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Child & Adolescent Psychopharmacology News, Volume 9, Issue 8, 2005

ADULT ATTENTION DEFICIT HYPERACTIVITY DISORDER

By Richard H.Weisler, MD

Attention-deficit/hyperactivity disorder (ADHD) -- characterized by developmentally inappropriate degrees of impulsivity, hyperactivity, and inattention -- is one of the most prevalent chronic health conditions in children, affecting approximately 10% of school-age youth in the United States.

ADHD is a neurobehavioral disorder of childhood onset that frequently persists into adolescence and adulthood, and although adult onset of ADHD is not thought to occur, clinical presentation may not appear until adulthood.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) recognizes 3 subtypes of ADHD: predominantly inattentive, predominantly hyperactive/ impulsive, and combined. While hyperactivity and impulsivity may be relatively easy to identify in a child with ADHD, these symptoms tend to remit with age, leaving
inattentive symptoms that may be overlooked in adults with the disorder. Alternatively, adults may present with inattentive symptoms that were not recognized in childhood or did not meet earlier diagnostic criteria that emphasized motoric symptoms.

Consider a sample of 149 clinically referred adults with ADHD, of whom more than 90% reported inattentive symptoms to the clinician investigator. When diagnosed using DSM-IV criteria, 56% of these patients met the diagnostic criteria for ADHD combined subtype, 37% for inattentive subtype, and only 2% met the criteria for hyperactive/impulsive subtype. This profile of ADHD subtypes differs dramatically from that typically observed in children with ADHD.

Epidemiologic data collected during an update of the National Comorbidity Survey indicate that the prevalence of adult ADHD according to DSM-IV criteria is 4.4% in the United States. As many as 9 million adults in the US may therefore be affected by ADHD, making it an important public health problem considering the negative impact on long-term social, emotional, academic, driving, and vocational outcomes.

Feelings of social and academic inadequacy and low self-efficacy that develop in childhood are often carried through adolescence and into adulthood, and some adults with ADHD describe an awareness that they "just don't seem to get it." Adults with ADHD may be socially obtuse as well as impulsive, and this translates into turbulent interpersonal relationships -- both romantic and in the workplace.

Results of a national survey of 500 adults with ADHD and 501 age- and gender-matched adults without ADHD illustrate the life impairments associated with the disorder. Significantly fewer adults with ADHD had attended college, twice as many had been divorced, and half as many were completely satisfied with their professional life and career track.

Neurobiology of Adult ADHD

Although the neurobiologic basis of ADHD has not been completely defined, dysfunction of dopaminergic and noradrenergic pathways and abnormalities in frontal networks or frontal-striatal dysfunction are among the factors implicated. It is well established that the stimulant medications potentiate the actions of both dopamine and norepinephrine in the synapse. Neuropsychologic models of ADHD stress impairment in executive function as a fundamental deficit in ADHD. Impaired executive function includes deficits in working memory (verbal and nonverbal), self-regulations (affect, motivation, and arousal) and the ability to analyze behavior and synthesize novel responses.

Childhood tasks typically require simple responses to the specific demands of parents or teachers, whereas adulthood tasks involve organization, future planning, balancing competing demands, and independent thinking. Failure to perform academically is the single most common reason for the initial referral of children and adolescents with ADHD, and academic difficulties may impact later academic achievement and occupational success in adulthood. Adults with ADHD often have a history of poor job performance, academic underachievement, and chronic stress associated with a poor ability to manage responsibilities that other adults take for granted. The restlessness, distractibility, inattention, and impulsivity inherent to adult ADHD underlie the typical functional impairments, such as procrastination when facing complex tasks and the inability to finish complicated projects.

Yet many adults with ADHD are able to channel the novelty-seeking behavior and intellectual curiosity into high-energy, demanding careers as physicians, lawyers, stockbrokers, sales people, and entrepreneurs.

Adult ADHD: A Valid Psychiatric Diagnosis?

