's a much more elaborate disorder than in children," says Russell Barkley, Ph.D., a psychiatry professor at the Medical University of South Carolina. "It's more than paying attention and controlling impulses. The problem is developing self-regulation." This self-control affects an adult's ability not just to do tasks, but to determine when they need to be done, says Barkley. "You don't expect 4- or 5-year-olds to have a sense of time and organization, but adults need goal-directed behavior--they need help in planning for the future and remembering things that have to get done." 

Studies have indicated that adults with ADD are much more likely to have substance abuse problems than adults who do not have ADD. They are also more likely to suffer from depression and anxiety, be fired from jobs, and get divorced than non-ADHD adults.

For adults, the most common symptom is a sense of underachieving. According to Hallowell, "No matter how well you are doing, you always have a sense of missing a lot in work, school, jobs relationships. That is what most often finally brings adults in for diagnosis and treatment." The Hallowell Center identifies the following indicators to consider in an individual when ADD is suspected and recommends that individuals with at least twelve of the following behaviors since childhood &mdash; provided these symptoms are not associated with any other medical or psychiatric condition &mdash; consider professional diagnosis:


 * 1) A sense of underachievement, of not meeting one's goals (regardless of how much one has actually accomplished).
 * 2) Difficulty getting organized.
 * 3) Chronic procrastination or trouble getting started.
 * 4) Many projects going simultaneously; trouble with follow through.
 * 5) A tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark.
 * 6) A frequent search for high stimulation.
 * 7) An intolerance of boredom.
 * 8) Easy distractibility; trouble focusing attention, tendency to tune out or drift away in the middle of a page or conversation, often coupled with an inability to focus at times.
 * 9) Often creative, intuitive, highly intelligent.
 * 10) Trouble in going through established channels and following "proper" procedure.
 * 11) Impatient; low tolerance of frustration.
 * 12) Impulsive, either verbally or in action, as an impulsive spending of money.
 * 13) Changing plans, enacting new schemes or career plans and the like; hot-tempered.
 * 14) A tendency to worry needlessly, endlessly; a tendency to scan the horizon looking for something to worry about, alternating with attention to or disregard for actual dangers.
 * 15) A sense of insecurity.
 * 16) Mood swings, mood instability, especially when disengaged from a person or a project.
 * 17) Physical or cognitive restlessness.
 * 18) A tendency toward addictive behavior.
 * 19) Chronic problems with self-esteem.
 * 20) Inaccurate self-observation.
 * 21) Family history of AD/HD or manic depressive illness or depression or substance abuse or other disorders of impulse control or mood.



Diagnosis
A multi-factored evaluation of an individual is important in the diagnosis of ADD. Diagnostic assessment of adults should be made by a clinician or a team of clinicians with expertise in the area of attentional dysfunction and related conditions. A professional diagnosis is the only way to distinguish true ADHD or ADD from other conditions that may cause symptoms that mimic ADHD. Most diagnostic tools are designed for childhood-onset ADHD, but can be easily adapted to the different circumstances of an adult.

The diagnosis criteria require multiple symptoms observed in multiple settings (school, home, work, etc.) within the preceding 6 months. The full criteria are listed at this link: Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

It is important to note that the symptoms must clearly impair the individual's functioning. For children, one would generally expect that the symptoms would have a negative impact on academic performance, ability to meet appropriate behavioral expectations (following rules), and their ability to get along with others. Even if the checklist number of symptoms were met, and in multiple settings, if the symptoms were mild and did not create difficulties in any of these areas, then ADHD would not be diagnosed.

The diagnosis of ADHD is not a simple matter. It requires that careful attention be given to a number of specific symptoms, that information about a child's functioning be collected from different sources (at a minimum, the parents and a teacher), that there be a clear indication of impaired functioning in important life areas, and that other possible explanations for the child's symptoms be ruled out. 

However, it sometimes happens that parents or guardians of ADHD children will seek a second psychiatrist to prescribe ADHD medication, when one psychiatrist refuses. This is one of the criticisms leveled at the validity of ADHD as a diagnosis, along with the observation that ADHD is overdiagnosed, especially in Western countries.

Psychological testing for ADHD
Psychological testing for ADHD symptoms generally consists of obtaining multiple types of assessments. These usually include a clinical interview reviewing the DSM-IV criteria for ADHD diagnosis. The interview also needs to rule out as much as possible other types of syndromes which can cause attention problems, such as depression, anxiety, allergies and psychosis. Rating scales can be administered which provide measurement of the person's own view of their symptoms, as well as the views of parents, teachers, and significant others. Finally, computerized tests of attention can be helpful in providing a further independent assessment. These different assessments may not be consistent, but do provide a view of the person's difficulties. Subjectivity of the analysis can be compounded by the fact that physicians generally need not order psychological testing in order to make the diagnosis of ADHD, but many doctors use this kind of assessment to avoid over-diagnosis and treatment. The process of obtaining referrals for such assessments is being promoted vigorously by the President's New Freedom Commission on Mental Health.

