ADHD symptoms change across the lifespan, and across genders.
At a recent Lundbeck Institute for general practitioners, Dr Eleanor Holzapfel, a psychiatrist in private practice in Johannesburg, took the audience through ADHD in a nutshell. She explained that the core domains of ADHD include impulsivity, inattention, hyperactivity, but also include emotional dysregulation. In children, boys are more impaired than girls, with a male to female ratio of 4:1. This may be due to boys presenting with more hyperactive and impulsive symptoms, whereas girls are more inattentive and therefore a diagnosis may be missed. The picture changes when adulthood is reached. The ratio now changes to 3:2 male to female. Women are also twice as likely to have a lifetime history of psychiatric comorbidities, including Major Depressive Disorder (MDD), anxiety disorders and more past DSM Axis 1 disorders.
The symptoms of ADHD may change or improve over the lifespan, but it is also important to realise that the symptoms and presentation of hyperactivity and impulsivity in adults is different to that observed in children. In adulthood untreated hyperactivity and impulsivity causes significant functional impairment and may result in unplanned pregnancies, underachievement, unemployment, suicide, road accidents, marital discord, substance abuse and a general decreased quality of life.
ADHD is also a disorder which involves executive functioning, and as many as 86% to 96% of adult patients experience impairment in this area. Executive functioning includes many domains like emotional control, self-monitoring, organisation, impulse control, planning or prioritising, task initiation, working memory, flexibility and inhibitory control.
ADHD is multifactorial in origin
There are many proposed causes and risk factors for ADHD, just as there are many environments which may exacerbate the condition. Some of these may include a genetic disposition for the disorder, fetal exposure to toxins, epigenetic changes, psychosocial influences, chaotic family environments, peer influences, mismatch within the school or work construct, substance abuse, low self-esteem and social disability.
When an ADHD diagnosis is made, doctors can use any one of a number of standardised rating scales. These rating scales can assist the doctor with the screening and diagnosis of ADHD as well as monitoring response to treatment. They also need to look at symptoms from different areas in the patient’s life, such as home, school or the workplace. If possible, getting a family member or partner’s perspective can be extremely helpful. The developmental history, including past symptoms of ADHD as well as a family history should be taken into account. Before prescribing medication, consider recent or unstable substance use disorder, a history of seizures, cardiac history, history of diversion and other psychiatric co- morbidities.
What are the treatment goals and expectations when treating a patient with ADHD?
The treatment of ADHD needs to ensure that the patient has a sufficient response to the medication, the symptoms are decreased, there is improved quality of life, there is decreased functional impairment and an improved academic or occupational performance. Pharmacological treatment could include the stimulants methylphenidate and amphetamines; the non-stimulant atomoxetine or off-label use of other medicines such as bupropion, venlafaxine, clonidine, guanfacine and modafinil. Treating ADHD requires trial and error, and a lot of patience! There are many dosing options and combinations and an individualised treatment plan, which is multi-modal and multi- disciplinary needs to be developed. Monitor blood pressure, pulse, weight and height at each visit.
Treatment should also include non-pharmacological options, such as behavioural therapy and psycho-education. There is limited evidence for exercise and diet.