Kevin M. Antshel, PhD

This book is a welcome addition to the library of any mental health professional working in the field of developmental disabilities. An increasing number of developmentally disabled individuals are living in the community in independent or semi-independent settings. Relatively fewer persons who are generally more functionally impaired reside in institutional settings.

Psychiatrists and other mental health professionals are increasingly involved in the multimodal treatments provided in both settings. Thus, a book that provides relevant information regarding assessment and treatment of persons with developmental disabilities, especially one that approaches this issue from a life span perspective, is greatly appreciated.

The editors have assembled relevant reviews of the broad topics important to any practicing mental health clinician. While the title clearly states that the book is written with psychiatrists in mind, any clinician can readily use information provid-ed in the book. Except for the chapter on psychopharmacology, the others broadly apply to anyone working in the field. All are well written and contain relevant information. Several stand out in both novelty and practicality.

The chapter on geropsychiatry, written by John de Figueiredo, covers a topic not often found in other texts. As correctly noted by de Figueiredo, the aging population of individuals with developmental disabilities is an underserved cohort. He also covers the topic of diagnostic overshadowing (attributing psychiatric symptoms to the developmental disorder rather than to an independent psychiatric disorder). Diagnostic overshadowing is a very real challenge to mental health clinicians who work with this population regardless of age, yet it can be especially salient to those who work in geropsychiatry. (Diagnostic overshadowing is also covered in the assessment chapter written by Stephanie Hamarman.)

The chapter on acquired brain injury is especially helpful. Gregory O’Shanick and Ronald Savage outline many strategies and interventions for teachers who work with students with acquired brain injuries.

In a chapter on special education laws, Robin Church and Derek Glaaser address issues relevant to the Americans with Disabilities Act as well as the Individuals with Disabilities Education Act. Church and Glaaser use case examples that highlight the inherent complexities of these laws. The ethical and legal issues chapter, written by Judith Levy and Maureen van Stone, also has case examples to discuss decision-making capacities of individuals in this population and ethical and legal issues that may arise.

In sum, Dryden-Edwards and Combrinck-Graham have edited a wonderful text relevant to those mental health professionals who work in the developmental disabilities field. While there is some redundancy between chapters, and it would have been nice to see more charts, tables, and graphs, my overall impression of this book is quite positive. In fact, my largest issue with the book is its title; this book is a great reference for all who work with this population, not just psychiatrists.

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 What Works for Psychiatrists in Community and Institutional Settings 

Developmental Disabilities From Childhood to Adulthood:

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After reading this article, you will be familiar with:



• The differences between childhood and adult attention-deficit/hyperactivity disorder (ADHD).
• The extent of functional impairment with ADHD.
• The clinical scales that can be used to diagnose and measure adult ADHD.
• Available options for treating adult ADHD.



Who will benefit from reading this article?


Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.



Dr Faraone is professor of psychiatry and behavioral sciences, departments of psychiatry and behavioral sciences and neuroscience and physiology; Drs Antshel and Kunwar are assistant professors in the department of psychiatry and behavioral sciences at the State University of New York Upstate Medical University.

Drs Antshel and Kunwar report that they have no conflicts of interest concerning the subject matter of this article. Dr Faraone reports that he has received research support from Shire Pharmaceutical Development, Pfizer, NIMH, and the National Institute of Drug Abuse; and he is a consultant for Shire Pharmaceutical Development.



In the past 15 years, there has been an increasing awareness of the syndromal persistence of attention-deficit/hyperactivity disorder (ADHD) into adulthood. Once considered only a childhood disorder, ADHD has become increasingly recognized as a valid psychiatric disorder in adults.

 Proponents of ADHD as a valid adult diagnosis do not suggest that ADHD arises de novo in adulthood. Rather, adult ADHD is considered the natural continuation of childhood ADHD, albeit with a different topographical expression of symptoms. The focus of this article is to discuss what is known about ADHD in adults, with a particular emphasis on diagnosis and treatment strategies.



COMPARISONS WITH PEDIATRIC ADHD
Prevalence and symptoms


In children, the prevalence of ADHD is typically cited as between 3% and 5% of the general population while in adults, studies suggest that the prevalence is about 4%.

This is not surprising given that longitudinal research indicates that the majority (50% to 70%) of children with ADHD continue to show impairing symptoms as they age.

