Download Adult ADHD (2) - Florida Heart CPR

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2 hours
Florida Heart CPR*
Adult ADHD
Learning Objectives
Upon completion of this course, participants should be able to:
1. Review our current history and epidemiology of ADHD.
2. Evaluate the diagnostic criteria for ADHD.
3. Discuss current pharmacologic interventions for the treatment of ADHD.
Introduction
The appropriate identification and treatment of attention deficit/hyperactivity disorder (ADHD)
is a growing public health concern.[1] The disorder has been increasingly accepted as a disorder
in children.[2,3] However, it is only in recent years that adult ADHD has truly been recognized as
an entity unto its own and that adequate treatment for adults has become available. It is clearly
stated in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),
that attention deficit disorder is a disorder that can continue into adulthood. As ADHD is a
longitudinal, neuropsychiatric disorder, the criteria require the onset of some ADHD symptoms
in childhood, with onset prior to the age of 7 years. Approximately half of the children who are
diagnosed with ADHD will have symptoms that persist into adulthood.[4]
The appropriate recognition and treatment of adults with ADHD is a particularly pressing
problem for busy primary care physicians, given: (1) the high prevalence of and resulting
impairments from the disorder, (2) that ADHD patients are high utilizers of medical services, (3)
the lower identification rates of the disorder in adults as compared with children, and (4) the
ready availability of relatively safe and effective treatments.
A major recent advance in the treatment of adults has been the advent of longer-acting stimulant
preparations; their longer duration of effect better suits the extended day of adults with ADHD as
compared with shorter-acting agents. It should be noted that currently available medications for
adults are being prescribed off-label; they were specifically developed for children, and their use
has been extended to adults (which is actually the reverse of the medication development process
for most agents). This off-label characterization, in addition to the schedule II nature of
stimulants, may in part account for the some of the lack of comfort primary care physicians
express in treating adults with ADHD (Thomas Spencer, personal communication, September
2002). Future development of novel agents is likely to offer wider treatment options to
physicians and patients alike.
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We will review in this manuscript the history, epidemiology, diagnostic considerations, related
impairments, and treatment considerations for adults with ADHD, with a special focus on issues
pertinent to primary care clinicians.
History
Adult ADHD was not diagnosed until the mid-1970s due to a general lack of awareness.
However, states of pathologic restlessness have been diagnosed in children and adults for more
than a century. In the mid 1920s, an encephalitis pandemic (encephalitis lethargica, von
Economo's disease) occurred. Children and adolescents who survived the infection commonly
suffered a postencephalitic behavioral syndrome that was characterized by overactivity, lack of
coordination, learning disability, impulsivity, and aggression.[5,6]
The children's behavior was labeled as minimal brain dysfunction-like behavior. Adults who
were afflicted had Parkinson-like symptoms, including severe tremors, pathologic restlessness,
and akathisia. Patients also had specific lesions in areas of the brain rich in dopamine, providing
the first indication that states of pathologic restlessness were secondary to true neuropathologic
deficits and not merely driven by purely psychological causes. Subsequently, we have identified
dopamine as one the neurochemicals specifically involved in the pathophysiology of ADHD.
The similarities of the clinical presentations of children after encephalitis and what we currently
see as ADHD contributed to the understanding that structural damage could lead to symptoms
like restlessness, inattention, distractibility, and behavioral disturbances.
Epidemiology: Prevalence and Comorbidity
ADHD is generally thought to be a genetically transmitted neurobiologic disorder of the
dopaminergic and noradrenergic pathways. It appears to have a high genetic rate, with roughly
50% concordance in first-degree relatives. ADHD affects approximately 6% to 9% of children.
Of those children, somewhere between one third and two thirds continue to manifest ADHD
symptoms into adulthood, meaning that 2% to 6% (the most common estimate is 4%) of the
adult population has ADHD.[4] However, much of the data for these estimates were collected at a
time when the ADHD classification schema did not differentiate between the hyperactive and
inattentive subtypes, as it does now. As hyperactivity symptoms tend to wane in adults with
ADHD and become a sense of internal restlessness, it is likely that these estimates somewhat
underestimate the true prevalence of the disorder in adults.
