Until recently, little was known about the epidemiology of attention-deficit/hyperactivity disorder (ADHD) in adults. Bottom-up studies following children with ADHD into adolescence had shown variable rates of persistence, some of which depended on the definitions used. The traditional diagnosis was complicated by the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, which stated that ADHD could be diagnosed with inattentive symptoms alone. This resulted in diagnostic inconsistency as earlier investigations demanded the presence of hyperactivity while others did not. Diagnosis also depended on the site, the cohort, whether interviews versus rating scales were employed, and whether the subject or their parent were the source of information.

There is a complex overlap between major depressive disorder (MDD) and attention-deficit/hyperactivity disorder (ADHD). The different therapeutic options for adult ADHD mirror those used for children with ADHD. Both stimulant and nonstimulant medications are used to treat the disorder.

Fact or myth? ADHD is a solution for teachers and school psychologists to cope with the problem of uproarious or unusual kids. ADHD is a mixed bag for all suspected organic patients in psycho-therapy.

Four temperament factors, that are stable throughout life can be decomposed in terms of their underlying genetic structure and their relationship to neurotransmitters: Novelty Seeking, Reward Dependence, Harm Avoidance, Persistence (Robert Cloninger - 1987). A lot of other temperament factors, can be decomposed, such as: novelty and excitement seeking, attention span, organizational ability, impulsivity.

In this study, 155 adults were diagnosed by the DSM IV (APA) as suffering from Attention Deficit Disorder (ADD). All subjects filled out a questionnaire which classified each of them on a four-sequence scale: attention (length of the attention span, selective and divided attention), organization (in space and in time, long term memory, planning and decision making), impulsivity and need for excitement (novelty seeking, tendency to addiction).

What determines the diversity on these scales is probably a genetic variability (in D4 allele) causing over activity of the mesocortical dopaminergic pathway (related to the need for excitement), and of the mesolimbic dopaminergic pathway (related to the hyperactivity). Another effective factor is the insufficient development of the frontal lobe, leading to deficient inhibitory activity aimed at the seeking system (related to short attention span and the deficit in selective attention ability), and to deficit in learning ability, causing planning and decision making problems (related to the lack of organization).

Adult ADHD is a serious risk factor for co-occuring psychiatric disorders and negative psychosocial consequences. Given this background, instead of or in addition to psychopharmacological treatment there is a need for effective psychotherapeutic treatment options for adults with ADHD. Previous trials on psychotherapeutic concepts were based on cognitive behavioural and/or dialectical behavioural approaches and showed significant effects. In a pilot study, our structured skills training group program for adult ADHD led to significant symptomatic improvements (Hesslinger et al. 2007). The following study evaluated the program's effectiveness, feasibility and patient acceptability in a multicentre setting (N = 72, Philipsen et al. 2007). The therapy was well tolerated and led to significant improvements of ADHD, depressive symptoms and personal health status (p < 0.001). Patients regarded the program topics “behavioural analyses”, “mindfulness” and “emotion regulation” as the most helpful. As in our initial study, patients in the multicentre study rated the group setting as highly effective. This might be explained as result of greater peer support and the opportunity of learning from positive role models (e.g. during homework discussion). Following our staged approach, we are currently running a large randomized multicentre placebo-controlled study for the evaluation of the efficacy of this structured group program in adult ADHD that has been approved by the German Federal Ministry of Research and Education. In this study we compare the effects of purely medical management, specific psychotherapy, and the combination of both, comparable with the Multimodal Treatment Study of Children with ADHD (MTA).

Treatment of attention-deficit/hyperactivity disorder (ADHD) may positively impact the neurobiology of adult patientswith ADHD. Treatment may also minimize impairment from core symptoms and may alter the course of co-morbid disorders such as depression and substance use disorder. However, much of the information on stimulant use in adult ADHD comes from studies conducted in children, and it remains unclear whether there is a difference between children and adults when it comes to the side effects and tolerability of ADHD treatments. It is known that clinical presentation differs between adults and children, with adults demonstrating a higher percentage of mood disorders. Current treatments for adult ADHD include psychosocial therapies and pharmacologic therapies, the latter of which include the stimulants d-methylphenidate extended release (XR), OROS methylphenidate, lisdexamfetamine, and mixed amphetamine salts XR; and the nonstimulant atomoxetine, a selective norepinephrine reuptake inhibitor. There is need for additional study of treatment strategies for adult ADHD. Although all classes of ADHD medications are approved inadults, there are fewer approved formulations for adults than for children. Efficacy in adults is more subjective than in children, which may affect how efficacy rates for adult treatments are calculated. Adults also present a greater diversion risk than children. In addition, there are several new and emerging medication treatments worth considering.

This Expert Roundtable Supplement represents part 2 of a 3-part supplement series on adult ADHD led by Lenard A. Adler, MD. In this activity, Thomas J. Spencer, MD, discusses the neurobiology and geneticsof adult ADHD; Mark A. Stein, PhD, discusses stimulant therapy; and Jeffrey H. Newcorn, MD, reviews nonstimulants and psychosocial treatments.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) has been classically described as a children disorder until the late 1960s. However, research has shown that ADHD is not outgrown and young adults continue to experience problems and disability as they grow old. In addition, ADHD shares important features with Borderline personality disorder (BPD), such as impulsivity, emotional lability and dysregulation, which can make these disorders difficult to distinguish.