Faraone and colleagues reviewed the validity of adult ADHD based on the premise that validity of any psychiatric diagnosis is derived from a pattern of consistent data, with standard validation criteria including family history, treatment response, laboratory studies, clinical course, and outcome. Clinical symptoms of adult ADHD are not unlike those of children, though the intensity of various symptoms may change with age. Hyperactivity may not be problematic in adults, but impulsivity, distractibility, and restlessness can lead to significant impairments when juggling the complexities of daily life.

As in children with ADHD, these functional impairments occur in multiple domains, often including poor educational performance, occupational problems, and relationship difficulties. Adults with ADHD have increased rates of mood, anxiety, substance use, and antisocial personality disorders.

The validity of ADHD is strongly supported by family studies, which have demonstrated that adult relatives of ADHD children are at increased risk for ADHD as are the child relatives of ADHD adults. Twin studies estimate the heritability of ADHD to be about 0.70. This number means that about 70% of the variance in phenotype can be attributed to genetic rather than environmental factors.

Prefrontal dopaminergic hypoactivity has been demonstrated in both children and adults with ADHD, and the profile of neuropsychologic deficits in adults parallels that of children, with impairments in vigilance, motoric inhibition, executive functions, and verbal learning and working memory. In addition,the response rate of stimulant-treated adults with ADHD is similar to that of stimulant-treated children with ADHD. Thus, available evidence substantiates adult ADHD as a valid psychiatric diagnosis.

Diagnosis of Adult ADHD

Adult ADHD can be reliably diagnosed using the DSM-IV criteria, which includes the following key aspects of the diagnosis:

1) current symptoms, including at least 6 of 9 symptoms for one of the three ADHD subtypes (combined, inattentive, or hyperactive/impulsive);

2) childhood-onset of symptoms;

3) persistent symptoms (ie, at least 6 months or longer); and

4) at least 2 domains of impairment (ie, work, home, social life). Because obtaining information from a parent or employer may be problematic, clinicians usually must rely on the subject's accurate account of current symptoms and recollection of childhood symptoms. It is often possible for patients to obtain copies of their elementary, middle, and high school academic and test records that provide support for an ADHD diagnosis that was frequently missed.

The reliability and validity of self-ratings of symptoms associated with other types of psychiatric diagnoses have been demonstrated, and the same is true for adult ADHD. Studies have shown that adults with ADHD can provide an accurate assessment of their own behavior, and good correlations between subjects' and informants' ratings have been demonstrated if the questionnaires contain reasonably specific statements regarding past and present behavior.

Most primary care physicians and psychiatrists have not been trained to diagnose or treat adult ADHD. A survey of 400 primary care physicians (all of whom treated at least 30 patients per week with any combination of ADHD, bipolar disorder, depression, generalized anxiety disorder, or obsessive compulsive disorder) revealed that 48% did not feel confident diagnosing ADHD in adults. The survey was conducted in conjunction with Lenard Adler, MD, and the Adult ADHD Program at the New York University School of Medicine. Only 34% of respondents reported being "very knowledgeable" or "extremely knowledgeable" about adult ADHD; by contrast, 92% of respondents said the same for depression.

The survey results indicated that lack of clinical instruction in the diagnosis and treatment of adult ADHD and lack of a screening tool for adult ADHD are barriers to appropriate diagnosis of the disorder in adults. Adler and colleagues developed a new symptom assessment tool, an 18-item Adult ADHD Self-Report Scale (ASRS) Symptom Checklist (available at www.med.nyu.edu/Psych/training/adhdscreen18.pdf) to assist physicians in evaluating ADHD symptoms in adult patients. The ASRS is based on the 18 items of the DSM-IV and was validated in a well-characterized adult ADHD population, and can be completed and scored quickly and used to initiate a more thorough discussion of a patients' clinical history. A survey of primary care and psychiatry practices revealed that more than 90% of adults with undiagnosed ADHD were self-referred in both practice settings and more than 50% of previously undiagnosed adults had complained about ADHD symptoms to other health professionals in the past, so a quick screening tool may be particularly useful for this disorder.