Comorbidity is widely prevalent in adult ADHD, affecting by some estimates up to 3 in 4
individuals with the disorder. The mood disorders (major depression, bipolar disorder, and
dysthymia) have a comorbidity ranging from 19% to 37%. For anxiety disorders, comorbidity is
25% to 50%. The range for alcohol abuse is 32% to 53% and for other types of substance abuse,
including THC and cocaine abuse, is 8% to 32%. Self-medication with nicotine and excessive
doses of caffeine are often overlooked. The public health concerns for primary care physicians
are readily apparent, as there are increased rates of nicotine abuse seen in adults with ADHD The
rate of occurrence with personality disorders is 10% to 20% and with antisocial behavior is 18%
to 28%.[7-11] There is a 20% comorbidity for learning disabilities, particularly auditory processing
problems like dyslexia and auditory processing deficits.[7] These high rates of psychiatric
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comorbidity have several implications for primary care physicians. ADHD response rates are
likely to be decreased if significant comorbid conditions are not considered in treatment
planning. Furthermore, it is important not only to look for other psychiatric conditions in patients
with ADHD, but also to examine for ADHD in patients whose primary presenting problems are
psychiatric in nature. For example, for patients presenting with mood disorders, it is critical to
initially treat the mood disorder; however, if concomitant ADHD is missed, the likelihood of
successful long-term treatment is diminished.
Diagnosing the Adult With ADHD
Despite the medical evidence for persistence of the disorder, until recently, adult ADHD was
seldom diagnosed. Historically, awareness of adult ADHD has been limited, but growing
medical evidence in this area and changed DSM diagnostic criteria for childhood ADHD have
spawned more widespread recognition of this syndrome. Studies dating back to the mid-1970s
report the persistence into adulthood of ADHD symptoms such as inattention, impulsivity, and
overactivity. In 1980, DSM-III designated an Attention Deficit Disorder classification,
describing it as residual for adults, but that edition offered only a vague description of adult
symptoms.[12] In the revised third edition of the DSM (DSM-III-R),[13] the authors stated that
approximately one third of children with ADHD showed continuing signs in adulthood, but they
still did not code adult ADHD as a separate category. Only in the fourth edition of DSM (DSMIV) is there acknowledgement that the ADHD diagnosis persists into adulthood.[14] This edition
states that "symptoms attenuate during late adolescence and adulthood, although a minority
experience the full complement of symptoms of ADHD into mid-adulthood."[15] It is important to
note that while adult presentation of ADHD can occur, adult-onset ADHD is not a valid
diagnosis and most likely represents another condition. According to the DSM-IV definition,
ADHD begins in childhood. The diagnostic criteria state that evidence of the condition must be
demonstrated by age 7 years (Table 1).
Table 1. Evolving Diagnostic Criteria for ADHD[5]
DSM-III
- Name changed from hyperkinetic syndrome to attention deficit disorder
- Inattentiveness was central to diagnosis
- More emphasis on impulsiveness
- Can be diagnosed without hyperactivity
DSM-III-R - First time it included formal classification into adulthood
- For adults, it required symptom onset in childhood
- More emphasis on overactivity than DSM-III
- Name changed in this edition to attention-deficit/hyperactivity disorder
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DSM-IV
- Impulsive and hyperactive symptoms in same list but separately identified
- Distinction between inattention and other symptom clusters
Diagnosis and Clinical Features
The overall diagnostic criteria for an ADHD diagnosis include onset by age 7 years, impairment
from symptoms in at least 2 settings, and significant impairment in social, academic, or
occupational functioning. There are 3 subtypes of ADHD that have been defined by the DSM: a
predominantly inattentive type, a predominantly hyperactive type, and a combined type in which
elements of both inattention and hyperactivity are present. Diagnostic criteria suggest that those
diagnosed with the inattentive type have 6 or more inattentive symptoms present for more than 6
months and that those with the hyperactive type have 6 or more symptoms of hyperactivity
present for at least 6 months. To be diagnosed with the combined subtype, a person must have 6
or more inattentive symptoms and 6 or more hyperactive symptoms.