ADHD research in children and adults indicates that inattention and hyperactivity/impulsivity are the defining features of the disorder. For example, in a family study of ADHD, more than two-thirds of nonreferred adult relatives of children with ADHD reported current ADHD symptoms at levels comparable to those in pediatric participants with ADHD.

These data suggest that inattentive and hyperactive/impulsive symptoms are the defining features of ADHD in both clinically referred and nonreferred adults.

Despite the similar symptoms, several core DSM-IV ADHD symptoms (eg, hyperactivity) lessen or mollify over time.

 demonstrated that psychomotor activity levels decline after age 9 in the general population. Thus, "running about or climbing on things inappropriately" may have less predictive power as a diagnostic symptom in adulthood.

This has led to some diagnostic confusion and possibly underdiagnosis of adult ADHD.



In addition, teachers and school personnel are attuned to ADHD and are familiar with the disorder in children, while employers are likely to be less mindful of possible ADHD symptoms in adults. In the absence of a formal screening mechanism, adults with ADHD may also be less likely to be referred for treatment. Although the symptoms appear to be equally defining in children and adults, the topography of these symptoms may be quite different in adults, possibly contributing to ADHD underdiagnosis in adults.


Pediatric ADHD commonly co-occurs with multiple psychiatric disorders including mood, anxiety, and disruptive behavioral disorders.

Likewise, adult ADHD is associated with comorbid mood, anxiety, and substance use disorder diagnoses.

Comorbidity rates in adult ADHD do not differ as a function of gender; this is in contrast to the higher prevalence of externalizing disorder comorbidities observed in boys with ADHD.

ADHD in adults is not always comorbid with other psychiatric conditions, however, and some data suggest that uncomplicated ADHD exists in about 20% to 25% of adults with ADHD.


ADHD is a highly heritable condition (average heritability index = 0.76).

Family studies of pediatric ADHD suggest that the parents of children with ADHD are more likely than parents of other children to have ADHD themselves.

The same holds true in adult ADHD; offspring of parents with ADHD are more likely to have ADHD themselves.

 found a 57% prevalence of ADHD in children of adults with the disorder, which is much higher than the 15% prevalence of ADHD among siblings of children with ADHD.

Genetic factors appear to play a stronger role in those who continue to demonstrate clinically significant ADHD into adulthood than in those whose symptoms are in remission.

For example, a prospective ADHD study with a 4-year follow-up examined 140 boys with ADHD and 120 boys without ADHD at baseline. By midadolescence, 85% of the boys with ADHD continued to have the disorder. The prevalence of ADHD was significantly higher among the relatives of children with persistent ADHD than among relatives of children with ADHD whose symptoms were in remission.



Parents of persistent ADHD probands were 20 times more likely to have ADHD than parents of controls, whereas parents of nonpersistent ADHD probands showed only a 5-fold increased risk. Similarly, siblings of persistent ADHD probands were 17 times more likely to have ADHD than siblings of controls, while siblings of nonpersistent ADHD probands showed only a 4-fold increased risk.

When ADHD persists into adulthood, it is decidedly familial.




Significant functional impairment in educational, marital, interpersonal, and occupational realms and in motor vehicle operation is common in adult ADHD.

In fact, recently published longitudinal research findings indicate that ADHD in adults is a far more impairing disorder than many other disorders (eg, anxiety and mood disorders) across multiple domains of major life activities, especially educational and occupational functioning, money management, and management of daily responsibilities.

Adults with ADHD are also more likely to receive speeding violations and have their driver's license suspended.

These motor vehiclerelated infractions are not related to deficits in driving skills or knowledge.

Computer-simulated driving tests also demonstrate that adults with ADHD have more accidents and near-accidents.

Similar functional impairment findings have been seen in other studies that compared adults with ADHD and psychiatric control samples.

 compared adults with ADHD to age- and sex-matched psychiatric controls on educational and occupational achievement variables. Relative to psychiatric controls, adults with ADHD had fewer years of education and lower rates of professional employment. There is evidence that the lower rates of professional employment are not accounted for by comorbid psychopathology.



It is not surprising that adults with ADHD have lower rates of professional employment, given that academic underachievement and learning disabilities are common in children with ADHD.

A community study showed that the profile of impairments of adults with ADHD diagnosed in the community was similar to that seen in samples in whom ADHD was diagnosed in academic centers.

