ADHD diagnosis, symptoms, and long-term effects in adults

ADHD: Diagnose in Adults, Treatments, And Long-Term Effects

What is ADHD?

ADHD is a neurodevelopmental disorder and affects both adults and children. It is an ongoing or 'persistent' inattention pattern and/or a pattern of hyperactivity-impulsivity that has interference on daily life or normal development. People having ADHD might find it difficult to maintain attention and perform executive function ability of the brain, i.e. start an activity, organize and manage the tasks constituting the activity). They also have problems with working memory.

ADHD exists in three ways:

Inattentive

Hyperactive-impulse

Combined inattentive & hyperactive-impulse (APA, 203).

The condition begins in childhood -- experts say that this particular condition might set in before the child turns twelve. While a majority of the ADHD patients register lower symptoms of ADHD as adulthood sets in, some people carry with them the symptoms into adulthood (Duckworth & Freedman, 2013).

The symptoms that can be observed in adults include:

Having problems focusing e.g., difficulty maintaining a level of attention

Restlessness or the inability to relax.

Difficulty with inhibition -- one finds it difficult to await their turn e.g. In conversations.

Difficulty sticking to a schedule e.g., frequent missing of appointments and deadlines (Duckworth & Freeman, 2013).

ADHD symptoms show in a variety of situations (e.g., work, social, family as well as social obligations). For instance, someone young who finds it difficult to pay attention in class in college and also has problems finishing tasks at his job would make a better example of someone with ADHD than someone much older who just finds it difficult maintaining focus when talking to their spouse.

How is ADHD diagnosed/determined?

An assessment is done and covers formal history plus other useful information like academic records, doing psychological tests and holding discussions with loved ones or parents. People having ADHD in adulthood are likely to have been diagnosed and/or treated for the same condition in childhood. Adults worried that they are showing symptoms of ADHD should consider a meeting with a trained mental health practitioner as the first step of evaluating if indeed the symptoms are those of ADHD (Duckworth & Freedman, 2013).

A good psychiatric examination may be very useful since an adult, especially one that has not had ADHD before, who is experiencing fresh symptoms of problems maintaining a healthy focus might be suffering from a psychiatric or medical condition and not ADHD. Such conditions might be anxiety, depression or drug abuse. Medical conditions -like stroke, seizure or thyroid disease -- might also have symptoms linked to ADHD. So, besides carrying out a psychiatric examination, physical testing and examination should also be carried out to establish whether the symptoms are being caused by a condition other than ADHD (Duckworth & Freedman, 2013).

No one definite biological or psychological test exists for ADHD. The diagnosis of ADHD is a result of many investigation strands that are directed at finding out:

the severity or extent of the main symptoms and other associated issues the characteristics of the various symptoms in various settings the developmental history of the evident symptoms how the symptoms compare with the ones identified at the same level of development in other individuals the existence of some other mental or physical health disorders.

Because the assessment is pretty complex, it is important that various professionals cooperate and various techniques be used. The approach needed should be multi-modal, multi-agency and also multi-professional (NICE, 2008).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), as published by the American Psychiatric Association is a guide which puts forth the criteria to be made use of by mental health professionals, doctors as well as other qualified clinical professionals in the making of ADHD diagnosis. In its update in 2013, the guide gave ADHD a new definition which will influence the way the disorder is diagnosed in adults and children (APA, 2013).

What about ADHD has been altered by DSM-5?

Adult ADHD: For several years, the criteria for the diagnosis of ADHD stated that only children were diagnosed with ADHD. The criteria therefore implied that adults and teens having ADHD could suffer from it for several years without knowing the cause of the symptoms. DSM-5 ensured that there was a change to this and teens and adults can be diagnosed officially with ADHD now. The criterion now mentions and illustrates the way the disorder might present itself in teens and adults (APA, 2013).

In adult diagnosis, the medics consider middle childhood (age of 12) and the years as a teen and not as far back as childhood (age 7) (APA, 2013).

In DSM-IV TR, a previous edition, the three kinds of ADHD were called subtypes. They are now called "presentations"; and the "presentations" can change in the course of the life of an individual. This gives a better description of the way the disorder has an effect on an individual at the different phases of life (APA, 2013).

The key aspects of a full assessment covers clinical interview, carrying out a medical examination and administering rating scales to teachers and parents (for instance, self report). Other facets like cognitive, literary skills, neuropsychological, developmental assessments may be indicated or left out (NICE, 2008).