For those with the inattentive subtype, symptoms may include difficulty sustaining attention in
tasks or play and a lack of close attention to details in schoolwork or on the job. Other inattentive
symptoms include difficulty organizing tasks or activities; avoiding, disliking, or being hesitant
to engage in tasks of sustained mental effort; not following through on instructions at school or
work; and not listening when directly spoken to. Other symptoms include often losing things,
becoming easily distracted, and often being forgetful in daily activities.
Hallmark hyperactive subtype symptoms include fidgeting or squirming and leaving one's seat in
the classroom or in other situations where the expectation is to remain seated. Other symptoms
include talking excessively, feeling "on the go" or "motor driven," running about or climbing
excessively, having difficulty playing quietly, blurting out answers before questions are
completed, interrupting others, and having difficulty waiting one's turn.
Childhood vs Adult ADHD
As children mature into adulthood, the DSM-IV diagnostic threshold (at least 6 symptoms of
hyperactivity/impulsivity and/or inattention) often manifest differently. The formal restlessness
and hyperactivity that occurs in children is instead manifested as internal restlessness for adults
with ADHD. Whereas a child may be feeling "on the go" or running about and climbing too
much, adults may tend to overwork or choose occupations where getting up and down is an
essential component of the job. Examples include positions like sales representative or
stockbroker.
Impulsivity symptoms can lead to more serious consequences in adulthood. Adults with ADHD
often have a low frustration tolerance, which can lead to issues like high job and relationship
turnover, explosive or irritable episodes, and reckless driving. Poor time management and
difficulty completing and changing tasks are common manifestations of inattention. If possible,
adults often attempt to compensate for limited organizational skills by enlisting the assistance of
support staff.[16]
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Though ADHD symptoms generally may abate somewhat in adulthood, life also tends to become
more complex. Adults with ADHD have to get themselves up and organized for the day, and
then they often also have to get their children (who may also have ADHD) prepared for the day.
After a full workday, parents come home to children who need dinner, help with homework, and
their parents' time and attention. Adults with ADHD experience limitations in executive
functioning that make completing such multifaceted tasks taxing and difficult.
Validity of Adult ADHD Diagnosis
As described by Faraone and colleagues,[17] consistent evidence across a number of domains is
necessary to validate the adult ADHD diagnosis. One domain is reporting, which can
demonstrate that the person has had the clinical features that correlate with childhood ADHD.
This reporting can include self-report and the observations of significant others who knew the
person as far back as early childhood, such as a parent or older sibling. Both children and adults
show a family history of ADHD and a genetic concordance rate, which provides further
evidence.
Neuroimaging analysis shows somewhat similar brain abnormalities in children and adults,
although there are not enough comparable data to make a definitive statement.[17] All of the brain
imaging work with children and adolescents has used structural imaging, whereas the studies on
adults have employed functional imaging. In juveniles, the areas of the brain in which
abnormalities were observed were the prefrontal cortex, the striatum, the cerebellum, and the
corpus callosum.[18] In adults, it was the frontal brain regions.
In studies of molecular genetics, the evidence appears robust for both children and adults that the
D4 dopamine receptor gene is involved in the etiology of ADHD. This gene is known to mediate
a blunted response to the neurotransmitter dopamine, one of the presumed active
neurotransmitters in ADHD.[19]
Medication response is also another way to validate the diagnosis in adults. Two lines of
evidence support the validity.[17] Medications used in children are usually effective in adults with
ADHD. Furthermore, agents that treat ADHD, such as stimulant medications and reuptake
inhibitors, generally have effects on the two neurochemicals posited to be involved in ADHD,
namely norepinephrine and dopamine.
The course and outcome of impairments are similar in both groups, with both syndromatic and
symptomatic persistence. Based upon the limited clinical data available, both groups appear to
respond to treatment similarly. Moreover, numerous clinical correlates have been identified in
children and adults, including antisocial, depressive, and anxiety disorders. Adults also show the
clinically significant impairments that will be discussed below, including histories of school
failure, occupational problems, and traffic accidents.
Related Impairments
One area in which adults with ADHD suffer is educational outcome. According to evidence
gleaned from self-reports and high school transcripts, adults with ADHD experience significantly
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more grade retention (Milwaukee Young Adult Study [MKE]: 42% of people with ADHD vs
13% of the control group).[7] More students with ADHD are suspended (MKE: 60% ADHD vs
19% control) and more are expelled (MKE: 14% vs 6%). The drop-out rate is also higher (MKE:
32% vs 0%). On average, students with ADHD also had lower class rankings (MKE: 69% vs
50%) and lower GPAs (MKE: 1.7 vs 2.6). In addition, fewer enter college (MKE: 22% vs 77%).