Likewise, data from adults with previously undiagnosed ADHD indicated more psychiatric comorbidity and functional impairments than did non-ADHD controls; even when unrecognized, ADHD in adults is functionally impairing.



Elevated prevalence of substance abuse/dependence has consistently been reported in adults with ADHD.

An estimated 17% to 45% of adults with ADHD have histories of alcohol abuse or dependence and 9% to 30% have histories of drug abuse or dependence.

A study of treatment-naive adults with ADHD found that the risk of substance abuse/dependence developing over the life span is 2-fold compared with adults who do not have ADHD (52% vs 27%, respectively). Although a history of conduct or bipolar disorders increases that risk, ADHD is an independent risk factor for later substance abuse/dependence.

Studies have shown that compared with adults who do not have ADHD, adults with comorbid ADHD and substance abuse/dependence have an earlier onset and a greater severity of substance abuse.



Likewise, findings indicate that ADHD is elevated in substance users.

Studies of substance-dependent populations report the prevalence of ADHD ranges from 15% to 25%.

The presence of ADHD appears to potentiate the substance abuse/dependence, resulting in a more severe disorder and poorer outcomes.

The increased prevalence of substance abuse/dependence in ADHD has been reported in longitudinal studies that followed children with well-characterized ADHD into adulthood, as well as individuals with ADHD that is diagnosed in adulthood.

Finally, among those with substance abuse disorder, adults with ADHD have higher rates of separation and divorce and lower occupational achievement than their peers.


DSM-IV criteria for ADHD symptoms are based on earlier DSM editions, expert clinical opinion, and a field trial of the psychometric properties and utility of the item pool.

The proposed DSM-IV ADHD items were field-tested using a sample of 380 clinically referred children aged 4 to 17 years. The 18 items that appear in DSM-IV correlate highly with parent and teacher ratings of impairment and best differentiate ADHD from non-ADHD disorders.



Adults were not included in the ADHD field trials for DSM-IV. Thus, there was no attempt to assess the developmental appropriateness of the ADHD symptoms for diagnosing the disorder in adults. For example, DSM-IV symptoms such as "runs and climbs excessively" are clearly inappropriate for adults. Similarly, the cutoff score of 6 of 9 symptoms was based on pediatric data, which may be too restrictive for adults.

Unlike diagnosing ADHD in children, diagnosing ADHD in adults relies highly on self-report. Asking a 42-year-old man to recall behaviors before age 7 most likely introduces recall biases.



Stimulant medications are generally started at a low dosage and titrated as needed to optimize the symptom improvement without causing significant adverse effects. Common adverse effects are dry mouth, insomnia, decreased appetite, and headache. The optimal dosage is best determined by each patient's response. Traditionally, a trial with an immediate-release stimulant was undertaken before switching to a long-acting form; however, more recently, the American Academy of Child and Adolescent Psychiatry amended its practice parameters to recommend that long-acting agents be initiated first and titrated accordingly.

A stimulant is effective as long as it remains in the system and does not have long-lasting cumulative effects. Because immediate-release stimulants have to be taken multiple times, compliance can be an issue, especially in a population known to be forgetful and disorganized.



Atomoxetine is taken orally once or twice daily. Even with once-daily dosing, it provides full coverage in the evening with less rebound than may be observed with stimulants.

Atomoxetine also lacks the midbrain dopamine effects that have been linked to addictive potential.

There is also some evidence that atomoxetine may be particularly effective for adults with comorbid ADHD and depression.

Common adverse effects associated with atomoxetine are dry mouth, insomnia, nausea, decreased appetite, constipation, and sexual dysfunction. There is a black box warning for increased suicidal ideation in children but not in adults.

While the stimulants and atomoxetine are more commonly prescribed for adult ADHD, bupropion, modafinil, and desipramine have also been described as effective for managing ADHD and may be used as second-line agents.

Bupropion has demonstrated efficacy in open and controlled studies and may be particularly effective in adults with ADHD who have comorbid mood disorders.

Modafinil has also been shown to be efficacious for adult ADHD in 2 double-blind, randomized, placebo-controlled studies.

Rather than affecting dopamine and norepinephrine in the striatum, modafinil alters the balance of g-aminobutyric acid and glutamate. Desipramine has been shown to be efficacious for adult ADHD in a double-blind, placebo-controlled study.



Findings suggest that adults with ADHD are more likely to require polypharmacy than children with ADHD.