A number of other commonly used diagnostic and self-report rating scales are available to assist the clinician with an accurate diagnosis of adult ADHD. The Brown ADD Scale is a 40-item frequency scale completed by patients that explores the executive function aspects of cognition that are associated with ADHD. A more thorough Brown ADD Scale Diagnostic Form is also available and can be used for diagnosing ADHD. Both the clinician-rated and self-report Brown ADD Scales have been validated and are available from The Psychological Corporation (San Antonio, TX). The Conners' Adult ADHD Diagnostic Interview for DSM-IV surveys the presence of the 18 DSM-IV ADHD symptoms.

The screening version of the Conners' Adult ADHD Rating Scale (CAARS) is a 30-item frequency scale completed by patients that includes the 18 items outlined in the DSM-IV. (The clinician-administered and self-report versions of the CAARS have been validated and are available through Multi-Health Systems, Inc., North Tonawanda, NY.)

The ADHD Rating Scale (ADHD-RS) is an 18-item scale based on the DSM-IV criteria (available through Guilford Publications, Inc., NY). The ADHD-RS was developed and standardized as a rating scale for children, but clinician-raters can be trained to use this scale for adults. Adult-specific prompts have been developed by Adler and colleagues for use with the ADHD-RS. The clinician-rated versions of these rating scales also can be used to monitor treatment effectiveness over time.

Adult ADHD and Psychiatric Comorbidity

Psychiatric comorbidity is quite common with ADHD, and may affect as many as 3 in 4 patients. Mood disorders, including major depression, dysthymia, and bipolar disorder are comorbid with ADHD in 19% to 37% of patients. Comorbid anxiety may be present in 25% to 50% of adults with ADHD.

Determination of whether the primary diagnosis is ADHD versus depression or anxiety is difficult when patients present with anxiety, depressive symptoms, conflicts at work or home, or even substance abuse. Because of the symptom overlap between the mood-regulating symptoms of ADHD and the symptoms of anxiety and mood disorders, clinicians are likely to treat the presenting symptoms of depression or anxiety but the ADHD is often undiagnosed. In the adult patient who is nonresponsive to medications for depression or anxiety, ADHD may be present but unrecognized. For example, in a patient who is unresponsive to selective serotonin reuptake inhibitors for a diagnosis of depression, a longitudinal history maybe helpful in assigning the symptoms to the appropriate diagnosis -- ADHD symptoms tend to persist throughout the lifespan and are less episodic than those of comorbid mood or anxiety disorders.

Administration of the Hamilton Anxiety Scale (HAM-A), the Hamilton Depression Scale (HAM-D), or the Beck Depression Inventory in addition to an ADHD symptom rating scale may be required to determine if ADHD is the primary problem and the other disorders are comorbid. Direct medical costs (eg, inpatient, outpatient, and prescription drug costs) for adults with ADHD are approximately double that of age- and gender-matched adults without ADHD. Further study of the full medical and economic impact of ADHD and associated comorbidities in adults is needed.

Adult ADHD and Substance Use Disorders

There has been much concern over stimulant exposure potentially leading to substance use disorders (SUDs), yet adults with ADHD seldom seek stimulants and rarely abuse them. In fact, untreated ADHD is a significant risk factor for SUDs (even after correcting for other factors, such as socioeconomic status and conduct disorder). Substance use disorders are often comorbid with ADHD; for example, the lifetime prevalence rate of alcohol dependence in adults with ADHD is approximately 20% for women and 35% for men.

Many individuals with untreated ADHD may self-medicate in an attempt to improve adaptive functioning. For example, children with ADHD start smoking much earlier than their peers, and adult patients with ADHD are more likely to smoke and have more difficulty in quitting. The subjective and behavioral effects of nicotine may improve concentration and increase alertness and arousal in these patients.

