SYNDROME OF ADHD IN ADULTS – DIAGNOSTIC CRITERIA ANDINTERVENTION
The subject of this research is the syndrome of attention deficit hyperactivity disorder (ADHD) in adults, based on etiological theories, specific symptoms and diagnostic criteria in use. The importance of this theme is that childhood ADHD symptoms, as shown by a number of studies that used valid diagnostic criteria – will last more than 50% of cases in older adults. However, specific manifestations often change during life, and as following it is very likely that the manifestations of this syndrome are underdiagnosed in adults. Adults with and without ADHD, as parents of a child with ADHD need psychological formative intervention, for empowering appropriate educational resources to their own children.
1.1. Conceptual Delimitations
Neuropsihobiological research shows that ADHD is a neurobiological deficit with genetic determinism, which can be strongly influenced by education * (Dobrescu, 2010). Adults with ADHD who become parents are negative patterns and parenting is a failure. It is therefore important to know and diagnose adults dealing with children.
* Dobrescu, I., (sub red.), 2010, Manual de Psihiatrie a Copilului şi Adolescentului, vol. I, Ed. Medica, p. 316
ADHD is manifested by impairing executive functions (organizing, planning, working memory, selective attention, flexibility), due to dysfunction of dopaminergic and noradrenergic areas of the limbic system (cerebral amygdala, anterior cingulate gyrus, hippocampus).
ADHD is characterized by an early onset, before the age of 7 and a combination of hyperactivity, disorganized behaviour and poor concentration, inability to use the correct skills, anxiety, impulsivity and high level of distractibility. These features are pervasive and persistent over time.
1.2. Evaluation and Treatment
Adults who have kept some of the symptoms of ADHD presented in childhood are usually diagnosed as showing the syndrome in partial remission.
Assessment of ADHD in adults leads to the need to amend existing DSM-IV criteria, instead of the 6 criteria are sufficient to fulfill five of them * (Searight et al, 2000).
* Russell Searight, T., Burke, Rottnek, F., 1 noiembrie 2000, Adult ADHD: Evaluation and Treatment in Family Medicine, Family Medicine of St. Louis Residency Program, St. Louis, Missouri, American Family Physician
There is a consensus regarding disinhibition – as a central feature of the syndrome. People are unable to inhibit responses and show deficits in monitoring their behaviour. Hyperactivity – as a common feature among children with ADHD is less evident in adults; spontaneous impulses observed in children, at adults are replaced by restlessness, difficulty relaxing and feeling of being always “borderline”.
There is no single test to identify the syndrome and there is no practical possibility of determining the specific genetic and biological indicators, leading to a diagnosis. It will be based on a comprehensive assessment, which must include: examination of background and physical examination, to exclude any other potential source of manifestation of symptoms, a psychological examination and an interview with the adult`s spouse, parent or close friend.
ADHD symptoms differ from person to person, but corresponding to the criteria in the Diagnostic Statistical Manual of Mental Disorders (DSM-IV-TR), this may include: restlessness, irritability and difficulty in relaxing.
The diagnosis of this syndrome in adults is much more complex, because of the variety of conditions that produce similar symptoms. These conditions include: alcohol or drug addiction, depression and thyroid dysfunction.
Although the recognition of symptoms in adults can be difficult, once diagnosed, they have more options for treatment. Stimulant medications such as Ritalin, can cause possible unwanted side effects. Certain homeopathic remedies have been classified as extremely effective in some patients (eg, Avin Sativa – green oats and Gingko Biloba).
Many studies argue that the medication should be only part of the treatment. Multimodal approach seems to be the best way to improve symptoms.
The specific symptoms of ADHD in adults include:
- constant delays and forgetting tasks;
- anxiety;
- lack of organizational skills;
- low self-esteem;
- difficulty controlling anger;
- impulsivity
These symptoms must be persistent at least the last six months.
Ignoring these difficulties, can cause problems in the emotional, social, occupational and academic areas.
Many people assign their own symptoms to their fight with stress and the fast pace of the life they live, but these can be symptoms of undiagnosed ADHD. In this situation, answers to the following questions might help us * (Low, 2009).
* Low, K., 2009, Wondering If You Have Adult ADD?, About.com Guide, April 11
- Are you easily distracted?
