ADHD: Information & ADHD Specialists

About 3 to 5 percent of all children are affected by ADHD, with boys being affected about 3 to 8 times more often than girls.

The symptoms of ADHD can vary in severity and duration:

• In up to 80 percent of cases, they persist into adolescence, and
• in up to 65 percent of cases, into adulthood

According to estimates, 3 to 4 percent of adults worldwide are affected by ADHD.

ADHD is characterized by:

• Extreme motor (movement-related) restlessness and agitation: Those affected feel the need to run around, talk, make noise, and fidget much more frequently
• Impaired attention: Those affected are extremely easily distracted, have difficulty concentrating, and frequently switch activities
• Impaired impulse control: Those affected find it difficult to “pull themselves together” in any situation and have a low tolerance for frustration

The symptoms of ADHD begin within the first five years of life and persist over time. In about one-third of cases, the disorder continues into adulthood.

Inattention often leads to dangerous situations and accidents. Affected children frequently get into conflicts with classmates and teachers, which ultimately result in social problems.

During adolescence, motor restlessness usually decreases. However, increased impulsivity and reduced attention persist, thereby increasing the risk of:

• drug use
• Traffic accidents and
• Delinquency (criminal acts)

Typical ADHD Symptoms in Adults

The symptoms of ADHD were first discussed as early as the 19th century in the book *Zappel-Philipp*. George Still first described them scientifically in 1912.

He studied a group of males who were:

• were physically restless
• easily excitable, and
• difficult to control

He attributed these behavioral abnormalities not to a lack of parental care, but to changes in brain functions and structures.

The “Fidgety Philip” in the children’s book *Struwwelpeter* by the Frankfurt physician and psychiatrist Heinrich Hoffmann, published in 1844

In addition to the symptoms already mentioned, disturbances in emotional and affective regulation are also typical of ADHD.

This manifests itself, for example, in:

• Impulsivity
• Disorganization
• emotional lability with rapidly changing moods
• Outbursts of anger
• Difficulty planning and making decisions

ADHD symptoms affect the course of development as well as the daily lives and routines of those affected. 

Impairments often occur in the following areas:

• School
• Work
• Social life
• Relationships and
• Family

These manifest themselves in the form of:

• Dropping out of school or vocational training
• Frequent job changes and 
• unemployment, as well as
• Social relationship difficulties, including conflicts with parents, peers, and romantic partners

Comorbid conditions associated with ADHD in adults

In addition, comorbid conditions occur in up to 46 percent of cases, including:

• Mood disorders
• Substance use disorders
• Anxiety disorders and
• Personality disorders

There may also be links between ADHD and delinquency (criminal behavior) as well as addictive behavior.

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 conducted in connection with ADHD. They found that first-degree relatives of individuals with ADHD have an up to sixfold increased risk of also developing ADHD. 

In the case of identical twins, there is up to a 90 percent probability that both will have ADHD.

However, ADHD is likely not caused solely by genetic mutations. Rather, complex genetic changes and gene-environment interactions lead to the development of the disorder.

Neurobiological Causes of ADHD

Neurobiologically, the brain regions involved are those that control what are known as executive functions. These are mental functions that enable people to regulate their own behavior within the established framework of their environment.

In particular, regulatory circuits between the following are affected:

• frontal brain regions and the basal ganglia, as well as
• the frontal lobe and the cerebellum

Genetic alterations lead to changes in the release of catecholamines:

• serotonin
• dopamine, and
• norepinephrine

Researchers had already demonstrated this in the 1990s using positron emission tomography (PET). At that time, they discovered reduced glucose metabolism in the prefrontal cortex of individuals with ADHD.

Further imaging techniques followed, confirming the functional impairment associated with ADHD. These include, for example, volumetric magnetic resonance imaging (MRI). It revealed reduced volume in cortical regions and in the cerebellum.

There was also 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 inappropriate for

• age nor
• the developmental stage
• nor the situation at hand

.

From a neuropsychological perspective, this is primarily a disorder of cognitive control processes. As a result, those affected are no longer able to sustain their attention.

In addition, their ability to plan is also impaired. This affects behavior-driven impulse and emotion regulation as well as the evaluation of processes.

Children (and adults) with ADHD cannot concentrate for long periods and move around a great deal © Photographee.eu | AdobeStock

The Link Between ADHD in Adults and Substance Use Disorders

The link between ADHD and substance use disorders can be attributed to an impulse control disorder. Various researchers have studied this phenomenon.

According to Barkley’s model, the impairment of executive functions is primarily due to a disturbance in stimulus inhibition. This means that nerve cells transmit impulses only in a weakened form. As a result, the affected individual has difficulty controlling their behavior.

