Attention deficit hyperactivity disorder in adults

Kathmandu University Medical Journal (2007), Vol. 5, No. 2, Issue 18, 225-229
Case Series
Attention deficit hyperactivity disorder in adults
Perera MH1, Padmasekara G2, Perera CM3
Consultant Psychiatrist, 2Final Year Medical Student, Monash University, Australia, 34th Year Medical Student,
Monash University, Australia


Abstract
Introduction: Attention deficit hyperactivity disorder (ADHD) is a disorder that begins in childhood, characterised
by hyperactivity, inattentiveness and impulsivity. The disorder persists into adulthood but with some differences in
the way it presents.
Methods: This case series included 29 adult patients from a metropolitan, office-based, private psychiatric
consultant practice over a period of four years.
Results and Discussion: 72% were males and 28% were females, with a mean age of 28 years. Management
involved biological, psychological and educational approaches. Stimulants, including dexamphetamine and
methylphenidate, were mainstay in biological treatment and non-stimulant medications, such as, atomoxetine was
used infrequently. Comorbidities such as substance abuse and mood disorders were common among the study
group.
Conclusion: ADHD is an illness, the symptoms of which may persist into adulthood. With diagnosis of the disease
and the use of stimulants, adjunctive medications as appropriate, and behavioural interventions the patients will
obtain relief.


ttention deficit hyperactivity disorder (ADHD)
lack of ‘moral control’. He found that ADHD was
Ais an illness characterised by inattention,
more prevalent amongst children with cerebral issues,
hyperactivity and impulsivity. Diagnostic criteria for
and that it also affected children with normal IQ.
the disorder and a brief overview of the illness has
This supports current literature, that ADHD is a
been provided in the Diagnostic and Statistical
multifactorial disorder not always associated with
Manual by the American Psychiatric Association
lowered IQ6. Kramer and Pollnow described
(DSM-IV). International Classification of Diseases
hyperkinetic syndrome in children in 19327. This
(ICD 10), too has this recorded as an illness. As an
disorder was also called minimal brain dysfunction
illness that begins in childhood, there was a view that
syndrome and the earlier versions of ADHD was
the disorder did not persist into adulthood. However
called attention deficit disorder (ADD) (DSM-IV). A
it is now well known that it persists into adulthood1,2,3
detailed overview of historical aspects of adult
1,2,3. It is due to the fact that the individual/s are able
ADHD has been provided by Doyle8.
to control some aspects of the illness and/or the

features of hyperactivity, which tends to attenuate.
The American Academy of Paediatrics

Subcommittee9 has detected rates from 6.9% to
This article deals with an overview of the attention
10.3% depending on whether it is a school sample or
deficit syndrome mainly form the perspective of
community sample respectively.
adults, followed by an analysis of one of us (MP’s)
It is considered that at least 50% of those diagnosed
clinical experience of seeing mainly adult patients
in childhood continue onto adulthood10.
with ADHD.


It is sometimes thought that ADHD is a disorder
Review of literature
present only in the Western European cultures.

According to Thome4, the description of “Fidgety-
However, there are reports in the English literature
Phillip” by Heinrich Hoffman, a physician in
reporting this problem from other parts of the globe.
Germany in 1846 was probably the first mention of

ADHD (as we know today) in the medical literature.

Correspondence
In the English literature, George Stil5, is credited to
Dr Mahendra H Perera,
have described the condition in 1902. He described
Consultant Psychiatrist
43 children who had a constellation of symptoms
Suite B, Albert Road Clinic,
similar to that of the modern ADHD criteria.