- Do you have difficulty concentrating?
- Do you tend to be disorganized?
- During a conversation, do you concentrate on your partner`s message?
- Do you usually forget things (eg., a meeting or certain obligations)?
- Do You have difficulty following a process that has multiple steps?
- Do you have difficulty initiating or completing a project?
- Do you tend to delay certain activities?
- Do you have difficulty in setting priorities?
- Do you become impatient quickly?
- Do you often feel nervous or anxious?
- Do you have difficulties with time management?
- Do you have difficulty in finding objects at home or at work?
- Do you act before thinking about consequences?
- Do you speak before you think about the impact your words have on others?
- Do you tend to have lots of thoughts?
- Are you easily bored?
- Do you make mistakes when working on a boring or difficult project?
- Do you take risks often?
If the answer to most questions is “yes”, and manifested behaviours are quite severe, interfering with daily activities, it is possible that the person concerned to show the syndrome. An accurate diagnosis can be established only by a professional, who can exclude a number of other syndromes that may have similar manifestations in some stage of their evolution (depression, bipolar disorder, drug addiction, anxiety, phobias).
Before presentation the evaluation mode of the ADHD in adults, we review the diagnostic criteria for ADHD according to DSM-IV-TR – valid in a small proportion of adults with ADHD:
A. Either (1) or (2):
1. Six (or more) of the following symptoms of lack of attention that persisted for at least six months, at a level indicating poor adaptation andinconsistent with the developmental level:
Inattention
- often they don’t pay attention to details or they make mistakes because of negligence, at work or other activities;
- it is often difficult to concentrate on work tasks or on playing;
- frequently, does not seem to listen when spoken to;
- often does not follow the instructions and not finish their homework, chores or obligations (not due to an disturbance of opposition or misunderstanding of instructions);
- has often difficulties to organize tasks and activities;
- often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework);
- often loses the materials necessary for tasks or activities (eg., toys, homeworks, pencils, books or tools);
- his attention is frequently and easily distracted by external stimulus.
- he is often forgetful in daily activities.
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months, to a poor adjustment and inconsistent with developmental level:
Hyperactivity
- frequently moves his hands or feet or foieşte a wheelchair;
- often rises from his seat in classroom or in other situations in which to sit;
- often runs or climbs in situations where it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness);
- often has difficulty playing or participating in leisure activities quietly;s
- is frequently on the go or acts as if “it plugged”;
- often talks excessively.
Impulsiveness
- often misses the answers before the questions are completely formulated;
- often has difficulty awaiting turn;
- to interrupt or disturb others frequently (eg., enter into conversation or games).
- Some symptoms of hyperactivity-impulsivity or inattention that led to problems were present before age 7 years.
- Difficulties due to these symptoms are present in two or more circumstances: at school (or work) at home.
- There must be clear evidence of significant deterioration in the performance of social, academic or occupational.
- The symptoms do not occur exclusively during a pervasive developmental disorder (PDD), schizophrenia or other psychoses and may not be associated with other mental disorders (such as neuroticism, anxiety, dissociation or a personality disorder).
Codes based on the type of ADHD:
314.01 attention deficit hyperkinetic disorder together, combined type: if both criteria (A1 and A2) occurred in the last 6 months.
314.00 attention deficit hyperkinetic disorder accompanied, predominantly inattentive type: if A1 crietriul manifested in the last six months, but no criterion A2.
314.01 attention deficit hyperkinetic disorder accompanied, predominantly hyperactive-impulsive type: if criterion A2 was expressed in the last six months, but no criterion A1.
Note: Inpiduals who currently have symptoms that fit the criteria only partially (especially adolescents and adults) must be specified “in partial remission.”
314.9 Disorder with hyperactivity and attention deficit without further specification
This category is for disorders with symptoms of inattention or hyperactivity notable-impulsivity that do not meet criteria for attention deficit hyperkinetic disorder together.
Utah criteria (Wender, 1995, 2000) to assess ADHD in adults:
- History of childhood consistent with ADHD;
- Symptoms specific
- Hyperactivity and poor concentration
- emotional lability
- Impulsiveness
- Inability to complete tasks and disorganization
- low frustration tolerance
Utah criteria include in their composition and emotional aspects. Impulsive episodes, characterized by „rash temperament” are quickly forgotten by the person concerned, but are more difficult to forget by colleagues or family members.