Adult patients seeking a possible diagnosis may especially benefit from psychological assessment due to the greater ability to provide history and input. The relationship thus established may also help with behavioral solutions in addition to any medication which may be indicated.

Other forms of testing
Neurometrics, PET scans, or SPECT scans have been used for a more objective diagnosis. However, these may only be supplemental to the interview and behavioral criteria.

Treatment
The diagnosis itself is a form of remedial therapy for some adults. In the words of one woman, diagnosed at age 38 after both her sons has been diagnosed with ADHD, she felt a weight being lifted off her shoulders, saying "I'm not using ADHD as an excuse; it's an explanation. Now I understand why."

There are many options available to treat people diagnosed with ADHD. These options include a variety of medications, behavior-changing therapies, educational interventions, dietary modifications, and nutritional supplementation.

The usual course of treatment may include medications such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), amphetamine (Adderall), or pemoline (Cylert), which are stimulants that decrease impulsivity and hyperactivity and increase attention. However, there are also nutritional supplements, such as Lithinase, a chelated non-toxic form of lithium, which have been used successfully in the last thirty years as part of an integral health treatment to this condition.

There is a growing understanding that dietary intervention is a good place to start; when diet works, there is no need for medication. Furthermore, parents report that when their children need medication, they can use less when also on an additive-free diet. No research has yet been done on this.

Approximately 20-25% of people with ADD do not respond to medication. Most experts agree that treatment for ADHD should address multiple aspects of the individual's functioning and should not be limited to the use of medications alone. For children, treatment should include structured classroom management, parent education (to address discipline and limit-setting), and tutoring and/or behavioral therapy for the child. These can be adapted to the individual adult's circumstances and settings.

Generally, treatments which have proved effective for children were observed to work equally well or better in adults with similar diagnosis.

See main article Attention-deficit hyperactivity disorder for a listing of treatments.

Positive aspects of ADD
While ADD and ADHD are categorized as disorders, many individuals find their symptoms to be desirable. With or without hyperfocus, a common manifestation, ADD/ADHD in combination with successful coping skills may be utilized to achieve remarkable accomplishments. The list of historic figures and persons currently well-known in a wide range of fields who have displayed ADD/ADHD symptoms has been used by some medical and counseling professionals as a source of inspiration.

Organizations
There are large organizations and Internet groups for ADD/ADHD. Two of the larger Yahoo groups of this nature have hundreds of members, and one of these is focused on adults. (see external links section).


 * Attention Deficit Disorder Association (ADDA) (http://www.add.org)
 * CHADD - Children and Adults with Attention-Deficit/Hyperactivity Disorder (http://www.chadd.org)
 * Feingold Association of the United States (http://ADDdiet.com)
 * Learning Disabilities Association of America (http://www.ldaamerica.org)
 * National Center for Learning Disabilities (http://www.ld.org)
 * National Institutes of Health, DHHS:
 * National Institute of Child Health and Human Development (NICHD) (http://www.nichd.nih.gov)
 * National Institute of Mental Health (NIMH) (http://www.nimh.nih.gov)

Books

 * 1) Amen, Dr. Daniel G., Healing ADD: The Breakthrough Program That Allows You to See and Heal the Six Types of ADD
 * 2) Hallowell, Edward M, and Ratey, John J. Driven To Distraction : Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood
 * 3) Hallowell, Edward M, and Ratey, John J., Answers to Distraction
 * 4) Hartmann, Thom, Attention Deficit Disorder: A New Perspective
 * 5) Hersey, Jane, Why Can't My Child Behave?
 * 6) Lawlis, Frank, The ADD Answer

Websites

 * AmenClinic.com includes Online ADD test, ADD/ADHD info, discussion forums and links
 * Brainplace.com features SPECT imaging to show the brain and the areas that are affected by ADD/ADHD
 * National Mental Health association, AADD webspage
 * Adult Attention Deficit Disorder website with links
 * Helpguide: ADHD or ADD: Signs, Symptoms, and Subtypes
 * Hallowell Center founded by Dr. Edward M. Hallowell
 * An attendee's notes from Dr. Edward M. Hallowell's Workshop held in March  2003
 * Feingold Association of the United States Dietary intervention