Dr. Goodman is Director of the Adult Attention Deficit Disorder Center of Maryland, and Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine in Baltimore.
Disclosure: Dr. Goodman is a consultant to Avacat, Clinical Global Advisors, Eli Lilly, Forest Laboratories, JK Associates, McNeil, Medscape, New River Pharmaceuticals, Novartis, Schering-Plough, Shire, Thompson Reuters, and WebMD; is on the speaker’s bureaus of Forest Laboratories, McNeil, Shire, and Wyeth; has received research grants from Cephalon, Eli Lilly, Excerpta Medicine, Forest Laboratories, McNeil, New River Pharmaceuticals, and Shire; has received honoraria from Eli Lilly, Elsevier, Forest Laboratories, JK Associates, McNeil, Medscape, Shire, Synmed, Veritas Institue, WebMD, and Wyeth; and receives royalties from MBL Communications.
Please direct all correspondence to: David W. Goodman, MD, Assistant Professor, Johns Hopkins Univ School of Medicine, Dept of Psychiatry and Behavioral Sciences, Johns Hopkins at Green Spring Station, 10751 Falls Road, St 306, Baltimore, MD 21093; Tel: 410-583-2723; E-mail: email@example.com.
In 1998, the American Medical Association Scientific Counsel wrote that attention-deficit/hyperactivity disorder (ADHD) is “one of the best researched disorders in medicine”. Since then, rapidly emerging research coupled with increased interest by clinicians and the public have advanced the identification, diagnosis, and treatment of ADHD in patients of all ages. In treating patients with ADHD and their families, we hope that symptoms are reduced throughout the day leading to improved functioning, enhanced self-confidence, and better quality of life for all involved. Because of the volume of information, there is a need for clinicians to have rapid access to up to date reviews of clinically relevant information to assist in the accurate diagnosis and effective treatment of ADHD and associated psychiatric comorbidities. For the clinician, satisfaction comes from playing an instrumental role in facilitating this optimal outcome. This educational review presents information in brief text and tables for quick reference for the busy practitioner.
• Diagnostic accuracy is increased by establishing age of onset of symptoms, chronicity of symptom course, presenting symptom threshold and impairments, and family history of attention-deficit/hyperactivity disorder while ruling out co-existing psychiatric disorders.
“The Black Book of Attention-Deficit/Hyperactivity Disorder” is a concise presentation of rapidly accessible information important to clinicians diagnosing and treating these patients and their families. I have attempted to cull through the literature and present clinically relevant information in text and table format so that you can quickly find what you need to address the issues of the patient in front of you. I hope you find the format useful for the intended purpose and we welcome feedback for future editions.
Attention-deficit/hyperactivity disorder (ADHD) has been established as a valid psychiatric disorder in children for many years. In 1998, the American Medical Association Scientific Counsel wrote that ADHD is “one of the best researched disorders in medicine”.1 The explosion of neuroimaging research in the past 10 years has demonstrated clear differences in the ADHD brain from dopamine receptor density in the basal ganglion2 to morphologic differences in white matter,3 basal ganglion,4 and cerebellum5 to rate differences in the neurodevelopment of the frontal cortex.4,6 Heritability of 76% has been established with family, twin, and adoption studies.7 With a growing number of prospective longitudinal studies of ADHD children followed 10–20 years into adulthood,8 we have come to understand that up to 65% of these children will continue to have persistent and impairing ADHD symptoms. From these findings and epidemiologic data, the prevalence of ADHD in children is 7.8% (4.5 million)9 and 4.4% (9–10 million)11 in adults in the United States. Of the children with ADHD, <60% have been treated in the past year while only <15% of the ADHD adults have been treated in the past year.10
The criteria for diagnosing ADHD and its subtypes are enumerated by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.11 The original symptom criteria were field tested in children 5–17 years of age12 and not in older patients with ADHD. Therefore, when diagnosing adults, clinicians and researchers have had to extrapolate the symptoms that appear at older ages. This clinical extrapolation has been aided by following children with ADHD into adolescence and adulthood to see which symptoms persist with impairment and which subside. With age, some patients develop compensatory skills to limit the interference they experience from their symptoms. Although impairments may not appear evident, these patients are often working harder daily to achieve what someone else achieves with little effort.
As individuals with ADHD ages, life presents ever-changing demands often requiring a greater ability to remember and organize daily tasks. Children with ADHD not diagnosed in childhood because they did not present with disruptive behavior or severe academic decline may face challenges later in life as the demands of adulthood exceed their ability to compensate. It is at this time they may present to clinicians with complaints of frustration, demoralization, anxiety, and depression. Given the high prevalence rate in children and adults relative to other psychiatric disorders, an ADHD assessment should be included in every initial mental health evaluation.
In recent years, research has focused on the concurrent psychiatric comorbidities that can complicate the diagnostic process. In children, oppositional defiant disorder and conduct disorder were commonly understood and identified. With emerging research, anxiety and mood disorders in children with ADHD have necessitated greater clinical acumen for accurate diagnoses. The same diagnostic complexities are introduced in older patients with ADHD. The onset of substance abuse, major depression, bipolar disorder, and anxiety disorders add a new dimension to developing a treatment algorithm in the presence of ADHD. Diagnostic prioritization of multiple concurrent disorders is necessary to construct a treatment algorithm. The goal is to effectively treat one disorder without worsening the other disorders. For children and adolescents, the American Academy of Child and Adolescent Psychiatry guidelines lay out a systematic approach to the treatment of ADHD and co-existing disorders. For adults, there are no such guidelines established.