Emotional lability is characterized by short bursts, intense and range from euphoria to anger and despair.
Other manifestations of adults with ADHD include attribution of the following 5 dimensions:
- Activity and organization (refers to the difficulties met by the person in organizing the daily tasks);
- Sustained attention (includes issues such as: distraction, daydreaming);
- Sustainable energy and effort (feeling of drowsiness, low degree of completion of the tasks);
- Managing affective interference (low motivation, irritability, low tolerance to frustration);
- Working memory and the ability to update information (low performance);
P. Wender * (1996) conducted an extensive study on 300 patients with ADHD, using within the experimental group, psychostimulants like: Methylphenidate (Ritalin), Pemoline (Cyclert), L-deprenyl (Selegiline), Bupropion (Wellbutrin), Levodopa, Dl-phenylalanine and L-tyrosine, and in the case of the control group – the placebo treatment. The author found that approx. 60% of the patients receiving stimulant medication show significant improvements, in comparison to only 10% of the control group who received the placebo treatment. The results of the two groups were assessed using the Global Assesement of Functioning (DSM-IV). among all the substances administered, major effects were found following the administration of Methylphenidate, Pemoline and MAO inhibitors.
A complete treatment for adults with ADHD involves informing these people about the disorder and presenting the therapeutic matrix explaining the advantages and disadvantages of drug administration. Among the changes that patients may experience after drug administration, Wender lists:
* Wender, P.,1996, ADHD in Adults, Psychiatric Times, vol. 13. no. 7, p. 7-9
- reducing motor agitation; patients are able to relax, to sit for a longer period of time at the office or while watching a movie;
- the ability to concentrate improves significantly; increase of patients’ attention to conjugal conversations and thus, reduction of marital conflict;
- to reduce the moments of “boredom”; the mental state is described as stable;
- patients become less irritable, outbursts of anger are reduced in frequency and intensity, to extinction;
- improvement of the organizational capacity (at school, at the workplace, at home);
- are able to overcome life problems, becoming more secure when facing difficult situations;
- improves the ability to listen to conversations of others, become more tolerant in traffic, an increase in self-control in social situations.
The Treatment of adults with ADHD often includes stimulants. These present loke side effects an increase of the blood pressure and pulse, which could lead to strokes and heart attacks. Before initiating any treatment, adults with ADHD should receive a full medical examination (Austin * et al, 2007).
* Austin, M., Reiss, N., Burgdorf, L., 2007, Adult ADHD Treatment – Medication, About. com Guide
1.3. Etiology, mechanisms and intervention in ADHD:
1.3.1. Neurobiological basis:
Modern methodology of investigation, especially the so-called functional imaging (fMRI-functional magnetic resonance imaging, PET – Positron Emission Tomography, SPECT – single positron emission computed tomography etc.) but also the neurophysiology investigations, including Electroencephalography / EEG quantitative, evoked potentials or MEG (magnetoEEG) – have made important contributions to the knowledge of the neurobiological mechanisms underlying the ADHD and its upholding to the adult age.
Thus, it has been demonstrated the involvement of the preforntal and parietal lobe, the limbic system, the basal nuclei and the cerebellum in the genesis of different clinical forms of ADHD- by studies of the computerize EEG (an increasing amonut of slow theta waves especially in the prefrontal lobe, and in some cases an increasing amonut of the beta waves), confirmed by the studies on the local cerebral blood flow, demonstrating a decrease in the prefronal regions and at the level of the links between these regions and the limbic system via the striated area, especially at the level of the caudate nuclei (Himelstein et al, 2000; Brennan and Arnsten, 2008; Arnsten et al, 2009).
Also, the studies that use the PET to evaluate the cerebrale glucose’s metabolism (see picture 1) have demonstrated it’s decrease on adults, (Zametkin et al. 1990), but also on teenagers with ADHD.
Figure 1. The analyze of the cerebral activity using PET on people with ADHD and without ADHD (after Zametkin et al,1990).
