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Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a common disorder afflicting 4% to 12% of school-age children[1] and up to 4.7% of the American adult population.[2] Despite this high prevalence, the condition is often overlooked in adults. This is most unfortunate because ADHD is readily identifiable and amenable to treatment. Improving the outcomes of ADHD patients should be a high priority for all medical health professionals. This clinical vignette typifies a case of adult ADHD, and the ensuing discussion highlights the impact of this illness and the necessity for treatment.


Presentation
Campbell is a 31-year-old nurse who presented to her psychiatrist subsequent to the recommendation of her internist. She reported that she was doing poorly at work. Her supervisor was concerned that she was frequently late, made careless mistakes, and had regular confrontations with coworkers. Campbell also reported tension with her husband in regard to her chronic disorganization and failure to pay household bills on time. Furthermore, in the past year she had received 2 speeding tickets and had caused a traffic accident. She also mentioned her husband's concern that she regularly was drinking 2-3 glasses of wine in the evenings. Ultimately she admitted that was feeling quite anxious and depressed over her circumstances.
As a young girl, Campbell did well in school and rarely got into trouble. Few concerns were raised until her high school counselors lamented that her marginal grades did not reflect the exceptional standardized scores on her college entrance examinations. While in high school, Campbell saw several psychotherapists. The focus of discussion was her tense relationship with her parents and her eating disordered behavior. During late adolescence, she also began to experiment with alcohol and marijuana.

When Campbell entered her early 20s, her alcohol abuse intensified. At her family's insistence, she attended Alcoholics Anonymous for several months but chose not to continue. This was followed by 2 separate trials of antidepressant medication, both of minimal benefit. After these treatments failed, she was diagnosed with bipolar disorder. Her family history contributed to this diagnosis. Campbell's mother suffered from chronic depression and her brother, a recurrent petty criminal, was also under psychiatric care. In addition, her sister's son had recently been diagnosed with a learning disability.

On the day of this recent examination, the office staff noted that while she was in the waiting room, Campbell displayed angry impatience when the doctor was delayed 20 minutes. During the interview, she was anxious and fidgety at first, but her anger quickly subsided and she was able to articulate effectively the distress that her free-floating anxiety caused her. She reported problems with concentration and focus. She also noted that her motivation was inconsistent and that her organizational skills and memory were subpar. Although she was frustrated, she was not hopeless. She denied suicidal ideations and displayed no evidence of a psychotic thought process.

Campbell reported a history of exertional asthma and atypical migraines. A recent laboratory examination revealed mild anemia, but all other blood indexes were within normal limits. Her current medications included sertraline 100 mg daily, which, she complained, diminished her libido. For the past 12 years, she smoked about 10 cigarettes each day and typically consumed 2 glasses of red wine each evening.

Medical Evaluation and Intervention
After the diagnostic interview, the psychiatrist administered a full battery of diagnostic tests. The Hamilton Depression Scale (HDS) revealed mild levels of depression; the CAGE Questionnaire indicated alcohol use; and both the Adult ADHD Self-Report Scale v 1.1 and the Connors Adult ADHD Rating Scale were positive. Neither the Young Brown Obsessive-Compulsive Disorder Scale (Y-BOCS) nor the Young Mania Rating Scale (YMRS) was elevated.

Campbell was diagnosed with ADHD, combined type, and treated with extended-release mixed amphetamine salts (MAS XR); the dose eventually was titrated to 30 mg daily. In addition, the psychiatrist referred Campbell to a psychologist for cognitive-behavioral therapy.

Outcome
Within several weeks of commencing treatment, Campbell reported that she was doing better. On medication, her concentration improved and she was performing more accurately at work. Her fatigue had lessened, and it was easier for her to transition from sleep to wakefulness. As a result, Campbell's punctuality at work improved. Her husband noted that she was more attentive to their conversations and was paying bills on time. She also reported less generalized anxiety and noted that her alcohol consumption had diminished.