Because of our understanding of ADHD as a potentially life-long disorder, the American Psychiatric Association committee working on diagnostic revisions for the forthcoming DSM-V will consider the research accumulating on the presentation of ADHD across the life span. This means that symptom descriptions will need to be age congruent and the threshold number of symptoms will be reconsidered. The age of onset before 7 years of age is likely to be increased because individuals with inattentive type are typically diagnosed after 7 years of age.13 However, remember that ADHD is a childhood disorder that may persist into adulthood so the age of onset needs to be set in childhood/early adolescence. The criteria of impairment in >2 domains is likely to remain because this is a disorder that impacts multiple domains of life. However, the degree of impairment and the domains may require greater clarification because adaptive skills, IQ, and environmental structure may alter the appearance of impairments.11 The work to be done for the forthcoming DSM-V will greatly broaden and enhance our ability to identify ADHD accurately in all age groups.
This educational review has been divided into specific topics. “Neurobiology” reviews the epidemiology of child and adults with ADHD in the US and internationally, and a review of neuroimaging findings. “Diagnosis” presents the diagnostic criteria in the DSM-IV-TR; a review of extrapolated diagnostic criteria for adults; a list of ADHD rating scales for children, adolescents, and adults, and defines and reviews executive dysfunction and functional impact of ADHD. “Treatment Guidelines” reviews the current ADHD treatment guidelines for child, adolescent, and adults with ADHD established by the current meta-analyses of research findings; treatment algorithms for pure ADHD and ADHD with co-existing psychiatric comorbidities. “Treatment Options” provides a list of medications available and approved by the US Food and Drug Administration, a list of stimulant delivery vehicles, distinguishing efficacy from effectiveness of treatments, a review of complementary treatments and research findings in controlled studies, a review of current safety considerations and side effects for ADHD medications in age specific populations, and a review of psychotherapies employed.
The rapidly emerging research coupled with increased interest by clinicians and the public at large will advance the diagnosis and treatment of ADHD in patients of all ages. We hope that in treating patients with ADHD and their families symptoms are reduced throughout the day leading to improved functioning, enhanced self-confidence, and better quality of life for all involved. For you, the clinician, satisfaction comes from playing an instrumental role in facilitating this optimal outcome. I hope this article provides you with the assistance to achieve this goal.
With decades of research on childhood ADHD, the validity of the disorder is well substantiated. Although adult ADHD was presented in psychiatric literature in the mid-1970s, the emerging body of literature on ADHD across the lifespan has exploded in the last 2 decades. New technologies have allowed science to investigate genetic markers. Neuro-imaging has facilitated a better understanding of developmental, structural, molecular, and functional difference in the brains of children and adults with ADHD. Longitudinal studies have verified that 1 in 2 children with ADHD will continue to have impairing symptoms into adulthood. The negative consequences of untreated ADHD have been enumerated across the lifespan of patients with ADHD. High rates of psychiatric comorbidities add complexity to the diagnostic assessment and prioritization in order to formulate a thoughtful treatment algorithm. The psychiatric literature is extensive for clinical guidance when treating children; however there remains a paucity of adult studies that offer clinical guidance for the treatment of adults with ADHD and co-existing psychiatric disorders.
Efficacy trials for children have clearly demonstrated the benefits of medication and behavioral psychotherapies tailored to the specific symptoms and needs of the child and family. Although limited, a growing body of efficacy trials in adult ADHD over the past 20 years also demonstrates the benefit of medications and specific therapies. The specific approval of medications by the FDA in the past 7 years to treat adults with ADHD helps encourage the identification and treatment of these patients. Advances in medication delivery systems have introduced different mechanisms in order to extend the duration of action. Safety issues have been recently highlighted by the FDA and physicians need to be knowledgeable about assessing medical risk factors in patients. With the treatment of adults versus children, physicians have new considerations in treatment like pregnancy, substance abuse, and poly-pharmaceutical treatment of concurrent medical conditions (ie, cardiovascular disease, diabetes, hypertension, pain syndromes). Patients often use complementary and alternative treatments without substantial controlled trial efficacy. The conceptual distinction between efficacy and effectiveness will become increasingly relevant as treatment comparative trials look at the economics of treatment.
Because formal training in ADHD is highly variable and virtually absent for adult ADHD, many physicians find they need to learn about this disorder in clinical practice. Summarizing this literature into clinically relevant and rapidly accessible information is critical to facilitating this educational pursuit. This article presents a portion of the tables and text from the book, in which you will find additional tables and information on rating scales, child treatment algorithms for comorbid disorders, and elaboration of Americans with Disabilities Act and Individual Education Plan criteria. This educational review presents the distillation of literature into clinical topics, and is written in table format for a fast read. The unique format of this article and its presentation of up-to-date clinically relevant information makes it a useful addition to the library of clinicians caring for ADHD patients and their families. PP
The following references are the complete list from “The Black Book of ADHD—1st Edition” and the original numbering from that clinical handbook has been kept for this Educational Review. Although not every reference was used in this article, the inclusion of the entire reference list reflects the breath and depth of the clinical handbook’s content for readers who consider adding it to their library.
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