In the right side of the image it can be noticed that inpiduals with ADHD have a less intense brain activity
than those without this disorder concerning the activity control.
The medical treatment aims to actrivate these „control” centers.
There were found differecences in teenage boys and girls, yet unexplained, between the aspects of the cerebral metabolism in ADHD (Ernst et al., 1997; 1998). In addition, there were found significant functional asimmetry of diffrent cerebral areas, for example, a reduced metabolic activity in the left anterior frontal region, strongly correlated with the severity of the ADHD symptoms (Zametkin et al, 1990), which confirms the bond between the cerebral activity of a certain region and the typical behavior that inpiduals with ADHD have (express).
Studies based on a simple CT exam haven’t identified a signifiant difference between children and normal adults and the ones with ADHD, but it was noticeable a high brain atrophy in adults with ADHD that have a history of substance abuse. This abuse explaines better the atrophy than ADHD does (Barkley, 2006 b).
A much more sensitive analysis of the brain structures based on the MRI and fMRI reveales a number of differences in some cortical areas between normal children and those with ADHD. The brain areas often described in the MRI studies as being involved in determining ADHD, are shown in Figure 2. It can be observed thereby, that the areas resposable for the ADHD syptomatology are mainly: the prefrontal cortex and the striaded area.
Figure 2. The right brain hemisphere indicating cortical areas
mainly involved in the ADHD determination(Barkley, 2006 a şi 2006 b).
Hynde et al. (1993) sustain that children with ADHD caudate region of the left hemisphere is less, having a reverse configuration than a normal children. If at normal people left hemisphere caudal nucleus are higher than those in the right hemisphere, at children with ADHD this configuration is not observed. Hynde’s results (1993) are consistent with studies that found decrease local blood flow in these regions. Similar studies using quantitative MRI, indicates a smaller frontal area of the right hemisphere and a smaller size of the caudate nucleus and globus pallidus at children with ADHD, compared with normal children (Castellanos et al, 2002). The same authors had identified a lower volume of the cerebellum in ADHD than normal, which is consistent with recent research that assigns a major role in cerebellum motor manifestation of aspects from planning work and other executives.
A particular aspect of these studies refers to the size of caudate nucleus, which is lower at children with ADHD than in normal ones; but there is no consensus regarding which specific part of the nucleus is smaller. Hynde et al. (1993), Ernst et al (1998), Giedd et al (2001), identify the left caudate nucleus to be smaller; and Castellanos et al. (1996 and 2002) identifies the caudal nucleus more atrophic in the right side. Brains of normal people have a front region of constant asymmetry of the hemispheres, the right one is larger than the left one (Giedd et al, 2001). This argument led Castellanos to claim that lack of this asymmetry may mediate specific events for ADHD.
It is important to note that none of neuroimaging studies have identified that people with ADHD have brain damage. The aspects described in these studies refer only to some of the size of brain areas, most of the times missing asymmetry (the frontal regions or the caudate and globus pallidus nucleus), while these asymmetries are found in normal inpiduals. When deficits are identified at the cerebral level, most often they are the result of abnormalities arising in the development of these cerebral regions most likely causes are genetic. Finally, genes determine largely cerebral development (Barkley, 2006, 2006 b, 2008).
Research of brain neurochemistry, explosive developed early ‘90s showed that ADHD symptoms are caused by a neurophysiological dysfunction of the brain. Various studies using PET and SPECT have confirmed that there is a clearly defined difference between inpiduals with ADHD and those without. ADHD based mechanisms are complex and are further investigated.
It was found that the brain chemical balance is unbalanced and neurotransmitters, especially Dopamine (and Norepinephrine, Serotonin, Glutamate) and their receptors are in low quantities in certain brain regions, usually asymmetric, those with ADHD, not only in the cortex, but also in subcortical nucleus, limbic system, cerebellum and brainstem. Several authors have documented these issues and their correlation functions of certain psychological and behavioral changes in ADHD (Zametkin 1990; Murphy and Barkley, 1996; Ernst et al, 1998; Carlsson et al, 2000; Comings et al, 2000; Himelstein et al, 2000; Roth and Saykin, 2004; Arnsten et al, 2009). Thus, it was found that, for example, right prefrontal cortex is involved in “editing behavior” and resistance to fun. Caudate nucleus and pale globe help automatically to extinguish the response, to allow for deliberation of the cortex and to synchronize neurological input in various regions of the cortex. The exact role of vermish is not clear, but studies made so far, suggest that is involved in planning and motivation. However, the major role appears to be owned by impaired of prefrontal cortex, for cerebral blood flow is decreased by 65% at children with ADHD during intellectual effort, compared with normal children.