Well-controlled, longitudinal studies suggest that pharmacologic treatment for ADHD significantly lowers the risk for SUD in the high-risk, mid-adolescent age group that experiment with illicit drugs. A longitudinal study of adolescent boys with ADHD revealed that pharmacotherapy of ADHD was associated with an 85% reduction in risk for SUD in ADHD youth, and a recent meta-analysis of all long-term studies that examined SUD outcomes among pharmacologically treated and untreated youths with ADHD revealed a 2-fold reduction in risk for drug and alcohol use disorders in stimulant-treated youths with ADHD. These studies provide substantial evidence documenting the protective effect that treatment of ADHD with stimulant medications provides against the development of SUDs.

Treatment of Adult ADHD

Appropriate pharmacotherapeutic intervention early in the course of the disorder may improve academic and social outcomes and limit the psychiatric and interpersonal complications associated with ADHD. In children and adolescents with ADHD, the response to stimulant medications is robust -- a response rate of 70% has been documented for both immediate-release amphetamine and methylphenidate formulations. When adults with ADHD are dosed appropriately with stimulant medications in controlled studies, the response rate is similar to that observed in children.

Spencer and colleagues were the first to demonstrate that adequate doses of stimulant medications in adults with ADHD led to a good response. In two small, placebo-controlled, crossover studies, response rates of 70% were observed using 1.0 mg/kg/d of methylphenidate or 0.9 mg/kg/d of mixed amphetamine salts (Adderall).

Although the response to stimulants was dramatic in both studies, immediate-release stimulant formulations were used. Adults with ADHD, who may be impulsive, forgetful, and disorganized, are likely to benefit from once-daily formulations of stimulant medications. A variety of extended-release stimulant medications are available, including Adderall XR, a novel, extended-release capsule formulation of mixed amphetamine salts in which 50% of the dose is formulated as immediate-release pellets and 50% as delayed-release pellets; Ritalin LA, a long-acting methylphenidate formulation with a bimodal release profile that simulates twice-daily dosing; Concerta, an OROS delivery system that provides an initial bolus of methylphenidate followed by a controlled rate of release; Metadate CD, in which 30% of the administered methylphenidate dose is released immediately and 70% of the dose is formulated for extended release; and Focalin XR, and extended-release formulation of dexmethylphenidate.

Long-acting stimulant formulations are associated with improved medication compliance and the pharmaceutical properties of extended-release stimulant formulations may prevent abuse of these medications.

Adderall XR for Adult ADHD

In the largest adult ADHD stimulant study to date, treatment with once-daily Adderall XR 20, 40, and 60 mg led to significant, positive clinical responses in adults with ADHD. At least a 30% decrease in ADHD-RS scores occurred in 74% of patients receiving Adderall XR 20 mg, 80% of patients receiving 40 mg, and 82% of patients receiving 60 mg. Baseline symptom severity was similar for both men and women and symptom reduction (decrease of 13-14 unit points on the ADHD-RS) was similar for both groups. Based on CAARS:Self-report scores, the magnitude of ADHD symptom improvement was similar 4 hours and 12 hours after a single morning dose of Adderall XR. These results suggest that Adderall XR provides significant symptom relief throughout the day and into the evening hours for adults with ADHD.

Adderall XR is the first stimulant medication to receive US Food and Drug Administration (FDA) approval to treat adult ADHD. Optimal results (ie, greater reduction in target symptoms for an individual patient) may be observed at higher doses of stimulant medications. In the adult Adderall XR study, adults with mild ADHD symptoms (ADHD-RS baseline score <32) had significantly greater reduction in symptoms while receiving Adderall XR 20 mg, while adults with severe ADHD symptoms (ADHD-RS baseline score <32) had significantly greater reduction in symptoms while receiving Adderall XR 60 mg. In a long-term, open-label extension study of Adderall XR, 16% of participants were receiving Adderall XR 20 mg/d, 37% were receiving 40 mg/d, and 47% were receiving 60 mg/d after up to 18 months of treatment.