For those who do go to college, those with ADHD have a lower college graduation rate (5% vs
35%).[7]
Once in the work world, problems continue. Employees with ADHD are more likely to be fired
(MKE: 55% of adults with ADHD vs 23% of the control group). They change jobs more often
(MKE: 2.7 jobs for people with ADHD vs 1.3 jobs in the control group over the 2-8 years since
leaving high school). They also display more ADHD/oppositional defiant disorder symptoms on
the job and garner lower work performance ratings (MKE: as rated by current supervisors). The
employment problems mentioned above lead 35% of those with ADHD to become selfemployed by the time they are in their 30s.[7]
Self-reports reveal that those with ADHD also have higher sexual-reproductive risks. They begin
sexual activity earlier than their peers (15 years vs 16 years), have many more lifetime sexual
partners (18.6 vs 6.5), and tend to stay with each partner for less time than other adults do. They
are less likely to employ contraception and have a far greater risk of teen pregnancy (38% vs
4%). Fifty-four percent of adults with ADHD do not have custody of their offspring. Adults with
ADHD are also at a higher risk of contracting sexually transmitted diseases (16% vs 4%).[7]
Motor vehicle driving risks are one additional area where there are striking differences between
those with ADHD and the general population. According to assessments based on self-report,
driving records, lab testing, driving simulators, and behind-the-wheel tests, adults with ADHD
are at significantly higher risk for motor vehicle accidents. Driving risk assessments revealed that
adults with ADHD displayed poorer steering, more false braking, and slower reaction times to
significant events than did other adults. When placed on driving simulators, ADHD patients
tended to accelerate into critical incidents rather than breaking away from them.[20] Adults with
ADHD were reported as using fewer safe driving habits, being more likely to drive before
licensing, and having more accidents (and more faults) than other drivers (2 to 3 for ADHD
adults vs 0 to 2 in the control group). There is a far higher percentage of ADHD adults with 2 or
more crashes than in the control group (40% vs 6%). The same is true for 3 or more crashes
(26% vs 9%). They also had more citations for speeding (4 to 5 vs 1 to 2), worse accidents
($4200 to $5000 in damage vs $1600 to $2200), and a greater percentage of crashes with injuries
(60% vs 17%). Drivers with ADHD had more suspensions/revocations (mean 2.2 vs 0.7) and
license suspensions (22% to 24% vs 4% to 5%).[7] Clearly, the presence of ADHD
symptomatology correlates with significant differences in one's life course and quality of life.
Pharmacologic Treatments
The medications shown to be effective for adults are similar to those that have been examined in
children. However, no medications are specifically approved for the treatment of adult ADHD,
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and the vast majority of the research has been on children and adolescents. To date, the medical
literature contains reports of just 9 controlled trials of off-label use of stimulants in 272
adults.[4,21-27] The existing evidence has shown that stimulants are effective, but the response
rates of adults have been somewhat less consistent than the response rates in trials with children.
This may in part be due to the lower doses and less strict diagnostic criteria employed in earlier
trials, as compared with those in later studies. For example, when stricter criteria and appropriate
adult doses are studied, such as in the mixed amphetamine salt trial by Spencer and
colleagues,[27] 70% of patients showed improvement of ADHD symptoms with the active
compound, compared with 7% of those taking placebo.
