Around 3 to 5 percent of all children are affected by ADHD, boys around 3 to 8 times as often as girls.
The symptoms of ADHD can be more or less severe
- in up to 80 percent of cases into adolescence and
- persist into adulthood in up to 65 percent of cases.
It is estimated that 3 to 4 percent of adults worldwide are affected by ADHD.
ADHD is characterized by
- extreme motor (movement-related) restlessness and compulsiveness. Those affected have a much greater need to run around, talk, make noise and fidget
- disturbed attention: those affected are extremely easily distracted, can hardly concentrate and frequently change activities
- impaired impulse control: those affected find it difficult to "pull themselves together" in every respect and have little tolerance for frustration
The symptoms of ADHD begin in the first five years of life and persist over time. In around a third of cases, the disorder persists into adulthood.
The inattention leads to relatively frequent dangers and accidents. Affected children often get into conflicts with classmates and teachers, which ultimately lead to social problems.
In adolescence, motor restlessness usually decreases. However, the increased impulsivity and reduced attention remain, so that the risk of
- drug use,
- traffic accidents and
- delinquency (criminal acts)
is increased.
Typical ADHD symptoms in adults
The symptoms of ADHD were already discussed in the 19th century in "Fidgety Philipp". George Still described them scientifically for the first time in 1912.
He recorded a male cohort who were
- motorically restless,
- easily excitable and
- difficult to control.
He did not attribute the behavioral problems to a lack of parental care, but to changes in brain functions and structures.
The "fidgety Philipp" in the children's book Der Struwwelpeter by Frankfurt doctor and psychiatrist Heinrich Hoffmann from 1844
In addition to the symptoms already mentioned, disorders of emotion and affect regulation are also typical of ADHD. This manifests itself, for example, in
- impulsiveness
- disorganization
- emotional instability with rapidly changing moods
- outbursts of anger
- Weakness in planning and decision-making
The symptoms of ADHD influence the course of development as well as the life and everyday life of those affected. It often occurs in the areas of
- school,
- work,
- social environment,
- partnership and
- family
to impairments. They manifest themselves in the form of
- Dropping out of school and training,
- frequent job changes and unemployment as well as
- Disruptions in social relationships with conflicts with parents, peers and in relationships.
Co-occurring disorders of ADHD in adults
In addition, other comorbidities (concomitant disorders) occur in up to 46% of cases, including
Links between ADHD and delinquency and addictive behavior are also possible.
The cause of ADHD is not entirely clear. In addition to genetic factors, birth complications and changes in brain metabolism may play a role.
Familial clustering and genetic causes of ADHD
In the past, twin and family studies have been carried out in connection with ADHD. They have shown that first-degree relatives of ADHD sufferers have an up to 6-fold increased risk of also developing ADHD compared to healthy families. In the case of identical twins, both are affected by ADHD with a probability of up to 90 percent.
However, ADHD is probably not only caused by genetic changes. Rather, complex genetic changes and gene-environment interactions lead to the development of the disease.
Neurobiological causes of ADHD
Neurobiologically, regions of the brain that control the so-called executive functions are affected. These are mental functions with which people control their own behavior within the set framework of their environment.
In particular, control circuits between
- frontal brain regions and basal ganglia and
- frontal and cerebellum.
The genetic changes lead to modifications in the release of the catecholamines
- serotonin,
- dopamine and
- noradrenaline.
This was already demonstrated in the 1990s using positron emission tomography(PET). At that time, a reduced glucose metabolism in the prefrontal cortex was discovered in ADHD sufferers.
This was followed by further imaging procedures that confirmed the functional impairment in ADHD. These include volumetric magnetic resonance imaging. It showed a reduced volume in cortical regions and in the cerebellum.
It also provided evidence of increased dopamine transporter density in parts of the basal ganglia.
Neuropsychological causes of ADHD
The impairment of executive functions leads to behavior that is neither
- the age or
- the stage of development,
- nor the respective situation.
appears appropriate. From a neuropsychological point of view, this is a disorder of cognitive control processes in particular. As a result, those affected are no longer able to maintain their attention.
In addition, the ability to plan is also impaired. This affects behavioral impulse and emotion regulation as well as the evaluation of processes.
Children (and adults) with ADHD cannot concentrate for long and move around a lot © Photographee.eu | AdobeStock
Connection between ADHD in adults and addiction disorders
The link between ADHD and addictive disorders can be traced back to an impulse control disorder. Various scientists have investigated this.
According to Barkley's model, the disorder of executive functions is primarily due to a disorder of stimulus inhibition. This means that the nerve cells only transmit impulses in a weakened form. As a result, those affected cannot control themselves as well.
The cognitive-energetic model according to Sergeant attributes executive dysfunction to a lack of energetic regulation of
- activation,
- effort and
- attention
attention.
People without ADHD can postpone positive reinforcements ("work first, then pleasure"). This helps them to organize themselves and complete their tasks. People with ADHD cannot do this to the full extent.
