ADHD in Adults. Characterization, Diagnosis, and TreatmentRichard Balon, MD
Wayne State University, Detroit, MI, USA
Edited by Jan K. Buitelaar, Cornelis C. Kan, and Philip Asherson. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-86431-2; pp 314; $85 (hardcover).
The diagnosis and management of attention-deficit/hyperactivity disorder (ADHD) in adults have been and still remain a bit controversial for many clinicians. Some simply have a hard time with this diagnosis because for years we were supposed to believe that adolescents magically outgrew this problem by age 18. Others do not feel comfortable prescribing the mainstay of ADHD treatment (ie, stimulants), worrying about their abuse and potentially introducing young adults to substances that could be abused. Also, many are put off by the real or perceived push by the pharmaceutical industry to use ADHD medications in general. At times, clinicians outside of the United States have considered ADHD a North American problem that is overdiagnosed and stimulants are overused. Nevertheless, the concept of adult ADHD gradually has been more accepted and patient requests for help are mounting. The editors of this book, Drs. Buitelaar, Kan, and Asherson, put together a team of authors from 10 countries to provide the latest on diagnosis, characterization, and management of this disorder because they believe that “adult ADHD has finally grown up into a mature entity with its own adult-specific challenges” (p xi).
The book is divided into 7 sections (altogether 25 chapters) and 2 appendices. The first section, “The development of adult ADHD as an epidemiological concept,” addresses in 3 chapters the course and persistence of ADHD through the life cycle; the prevalence and correlates of adult ADHD; and gender differences in ADHD. The authors bring to the reader’s attention the fact that although the rate of remission from the full disorder in patients age 18 to 20 is fairly high, nearly one-third of patients still experience some symptoms past this age and the majority of ADHD patients continue to report low levels of functioning despite full symptomatic remission (p 5). Adults with ADHD have fewer years of education and lower rates of professional employment. ADHD predicts social maladjustment, immaturity, and high rates of separation and divorce (p 5). Many researchers emphasize that distribution of the 3 cardinal symptom clusters in children (inattention, hyperactivity, and impulsivity) shifts in adulthood so that inattention becomes the most prominent symptom cluster, while other symptoms, such as affective lability, explosive temper, inability to tolerate stress, and dysphoria, become more prominent (p 9).
The second section, “Insight into the pathophysiology of ADHD is adults,” reviews in 4 chapters quantitative and molecular genetic studies of ADHD in adults; structural and functional magnetic resonance imaging findings in adults with ADHD; electrophysiological studies of adult ADHD; and emission tomography in adult ADHD. The 2 chapters of the third section, “Assessment and diagnosis of adult ADHD,” focus on diagnosing ADHD in adults and neurocognitive characteristics of adults with ADHD. Adults with significant inattention often experience specific executive functioning deficits such as difficulties with manipulating and organizing information (p 95). The authors also suggest that adults with ADHD often present with chronic conflicts with authority and difficulties in spouse and peer relationships, leading to frequent job changes and poor academic performance despite average or above average intelligence.
The fourth section, “Comorbidities of adult ADHD,” discusses in 7 chapters adult ADHD and mood disorders; ADHD and anxiety disorders in adults; ADHD and the substance abuse disorders; adult ADHD and organic brain disorders (including psychotic symptoms and tics); overlap between ADHD and autism spectrum disorder in adults; ADHD in adults with intellectual disabilities; and ADHD, personality, and its disorders. The chapter on ADHD and anxiety disorders emphasizes that we still need to figure out whether anxiety is a moderator of ADHD treatment and whether attention is a moderator of anxiety treatment (p 135). The chapter on ADHD and substance abuse provides suggestions for treating adults suffering from ADHD and substance abuse (eg, the need to stabilize substance abuse initially and the use of nonstimulants). The authors emphasize there is no evidence that pharmacologic treatment of ADHD exacerbates substance use disorders.
Four chapters of the fifth section, “Pharmacological treatment of adult ADHD,” deal with stimulants for adult ADHD; the use of nonstimulant drugs in the treatment of adult ADHD; medication management in adult ADHD; and abuse potential of stimulant drugs used to treat ADHD. The chapter on using stimulants is a review of studies of various stimulants and their preparations without much guidance. The chapter on medication management in adult ADHD is the most useful chapter in this book. This chapter proposes that, honestly stated, ADHD cannot be treated without medication (p 219). The author emphasizes that leaving the decision to take medication to the patient alone may lead to less favorable outcomes; anxiety, mood, and substance use disorders (SUDs) generally are treated first (tachycardia that may accompany stimulant treatment may increase anxiety symptoms); hard drugs must be stopped first, but cannabis could be decreased gradually during treatment; stimulants and antidepressants could be combined safely, and other useful advice, including psychoeducation about stimulants. An interesting part is the review of dosing in adult ADHD, which is more frequent than one may be used to when treating children and does not shy away from evening administration, which supposedly reduces rebound symptoms and makes the patient calm enough to fall asleep. The chapter on abuse potential of stimulant drugs states that the literature suggests that stimulant treatment early in life serves a protective function against developing SUDs, although this should be regarded with caution (p 231).
The 3 chapters of section 6, “Psychological and social treatment strategies for adult ADHD,” present information on psychoeducation for adults with ADHD; discussion of coaching in ADHD; and clinical applications of research on cognitive-behavioral therapies for adults with ADHD. The last section, “Alternative biological treatments,” contains 2 chapters about neurofeedback training for adult ADHD and alternative and complementary treatment for ADHD (amino acids, essential fatty acids, herbals, iron, homeopathy, massage, vitamins, acupuncture, yoga, meditation, and others).
The Afterword presents some suggestions for DSM-5 criteria of adult ADHD. The 2 appendices list patient organizations for ADHD in various countries, and useful Web sites for ADHD.
Despite a lot of theoretical material (eg, genetics, imaging), this is a useful volume that would be appreciated by anybody interested in adult ADHD. The clinically oriented chapters provide good, practical guidance for evaluation and treatment. Reading this volume also would help to alleviate anxiety among clinicians who are not used to prescribing stimulants and other treatment modalities to adults suffering from ADHD. They will realize that problems faced by some adults complaining of inattention and other symptoms are real, that these patients could be reasonably treated, and that they may not be induced to abuse these drugs by prescribing them.
Annals of Clinical Psychiatry ©2012 Quadrant HealthCom Inc.