In addition, there is some evidence that baseline clinician ratings of ADHD symptoms are stronger predictors of pharmacotherapy treatment outcome than baseline patient reports.85




A psychosocial treatment component is generally recommended in addition to pharmacotherapy.

Although cognitive-behavioral therapy (CBT) has not been shown to be effective in children with ADHD, there are reasons to be optimistic that CBT may be effective in adults with ADHD. For example, CBT is generally more effective in adolescents than in preadolescents.

Similarly, CBT may be effective for reducing functional impairments in adults with ADHD being treated with stimulants.

 developed a supplemental CBT program for adults with ADHD who were recieving medication. Initial results from a small-scale study of this manualized therapy have been showing significant benefits beyond those achieved by medication alone.

 have also created a CBT program for adults with ADHD. In their open study, 43 adults with ADHD were treated for 6 months with a combination of pharmacotherapy and CBT. Findings from this study suggest that the combined treatment approach was effective across both symptom and functional parameters.




Despite our increased understanding of adults with ADHD, there is much that we still do not know. For example, most of the adult ADHD research has used samples of college students or adults under the age of 40. Thus, we know far less about ADHD in middle age and beyond. Following children longitudinally across the life span also presents a unique method of tracking not only interindividual change but also intraindividual change. The use of cross-sectional research designs limits our ability to assess these parameters. As Barkley, Biederman, and others' longitudinal samples continue to age, we will know more about the continuation of ADHD in middle and late adulthood.

Pediatric ADHD is more common in boys than in girls.

This sex-based difference, however, appears less marked in adult ADHD.

Relative to boys with ADHD, lower rates of externalizing disorders in girls have been found.

The presence of an externalizing comorbid condition increases the likelihood that a child will be clinically referred for ADHD. Referral biases are possibly less salient for adults who, unlike children, can refer themselves for treatment. While this hypothesis has intuitive appeal, future studies should consider possible sex-based differences in ADHD across the life span.

Further research is needed to clarify whether the DSM-IV approach to ADHD should be modified for adults. DSM-IV recognizes developmental changes in the expression of ADHD in several ways. It cautions diagnosticians that with maturation, symptoms become less conspicuous. Older children may be restless and fidgety but not overly hyperactive. With age, inattention may predominate as tasks at school require increasing levels of attention. DSM specifies that symptoms are considered present only if they are maladaptive and inconsistent with developmental level.

DSM-IV includes the category of ADHD in partial remission for individuals (especially adolescents and adults) who currently have symptoms but no longer meet full criteria. The net effect of developmental changes is to make it more difficult for children with ADHD to meet criteria for the disorder as they get older. Although this reflects the true remission of the disorder to some extent, it may also be because of the use of insensitive diagnostic criteria.

For example, Barkley and colleagues

 examined the utility of DSM criteria for ADHD when used with adults, and they showed that only 6 to 8 symptoms were required to diagnose ADHD in adults. (DSM-IV stipulates that 12 symptoms must be present to diagnose ADHD.) The single symptom of "often being distractible" was sufficient to differentiate ADHD from typically developing adults while 5 to 7 more symptoms were needed to discriminate those with ADHD from clinic-referred adults. Inattention and verbal impulsivity symptoms were the best discriminators between patients with ADHD and clinical controls.

 Barkley's work as well as the work of others on the developmental sensitivity of ADHD symptoms has clear implications for the development of DSM-V.

Also relevant to DSM-V, the age-of-onset criterion (onset before 7 years) has virtually no empirical support.

Other investigators have argued that the onset criterion should be broadened to include midadolescence or more generically phrased as "onset in childhood."



Finally, as a function of educational and occupational impairments, clinicians may be asked to make recommendations concerning the need for and types of accommodations for those settings. In addition to a need for the clinician to be familiar with the standards of the Americans with Disabilities Act, which is required for obtaining such accommodations, it will also be important for future research to consider which accommodations are effective. For as often as they are used, there is remarkably little evidence that "extra time on tests" and/or "testing in a quiet, nondistracting environment" are effective for adults with ADHD.

In the past several years, there has been an increasing awareness of the syndromal persistence of ADHD into adulthood. Once considered only a childhood disorder, ADHD has become increasingly recognized as a valid psychiatric disorder in adults.

Kevin M. Antshel, PhD

Articles

Developmental Disabilities From Childhood to Adulthood:

Diagnosing and Treating ADHD in Adults