According to Sonuga-Barke's "delay aversion theory" (2005), ADHD sufferers therefore develop symptoms such as
- Impulsivity,
- "Sensation seeking" (search for new "kicks") and
- inattention, especially in situations with low or short reinforcement intensity.
High sensation seeking in particular is associated with an increased risk of developing addiction.
A prerequisite for the diagnosis of ADHD is that the symptoms in the three core areas
- motor hyperactivity,
- impulsivity and
- attention deficit disorder
are already detectable before the age of 7. As a result, the diagnosis is usually made in childhood.
Diagnostic criteria
Inattention
- Often does not pay attention to details or makes careless mistakes
- Often has difficulty maintaining attention during tasks or play
- Often does not seem to listen when others speak to him/her
- Often does not follow through on instructions from others and is unable to complete work at the workplace
- Often has difficulty organizing tasks
- Has an aversion to tasks that require prolonged mental effort
- Often loses objects that he/she needs for activities
- Is often distracted by external stimuli
- Is often forgetful in everyday activities
Hyperactivity
- Frequently fidgets with hands or feet and slides around on the chair
- Frequently stands up in class or in other situations where sitting is expected
- Frequently runs around or climbs excessively in situations where this is inappropriate
- Often has difficulty playing quietly or engaging in leisure activities quietly
- Is often on the move or often acts as if he/she is driven
- Often talks excessively
Impulsiveness
- Often blurts out answers before the question is finished
- Finds it difficult to wait his/her turn
- Interrupts and disturbs others frequently
For the diagnosis of ADHD
- 6 out of 9 symptoms from the area of inattention or
- 6 out of 9 symptoms from the areas of hyperactivity/impulsivity
to an extent that is inappropriate for the age or situation. In addition, the symptoms must contribute to impairments in at least two areas of life. These must not be better explained by other mental disorders, e.g. affective disorders or social behavior disorders.
The following criteria must also be met:
- Symptoms occur before the age of 7
- The impairments caused by the symptoms are clinically significant with effects on social or academic functioning, for example
- Impairments are evident in two or more areas, e.g. school, home
- The symptoms cannot be better explained by another mental disorder
ADHD is not always diagnosed in childhood. In the case of a later diagnosis, the childhood symptoms must be assessed retrospectively. The therapist must then assess whether the criteria persist into adulthood.
The diagnosis of ADHD in adults is complex and is based on guidelines. The diagnosis is made more difficult by the presence of other psychiatric disorders. Overlapping symptoms can make it difficult to differentiate between the disorders.
Wender-Utah criteria for ADHD in adults
The course of the disorder also plays a major role in the diagnosis of ADHD in adults. In addition
- External anamnesis (questioning relatives),
- family stress and other psychological or organic disorders as well as the medication taken.
- the medication taken.
The symptoms change over the course of development. The diagnostic criteria alone are therefore not helpful for recording ADHD symptoms in adults.
This is why the Wender-Utah criteria can be an additional aid to diagnosis. They capture
- the core symptoms,
- their changes in the development process, as well as
- other symptoms such as affective instability (rapid mood swings), disorganization or overreactivity,
The latter are often associated with ADHD, but are not otherwise used in the diagnostic guidelines.
The Wender-Utah criteria are:
Inattention
- Inability to follow conversations attentively
- Increased distractibility
- Difficulty concentrating on written texts or work tasks
- Forgetfulness
Hyperactivity
- Inner restlessness
- Inability to relax
- Inability to perform sedentary activities
- Dysphoric mood during inactivity
Impulsiveness
- Interrupting others in conversation
- Impatience
- Impulsive shopping
- Inability to delay actions in the process
Affect instability
- Alternation between neutral, depressed and elevated mood - lasting from a few hours to a maximum of a few days
Disorganization
- Insufficient planning and organization of activities
- Tasks are not completed
Lack of affect control
- Persistent irritability, even for minor reasons
- Reduced frustration tolerance and short outbursts of anger
Emotional overreactivity
- Inability to deal adequately with everyday stress
- Reduced stress tolerance for everyday demands
In addition, standardized neuropsychological and test-psychological procedures are also available for adults. They are used to validate the diagnosis and classify the severity and manifestation of the disorder.
These procedures include, for example
- Wender-Utah Rating Scale (WURS),
- Connor's Adult ADHD Rating Scale (CAARS),
- ADHD Self-Report Scale (ADHD-SB) or ADHD Diagnostic Checklist (ADHD-DC),
ADHD in adults and alcohol dependence
Doctors know from long-term studies that adults are more prone to alcohol dependence if they had ADHD as a child. The risk of addiction is 3-4 times higher. If there is also a social behavior disorder, the risk increases by a factor of 5 to 7.
Conversely, around 20 percent of alcohol addicts have childhood ADHD.
