The Clinic for Adult Attention Problems (CAAP) is a multidisciplinary specialty clinic. The primary mission of the clinic is to provide exemplary patient care through state-of-the-art assessment and treatment and to expand knowledge through research.

Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is the most common behavior disorder diagnosed in children and teens. ADHD refers to a group of symptoms that begin in early childhood and can continue into adulthood, causing difficulties at home, at school, at work, and within the community if not recognized and treated.

Difference between ADHD and ADD?

ADHD (Attention-Deficit/Hyperactivity Disorder) is the term used in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) diagnostic criteria. ADD (Attention Deficit Disorder) with or without hyperactivity is the older term from the DSM-IIIR.

Three Subtypes / Types Attention Deficit Hyperactivity Disorder

• Inattention. This is the most common symptom. In addition to having difficulty paying attention, people with this ADHD symptom often are unable to consistently focus, remember, and organize. They may be careless and have a hard time starting and completing tasks that are boring, repetitive, or challenging.
• Impulsiveness. People who frequently act before thinking may not make sound judgments or solve problems well. They may also have trouble developing and maintaining personal relationships. An adult may not keep the same job for long or spend money wisely.
• Hyperactivity. A hyperactive child may squirm, fidget, and climb or run when it is not appropriate. These children often have difficulty playing with others. They may talk a great deal and not be able to sit still for even a short time. Teenagers and adults who are hyperactive don't usually have the more obvious physical behaviors seen in children. Rather, they often feel restless and fidgety, and are not able to enjoy reading or other quiet activities.

Adult ADHD

Attention deficit hyperactivity disorder (ADHD) in an adult is often not noticed because the person may maintain relationships, stay organized, and hold a steady job. It is not unusual for a parent to discover he or she has ADHD when his or her child is diagnosed with the disorder. The key to the diagnosis of ADHD for an adult is the presence of symptoms before he or she was 7 years old.

Hyperactivity in adults is often seen as:

• Fidgeting. Typically they swing their legs, shift in their seats, or tap their fingers.
• Constant motion. They feel "revved up," on the go, and show little or no ability to relax until exhausted.
• An inability to relax. They have difficulty trying to relax or to do quiet activities such as reading or watching television.

 Inattention in adults is often seen as:

• Difficulty completing tasks that they do not find interesting or easy. However, these adults may become obsessed with activities that are interesting and enjoyable.
• Difficulty maintaining relationships.
• Difficulty focusing their attention on conversations, reading materials, or jobs. They may frequently move from one job to another.
• Forgetfulness, misplacement, or loss of things.
• Distractibility.

 Symptoms of ADHD may affect an adults:

• Job performance. Their work performance may be inconsistent because they have problems organizing their work, managing their time, and concentrating on one task at a time. They may be forgetful and misplace or lose things. They may quit their jobs out of boredom.
• Personal relationships. Relationships may suffer for adults who have problems focusing their attention on conversations, "reading" the behavior and moods of others, and expressing their own feelings.
• Temper. Becoming easily frustrated often is related to having difficulty tolerating stress. These adults may overreact and have a short, quick temper.
• Problem-solving ability. Adults who have difficulty waiting for things they want may not be able to accurately foresee the consequences of their actions. As a result, they may engage in risky behaviors, such as unprotected sex, alcohol and drug use, or unwise financial ventures.

Causes of Attention Deficit Hyperactivity Disorder

Although the exact cause of ADHD remains unknown, research has increased in the last decade. At present, the most likely cause of ADHD is believed to be genetic, but other causes have been implicated as well.

Research repeatedly demonstrates that ADHD runs in families. Recently published data in Pediatric Annuals indicate that the child of an adult with ADHD has approximately a 25% chance of having ADHD. There are also indications that the type of ADHD that persists into adulthood is more highly genetic than the type that diminishes in childhood.

A family history of alcoholism and other mood disorders seems to be associated with an increased risk of ADHD. This may imply some type of genetic commonality between these disorders.

Although the cause of ADHD is unknown, some researchers believe it is due to many factors. In addition to genetic causes, there are other environmental and medical factors that can cause ADHD-like symptoms. Careful examination, however, reveals important differences between these disorders and ADHD. Overall studies have concluded that heredity explains, on average, the majority of ADHD-like behavior exhibited by children, while environmental factors explain only approximately 20% of this type of behavior.

In the past, uncertainty about the causes of ADHD created a fertile climate for speculation of all kinds. Many theories - notably those holding parents to blame in some way for their child's uncontrolled behavior - have been advanced and were later determined to be unfounded.

Among the most well-known include:

• Food/Diet
• Poor Parenting
• Excessive television watching or video-game playing
• Hormones

These factors were initially believed to be causes of ADHD because they appear to be connected. Parents claim that when they fed their children sugar or various other foods, they become more hyperactive, certain diets claimed to eliminate hyperactivity. Professionals who witnessed uncontrolled behavior concluded that parenting methods must be flawed. Hyperactive children seemed to watch more TV and play more video games than other children. It seemed plausible that the emotion inherent in ADHD could stem from some kind of hormonal imbalance, much like the moodiness of adolescence.