Sergeant’s cognitive-energetic model attributes the impairment of executive function to a lack of energetic regulation in the following areas:

• Activation
• Effort, and
• Attention

People without ADHD can delay positive reinforcements (“Work first, then play”). This helps them with self-organization and completing their tasks. People with ADHD are not fully able to do this.

According to Sonuga-Barke’s (2005) “Delay Aversion Theory,” this leads to symptoms such as:

• Impulsivity
• “sensation seeking” (the search for new “thrills”) and
• Inattention, particularly in situations with low or short-lived reinforcement intensity
• High levels of “sensation seeking,” which are associated with an increased risk of developing addiction

A prerequisite for a diagnosis of ADHD is that symptoms in the three core areas are already evident before the age of 7.

The core areas are:

• Motor hyperactivity
• Impulsivity, and
• Attention Deficit

Consequently, the diagnosis is usually made during childhood.

The diagnostic criteria

Inattention:

• Often fails to pay attention to details or makes careless mistakes
• Often has difficulty sustaining attention during tasks or play
• Often appears not to listen when others are speaking to them
• Often fails to follow others’ instructions and is unable to complete tasks at work
• Often has difficulty organizing tasks
• Dislikes tasks that require sustained mental effort
• Often loses items needed for activities
• Is often distracted by external stimuli
• Is often forgetful during daily activities

Hyperactivity:

• Often fidgets with hands or feet and squirms in their chair
• Often stands up in class or in other situations where they should remain seated
• Often runs around or climbs excessively in situations where it is inappropriate
• Often has difficulty playing quietly or engaging calmly in leisure activities
• Is frequently on the go or often acts as if driven by an inner urge
• Often talks excessively

Impulsivity:

• Often blurts out answers before the question is finished
• Has a hard time waiting for his or her turn
• Frequently interrupts and disrupts others

For a diagnosis of ADHD, the following criteria must each be present to a degree that is inappropriate for the person’s age or the situation:

• 6 out of 9 symptoms in the inattention category or
• 6 out of 9 symptoms from the hyperactivity/impulsivity category

In addition, the symptoms must contribute to impairment in at least two areas of life. 

These impairments must not be attributable to other mental disorders, such as mood disorders or social behavior disorders.

Furthermore, the following criteria must be met:

• Symptoms must have been present before the age of 7
• The impairment caused by the symptoms is clinically significant, with effects, for example, on social or academic functioning
• Impairments are evident in two or more areas, such as school and at home
• The symptoms cannot be better explained by another mental disorder

ADHD cannot always be diagnosed during childhood. In cases of later diagnosis, doctors must retrospectively assess childhood symptoms. The therapist must then determine whether the criteria persist into adulthood.

The diagnosis of ADHD in adults is complex and follows established guidelines. The diagnosis is complicated by the presence of other psychiatric disorders. 

Overlapping symptoms can make it difficult to distinguish between different disorders.

Wender-Utah Criteria for ADHD in Adults

The course of the disorder also plays a major role in the diagnosis of adults.

In addition:

• third-party medical histories (interviews with family members)
• an assessment of family history and other mental or physical disorders, as well as
• medications currently being taken

Symptoms change over the course of development. The diagnostic criteria alone are therefore not helpful for identifying ADHD symptoms in adults.

For this reason, the Wender-Utah criteria can serve as an additional diagnostic tool. 

They identify:

• The core symptoms
• How these symptoms change over the course of development, as well as
• Additional symptoms such as affective lability (rapid mood swings), disorganization, or overreactivity

The latter are frequently associated with ADHD but are not otherwise included in 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
• Impulsivity
• Interrupting others during conversations
• Impatience
• Impulsive shopping
• Inability to delay actions
• Mood lability
• Fluctuations between neutral, depressed, and elevated moods—lasting from a few hours to a few days at most
• Disorganization
• Inadequate planning and organization of activities
• They are unable to complete tasks
• Lack of emotional control
• Persistent irritability, even over minor matters
• Reduced tolerance for frustration and brief outbursts of anger
• Emotional overreactivity
• Inability to cope adequately with everyday stress
• Reduced stress tolerance in response to everyday demands

In addition, standardized neuropsychological and psychological testing procedures are also available for adults. These are used to validate the diagnosis and to classify the severity and extent of the disorder.

These procedures include, for example:

• Wender-Utah Rating Scale (WURS)
• Connor’s Adult ADHD Rating Scale (CAARS)
• ADHD Self-Assessment Scale (ADHS-SB) or Diagnostic Checklist (ADHS-DC)

ADHD in Adults and Alcohol Dependence

Long-term studies have shown that adults who had ADHD as children are more likely to develop alcohol dependence.

The risk of dependence is 3–4 times higher. If there is also a social behavior disorder, the risk increases by a factor of 5 to 7.

Conversely, approximately 20 percent of people with alcohol dependence had ADHD as children.