Clinical Interview

Clinical interviews are always done by psychiatrists, specialty nurses, psychologists or pediatricians; and are often semi-structured, format-wise, to allow systematic investigation of the major issues. While interview instruments that are fully structured are always made use of in research, their inflexibility has limited their usage. The main aim of the interview is detailing the full range of issues and their history as well as demographic information regarding family, education and health. It is useful to know the way the patient and their family have previously tried to deal with the issue over time and the effect the problems have had on the family and the child. The design of the interview allows for the highlighting of further assessments which could help in facilitating diagnosis as well as intervention planning (NICE, 2008).

Standardized Rating Scales

They assist in evaluating mental health, behavioral and social problems and have normative data enabling comparisons with other members of the population, particular clinical groups or both. Three main kinds exist:

1.

Broad-band instruments made use of in evaluating psychosocial and behavioral functioning: the Strengths and Difficulties Questionnaire (Goodman, 2001) is an example that is used widely. Achenbach scales is also another example (Achenbach, 2003) that covers the ages of 18 months up to 59 years with parent, adult, adolescent and teacher self-report versions. Conners' Rating Scales' (CRS) long version can be used by teachers and parents.

2.

Narrow-band scales specific to ADHD symptom-atology: examples are the Brown Attention Deficit Disorder Scale, Human Situations Questionnaire and the Brown Attention Deficit Disorder Scale.

3.

The other scales used for rating are made use of in evaluating other kinds of mental health symptoms which coexist, or have some association with ADHD like self-esteem, conduct problems, depression and anxiety.

The scales are limited in such ways as just having a moderate level of inter-rater reliability (Verhulst & Van der Ende, 2002) and also incomplete specificity and sensitivity in comparison with full diagnostic assessments. Several scales give a description of only the symptoms and remain silent on the developmental appropriateness or impairment level. If developmental appropriateness is taken into account, then it is through requesting the rater to make a judgment as per what can be taken to be normal for someone of a similar age. This can be difficult for someone who is not an expert at rating and errors as regards interpretation may arise (NICE, 2008).

Educational and Occupational Adjustment

A crucial aspect of the assessment process is understanding the adjustment of a young individual or child at school or the functioning of adult at their workplace. Besides giving information collected by the questionnaire, it can be requested of teachers to provide particular information regarding academic and social functioning. If certain problems exist as regards functioning in the school environment, the assessing clinicians may undertake direct observation in a classroom environment or some other situations that are less structured (NICE, 2008).

Medical Assessments

People who have been referred for ADHD assessment are attended to by pediatricians or psychiatrists. A major objective is ruling out those disorders that may have symptoms similar to those of ADHD. Some of the disorders include thyroid disorder, epilepsy, iron deficiency anemia and hearing impairment. By doing this, the medics note early the contributions that the symptoms of these disorders might have contributed. The assessments carried out also include the parents of the child being asked about the response to the risk factors. Physical signs registered by various genetic conditions that may raise the risk of developing ADHD are also identified. Some other neurological, developmental and physical disorders that should be noted might also exist. Such conditions include sleep disorders, chronic tic disorders, dyspraxia as well as developmental coordination disorder. These disorders influence the nature of later management. Following the diagnosis, if there is confirmation of ADHD, and drug therapy is on the table, examination covers baseline measurements of weight, height, pulse rate and blood pressure. These factors are continuously monitored during the course of the therapy (NICE, 2008).

Psychological and Psychometric Assessment

Clinical and educational psychologist may carry out further assessments in case they suspect the presence of learning difficulties like dyslexia, literacy skills or dyscalculia. These problems might help them understand what is causing attention difficulties. ADHD, in the present case, will also need to be addressed (NICE, 2008).

The patient may also exhibit global learning disabilities, specifically hyperkinetic disorder. The needs specific to his or her intellectual status ought to be established so that developmentally appropriate therapy is designed. There is a likelihood of the presence of cognitive impairments involving attention, memory, etc. And they should be properly investigated by educational and clinical psychologists. Several tests exist for this; of concern to us being the ones measuring attention. A certain popular test is called Everyday Attention for Adults and the Test of Everyday Attention for Children (NICE, 2008).

Treatments

In Children

For ADHD that is defined as moderate by the DSM-IV criteria -- guidelines given by NICE make recommendations that group training together with/or individual psychological treatments should be the first course of action. The practitioner should consider what the family prefers for the child that has been diagnosed with ADHD. When the symptoms are relatively mild, approaches leaning towards psychological treatments can be very effective. There is also very low risk with psychological treatment in relative comparison to medication. Progress, though, has to be constantly reviewed so that adjustments are made and a switch to psychological interventions made if no progress has been registered (Bolea-Alamanac et al., 2014).