All within the possible causes of the disorder, we could remember an experiment that demonstrated a link between a person’s ability to pay attention and the activity level of the brain. To the subjects participating to the experiment were given to memorize a list of words. It was used PET to measure level of glucose used by areas that inhibit impulses and control attention. Glucose is the main source of brain power. The researchers found significant differences between people with and without ADHD. In those with ADHD they found a lower level of consumption of glucose, whence the existence of a much lower level of activity in some parts of the brain, which might cause distraction.
It was assumed and confirmed that the basis of the pathogenesis of the syndrome are disorders of activation of reticular formation, which helps coordinate learning and ability to maintain attention. Disorders of the activation function of reticular formation are related to the shortage of noradrenaline. Failure of adequate processing leads to a situation where different visual stimulus, sound, emotional become superfluous for the children, causing restlessness, agitation and aggression. In fact, years ago, Dr. Paul Wender (Wender, 1996) advanced the theory, according to which that MBD may have a genetic origin, being produced by a decrease of catecolaminergice functioning. Some biochemical studies performed on children with this syndrome have shown that not only is disturbed metabolism of Dopamine, but also other neuromediators – Serotonin and Norepinephrine.
1.3.2. Genetic studies:
Recent discoveryes in genetics, especially molecular genetics have demonstrated the involvement of several genes in the genesis of ADHD. Undoubtedly, ADHD is a genetic disorder “polygenic”, in which only one gene is affected. This conclusion was reached otherwise and empirically researching families of children with ADHD; for childrenwho come from families affected are 5-7 times more likely to develop disease than those from unaffected families and children who have a parent with ADHD are likely to provide 50% syndrome. In addition, twin studies have shown that 80% of differences in terms of attention, hyperactivity and impulsivity between people who have ADHD and those who do not have, can be explained by genetic factors. Factors that are linked to ADHD, but do not have a genetic substrate are: premature birth, consumption of alcohol and cigarettes during pregnancy, radiation exposure in childhood and the presence of brain disorders involving the prefrontal cortex. (Comings et al, 2000; Wender, 2000; Barkley 2006 b; Arnsten et al, 2009).
Studies of psycopathology among families with hyperactivity and attention deficit cases, studies on adoption and studies on twins have suggested the presence of a genetic contribution in the etiology of this disorder. Primary records have revealed that the fathers of hiperactive children show a high incidence of alchoholism, sociopathy and a history of childhood laden with learning dificulties and behavioral disorder. It was also pointed out a correlation between the ADHD symptoms and early consumption of alcohol among children who come from alcoholoic families.
The syndrome of attention deficit and hyperactivity (ADHD) is considered to be highly influenced by the genetic factor, because- besides the many studies on twins that reveal that the global imaturity is a part of the genetic effects of the ADHD both in girls and in boys, it was also discovered the presence of many parental factors that interfere (Wender, 1987 şi 2000; Murphy and Barkley, 1996; Lensch, 2000; Searight and Rottnek, 2000; Schmidt et al, 2002; Barkley, 2006 b şi 2008; Low, 2009): genetics (the way the affection is given) and educational (behavioral patterns, aspects of the attachment, the ability to offer rewards and to respect rules- coming from the parents with ADHD and the normal parents that have chldren with ADHD).
1.3.3. The importance of the environmental factors:
The capacity to sustain an efficient level of intelectual and affective concentration derives, at least partially, from the parent’s ability to strengthen the pursuit of meaningful goals. It was acertained that children who come from chaotic organized families fail to develop this capacity. The attention of a child can be pieced due to an extremly distractable environment or by an anxiety (mostly related to the performance in difficult school tasks). Also, internal psychological conflicts can determinate the attention’s orientation inward and disturbances of the attentional mechanisms.