31 Albert Road
MELBOURNE VIC 3004, Australia
Although phenotypically accurate, he attributed it to a
Email: relax101@gmail.com
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Yoshimasu et al11 have explored ADHD in Japan and
stimulation, audio-visual entrainment, and coaching
noted the multifactorial nature of this illness and the
on life skills and adapting to the ADHD24.
need for a holistic approach. Al-Haidar12 described

their experiences with ADHD in a child psychiatry
Materials and methods
clinic in Saudi-Arabia. A Korean community based
Data from 29 patients with ADHD seen over a period
study also reported children with ADHD13. Oncu B14
of four years in a metropolitan, office-based,
also described ADHD in a Turkish population.

psychiatric private practice were analysed
ADHD has also been explored in China15 and India16.
retrospectively. These were derived form

approximately 350 patients that were seen by the
ADHD appears to have a high heritability index of
principal author. The patients included those who
about 0.817 and as such, genetic links are being
were referred from other health professionals for
studied. However, at present there is no strong
specialist opinion, those who had self-diagnosed and
evidence for any one gene in particular although there
were seeking confirmation and patients who were
are a few candidate genes which are gathering
already diagnosed with ADHD and requiring
increasing evidence18. Within this arena, it is thought
continuing care. The case series provides a cross
that a dopamine imbalance may be a
sectional overview of these patients. Data was
causative/contributing in ADHD19.
obtained from the medical records.


Social factors alone are no longer thought to be a
Results and Discussion
causative agent in ADHD pathophysiology.

The patient population consisted of 21 males and 8
However, factors such as smoking during pregnancy
females. The mean age was 37 years (SD 10) with
leading to fetal hypoxia, premature delivery, lead or
the youngest patient being 19 years and the oldest
alcohol poisoning, and head injury have been
patient being 63 years. The mean age at diagnosis
implicated with ADHD20.
was 28years (SD 13). Some patients had not been

diagnosed previously as their symptoms were
The treatment of ADHD was serendipitously
predominantly of the inattentive type and did not
discovered by Bradley21. In Bradley’s initial study,
show the classical hyperactivity.
he sought to reduce post-tap headaches in normal

children by administering benzedrine. The effect on
Although those who were diagnosed as adults did
headaches was negligible, however teachers noted
have symptoms in their childhood, for one reason or
remarkable improvement in certain children’s’ school
another, they were not diagnosed. As they matured
performance, and as such, a second trial was
they have developed coping strategies. However, the
commenced, which showed Benzedrine’s positive
manifestations related to the illness have continued to
effects. However, medicating children was
be problematic for these patients. Therefore, making
condemned after much skepticism, and benzedrine in
a diagnosis itself, gives them a measure of relief
ADHD took a low profile ‘till the 60’s, when children
because this helps them to understand their
were found to be helped by methylphenidate.

difficulties. Most of these patients have required the
Antipsychotic medications too have been used in the
biological treatments to control the manifestations of
past (and sometimes even now) in an attempt to
the illness.
reduce the symptoms of ADHD. Clonidine too is

used in childhood ADHD.
Table 1: Medications

Medication
N
%
Stimulants, such as dexamphetamine, and
Dexamphetamine 15
52
methylphenidate are considered to be the first line of
Methylphenidate 8
28
medication in ADHD1. Atomoxetine, which is a non
Atomoxetine 1

3
stimulant medication, is also considered effective in
No Stimulant medication
5
17
ADHD22. Other medications are anti depressants,23

mainly bupropion.


The majority (52%) were on dexamphetamine, and
Non-drug interventions have also been promulgated
28% were on methylphenidate (Ritalin). Table 1
as primary treatment strategies for ADHD. These
gives details of medication use. Dexamphetamine
have been well described by Weiss and Weiss1.
was the medication of choice for most patients, as it
Other treatment modalities, if relevant and applicable
is available in the Pharmaceutical Benefits Scheme
include behavioural modification, educational
(PBS) in Australia, which provides medication at
interventions, dietary modification, cerebellar
subsidised prices. Initially dexamphetamine was the
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only medication available under the Pharmaceutical
ADHD responds well to stimulant medications,
Benefits Scheme (PBS), which heavily subsidises the
however there are a few patients who may not require
drug cost. Hence most patients were started on
medications in the management of their illness.