Cognitive-behavioral therapy had allowed her to understand the impact that her previously undiagnosed ADHD had on her life, and she was benefiting from the organizational techniques that her therapist offered. Six weeks into treatment, noting that her depressive symptoms were relieved, the psychiatrist discontinued the sertraline, and her libido returned to baseline.

Discussion
Campbell's situation is typical of many adults with ADHD. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. Although the condition is commonly thought of as a childhood disorder, an estimated 30% to 60% of children diagnosed with ADHD have symptoms that persist into adulthood.[3] Hyperactivity tends to diminish with age but inattention often persists.[4] Symptoms of inattention, such as making careless mistakes, having difficulty sustaining attention and staying organized, and being easily distracted and forgetful, are the complaints that compel most adults to seek treatment.[5]
ADHD is a pervasive disorder that affects all aspects of one's life, including school and work performance and interpersonal relationships. Parents of school-age children who have these symptoms are often mandated by the schools to seek evaluation. However, as with Campbell, many adults present because of marital strain or job difficulties. Clinicians should be sensitive to the fact that ADHD symptoms are frustrating both to the individual afflicted and to those around that individual.

Clinicians should be aware that ADHD runs in families. Extensive research has been conducted on the genetics of the condition. Adult relatives of children with ADHD have elevated rates of the condition, as do child relatives of adults with ADHD.[6] ADHD is considered one of the most heritable of all traits.[7]
ADHD is a disorder of underperformance. One common myth is that ADHD is associated with low intelligence. In fact, intelligence is an unrelated variable, although individuals with higher intelligence can compensate for their deficits to an extent, and therefore are typically diagnosed later in life.[8] Although many struggle in school, it is not uncommon for adults with ADHD to have a history of some academic success. Consistently demonstrating their capability is a constant challenge, and this lack of tenacity accounts for Campbell's undistinguished grade point average in contrast to her high college entrance examination scores.
Need for Accurate Diagnosis

ADHD is often misdiagnosed. The reasons for this phenomenon are multifactorial. Many individuals express feelings of frustration over the totality of their symptoms, and unless their complaints are adequately clarified, the clinician may inaccurately conclude that the patient is suffering from a depression.[9] As with Campbell, multiple treatment failures with antidepressant medications should signal that the depression diagnosis is erroneous. Most adults who have ADHD also have at least 1 other psychiatric condition.[2] Common comorbidities include mood disorders, anxiety disorders, substance use disorders, learning disabilities, and personality disorders.[10] Deciphering these comorbidities often presents a diagnostic challenge.

Diagnostic Tools
To aid the process of diagnostic accuracy, symptom assessment scales are of great benefit. Many scales are proprietary and entail a per use cost. The Adult ADHD Self-Report Scale was developed by the World Health Organization and is in the public domain and thus can be used free of charge. Given the high prevalence of ADHD and the importance of delineating ADHD from its many comorbid conditions, it is advisable to use these scales early in the diagnostic process along with the more traditional mood, anxiety, and substance abuse rating scales.[11]

Roughly 20% of adult patients with major depression and generalized anxiety disorders are estimated to also have ADHD.[12] At least 15% of those with bipolar disorder meet the criteria for ADHD, and one quarter of individuals with substance use disorder have ADHD.[13] Failure to identify and treat the ADHD comorbidity results in a suboptimal clinical outcome. Patients being treated for these primary conditions, particularly those with a poor response to treatment, should be re-evaluated for the presence of ADHD.
Distinguishing ADHD From Bipolar Disorder

One of the most important distinctions to make in an adult is between bipolar disorder and ADHD. Many times hyperactivity is misinterpreted as hypomania or mania. However, several differentiating characteristics distinguish the 2 disorders. ADHD starts early on in life, often evident by age 7, and is associated with learning problems; ADHD is a chronic condition closely associated with academic and behavioral problems. Bipolar disorder is less prevalent, but more commonly diagnosed in adults. These bipolar symptoms are episodic and characterized by normal or near-normal interepisode functioning. Patients with mania have the potential to become psychotic, a phenomenon not associated with ADHD. The mood episodes in bipolar disorder are lengthy; depressive and manic states can last for weeks and months. By contrast, ADHD is characterized by rapid mood swings, with patients often demonstrating mood fluctuations within the course of an hour. An unintended benefit of pharmacologic ADHD treatment is mood stabilization. Similar to many adults with ADHD, Campbell had been misdiagnosed with bipolar disorder.[14]
Impact of ADHD

