الفهرس يوجد فقط 14 صفحة متاحة للعرض العام
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المستخلص
Attention deficit hyperactivity disorder (ADHD) is a very common disorder among children at school age and adolescents. Recent research indicates that this disorder is not outgrown in adulthood but it persists in many cases leading to serious consequences that affect the whole aspects of the patient’s life.
The prevalence rate of ADHD among school aged children is 3 -5 %, an Egyptian study done in Assuit revealed this rate to be 6 %. About two third of these patients continue to have problems with the disorder in their adult life; nevertheless its aetiology and pathophysiology are still not clear.
ADHD is considered a multi factorial neuro behavioral disorder. The dysregulation of neurotransmitters, namely norepinephrine and dopamine in the prefrontal cortex and subcortical structures, the prenatal, natal, postnatal risk factors like exposure to teratogen, birth hypoxia, and exposure to toxins in addition to genetic factors are all important factors in the aetiology of this disorder.
There are several predictors of persistence of ADHD into adulthood including the severity of symptoms, the subtype differences as children with the inattentive type, may be at reduced risk, in addition to comorbidity of psychiatric disorders like ODD, CD. It is also hypothesized that females may have less risk inaddition to low IQ which is related to poor adaptive skills and to impaired functioning over time. Other negative outcome variables for ADHD are related to the family conditions and socioeconomic status; also individuals with familial ADHD have higher risk. Early treatment also is another important predictor for the outcome of ADHD in adulthood, however this issue needs further study to indicate whether it affects outcome or not.
The core symptoms of ADHD which include inattention, hyperactivity and impulsivity all lead to marked psychological problems with social interactions, self esteem, learning problems, academic difficulties, and underachievement, leading to marked dysfunction in the major domains of a person’s life. Thus a patient with ADHD has poor interpersonal relations in his family, marriage or work. This patient also has problems both in education and later in occupational functioning, such problems are substantial reasons for seeking medical advice.
The core symptoms of ADHD usually manifest differently in adulthood. Hyperactivity often changes to inner restlessness; the patient has constant activity, unable to sit still for long time, talks excessively leading to continuous tension both at home or work. Inattention usually manifests in disorganization, poor time management and forgetfulness. Impulsivity in adulthood usually manifests in poor decision making, poor capability to listen to others, risky driving and sexual behaviors.
The frequent complaints commonly presented by adults seeking evaluation for ADHD include cognitive complaints, such as inability to concentrate, forgetfulness, and confusion, complaints due to difficulties in self-regulation e.g., lack of organization, inability to establish and maintain a routine, poor discipline and complaints derived from both the cognitive and the self-regulation issues. These take the form of problems at work (difficulty finding and keeping jobs, performance on jobs below level of competence, inability to perform up to intellectual level at school), and reactive emotional distress (depression, low self-esteem).
Several diagnostic systems are proposed for the diagnosis of ADHD in adulthood including the Wender Utah criteria, the DSM IV criteria, and the ICD 10 criteria however they are all in efficient to diagnose patients with ADHD in the adulthood and lead to under diagnosis and misdiagnosis of the disorder.
The diagnosis of ADHD in adulthood is difficult as its core symptoms are experienced by every individual, also many disorders either psychiatric such as mood disorders, anxiety disorders, and borderline personality disorder or medical such as thyroid disease, epilepsy and dementia may present with such symptoms, in addition to the high incidence of comorbidity with ADHD in the adulthood including antisocial personality disorder, substance use disorders, mood disorders, generalized anxiety disorder, learning disorders.
Steps of the diagnosis of adult ADHD are:
1. Assess current ADHD symptoms (within the last 6 months) using rating scales with adult norms.
2. Establish a childhood history of ADHD.
3. Assess functional impairment at home, work and school and in relationships.
4. Obtain developmental history, including during perinatal, childhood and school years.
5. Obtain psychiatric history: rule out other psychiatric disorders or establish comorbid diagnosis e.g. learning disabilities, mood and anxiety disorders, personality disorders and substance abuse, especially marijuana abuse.
6. Obtain family psychiatric history, especially concerning learning problems, attention and behavior problems, ADHD and tics. Inquire about all first degree relatives (parents, siblings and offsprings)
7. Perform physical examination: rule out medical causes of symptoms (e.g. serious head injury, seizures, heart problems, thyroid problems) or contraindications to medical therapy (e.g. hypertension, glaucoma).
Many Investigations are available for adult patients with ADHD however none of them is diagnostic. They include psychometric evaluation by various tests like continuous performance tests, the Stroop test, the Trail Making test, the Controlled word association test and others, however ADHD can be diagnosed even when these tests are normal and they are only good positive tests.
Brain imaging using MRI, fMRI and PET scans have been useful to investigate the neuro anatomical basis of ADHD including the small size of the left-orbito- frontal cortex found in a small study done on 8 patients, the focal dysfunction in areas such as dorsal anterior cingulate cortex, dorsolateral prefrontal cortex and the striatum, however brain imaging studies can’t be used in diagnosis as there is currently a very little number of studies on adults and there results didn’t yield specific results that can be used for diagnosis.
The treatment of ADHD in adulthood includes both pharmacological and psychotherapeutic approaches which can help the patients hand in hand both in improving the core symptoms of the disorder and in ameliorating the psychological impacts and improving the dysfunctional domains of the patient’s life.
Pharmacotherapy includes stimulant and non stimulant medications. For long time stimulants have been the mainstays for treating patients with ADHD, recent studies indicated its efficacy in treating the disorder however there are major concerns about its abuse potential especially in the presence of high incidence of comorbidity between ADHD and substance use disorders.
Non stimulant medications include tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRIs), Bupropion, Atomoxetine. Only one of them which is atomoxetine is approved by the FDA in 2003 in treating patients with adult ADHD.
Cognitive behavioral therapy (CBT) is the most effective form of psychotherapy that can applied to patients with ADHD either on an individual or group basis. Also family therapy and marital therapy are essential.