Adult attention-deficit/hyperactivity disorder (ADHD) is a chronic condition that is characterized by a combination of symptoms, including difficulty concentrating/inattention, hyperactivity, and/or impulsive behavior. Symptoms of ADHD can progress (or in some cases decrease) over time. If unrecognized and/or unaddressed, they can also lead to poor self-image, problems in interpersonal relationships, performance issues at work or at school, and other problems that can deeply affect multiple areas of our patients’ lives. Unfortunately, however, adult ADHD frequently goes unrecognized, leading to increased risk for serious psychiatric and productivity-related sequelae. In this article, I’ll discuss why adult ADHD is commonly missed, conventional treatment for adult ADHD, and a few additional considerations and evidence-based adjunctive therapies in the treatment of ADHD.
How is adult ADHD different from childhood ADHD?
ADHD does not always present in adulthood the way it does in childhood. For example, ADHD is frequently characterized by hyperactivity in childhood, but hyperactivity actually tends to decrease in adulthood, while difficulty concentrating, inattention, and impulsiveness may persist.
The symptoms of adult ADHD usually begin in childhood; however, in some cases they may not be diagnosed in childhood because the patients are able to compensate for their symptoms up to a certain point. This ability to compensate for ADHD symptoms in childhood, which leads to delayed diagnosis, appears to be positively correlated with IQ. In essence, the children are still able to get their work done and stay on task to a certain point, so teachers and parents are less likely to suspect ADHD, and they’re also less likely to seek out medical evaluation and treatment.
Are there any other reasons why ADHD may be missed or misdiagnosed in adulthood?
ADHD has been termed a “hidden comorbidity” with other psychiatric concerns. This is partly because the symptoms of inattentive-type ADHD can be misinterpreted as symptoms of depression, while ADHD that is characterized by hyperactivity can be misinterpreted as symptoms of an anxiety spectrum disorder. Furthermore, research demonstrates that comorbid ADHD among psychiatric in-patients and out-patients is fairly commonly unrecognized. [1] This is highly problematic because this same study demonstrated that the patients’ current suicide risk was significantly associated with the presence of undiagnosed adult ADHD.
That being said, it is essential for practitioners to be able to discern between the symptoms of adult ADHD and other mental health concerns like anxiety and depression, and to be able to make all appropriate diagnoses as well as prescribe appropriate treatments.
Things to consider when diagnosing adult ADHD
When considering making a diagnosis of adult ADHD, there are a few things that practitioners should consider. First of all, we need to make sure that the person’s symptoms are not attributable to another psychiatric concern. In other words, we need to consider (and rule out when possible) anxiety, depression, bipolar disorder, substance abuse, and other mental health concerns. We also need to make sure that the patient’s symptoms are not due to another medical concern, such as mild cognitive impairment, brain fog or focusing issues due to suboptimal thyroid function, concentration issues due to inadequate sleep or suboptimal glucose levels, seizure disorders, or other potential causes of traumatic brain injury.
What are the conventional means of addressing adult ADHD?
Medication prescribed to address symptoms of ADHD can be placed into two classes. These classes are stimulant medications, including drugs that contain methylphenidate or amphetamine, and non-stimulant medications. Stimulant medications are typically prescribed to boost and balance neurotransmitters. Non-stimulant medications that are prescribed to address ADHD symptoms usually include the cognition-enhancing drug Strattera (atomoxetine) and antidepressants like bupropion. They can also include other drugs aimed at also addressing comorbid conditions, such as is the case with metadoxine in people with comorbid alcohol abuse and lithium in comorbid bipolar disorder. [2]
What potential contributing factors and adjunctive therapies should practitioners consider when treating adult ADHD?
Other things to consider when diagnosing and treating adult ADHD include nutritional deficiencies that may be contributing to patients’ symptoms.
For example, research demonstrates that people diagnosed with ADHD also tend to have higher incidences of magnesium deficiencies than healthy controls. [3] Additionally, research demonstrates that lower concentrations of vitamins B2, B6, and B9 were associated with adult ADHD. [4] Lower levels of vitamins B2 and B6 were also associated with greater symptom severity.
As far as additional adjunctive therapies are concerned, research demonstrates that over several sessions of visual and auditory neurofeedback therapy, people diagnosed with ADHD were able to reduce their slow wave brain activity and/or increase their fast wave activity. Those who complete a course of neurofeedback sessions tend to display reduction in primary ADHD symptoms, and research suggests that their outcomes compare favorably to those of stimulant medication. [5]
Summary
To summarize, adult ADHD is a frequently missed condition that can significantly impact our patients’ lives. It is critical that providers familiarize themselves with the presentation of adult ADHD, and educate themselves concerning available treatment options. In addition to conventional therapies, including stimulant and non-stimulant medication, providers should be aware that nutritional deficiencies have been associated with ADHD in adulthood and that addressing these deficiencies may result in improvements in symptoms.
References:
[1] Bitter, I., Mohr, P., Balogh, L., Látalová, K., Kakuszi, B., Stopková, P., Zmeškalová-Jelenová, D., Pulay, A., & Czobor, P. (2019). ADHD: a hidden comorbidity in adult psychiatric patients. Attention deficit and hyperactivity disorders, 11(1), 83–89. https://doi.org/10.1007/s12402-019-00285-9
[2] Buoli, M., Serati, M., & Cahn, W. (2016). Alternative pharmacological strategies for adult ADHD treatment: a systematic review. Expert review of neurotherapeutics, 16(2), 131–144. https://doi.org/10.1586/14737175.2016.1135735
[3] Effatpanah, M., Rezaei, M., Effatpanah, H., Effatpanah, Z., Varkaneh, H. K., Mousavi, S. M., Fatahi, S., Rinaldi, G., & Hashemi, R. (2019). Magnesium status and attention deficit hyperactivity disorder (ADHD): A meta-analysis. Psychiatry research, 274, 228–234. https://doi.org/10.1016/j.psychres.2019.02.043
[4] Landaas, E. T., Aarsland, T. I., Ulvik, A., Halmøy, A., Ueland, P. M., & Haavik, J. (2016). Vitamin levels in adults with ADHD. BJPsych open, 2(6), 377–384. https://doi.org/10.1192/bjpo.bp.116.003491
[5] Butnik S. M. (2005). Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder. Journal of clinical psychology, 61(5), 621–625. https://doi.org/10.1002/jclp.20124