Individual psychological interventions might also have behavioral intervention approaches or cognitive training. These interventions' objective is improving neuropsychological deficits involving executive functioning and working memory. A meta-analysis involving randomized controlled trials done in the recent past (Sonuga-Barke et al., 2013) gave confirmation to cognitive training effectiveness for symptoms of ADHD following the completion of ratings by assessors that are not blinded, but also found out that positive effects weren't demonstrable in the instances of usage of blinded assessors (evidence level Ia). Children under the age of 13 were the main focus of these studies. Behavioral interventions are grounded on either principles aiming to improve impairments or ADHD symptoms, or on principles concerned with social learning aimed at improving social skills. Several studies in assessing how effective they are, have made use of the two as a two-faceted intervention plus working with the family. Studies that assessed the effectiveness of social and behavioral skills interventions that were put under review for NICE guidelines involved mainly children below 13 years of age. Evidence existed of the effectiveness of these interventions for the main ADHD symptoms and also in the instances of conduct problem symptoms, self-efficacy and social skills. Because of the age of a majority of the participants, the findings can't be generally applied to adolescents. However, in the case of adolescents, interventions at the individual level could be more effective or acceptable than the parent training or education interventions (Bolea- Alamanc et al., 2014).

In Adults

The NICE guidelines give recommendations that prescribe drug treatments for ADHD as concerns for the right psychosocial treatments. Furthermore, psychological treatment might give support during childhood-adulthood transition and also during various stages of life. Also, psychological techniques can be made use of in improving acceptance of the diagnosis and in treating residual symptoms and co-morbities which do not need pharmacological treatment. NICE guidelines do recommend the use of individual or group interventions making use of cognitive behavioral paradigm. Cognitive behavioral strategies used in improving core ADHD symptoms include memory aids and self-instructional training for the purpose of attention enhancement, 'stop and think' techniques to lower impulsivity, time schedules and diaries to enhance organizational skills and other training to enhance communication abilities like social skills and assertiveness training (Young and Amarasinghe, 2010). Cognitive behavioral therapy as traditionally used might need to be factored in the ADHD patients' requirements. The needed adaptations include strategies for the avoidance of procrastination, frequent feedback and reward systems. Cognitive remediation gives techniques focusing on the retaining of cognitive function, teaching external and internal compensatory strategies and also doing environmental restructuring so that physical environment functioning is maximized. 'Acceptance strategies' encouraging the balancing of change with acceptance is used to supplement cognitive behavioral therapy techniques in dialectical behavior therapy (Bolea-Alamanac et al., 2014).

The recent past has seen an increase in the number of published psychological therapy research as concerns treating ADHD in adults. Nonetheless, there are some methodological problems (limitations of blinding, mixed interventions and absence of comparatively similar intervention) that make the results realized just preliminary and prone to reporting and selection bias. Psychotherapy efficacy in a trial carried out by well trained and motivated professionals fails to guarantee that effect of the same nature can be obtained when extending the interventions to situations in 'real-life,' where the patients receive varied levels of support (Nutt and Sharpe, 2008; Bolea-Alamanac et al., 2014).

In spite of the limitations, a few commonalities exist. Several of the studies apply cognitive behavioral therapy paradigm, are structured to follow skill-based programs including practicing in daily activities. On the effect sizes being reported, these are always larger differences, even with the variance in the assessment methods in various studies (Bolea-Alamanac et al., 2014).

Pharmacology of Drug Treatments for ADHD

Until recently, selective noradrenaline re uptake inhibitor, dl-threo-methylphenidate (methylphenidate) and atomexitine were the only approved drugs being used in managing ADHD in Europe. Dopamine and noradrenaline are the transmitters that have been associated with therapeutic functioning of drugs used for the treatment of ADHD (Bolea-Alamanac et al., 2014).

It has been 70 years since it was observed that stimulant drugs may help in improving children's hyperactive behavior. Dexamfetamine and methylphenidate have been around in the United States since the year 1955. Drug prescriptions for ADHD have significantly increased in the UK since the mid-1990s and are driven mainly by alterations to regulations and the availing of MR, Concerta XLR, Medikinet XLR, Equasym XLR as well as atomexetine (StratteraR). Some other medications that are used less frequently for the treatment of ADHD and which have not gone through the approval process are bupropion, nicotine patches, risperidone, imipramine and clonidine (NICE, 2008).