Studies of other stimulant medications in adults with ADHD also indicate that higher doses may be required for optimal effectiveness in adolescents and adults with ADHD. In a community assessment study of 264 adolescents and 136 adults treated with Concerta for 9 months, Stein and colleagues reported that 11% of subjects withdrew due to lack of efficacy at the highest dose (54 mg/d), suggesting that higher stimulant doses may be necessary. In a long-term, open-label extension of Focalin XR (effective at half the dose of racemic methylphenidate), approximately 25% of subjects in the study were receiving a mean daily dose of >20 mg, 38% were receiving 20 to 30 mg/d, and 38% were receiving >30 mg/d. The distribution of stimulant doses in these long-term, open-label studies of adults with ADHD is likely to be representative of real-world clinical practice.

The most common side effects associated with stimulant medications in adults with ADHD include dry mouth, decreased appetite, insomnia, and headache. In the Adderall XR and Focalin XR studies of adults, side effects were typically mild and not dose-related. Stimulant-associated side effects tend to diminish over time. In the long-term Adderall XR study, 84% of adults reported a side effect during the first month of treatment compared with 33% during the second month and only 10% at month 5 and beyond. Less than 6% of participants reported that side effects outweighed the beneficial effects of treatment with Adderall XR. The use of stimulant medications in the treatment of adults with ADHD appears to be quite safe from a cardiovascular perspective, although amphetamine abuse and misuse may pose cardiovascular risks. During both short-term and long-term Adderall XR treatment, mean changes in systolic (2-3 mm Hg) and diastolic blood pressures (1 mm Hg) were small in magnitude.

Nonstimulant Medications for Adult ADHD

The study of nonstimulant medication treatment options for adult ADHD is an active area of research. Strattera (atomoxetine) is a selective norepinephrine reuptake inhibitor (SNRI) that reduces ADHD symptoms in adults with ADHD and was recently approved for this indication by the US FDA, but the effect is less robust than that of stimulant medications.

In 515 adults with ADHD who participated in two randomized, double-blind, placebo-controlled,10-week studies of Strattera, the effect sizes were 0.35 and 0.4. A long-term study of Strattera adults with ADHD indicated continued effectiveness for up to 2 years. The initial dose was 50mg/d and the dose could be increased up to 160 mg/d based on tolerability and efficacy. At endpoint, the most common doses were Strattera 50 mg/d (16% of participants), 80 mg/d (23%), 120 mg/d (51%), and 160 mg/d (7%). For adults receiving <100 mg/d, approximately 40% experienced a reduction of >30% on the CAARS, and of those receiving >100 mg/d, 50% experienced this level of symptom reduction. Of the 384 patients who enrolled in the long-term Strattera study, 25% withdrew because of lack of efficacy. The most common side effects reported during long-term Strattera treatment were dry mouth, headache, insomnia, and erectile dysfunction; side effects led 11% of adults to withdraw from the study.

Other nonstimulant medications that have been studied for the treatment of adult ADHD include tricyclic antidepressants, bupropion, and venlafaxine; however, the efficacy and safety of these medications for adult ADHD are less well defined than the safety and efficacy of stimulants because the nonstimulant studies have typically included a small number of subjects treated for a short period of time. A larger (N =162) short-term, placebo-controlled, optimal-dose study of Wellbutrin XL demonstrated a medication effect size of 0.6 in adults with ADHD, and 50% of patients achieved a decrease of >30% in ADHD-RS total scores. Other medications currently in clinical development for the treatment of ADHD include a methylphenidate patch, a nicotinic analogue, a glutamate AMPA receptor modulator, and a chemically novel inhibitor of dopamine and norepinephrine reuptake.

