Paper
Attention‐deficit hyperactivity disorder in a life perspective
Published May 1, 2003 · H. Steinhausen
Acta Psychiatrica Scandinavica
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Abstract
There is no doubt that attention-deficit hyperactivity disorder (ADHD) is a very common mental disorder that originates in childhood and continues into adulthood with a debilitating course in many afflicted individuals. The term ADHD is a precise description of the cardinal features of impaired attention and overactivity, with disinhibition and impulsivity being important underlying or associated characteristics. While ADHD is based on Diagnostic Statistical Manual (DSM) criteria and according to various international surveys and our own study (1) amounts to 2–5% of the child population, the term hyperkinetic disorder (HD) reflects the ICD-nomenclature and implies a more restricted core group of more severely afflicted subjects leading to lower prevalence rates. In particular, the differentiation between an inattentive type or attention-deficit disorder without hyperactivity (ADD) and a combined type (ADHD) that was first introduced in DSM-III, then skipped in DSM-III-R, and reintroduced in DSM-IV, but not represented in ICD-10, may have led to a large and unreliable increase in diagnoses of ADHD and ADD in clinical practice. Given the wide popularization of the ADD concept, both in the professional and lay public, there is sufficient concern that the still limited validation of the ADD concept and a lack of recognition of the many issues of differential diagnoses, with attentiondeficit being a core symptom in many mental disorders, may have led to an increase in falsepositive cases in clinical practice. On the other hand, long-term outcome observations of ADHD children have clearly shown that besides a high rate of antisocial personality and substance abuse disorders, there is also a considerable proportion of persisting ADHD with hyperactivity remitting more frequently than attention-deficit, so that a residual type of ADD may result. Originating from child outcome studies, the interest in adult manifestations of ADHD has emerged only in the recent past whereas children with ADHD or HD have been identified for many decades. With a lack of precise epidemiological data, the prevalence of adult ADHD has been estimated to amount to 2–3%. Differential diagnoses in adult ADHD subjects include depression, bipolar disorder, anxiety disorder, substance abuse disorder, schizophrenia, and various personality disorders, including most notably antisocial and borderline personality disorder. Thus, a thorough assessment considering these co-morbid conditions by a skilled expert is essential in order to identify true ADHD patients and implement adequate treatment. The present issue of this journal contains a study by Hesslinger et al. (2) dealing with these important issues of differential diagnosis and co-morbidity in adult ADHD. The study expands our knowledge by focussing on the link between ADHD and recurrent brief depression (RBD) and showing that RBD is a very common co-morbid lifetime condition, whereas the reverse association is less common. As the authors state, this association of adult ADHD with RBD may have important implications for medical treatment. Pharmacotherapy has been the major avenue of treatment of ADHD children for decades and the central role of stimulants has been convincingly documented again in one of the most extended and thorough studies on treatment outcome that, so far, has been performed with children. Including 579 ADHD children the Multimodal Treatment of ADHD study has clearly shown that stimulant treatment is of utmost importance for the management of ADHD (3). Thus, the MTA study added further evidence to the efficacy of stimulants that has been proven in large numbers of wellcontrolled studies. However, there is some concern that stimulants may be overprescribed in the community for children who do not meet full criteria for ADHD or even received false-positive diagnoses leading to overtreatment (4). Overprescription may represent a new major problem in addition to those insufficiently identified true ADHD cases representing the problem of undertreatment. The latter problem may be even more representative for adult ADHD patients who, This issue of Acta Psychiatrica Scandinavica also indudes a short biography of H.-C. Steinhausen. Acta Psychiatr Scand 2003: 107: 321–322 Printed in UK. All rights reserved Copyright a Blackwell Munksgaard 2003
Adult ADHD is a common mental disorder with recurrent brief depression, highlighting the need for thorough assessment and treatment planning.
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