In the last several years, several longer-acting stimulant preparations have been marketed; these
include agents in the methylphenidate (Concerta, Ritalin-LA, and Metadate CD) and mixed
amphetamine salt (Adderall XR) classes. These medications offer significant advantages of
longer duration and less variability of effect than shorter acting versions of stimulants. The risk
of noncompliance and possible "rebound" effects (where ADHD symptoms dramatically return
after wearing off a dose) is reduced with these agents. Their durations of effect are generally in
the range of 8 to 12 hours, which fits the profile of a full day for an adult with ADHD. However,
a preliminary survey did find that almost 4 in 10 patients treated with a long-acting
methylphenidate preparation did require supplementation with shorter acting stimulants either in
the morning (to "ramp up" the onset of action) or in the afternoon (to extend the duration of
effect).[28]
Stimulants remain the standard-bearers of ADHD treatment, but nonstimulants also offer the
possibility of effective treatment. Studies of off-label use of nonstimulants for adult ADHD have
assessed the efficacy of essentially 3 classes of drugs: those that affect norepinephrine and
serotonin (tricyclic antidepressants and venlafaxine), those that affect norepinephrine and
dopamine (bupropion), and those that affect norepinephrine alone (atomoxetine). Monoamine
oxidase inhibitors, nicotinic agonists, and antihypertensives have also all been studied in
relatively small numbers. The tricyclic antidepressants have generally not been used in adults
because of concerns about the side effects associated with their use. SSRIs appear to have little
effect on core ADHD symptoms, although they seem to be beneficial for those with comorbid
depressive disorders.[4]
Clinical investigation of the efficacy of a new drug called atomoxetine, which is a
norepinephrine reuptake inhibitor currently undergoing US Food and Drug Administration
(FDA) review, has suggested its efficacy in the adult population. An initial double-blind,
placebo-controlled, crossover study of adults with ADHD (n = 21) demonstrated a mean
reduction in the ADHD rating scale of approximately 8.5 points (vs 0.3 points for placebo, n =
21) over a 3-week period with a dose of 80 mg/day (Spencer et al 1998).[29] Two additional
large-scale, randomized, controlled trials of atomoxetine in adult ADHD have also been
undertaken. At a daily dose of 60 mg/day titrated to a maximum dose of 120 mg/day, the
atomoxetine effects were apparent by week 4 and persisted and grew over 8 weeks of treatment.
Significant effects were demonstrated in both trials.[30,31] If approved by the FDA for use in
adults who have ADHD, atomoxetine will represent the first ADHD drug specifically available
for this indication. It has been considered for once-daily dosing since it has a relatively long
duration of effect. Also, because atomoxetine is not a stimulant, there is the possibility of a lower
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risk of inducing tics and psychosis, although this has not been clinically demonstrated to date
(Table 2).
Table 2. Adult ADHD Trials
Stimulant Trials in Adult ADHD
STUDY,
YEAR
DIAGNOSTIC N
CRITERIA
DESIGN
MEDICATION DURATION RESPONSE
RATE
Methylphenidate
Wood et al, RDC
1976[32]
15 D-B; P-C
Open-label
MPH
4 weeks
+
Pemoline, TCAs
Mattes et
DSM-III
al, 1984[33]
26 D-B; P-C;
crossover
MPH
6 weeks
-
Wender et DSM-III
al, 1985[22]
37 D-B; P-C;
crossover
MPH
5 weeks
+
Gualtieri et DSM-III
al, 1985[23]
8
MPH
2 weeks
+/-
Shekim et DSM-III-R
al, 1990[34]
33 Open-label
MPH
8 weeks
-
Spencer et DSM-III-R
al, 1995[25]
23 D-B; P-C;
crossover
MPH
7 weeks
+
Iaboni et al, DSM-IV
1995[35]
30 D-B; P-C;
crossover
MPH
4 weeks
-
D-B; P-C;
crossover
Pemoline and Dextro-amphetamine
Wilens et DSM-IV
al, 1996[36]
42 D-B; P-C;
crossover
Pemoline
10 weeks
+
Wilens et DSM-III-R &
al, 1999[37] DSM-IV
35 D-B; P-C;
crossover
Pemoline
10 weeks
-
Horrigan et DSM-III