Psychosocial Treatment Strategies for Adult ADHD

Though ADHD is a neurobiologic disorder and symptoms tend to improve considerably with pharmacologic treatment, most adults with ADHD will benefit from supportive therapies to cope with day-to-day issues. Psychological therapies for adults with ADHD include counseling, learning to use behavior management principles and cognitive strategies, improving organization skills, and implementing academic or vocational accommodations.

Individual counseling may help the patient examine and understand existing coping strategies and determine what methods are working and where there is a need for improvement. Therapists can teach the adult patient the communication skills necessary to improve the important relationships in their life, and family or marital counseling also may be useful. Behavior management principles, such as a reward and punishment system, can help patients learn self-reinforcement skills. Cognitive therapy can be particularly effective for patients who have developed distorted beliefs about themselves as a result of chronic ADHD symptoms, especially if these beliefs have led to depression and anxiety. A combination of cognitive strategies and behavioral management principles can help patients learn to organize, prioritize, and accomplish various tasks. Learning to establish realistic timelines for long-term goals and completing the smaller steps needed to achieve these goals is an important cognitive technique that counselors may use for patients with ADHD.

Accommodations in the workplace also may be helpful, for example, using white noise to block distractions or limiting interruptions from phone calls or e-mails. Diligent use of a daily planner, whether paper or digital, is helpful for any adult in the fast-paced environment that is modern-day life, but for the adult with ADHD, a daily planning ritual may be crucial to success in both their personal and career environment.

Educational resources for ADHD may help adults attain a sense of control instead of feeling helpless and frustrated. Support groups are available locally and nationally. Some adults may benefit from personal coaching, and there are many personal coaches who specialize in coaching adults with ADHD.

Conclusion

The vast majority of adults with ADHD have never been diagnosed or treated, and as such adult ADHD is a major public health problem because of the significant consequences. Appropriate screening for adult ADHD may help identify those patients who might benefit from a thorough diagnostic evaluation. If DSM-IV diagnostic criteria for adult ADHD are met, discussion of medication options and psychosocial interventions can begin. This may include referrals to other health professionals as appropriate, as well as provision of information regarding support groups and other educational resources. The self-awareness gained through a diagnosis of adult ADHD may diminish frustration and embarrassment for the adult patient with ADHD and ultimately improve self-efficacy, educational attainment, work performance, and social competence.

If the spouse, family, and boss are aware that the patient's symptoms and problems are due to ADHD, they may be more supportive and accommodating.

Case Study

Mark Dillon was a 27-year-old student when a college instructor pointed out the discrepancy between the quality of his written homework and his class work. Mark's homework assignments were completed accurately and submitted on time, but the instructor noticed that he was a slow learner and too dependent on other classmates for help during class. In addition, Mark's low test scores did not reflect the quality of his written assignments. The instructor suggested that he see a counselor at the university's health services center. Mark was then referred to a psychiatrist for a complete evaluation. One of the DSM-IV criteria for a diagnosis of adult ADHD is onset of symptoms before age seven years. As part of the diagnostic evaluation, Mark's psychiatrist completed a thorough history, including documentation of behavior and academic performance as a child and adolescent.

In elementary and middle school, Mark's academic performance bounced around between that of a mediocre and a good student: "I would watch Tom and Jerry and Woody Woodpecker cartoons while doing my homework and didn't get much done." He talked and joked in class and was frequently written up for bad behavior: "I would not give my parents the written warnings from the teachers, and invariably the teacher would call my house and I'd be punished."

Despite being punished, Mark said: "My behavior did not change. I was always quick tempered and distractible. I would say the wrong thing or do the wrong thing and it made it hard for me to have real friends." In high school, Mark was definitely known as the class clown. He was in the 50th percentile of his graduating class and had a 2.7 GPA at a noncompetitive high school. Looking back, Mark says "My parents and teachers were so frustrated with me, they were just glad that I graduated from high school."

Mark's GPA was 1.8 and he was on academic probation in his sophomore year of college when he was first referred to the psychiatrist, who, after confirming a diagnosis of ADHD, gave Mark the option of enrolling in the short-term, placebo-controlled study of Adderall XR.