However, carefully designed, rigorous studies failed to find that any of these observed associations were causes of ADHD, nor could any of these factors modify the symptoms of ADHD. For example, contrary to parental beliefs, sugar did not make children significantly more hyperactive. No diet, in fact, was found to reduce ADHD symptoms. Parenting techniques did not improve symptoms; parental frustration was in fact found to be an effect, not a cause, of ADHD.

Excessive television watching and video game playing also was determined to be a symptom, not a cause, of ADHD. It is a form of stimulation that helps children with the disorder sustain focus and control internal feelings of agitation via a mechanism similar to that at work with medication. Increasingly it has become clear that ADHD is a neurological disorder that requires a medical diagnosis and treatment.

How is adult ADHD different from childhood ADHD?

Adults with ADHD may still have trouble seeing what they do that irritates others, but with age they may learn to monitor others' reactions and adjust their own behavior accordingly. They may learn to minimize the impact by creating an ADHD-friendly environment and by developing coping strategies. For example, a child who feels restless and frustrated sitting in the classroom all day may feel much better as an adult in his job. In these circumstances, behaviors that are problematic in the classroom may be adaptive on the job. An adult with ADHD can often modify his activities to suit his temperament, whereas children are forced to deal with the ADHD-challenging environment of school.  Also, in adult ADHD the person who seeks treatment is most likely the person who receives it. This difference has several important implications. It means that children are more likely to be referred for problems that bother other people, such as being disruptive or defiant. Adults are more likely to come in for problems that bother them.

Adults with ADHD also may have more difficulty than children in getting objective feedback about their response to treatment. Healthcare professionals contact teachers routinely, but getting objective reports from employers can be more problematic. Often adults use their spouse or roommates for this purpose, but this only provides feedback on evening behaviors rather than daytime behaviors.  Adult ADHD is almost equally divided between men and women, whereas ADHD in children is more commonly diagnosed in males. Since there is no evidence that men grow out of ADHD faster, this suggests different diagnostic patterns in the two age groups. ADHD is highly genetic, so that about one quarter of the parents of children with ADHD will have ADHD.

How common is adult ADD?

ADHD affects about 3-7% of children, and about 4% of adults have ADHD. This means that there is likely to be about one child with ADHD in every classroom. Certain occupations draw ADHD individuals, and therefore they may be over-represented in certain professions. About 60% of children diagnosed with ADHD continue to exhibit symptoms as adults.

Diagnosing ADHD in Children

ADHD is usually diagnosed when a child is 6 to 12 years of age. Children in this age group are most easily diagnosed because symptoms caused by ADHD become more noticeable in a school setting. It is more difficult to diagnose ADHD in a child younger than age 6 because the symptoms can also occur periodically during normal development.

ADHD is diagnosed by first having a thorough medical exam to rule out other conditions. An evaluation by a physician, psychologist, or child and adolescent psychiatrist uses specific criteria established by the American Psychiatric Association (APA). Observations of a child's behavior documented by parents, classroom teachers, and others who have regular contact with the child are evaluated.

Diagnosing ADHD in Adults

The clinician will perform an evaluation for ADHD which should include a comprehensive clinical interview surveying past and present ADD symptoms, developmental and medical history, school history, work history, psychiatric history, social adjustment and general day-to-day adaptive functioning.  This comprehensive interview is intended first to identify evidence of core ADD symptoms and then to ensure that the history of these symptoms is both chronic and pervasive. This exam usually requires one or two hours at minimum. Ideally, the interview should rely on several informants, such as a parent or significant other, and survey behavior from multiple settings (i.e., school, work, home). It is also imperative that the clinician attempt to rule in or rule out other psychiatric diagnoses that may better explain presenting symptoms.

Since many adults are long unaware that they may have ADD, an adult evaluation should also review any available past objective records such as report cards, transcripts or prior testing/evaluation reports. In some cases psychological testing is helpful in treating Adult ADD. A comprehensive evaluation is needed in diagnosing adult ADHD for three reasons: to establish an accurate diagnosis, to evaluate for the presence of coexisting medical or educationally disabling conditions, and to rule out alternative explanations for behaviors and/or relationship, occupational or academic difficulties.

The cornerstone for the adult diagnosis of ADHD is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR).  ADHD is diagnosed based on three components:

• Symptoms - Adults with ADD may tell their physician about symptoms including: lack of focus, disorganization, restlessness, difficulty finishing projects, and/or losing things.
• Impairments - An adult with ADHD may have difficulties at work, at home, and in personal relationships.
• History - Adults with ADHD must have had their first symptoms prior to age 7, and these symptoms must have continued to cause impairment on a regular basis since then.

Affects of ADHD at work and at home

ADHD can make it hard for a person to complete tasks that he or she finds tedious, such as organizing taxes, cleaning their desk, responding to correspondence, and providing employers with detailed reports. ADHD can also cause problems in getting along with others or talking too much on the job. At home, close family members often complain that behaviors such as being lively or spontaneous that are attractive at first glance become wearing over time. Families may resent having to suffer the consequences of impulsive behaviors that they cannot control. This frustration with impulsivity is as difficult for parents as it is later for spouses.