al, 2000[38]
24 Open-label
Dextroamphetamine
16 weeks
+
Spencer et DSM-IV
al, 2001[27]
27 D-B; P-C
Dextroamphetamine
7 weeks
+
Total N =
11
300 Double-blind, Stimulants
N=9
Variable
Open-label, N
=3
Nonstimulant Trials in Adult ADHD
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STUDY,
YEAR
DIAGNOSTIC N
CRITERIA
DESIGN
MEDICATION DURATION RESPONSE
RATE
Reuptake Inhibitors
Wilens et DSM-III-R
al, 1995[24]
37 Retrospective, Desipramine,
chart review
nortriptyline
50 weeks
+
Wilens et DSM-IV
al, 1996[36]
43 D-B; parallel
Desipramine
6 weeks
+
Wender &
Reimherr,
1990[39]
14 Open-label
Bupropion
14 weeks
+
Wilens et DSM-IV
al, 2001[40]
38 D-B; P-C
Bupropion-SR
6 weeks
+
Findling et DSM-IV
al, 1996[41]
10 Open-label
Venlafaxine
8 weeks
+
Wilens et DSM-IV
al, 1995[24]
2
Venlafaxine
-
+
Adler et al, DSM-III-R
1995[42]
16 Open-label
Venlafaxine
8 weeks
+
Reimherr et DSM-III-R
al, 1995[43]
18 Open-label
Venlafaxine
8 weeks
+
Spencer et DSM-III-R
al, 1998[29]
21 D-B; crossover Atomoxetine
7 weeks
+
Mattes et
DSM-III
al, 1986[44]
13 Open-label,
retrospective
3 to 50
weeks
+
Taylor et
DSM-IV
[45]
al, 2001
17 D-B; crossover Guanfacine
7 weeks
+
12 Open-label
8 weeks
-
WURS
Open-label,
case reports
Antihypertensives
Propranolol
Amino Acids
Reimherr et DSM-III
al, 1987[46]
L-tyrosine
Nicotine and Cholinergic Agents
Conners et DSM-IV
al, 1996[47]
11 D-B; crossover Nicotine patch
2 days
+
Wilens et DSM-IV
al, 1999[37]
29 D-B; P-C
7 weeks
+/-
7 weeks
+
ABT-418
Alertness Medications
Taylor et
DSM-IV
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22 D-B; crossover Modafinil vs
10
al, 2001[45]
Modafinil
press
release,
2000[48]
amphetamines
DSM-IV
113 D-B; P-C;
crossover
Modafinil
7 weeks
-
ADHD, attention deficit/hyperactivity disorder; RDC, Research Diagnostic Criteria of Spitzer et
al[49]; DSM, Diagnostic and Statistical Manual of Mental Disorders; D-B, double-blind; P-C,
placebo-controlled; MPH, methylphenidate; TCAs, tricyclic antidepressants; WURS, Wender
Utah Rating Scale[50]
Conclusion
Since adult ADHD has been underdiagnosed and undertreated for an extended period of time, it
is important for physicians to understand the adult ADHD diagnosis and learn to recognize its
symptoms. Adult ADHD is a highly prevalent and impairing condition. Appropriate recognition
of the condition is critical since effective and well tolerated treatments, particularly longeracting, newer-generation versions of stimulants, are now available. New drugs, like the
norepinephrine reuptake inhibitor atomoxetine, are currently being developed, which may fit the
lifestyle of the adult with ADHD. Appropriate identification of adult ADHD is likely to lead to a
substantial reduction in the burden of the illness, not only to the individual, but also to his/her
family and the healthcare system in general.
*This update mentions off-label uses for some medications. These may describe clinical uses for
medications that have not been approved by the US Food and Drug Administration.
References
1. Centers for Disease Control and Prevention. Attention Deficit Disorder: A Public Health
Perspective. Atlanta, Ga. September 1999. Available at:
http://www.cdc.gov/ncbddd/adhd/publichealth.htm. Accessed October 10, 2002.
2. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attentiondeficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs,
American Medical Association. JAMA. 1998;279:1100-1107.
3. American Academy of Pediatrics. Diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder (AC0002). Pediatrics. 2000;105:1158-1170.
4. Wender PH, Wolf, LE, Wasserstein J. Adults with ADHD: an Overview. Ann N Y Acad
Sci. 2001;931:1-16.
5. Arnold LE, Jensen PS. Attention deficit disorders. In: Kaplan HI, Sadock BJ, eds.
Comprehensive Textbook of Psychiatry, vol 2. 6th edition. Baltimore, Md: Williams &
Wilkins; 1995.
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6. Wender PH. Attention Deficit Hyperactivity Disorder in Adults. New York: Oxford
University Press; 1995:80-81.