Even if this idea is not accepted nowadays, many years before, it was beleived that there is a bond between hyperactivity and diet. This theory presented a high level of credibility based on the parent’s reports, describing their children’s behavioral reactions after eating a certain foodstuff. Recent researches have not indicated the existance of a scientific support for this theory.
1.3.4. The psychological context:
The psychomotor instability charcteristic to the ADHD syndrome can be a part of a traumatic situation. The more the child is smaller as age, the more the way he/she expresses a motric difficulty or a mental tension passes more easily through the body causing a reactional tension. A 2-3 years old child, and even older presents a natural instability, common, expressed through a week attention and explosive motricity, often related to the multiplication of the experiences and „discoveries”. Unfortunately, the entourage does not easily accept this type of demeanor (behaviour). Faced with the intolerant attitudes of the environment, the child with motric instability can exacerbate his/her symptoms and manifestations. Therefore, it appears the question of the environment’s intolerance level, especially the family’s, towards the psycomotor symptoms. This level is very low in the families where one or both parents have ADHD. The educational and psycological intervention, formative- or therapeutic, but also couseling regarding the change in the parental pattern (if necessary) este often required and benefic, both for the adult with ADHD and the child or the entire family.
1.3.5. Prognosis:
ADHD syndrome represent an important issue in public health. It’s prevalence varies between 4% AND 19%, depending on what criteria are used (Taylor, 1994).
The prognosis is bad, because reaching the adlut life, inpiduals with ADHD show a high risk of delinquency, criminality, drugs abuse, family and professional failure, and other difficulties in social adjustment. It was highlighted that the children from families that have a very low economical status and the boys, are generally likely to develop this syndrome.
1.3.6. Psychological mechanisms used in psychotherapeutic intervention
Specialists are trying to find out how the brain structure and the observed genetic abnormalities on ADHD children are ralated to the behavioral characteristics of this disorder?
How structural and genetic anomalies identified at ADHD childrens is correlated with behavioural characteristics of this disorder ? How can we intervene with psychotherapy on children to prevent the persistance of the disorder at the adult age?
Barkley (2006 a; 2006 b; 2008) have concluded that in ADHD the central deficit refers to the behavioral inhibition and self-control.
Self-control or the capacity of inhibition / delay of the initial motor response at a certain event represents a critical substantiation for any kind os task. Childre that are in the process of growing gain the capaity to exercise control on the mental activities, on the executive functions, hepling them to ignore the distractable factors, renaming the aims and following the necessary steps for accomplishement. Accompleshing a goal either in a game or in work, inpiduals must be capable to remind themself the goal, to master their emotions and corectly channel the motivation.
Executive functions that interfere in this process (Roth and Saykin, 2004; Schmidt et al, 2002) can be grouped in four mental activities, whose practice is manadtory in the psycotherapeutic intervention- to prevent perpetuation of the disorder from the child age to the aduld age:
Working memory – keeps informations during the execution of a task, even if the initial stimulus that provided the information is missing. This evocation is crucial for the goal-directed behaviour; it provides ways to imitate the others new and complex behaviour (all these aspects are seen in inpiduals with ADHD).
The internalization of the language – represents an other executive function. Before the age of 6, children talk to themselves out loud, frequently reminding how did thei accoplished a particular task in the attempt to solve a problem. The internalization, the self-directing speech allows them to reflect on itself, to follow rules and instructions, to use self-questioning as a form of solving a problem and aquire the ability to build „meta-rules” (the foundation for understanding and usage of the rules). It has been shown that the internalization of the self-directing speech is delayed at children with ADHD.
Control of the emotions, motivation and arousal state – represents the third executive function involved
Reconstruction – the last of the executive function used to aquire self-control accompanies two separate processes: suppression of the observed behaviour and the combination of the parts in new actions which are not learned from previous experiences. The capacity of reconstruction offers the inpiduals a high level of influenece, flexibility and creativity; all these allowing humans to concentrate on a certain aim, without mechanical storage of the required steps. This aspect allows the child to self-direct his/her behaviour along the increasing intervals by combining the behaviours in a long chain, in order to achieve the goal.
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Correspondence to:
‘Dimitrie Cantemir’ University, Tg. Mures mail: stanciu_camelia74@yahoo.com Tel. 0740-526.123