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Wednesday, June 19, 2013
Attention Deficit Hyperactivity Disorder
Young adult with ADHD
I write about a 29 year old male who has demonstrates all of the characteritics of ADHD. When he was young (high school age) he was tested and the results said that he had mild AD but that his testing indicated that with minimal effort he could pass in school. Therefore, there was no recommendation for treatment with medicine, and he has been trying to deal with it as best he can. With the stressors of adult life, job, finances, family, etc., it seems that the characteristics and symptoms are beginning to trouble him more and more. He has read up about ADHD, feels sure that he has it, but is unsure whether the medications that are designed for smaller children will work with an adult. He is also perplexed as to whether he wants to get into trying stimulants. He already has difficulty sleeping because he works rotating shifts. He is contemplating taking sleeping medication to enable him to sleep better which he hopes will help the other symptoms. We have the question, what do you treat the ADHD or the inability to sleep? And where does an adult go for this type of help?
The information provided raises more questions than it answers. Why would ADHD symptoms be more troublesome with age?
It sounds as if this patient did not have enough trouble early on to get an evaluation until high school, at which time it was considered not impairing enough to need treatment. There are several possible explanations: Was he possibly so bright that he was able to compensate academically as a child, but as life became less structured in H.S. and especially as an adult, his intelligence could no longer make up for inattentiveness and disorganization? Or was he in such a poor school that everyone was doing equally badly? Could he have a progressive neurological disorder or traumatic brain injury cause actual deterioration over time in mental function including executive function? How about substance use, such as marijuana, causing gradual brain deterioration? More benignly, could he have depression or anxiety mimicking ADHD? (Mood disorders have a higher rate of onset after puberty.) It seems that a comprehensive neurological and psychiatric evaluation, including not only physical exam and mental status exam, but possibly brain scan and/or EEG might be in order.
Another issue is the sleep cycle disruption by shift work. Sleep deprivation can bring on mood disorders and interfere with attentiveness and other executive function. Did the symptoms just get intolerable after starting shift work?
Certainly sleep hygiene needs to be a prime consideration. This might require changing jobs. Meanwhile, over-the-counter low-dose melatonin might be a way of initiating sleep onset when necessary to do so out of the normal phase.
If a decision is made to medicate ADHD, adults respond to stimulants, although perhaps not quite as well as school children do. They and atomoxetine, not a stimulant, have been shown in controlled trials to work well in adults and have an FDA-approved indication for ADHD. In addition, other medications that often do not work as well in children have good controlled evidence of off-label efficacy in adults, such as tricyclic antidepressants, MAO inhibitors, modafinil, even nicotine. Guanfacine is another nonstimulant with controlled evidence of efficacy. Various medical and other treatment options are described in "A Family's Guide to ADHD," 2004, Handbooks in Health Care, Newtown, PA 18940, WWW.HHCbooks.com. See especially Table 4-2 on pp. 36-37. The analogous reference for professionals, with more details about diagnosis and treatment options, is "Contemporary Diagnosis and Management of ADHD" (same publication details).
This young man should have evaluation by a psychiatrist or neurologist with experience in ADHD.
L Eugene Arnold, MD, MEd
Professor Emeritus of Psychiatry
College of Medicine
The Ohio State University