Car Crashes and Criminality
The public health implications of ADHD are profound and need to be appreciated by physicians and public policy makers alike. Like Campbell, individuals with ADHD frequently encounter driving problems. A study conducted by Russell Barkley revealed that young adults with ADHD were far more likely to have their licenses revoked.[15] A percentage of young adults with ADHD start driving without bothering to obtain a driver's license. Compared with cohorts without ADHD, afflicted young adults were more likely to receive multiple traffic and speeding citations, and be involved in vehicular crashes.[15]

Despite Campbell's alcohol use, she had minimal contact with the criminal justice system. Her brother was less fortunate, and this reflects the experience of many individuals with the hyperactive-impulsive type of ADHD. This group is twice as likely to have been arrested and convicted of a crime. In a long-term study, 9% of individuals with ADHD had been jailed compared with 1% of those without the condition.[16] Evidence suggests that early intervention is the primary determinant for reducing the problematic relationship between ADHD and criminality.

Life Satisfaction Is Lower
Recent studies have confirmed that adults with ADHD have lower levels of satisfaction in all domains of life. Only 47% of adults with ADHD report satisfaction with their family life, compared with 68% of those without the condition.[17] Compared with those without the condition, twice as many individuals reported contentment with their professional life.[17] It is no small wonder that those with ADHD experience life differently from those without ADHD: Adults with ADHD are twice as likely to be divorced and 3 times more likely to be currently unemployed.[17]

Treatment
In the last several years, pharmacologic treatment of ADHD has become more sophisticated. Multiple studies have confirmed that these medications positively affect core ADHD symptoms. They work by enhancing levels of dopamine and norepinephrine.[18] At present, 3 agents have received US Food and Drug Administration (FDA) approval for use in adults -- MAS XR, dexmethylphenidate XR, and atomoxetine. However, several other agents are widely used in clinical practice and treatment trials for adults with ADHD. The 2 major stimulant categories used to treat ADHD are the amphetamines and methylphenidates; nonstimulants include atomoxetine. Stimulants comprise the majority of child and adult ADHD treatment.

Amphetamines include dextroamphetamine (d-amphetamine) and MAS. The major recent advances have occurred with delivery mechanisms. MAS XR is an extended-release product that provides 10-12 hours of coverage, which allows for more convenient and confidential administration of the medication. Lisdexamfetamine dimesylate (LDX), which was approved in 2007 for use in children may become another alternative for adults. LDX is composed of d-amphetamine linked to the amino acid lysine. The lysine attachment renders the molecule inert until gastric enzymes cleave the lysine and activate the molecule. The necessity of the gastric enzyme exposure before activation ensures that the medication cannot be misused if snorted or intravenously injected. LDX is also long-acting and has consistent pharmacodynamic properties.[19]
Methylphenidate is available in immediate-release (4-hour duration of action), longer acting (6- to 8-hour duration), and extended-release (10- to 12-hour duration) formulations. Osmotic-release oral system (OROS) methylphenidate slowly releases the active ingredient over 12 hours. Dexmethylphenidate utilizes only the active or dextro portion of the methylphenidate molecule; dexmethylphenidate is available in immediate- and extended-release formulations.[20] Finally, the methylphenidate transdermal system is a nonoral alternative that delivers the active ingredient via skin patch, with a duration of effect for up to 3 hours after the patch is removed (with optimal wear time of 9 hours).
In 2002, the FDA approved the nonstimulant atomoxetine for ADHD treatment. Atomoxetine is a selective norepinephrine reuptake inhibitor. This medication often takes longer to take clinical effect, but has a powerful anxiolytic effect and minimal abuse potential.[21]