Diagnosis of alcohol dependence
According to ICD-10, alcohol dependence exists if at least 3 of the following 6 criteria occur simultaneously within a year:
- Insatiable craving for alcohol (craving)
- Loss of control over the amount or time of consumption
- Development of tolerance
- Withdrawal symptoms
- Continued consumption despite evidence of psychological, physical or social harm
- Neglect of pleasures, interests or obligations due to alcohol consumption
Links between ADHD in adults and alcohol dependence
The links between the causes of ADHD in adults and alcohol dependence are still unknown. What is discussed is
- a common genetic "final route",
- misguided self-medication,
- an additional risk potentiation through social drift as a result of numerous experiences of failure in the course of development or
- comorbid disorders such as social behavior disorder or dissocial personality disorder.
The self-medication hypothesis states that ADHD sufferers experience pleasant feelings from a small amount of alcohol. Patients feel an improvement in inner restlessness, attention deficit disorder and also affective instability. The person affected thus associates alcohol with an improvement in their situation. After a certain period of time, regular consumption develops into dependence.
The risk of developing dependence is not limited to alcohol. This early development of dependence on alcohol can be the "gateway" for the early abuse of other substances.
Progression and prognosis of ADHD and alcohol dependence occurring at the same time
Alcohol-dependent ADHD sufferers often have a more severe course and a less favorable prognosis than alcoholics without ADHD.
This is another reason why ADHD should be treated as early as possible. This also serves to prevent the development of alcohol dependence or addiction in general.
ADHD in children is treated on the one hand through a consistent parenting style and appropriate educational measures.
In addition, methylphenidate (Ritalin®) is often used as a medication. It is currently considered the most effective treatment method for ADHD.
Drug treatment improves around 50 percent of the cardinal symptoms of ADHD in adults. It often also has a positive effect on mood instability.
Additional psychotherapy is necessary to improve time management, organization and planning.
Drug therapy for ADHD in adults
Methylphenidate (MPH) works best in the drug therapy of ADHD in adults.
Atomexetine, a noradrenaline reuptake inhibitor, also significantly reduces symptoms in up to 50% of cases. The drug has therefore been approved in several countries for the treatment of ADHD in adults.
Antidepressants also appear to be promising. They influence the dopaminergic (e.g. bupropion) or serotonergic brain metabolism (e.g. venlafaxine).
Overall, there are numerous substances that can alleviate the symptoms of ADHD at any age.
In order to prevent the development of severe personality disorders, early drug treatment is urgently required. This can also halve the risk of developing addictive disorders.
Although the study situation is controversial, drug treatment starting in adulthood can also
- alleviate the cardinal symptoms of ADHD
- positively influence the course of an addiction
- increase motivation to persevere with psychotherapeutic treatment
Psychotherapy for ADHD in adults
The best form of therapy today is the combination of drug therapy with psychotherapy.
Numerous studies have examined test subjects undergoing such combined therapy. Their effect could always be proven, there was
- a significant reduction in ADHD symptoms
- a reduction in comorbid symptoms, such as anxiety or depression and
- an increase in general functioning
and an increase in general functioning.
These results already look good. However, no satisfactory results were achieved for dependency symptoms.
The young adults studied drank less alcohol. However, they did not reduce the number of drinking days. Between 60 and 80 percent of the test subjects also dropped out of therapy.
This is why alcohol dependence is currently being treated alongside ADHD.
Individual and group therapy for ADHD in adults
Overall, both group therapy and individual therapy interventions are possible for ADHD in adults. Which form is most suitable for treating the comorbidity of alcohol dependence and ADHD in adults is not yet clear.
In the past, group therapy methods have proved particularly effective for alcohol dependence alone. A combination treatment of individual and group therapy may be useful for comorbidity.
Safren and his colleagues developed a promising approach in the area of individual therapy for ADHD. They used cognitive-behavioral individual training in 12-15 sessions. It includes
- Techniques for organization and planning
- Reduction of distractibility
- Processing dysfunctional cognitions and
- Dealing with procrastination (postponement behavior)
The German version also includes a module
- on affect control,
- dealing with frustration and
- with inner tension
was integrated. It appears to be particularly helpful for the treatment of addictions.
Overall, psychotherapeutic group and individual therapies seem to really help those affected. They shed their basic assumptions that they were somehow "not functioning properly". They are also better able to integrate positive experiences.
However, scientific evidence that these therapies can also positively influence alcohol dependence is still lacking.
ADHD in adults and alcohol dependence is a frequently associated comorbidity (concomitant illness). The causes have not been clarified. However, it can be assumed that alcohol dependence develops as a result of gene-environment interactions.
Negative experiences and other psychiatric disorders increase the risk of developing a dependency disorder.
Drug therapy can reduce the risk here. Overall, early treatment of ADHD in childhood is recommended to prevent further psychiatric disorders.
In adults with ADHD and alcohol dependence, combined drug and psychotherapeutic treatments are promising.