Cure for ADD?

Like other chronic disorders, ADD is not curable. Some patients have a remission of the disease and may lead productive adolescent and adult lives. However, approximately 60% of children with ADHD will carry their symptoms into adulthood.

ADD is treatable. Fortunately, research is progressing on many fronts, making the outlook for people with ADD much more positive. Progress has been made toward better understanding this illness and its treatment, and scientists are using many approaches to learn more about what causes ADD. While no single therapy has been devised that "cures" ADD, many people with ADD are able to lead more satisfying lives.

Treatment for ADHD

There's no quick cure for ADHD. Medications can help, but experts also recommend behavioral therapy and counseling. Several clinical trials suggest that many of the stimulant drugs that help children with ADHD may also help adults. Particularly helpful may be the longer lasting formulations of these medications, which are better suited to adult lifestyles.

Examples of ADHD stimulants are Ritalin, Adderall, Dexedrine or Dextrostat, and Cylert. These drugs are not yet approved by the FDA for use in adults, although doctors can prescribe them if they choose. Also, these drugs can have serious side effects, so it's important to find the right dose. As of this writing, the only FDA-approved drug for adult ADHD is the non-stimulant Strattera. 

The bedrock of ADHD treatment, many experts believe, is behavioral therapy, emotional counseling, and/or practical support. Combining these three approaches with medication offers the best chance of significant, long-lasting improvement, according to the National Institute of Mental Health. Clinical trials are underway to test this idea. As many as three out of four adults with ADHD also suffer from emotional disorders. Treatment of these conditions usually requires the help of a psychologist or psychiatrist.

Treatment Process in Adults with ADD

The treatment process has three basic stages:

• Baseline evaluation: As part of the diagnostic evaluation, the physician or healthcare professional determines the target symptoms and the baseline degree of impairment
• Treatment strategy: The physician or healthcare professional forms a treatment strategy by prioritizing the target symptoms and determining which treatment methods are best suited to reduce them
• Symptom monitoring and strategy adjustment: A key part of Adult ADD treatment is monitoring of symptoms in various areas (such as learning, academics, family interactions, and peer relationships) and settings (such as home, workplace, social context)

ADHD and Strattera

Strattera is a norepinephrine reuptake inhibitor, a class of Attention-Deficit/Hyperactivity Disorder (ADHD) treatment that works differently from the other ADHD medications available.

Strattera works by selectively blocking the reuptake of norepinephrine, a chemical messenger or neurotransmitter, by certain nerve cells in the brain. This action increases the availability of norepinephrine, which is thought to be essential in regulating impulse control, organization, and attention. The precise mechanism by which Strattera works on Attention-Deficit Disorder (ADD) is not known.

Both Strattera and older treatments, like methylphenidate (the active ingredient in Ritalin^® and Concerta^®), are effective in treating ADHD. However, Strattera is the first FDA-approved treatment for ADHD that is not a stimulant and is not a controlled substance under the Controlled Substance Act. As a non-controlled substance, Strattera provides the convenience of physician samples and phone-in refills between physician visits. Strattera is the only medication approved by the FDA for the treatment of Adult ADD.

When should I expect to see the benefits of Strattera?

• While you are likely to notice improvements in ADHD symptoms by the first week, it may take up to a month to see the full therapeutic benefit of the effect as you or your child adjusts to the new medication.
• Remember that there are many variables that may affect the response to a new medication in addition to the normal ups and downs of daily life. Talk with your doctor or healthcare professional if you have any questions about changes during this transition time.

ADHD and Adderall XR

ADDERALL XR is a once-daily treatment for all types of attention-deficit/hyperactivity disorder (ADHD). ADDERALL XR capsules contain a mixture of different amphetamine salts. ADDERALL XR is thought to act as a dopamine/norepinephrine modulating agent, which means it helps restore a balance of these chemicals (called neurotransmitters) in those areas of the brain that control our ability to focus and pay attention to tasks. Medications like ADDERALL XR have been successfully used to treat ADHD since 1937, making them one of the oldest and most extensively studied continuously prescribed types of medication on the market.

What do neurotransmitters do and how does ADDERALL XR affect them? Dopamine (DA) and norepinephrine (NE) help the brain send signals between nerve cells. Many scientists generally believe that when there are not enough of these chemicals, the signals are not received and acted on properly. It is thought that ADDERALL XR causes more DA and NE to be available to normalize the signal transmission in the brain.

A single morning dose of ADDERALL XR significantly improves the three main symptoms of ADHD—inattention, hyperactivity, and impulsivity—throughout the day. ADDERALL XR has been shown to decrease distractibility, improve attention span, and increase the ability to follow directions and complete tasks. ADDERALL XR improves the ability to think before acting (decreased impulsivity) and decreases hyperactivity.

ADDERALL XR is not the only answer for ADHD. Medication often works best when used along with learning strategies in school and behavior modifications at home and in school. Some families also benefit from individual, family, or group psychotherapy.

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