Not only for children

By: Tal Barak and Dr. Rachel Ben Hayun
Senior physician in the Cognitive Neurology Unit, Rambam Health Care Campus

Although ADHD is defined as a childhood onset disorder (appearing before the age of 6-7 years), numerous adults are now seeking tests for this disorder. They usually do so after their military service or close to the time of their release from military service. "It comes together with their thinking about starting academic studies," confirms Dr. Rachel Ben Hayun, a senior physician in the Cognitive Neurology Unit, Rambam Health Care Campus. "They feel that they have a problem and come to check whether and how it can be treated."

In the past, ADHD was considered a childhood disorder that resolved with adolescence. However, it is now known that Adult ADHD affects 2% to 6% of the adult population (age 18+). These people represent about 50% of those who had this disorder in their childhood, grew up with it and continue suffering from it during adulthood. Additional interesting information is that the prevalence of this disorder is about three-four times higher in boys than in girls (possibly due to the fact that there are more cases of hyperactivity among boys). However, this gap between boys and girls decreases with maturation, reaching equality (1:1) in the adult population. By the way, although most of the people seeking therapy are students, the age range of people suffering from this disorder is very wide.

"Parents of children who have been diagnosed with ADHD often come here and ask to be assessed," says Dr. Ben Hayun. "Many of them, if diagnosed, realize what and how much they've lost because of lack of adequate treatment when they were young." "By the way, the oldest patient who came to the clinic at Rambam was more than 70 years old; he asked to be assessed after his grandson was diagnosed.

So, what did all the adults do with the problem before they were diagnosed? They managed somehow or other, says Dr. Ben Hayun, "Each of them found his own way to cope with it, in his own environment, which was more or less supportive, using his natural skills and intelligence. Some of them succeeded in exams, but their grades were usually lower than expected, based on their estimated ability, and without optimal utilization of their natural skills. This usually led most of them to feel severe disappointment, failure and the need to cope repeatedly with being labeled a "lazy student, always failing." At university or at work, where attention and concentration are required, these difficulties are even more prominent".

"ADHD touches, affects and impairs every area of life. Studies have shown that at the age of adolescence, people with this disorder become sexually active at a younger age, and with a higher number of partners. The percentage of drug users is higher than the average. The same is true for criminal activity. Adults experience difficulty functioning in their family environment, and difficulty spending times with their children, helping them with homework and playing with them. The rate of divorce is higher among people with Adult ADHD. They change jobs frequently and are involved in more motor accidents".

"In addition to the ADHD symptoms, the morbidity (incidence of the disease) is often associated with mood changes, such as depression or mania, anxiety and various addictions, which require an accurate diagnosis in order to be certain that the patient indeed suffers from Adult ADHD, and not only from a psychiatric disorder. "

The cause of ADHD is not yet clear. "Special imaging tests demonstrate a relative deficiency in dopamine (a neurotransmitter that transfers electrical signals in the brain) in people with ADHD," says Dr. Ben Hayun. Dopamine deficiency interferes with the function of the frontal lobes, which are responsible for functions of attention and concentration, memory, decision-making ability and other cognitive and emotional functions."

There is a high prevalence of genetic factors involved in ADHD.  A child with a parent who was diagnosed with ADHD has a very high chance (40%-50%) of developing the disorder. A child with a sibling diagnosed with ADHD has a 30% chance of developing the disorder.

Diagnosis of Adult ADHD

It is impossible to diagnose Adult ADHD using imaging devices; so, at present, clinical diagnosis is the only available tool. Brain CT and MRI scans may demonstrate a smaller volume of temporal lobes, basal nuclei and part of the cerebellum in people with ADHD. In addition, their metabolism is abnormal. However, at this stage, these findings are not sensitive enough to establish the diagnosis.

The diagnosis is based on the clinical story, test results, exclusion of syndromes with similar symptoms, and auxiliary tests:

1. The clinical story – evaluation of the patient's complaints based on the clinical, developmental and psychiatric history, and his/her achievements in all life areas. The details are recorded during an interview with the patient, the patient's spouse and the parents (if possible), as well as by completion of questionnaires. A number of  questionnaires are available, which are essentially similar to and based on the questionnaires used for ADHD diagnosis in children, and adjusted for adults. (See box.)
2. Auxiliary tests – such as blood tests, in order to exclude other reasons for complaints, such as impairment of the nervous system, iron deficiency, vitamin B12 deficiency and impaired thyroid function.
3. Neuro-psychological tests – performed by physicians and neuropsychologists; some of the tests are computerized. These tests are designed to evaluate the basic cognitive functioning capacity of the patient, his/her linguistic skills, memory, learning ability, and, of course, the functional capacity of attention and concentration systems. Emotional and social behavior patterns are also considered. Examples of computerized tests are the TOVA and CPT tests, which examine the ability to maintain optimal attention over prolonged periods of time. 

Dr. Ben Hayun: "It is important to emphasize that ADHD diagnosis cannot and must not be based only on the TOVA and CPT tests. Many people coming to our clinic ask for Ritalin treatment only on the basis of their TOVA test results. It doesn't work this way. These tests are only a part of the diagnostic process."

The treatment of Adult ADHD

Dr. Ben Hayun: "Not every one who experiences an attention and concentration problem has the "Attention Deficit Hyperactivity Disorder" syndrome. The factor causing the disorder must be diagnosed prior to treating the disorder."

"Combination therapy is usually required: medication therapy, treatment of the physical or psychiatric disorders, if any, and complementary therapy, for example, coaching, training workshops and courses to improve learning ability. Every recommendation is adjusted to the patient. In the Rambam clinic, we focus mainly on the primary diagnosis and medication therapy. We guide the patients to complementary therapies, depending on the patient's needs."

"Follow-up throughout the treatment is most important, in order to examine the efficacy of each treatment and make appropriate changes, and to monitor side effects, if any." 

Medication therapy  - Ritalin and all the rest

The well-known, most effective and recognized treatment of ADHD in both children and adults is medication therapy with stimulants, the best-known representative of which is Ritalin. Ritalin acts by preventing reuptake of dopamine into the nerve endings in the brain, thus increasing the level of dopamine, which is relatively low in people with ADHD. Dopamine control achieved by Ritalin treatment improves the cognitive function, mainly by enabling attention focusing and maintaining more effective long-term attention functions.

Various Ritalin tablet preparations are available on the market: short-acting Ritalin with 4-hour action, Ritalin that acts for 8 hours (LA-Ritalin and SR-Ritalin), Ritalin that acts for 12 hours (Concerta), and even Ritalin patches enabling transdermal delivery of the drug.

The possible common side effects of Ritalin treatment are: sleep disorders, headaches and loss of appetite.
Dr. Ben Hayun: "Ritalin is a medication, and the physician and the patient must together consider its advantages and disadvantages. Other medications are available, such as Strattera and Aderall – if Ritalin is ineffective or causes side effects."

Can Adult ADHD resolve without treatment?
Dr. Ben Hayun: "About 50% of the patients indeed recover without treatment, or learn to adjust and adapt their lives to their condition and to accept the difficulties caused by the disorder. In addition, hyperactivity symptoms decline with maturation. Many people 'treat themselves' without being aware of it – with coffee, cigarettes, alcohol, hashish or other drugs, and by adjusting their occupation and hobbies to the disorder."