At study baseline, Mark's ADHD-RS total score was 34 (20 on the inattentive subscale and 14 on the hyperactive/impulsive subscale). At week 1, his ADHD-RS total score was 22, and at week 3, it was 18. Test scores on his academic coursework started to improve shortly after starting the study. After the 4-week study was complete and subjects' doses were unblinded, it was revealed that Mark had been randomized to receive Adderall XR 40 mg/d; his ADHD-RS total score was 18 at study endpoint.

At that time, Mark and his psychiatrist decided to continue treatment with Adderall XR and increase his dose to 60 mg/d to determine if a higher dose might further improve his ADHD symptoms. However, Mark reported feeling impatient at times while taking 60 mg, and it was decided that his optimal dose was 40 mg/d based on ADHD-RS scores and overall tolerability.

Mark did experience mild side effects while taking Adderall XR, including dry mouth, a slight decrease in appetite, and a 10-pound weight loss. At 186 cm (6'1") and 96.4 kg (212 lb), Mark's body mass index (BMI) was 28 kg/m2 when he enrolled in the study; he weighed 91.8 kg (202 lb) 4 weeks later. This amount of weight loss was not problematic given that his physician had previously suggested that he lose 25 pounds to attain a BMI <25 kg/m2.

Mark also experienced mild emotional lability at 40 mg/d, but this did not require any dose adjustment or any intervention. Like other side effects typically associated with the stimulant class of medications, appetite suppression and weight loss diminish over time, much to the dismay of some adult patients. In clinical studies of Adderall XR in children, adolescents, and adults, average changes in blood pressure and heart rate were small and not clinically important. Mark's BP was 128/84 mm Hg at baseline and 126/82 at the end of the 4-week study and has remained stable during long-term Adderall XR treatment. Mark's HAM-D and HAM-A scores were 5 and 15 at baseline and did not change much during the course of the short-term study or during subsequent treatment.

By the end of the semester (after two months on Adderall XR 40 mg/d), Mark had a 2-letter grade improvement in almost all of his courses. He also said that he felt much more at ease socially. Mark continues to work with a coach that he met through a local ADHD support group. The coaching process nurtures personal awareness and responsibility. By focusing on executive functioning skills (eg, planning, prioritizing, and analyzing), the coach helps Mark develop strategies that lead to progress and success in his academic career and personal life.

Now, as a junior, his GPA is 3.8: "I went from thinking I was almost retarded and needing to drop out of college to thinking I had a lot of academic opportunities. Now, I look forward to what the future will bring."

Address correspondence to: Richard H. Weisler, MD, 700 Spring Forest Rd., Suite 125, Raleigh, NC 27609; rweisler@aol.com.

Suggested Reading

Biederman J, Faraone SV, Monuteaux MC, Bober M, Cadogen E (2004). Gender effects on attention-deficit/hyperactivity disorder in adults, revisited. Biological Psychiatry 55,
692-700.

Faraone, SV, Biederman J, Spencer T, et al (2000). Attention-deficit/hyperactivity disorder in adults: An overview. Biological Psychiatry 48, 9-20.

Faraone SV, Spencer TJ, Montano B, Biederman J (2004). Attention-deficit/hyperactivity disorder in adults. A survey of current practice in psychiatry and primary care. Archives of Internal Medicine 164, 1221-1226.

DuPaul GJ, Power TJ, Anastopoulos AD, Reid R (1998). ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. New York: Guilford Press.

Kessler RC, Adler L., Ames M, et al. The World Health Organization Adult ADHD Self-report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, in press.

Wilens TE, Faraone SV, Biederman J, Gunawardene S (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 111, 179-185.

Wilens, TE (2003). Drug therapy for adults with attention-deficit/hyperactivity disorder. Drugs 63, 2395-2411.

Copyright Guilford Publications Inc. 2005

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