7. Barkley RA, Murphy KR. Attention-Deficit Hyperactivity Disorder: A Clinical
Workbook, 2nd ed. New York: Guilford Publications Inc; 1998.
8. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity,
cognition, and psychosocial functioning in adults with attention deficit hyperactivity
disorder. Am J Psychiatry. 1993;150:1792-1798.
9. Murphy K, Barkley RA. Attention deficit hyperactivity disorder adults: comorbidities and
adaptive impairments. Compr Psychiatry. 1996;37:393-401.
10. Roy-Byrne P, Scheele L, Brinkley J, et al. Adult attention-deficit hyperactivity disorder:
assessment guidelines based on clinical presentation to a specialty clinic. Compr
Psychiatry. 1997;38:133-140.
11. Shekim WO, Asarnow RF, Hess E, et al. A clinical and demographic profile of a sample
of adults with attention deficit hyperactivity disorder, residual state. Compr Psychiatry.
1990;31:416-425.
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Third Edition. Washington, DC: American Psychiatric Press; 1980.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Press; 1987.
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press;
2000.
15. Wender PH. Adult manifestations of attention-deficit/hyperactivity disorder. In: Sadock
BJ, Sadock VA, eds. Kaplan and Sadock's Comprehensive Textbook of Psychiatry.
Philadephia, Pa: Lippincott Williams and Wilkins; 2000:2688-2692.
16. Weiss MA, Hechtman LT, Weiss G. ADHD in Adulthood: A Guide to Current Theory,
Diagnosis, and Treatment. Baltimore, Md: Johns Hopkins University Press; 1999.
17. Faraone SV, Biederman J, Spencer T, et al. Attention-deficit/hyperactivity disorder in
adults: an overview. Biol Psychiatry. 2000;48:9-20.
18. Castellanos FX. Toward a pathophysiology of attention-deficit/hyperactivity disorder.
Clin Pediatr. 1997;36:381-393.
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Adult ADHD Assessment
1. The similarities of the clinical presentations of children after encephalitis and what we
currently see as ADHD contributed to the understanding that structural damage could
lead to symptoms like ____________.
a. Restlessness
b. Inattention
c. Distractibility
d. Behavioral disturbances
e. All of the above
2. ADHD appears to have a ______ genetic rate, with roughly ___% concordance with firstdegree relatives.
a. Low; 8%
b. Moderate; 30%
c. High; 50 %
3. Comorbidity is prevalent in individuals with adult ADHD, especially with mood
disorders, learning disabilities, and _________.
a. Substance abuse
b. Diabetes
c. Coronary artery disease
d. Epilepsy
4. Acknowledgement that ADHD diagnosis persists into adulthood was not present until
the___.
a. DSM II
b. DSM III
c. DSM III-R
d. DSM IV
5. The DSM IV lists the diagnostic criteria for ADHD as: onset by age 7; impairment from
symptoms in at least 2 settings; and ______________ in social, academic, or
occupational functioning.
a. Significant impairment
b. Moderate impairment
c. Complete impairment
d. Slight impairment
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6. There are 3 subtypes of ADHD that have been identified by the DSM:
a. A predominantly inattentive type, a predominantly hyperactive type and a combined
type in which elements of both inattention and hyperactivity are present.
b. A predominantly manic type, a predominantly hyperactive type and a combined type
in which elements of both mania and hyperactivity are present.
c. A predominantly disorganized type, a predominantly hyperactive type and a
combined type in which elements of both disorganization and hyperactivity are
present.
d. None of the above
7. Neuroimaging, genetic analysis, and _____ are all used to assess and/or support the
validity of an adult ADHD diagnosis.
a. IQ tests
b. Personality tests
c. Medication response
8. Adults with ADHD have higher rates of
a. Sexual-reproductive risks
b. Motor vehicle accidents
c. Job turnover
d. All of the above
9. Adult ADHD has been historically _________ and _______.
a. Under diagnosed and undertreated
b. Over diagnosed and over treated
c. Misdiagnosed and mistreated
d. Under diagnosed and mistreated
10. A new drug called atomoxetine is a
a. Epinephrine reuptake inhibitor
b. Norepinephrine reuptake inhibitor
c. Serotonin reuptake inhibitor
d. Dopamine reuptake inhibitor
Florida Heart CPR*