Diagnosis of Alcohol Dependence

According to the ICD-10, alcohol dependence is diagnosed when at least 3 of the following 6 criteria are met simultaneously within a one-year period:

1. An uncontrollable craving for alcohol
2. Loss of control over the amount or duration of consumption
3. Development of tolerance
4. Withdrawal symptoms
5. Continued consumption despite evidence of psychological, physical, or social harm
6. 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 remain unknown to this day. 

One theory under discussion is:

• a shared genetic “downstream pathway”
• misguided self-medication
• an additional increase in risk due to social drift resulting from numerous experiences of failure during development or from comorbid disorders such as social behavior disorder or antisocial personality disorder.

The self-medication hypothesis suggests that individuals with ADHD experience pleasant feelings when consuming a small amount of alcohol. Patients report a reduction in inner restlessness, attention deficits, and emotional lability.

As a result, the individual associates alcohol with an improvement in their situation. Over time, regular consumption thus leads to dependence.

The risk of developing dependence is not limited to alcohol. This early development of alcohol dependence can serve as a “gateway” to the early abuse of other substances.

Course and Prognosis in Cases of Co-occurring ADHD and Alcohol Dependence

People with ADHD who are alcohol-dependent often have a more severe course of the condition and a poorer prognosis than alcoholics without ADHD.

This is another reason why ADHD should be treated as early as possible. This also helps prevent the development of alcohol dependence or substance abuse 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 frequently prescribed. It is currently considered the most effective treatment for ADHD.

Medication improves approximately 50 percent of the core symptoms of ADHD in adults. It often has a positive effect on mood swings as well.

Additional psychotherapy is necessary to improve time management, organization, and planning.

Medication for ADHD in Adults

Methylphenidate (MPH) is the most effective medication for treating ADHD in adults.

Atomoxetine, a norepinephrine reuptake inhibitor, also significantly reduces symptoms in up to 50% of cases. As a result, the drug has been approved in several countries for the treatment of ADHD in adults.

Antidepressants also appear promising. They influence dopaminergic (e.g., bupropion) or serotonergic brain metabolism (e.g., venlafaxine).

Overall, there are numerous substances available that can alleviate the symptoms of ADHD at any age.

To prevent the development of severe personality disorders, early medication treatment is urgently needed. This can also cut the risk of developing substance use disorders in half.

Although the research findings are controversial, medication treatment initiated in adulthood can also:

• alleviate the core symptoms of ADHD
• positively influence the course of a substance use disorder
• increase motivation to persist with psychotherapy

Psychotherapy for ADHD in Adults

The best form of treatment today is a combination of medication and psychotherapy.

Numerous studies have examined participants undergoing such combined therapy. The effectiveness has consistently been demonstrated. 

There was a significant reduction in ADHD symptoms, such as:

• a reduction in comorbid symptoms, such as anxiety or depression, as well as
• an improvement in overall functioning

While these results look promising, no satisfactory outcomes were achieved regarding addiction symptoms.

The young adults in the study did drink less alcohol, but they did not reduce the number of days they drank. Furthermore, between 60 and 80 percent of the participants discontinued therapy.

For this reason, treatment for alcohol dependence is currently being provided in parallel with ADHD treatment.

Individual and Group Therapy for ADHD in Adults

Overall, both group therapy and individual therapy interventions are possible for ADHD in adults. It is not yet clear which form is best suited for treating alcohol dependence and ADHD in adults.

For alcohol dependence alone, group therapy approaches have proven particularly effective in the past. A combination of individual and group therapy may be beneficial for this comorbidity.

Safren and his colleagues developed a promising approach to individual therapy for ADHD. They implemented a cognitive-behavioral individual training program consisting of 12–15 sessions.

It includes:

• Techniques for organization and planning
• Reducing distractibility
• Addressing dysfunctional cognitions, as well as
• managing procrastination

The German adaptation also includes a module covering the following topics:

• emotional regulation
• dealing with frustration and
• internal tension

It appears to be particularly helpful for the treatment of addiction disorders.

Overall, psychotherapeutic group and individual therapies seem to genuinely help those affected. They let go of their underlying belief that they somehow “didn’t function properly.” Furthermore, they are better able to integrate positive experiences.

However, scientific evidence that these therapies can also have a positive impact on alcohol dependence is still lacking.

ADHD in adults and alcohol dependence are frequently co-occurring conditions (comorbidities). The causes are not yet fully understood. However, it is assumed that alcohol dependence develops as a result of gene-environment interactions.

Negative experiences and other psychiatric disorders increase the risk of developing an addiction disorder.

Medication can help reduce this risk. Overall, early treatment of ADHD in childhood is recommended to prevent the development of further psychiatric disorders.

For adults with ADHD and alcohol dependence, combined medication and psychotherapy treatments show promise.