Attention-Deficit/Hyperactivity Disorder

Published on 03/03/2015 by admin

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21 Attention-Deficit/Hyperactivity Disorder

Kenneth Lakritz

Clinical Vignette

A 26-year-old draftsman consulted a psychiatrist for help with anxiety. He had begun a job 3 months earlier and had just been placed on probation for slowness and inattention to detail. This was his third job in three years since completing vocational education.

This patient acknowledged falling behind at work, but could not offer an explanation for this behavior. Although he had experienced an initial enthusiasm for his work, that feeling quickly faded. Subsequently, he found he was having substantial difficulty maintaining focus when he found his work to be “boring.” He agreed that he had a tendency to procrastinate, noting that despite having adequate funds he was behind on his taxes and mortgage. His wife reported that he sporadically abused alcohol and cocaine.

At age 8, he was diagnosed with hyperactive-type attention deficit disorder. Treatment with methylphenidate was successful. Subsequently he maintained adequate academic progress. The methylphenidate prescription was discontinued at age 18 after his high school graduation; his hyperactivity had not reappeared.

This vignette exemplifies an individual whose hyperactivity was successfully treated during childhood and later tolerated discontinuation of stimulant treatment without the recurrence of hyperactivity, but whose other associated cognitive impairments persisted. In adults, attentional disorders can present as apparent laziness, lack of focus, and procrastination. This patient needs a retrial of his ADHD medication.

Clinical Presentation

Attention-deficit/hyperactivity disorder (ADHD) is a common, well-characterized, and very treatable neuropsychiatric disorder surrounded by social and political controversy.

This occurs in 3–9% of school-age children; it has a definite genetic predisposition. Although some researchers find a higher prevalence of ADHD in boys than girls, other investigators dispute this, claiming that the sex disparity is an artifact of the more manifest behavioral disturbance and hyperactivity in boys (Fig. 21-1).

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Figure 21-1 Attention-Deficit Disorder.

The core symptoms necessary for the diagnosis of ADHD are (1) distractibility and (2) difficulty sustaining attention. Hyperactivity is not necessarily part of the clinical picture of ADHD. Affected children are at increased risk for school failure, antisocial personality disorder, and substance abuse.

Imaging studies may demonstrate anatomic abnormalities, usually size reduction and size asymmetry in the prefrontal cortex, striatum, and cerebellum. Functional imaging sometimes shows decreased frontal and striatal perfusion, especially on tests of sustained attention.

Therapy

Stimulant medications are the principal treatment modalities. These pharmaceuticals are highly effective and have few side effects when used correctly. Although there are concerns that these medications promote illicit drug use, clinical studies demonstrate that appropriate treatment actually decreases future risk of drug abuse. Atomoxetine and other noradrenergic antidepressants are a reasonable alternative for patients who abuse or cannot tolerate stimulants.

Prognosis

ADHD is diagnosable by age 8 and never starts in adulthood. When ADHD was initially defined, it was thought to resolve spontaneously during adulthood. Although hyperactivity per se does improve, 50% of ADHD patients maintain their cognitive disabilities and require ongoing treatment. These individuals need to be distinguished from adults with new complaints of restlessness, boredom, or impaired attention and no past history of childhood ADHD.

ADHD must also be distinguished from childhood mania. Both groups of patients are hyperactive and inattentive, but manic children are also irritable and usually overtalkative. This distinction can be difficult, in part because there is a comorbidity between the disorders; that is, most patients with childhood-onset bipolar disorder also have ADHD. These children’s mood symptoms should be treated first with mood stabilizers. A stimulant can then be added later on as necessary.

Significant objections are expressed to the current approaches for diagnosis and treatment of ADHD. These stem from its high prevalence and the fear that children are being inappropriately drugged, rather than having their educational needs carefully defined and subsequently met. In reality, ADHD is both overdiagnosed and underdiagnosed: some children are inappropriately treated, but many others are missed. Although improper use of medication can occur, individual assessment and medical treatment are not mutually exclusive. The failure to diagnose and treat ADHD is as undesirable as overtreatment.

Additional Resources

Barkley R. Attention-Deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment. 3rd ed. New York, NY: Guilford; 2005.

Bush G, Valera EM, Seidman LJ. Functional neuroimaging of attention-deficit/hyperactivity disorder: a review and suggested future directions. Biol Psychiatry. 2005 Jun 1;57(11):1273-1284.

Ellison-Wright I, Ellison-Wright Z, Bullmore E. Structural brain change in Attention Deficit Hyperactivity Disorder identified by meta-analysis. BMC Psychiatry. 2008 Jun 30;8:51.

Faraone SV, Wilens TE. Effect of stimulant medications for attention-deficit/hyperactivity disorder on later substance use and the potential for stimulant misuse, abuse, and diversion. J Clin Psychiatry. 2007;68(Suppl. 11):15-22.

Garrett A, Penniman L, Epstein JN, et al. Neuroanatomical abnormalities in adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2008 Nov;47(11):1321-1328.

Hallowell EM, Ratey JJ. Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder from Childhood through Adulthood. New York, NY: Touchstone; 1995.

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