dexamphetamine. However recently,
There were five patients (17%) who chose not to use
methylphenidate was also brought under this scheme.
medications, primarily of their own choice. Once the
In one individual the stimulants were ceased due to
illness was explained, these patients were
the probably use of illicit substances coupled with a
comfortable to not take medication and they were
resurgence of a pre-existing delusional disorder. One
able to cope with the symptoms.
patient was treated with the non-stimulant medication

atomoxetine (Strattera), which is a relatively new
Conclusion
treatment. The cost of atomoxetine is a major barrier
From our review of the literature it is noted that the
to trial its use in the adult ADHD population since it
symptoms of ADHD have been reported since the
is not yet a subsidised. Psychotropics used
19th century, it is prevalent in may parts of the world,
concomitantly include sodium valproate, sertraline,
and for which medication has been used from the 20th
citalopram, venlafaxine, amitryptilline, oxazepam,
century. ADHD is a disorder which begins in
diazepam, quetiapine, chlopromazine. Physical
childhood and may persist into adulthood. Various
evaluation prior to initiating stimulant therapy is
etiological theories exist, though none have been
desirable. Pre-treatment workup for these patients
proven. Pharmacological treatment is usually with
included full blood examination, urea and
stimulants and is effective and most often are
electrolytes, liver function tests, thyroid function
required. They need to be complemented by
tests, an electrocardiogram.
behavioural techniques and removal of known

precipitants.
Whilst there is a likelihood that the stimulants could

be abused in the present series only two patients
Case Study
attempted to do so and became obvious through the
Mrs X, is a 46 year old married, professional, lady
strict monitoring systems we had in place. This is in
with two children, who was referred with a history of
keeping with the general understanding of those who
chronic back pain, opiate and alcohol dependence,
treat the syndrome even among known persons with
and depression. Further elucidation of her history
substance use disorders28. The risk of misuse of
revealed that she had distractibility, impulsivity and
stimulants will be minimised if proper precautionary
difficulties with coping. She was diagnosed for the
measure are taken when prescribing the drugs. In
first time with ADHD at that juncture. She
view of the potential for the abuse of stimulants
responded well to methylphenidate (Ritalin).

prescriptions for such medications should be
Although she abused the other substances, the Ritalin
carefully controlled with close liaison with the
was not misused. On further evaluation it later
dispensing pharmacist.
became evident that both of her children suffered

with ADHD and in fact she thought that even her
ADHD is not a stand-alone disease. Psychiatric
aged mother may have suffered with the same
comorbidities were prevalent, being present in 23
syndrome. Although she had a high IQ and had
patients, and of this, 14 patients had mood disorders
achieved a high status in her professional life she
(Table 2). There was a family history of ADHD in
confessed that these were achieved with a great deal
13 patients (45%). It is important as clinicians, that
of difficulty due to a lack of focus, primarily. She
we are aware that co-morbid conditions may exist.
reported that the impulsivity and distractibility were

greatly reduced with the stimulant therapy. Effective
Insert Table 2 Here
treatment of her ADHD and some changes to her
Table 2: Comorbidities
lifestyle has helped her to remain abstinent from
Comorbidities N*
%
alcohol and other substances of dependence, and
Substance Use
17
59
resolved the tensions that had occurred between
Mood Disorder
14
48
herself and her husband who is also a professional.
Other
7
24
He has vouched for the veracity of her story.

No Co-morbidities
6
21
*Patients may have multiple comorbidities


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Appendix 1: Clinical Practice Points
• Diagnosis needs to be made with history and collateral information.
• Some patients have primary symptoms of inattention and impulsivity with minimal hyperactivity.
• In the adult patient, get retrospective information about childhood behviour to detect the presence
of symptoms during childhood.
• Although the history is of prime importance there are ancillary investigations such as
computerized tomography (CT) and cerebral imaging techniques which are available that are
complementary diagnostic aids to the history
• Baseline investigations including full blood examination, urea and electrolytes, liver function
tests, electrocardiogram and thyroid function tests.
• Illness education for the patient and significant others.
• Due precautions to be used when prescribing stimulant medications.
• Close monitoring and titrating the dose of stimulants.
• Psychological interventions in addition to medication.
• Avoidance of known precipitants e.g. allergens etc.
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