USPSych: ADHD In Teens and Adults: A Different Disease With Sterner Consequences

NEW ORLEANS, Nov. 17 -- Attention-deficit hyperactivity disorder (ADHD,) usually thought of as a condition of childhood, may persist into adolescence and adulthood, causing serious life problems.

Recent studies have found that 28% to 65% of children with ADHD will continue to manifest the disease in adolescence and early adulthood, said James T. McCracken, M.D., a psychiatrist at the University of California Los Angeles. Dr. McCracken spoke at a symposium held in conjunction with the U.S. Psychiatric & Mental Health Congress here.

For children, the prevalence is 6% to 8%, Dr. McCracken said. That rate drops to 4% to 6% for adolescents and to 2% to 4% in adults,

However, for those 2% to 4% of adults the consequences of ADHD can be severe, he added.

For example, ADHD is associated with high rates of co-morbidity with other mental disorders. "Co-morbidity is the rule, not the exception, for adolescents and adults with ADHD, particularly with anxiety and mood disorders," Dr. McCracken said.

Up to 35% of adolescents and young adults with ADHD will also have an anxiety disorder. And the co-morbidity rate for mood disorders is up to 48%, Dr. McCracken said.

In addition, ADHD is important to treat in adolescents and adults because of the danger it poses. Compared to those without ADHD, teens and young adults with this condition are more likely to:

• repeat a grade (less than 10% versus about 25%)
• acquire a sexually transmitted disease (about 5% versus about 15%)
• abuse alcohol and drugs (about 25% versus more than 50%)
• land in jail (about 20% versus about 40%)
• be fired from a job (about 25% versus about 55%)
• attempt suicide (less than 15% versus nearly 45%)

In addition, teenage girls with ADHD are more likely to become pregnant (less than 5% compared with nearly 40%), he added.

The nature of the disease changes as one ages. Symptoms of hyperactivity and impulsivity tend to decline as one grows older, but symptoms of inattention are "much more stubborn and persistent," Dr. McCracken said.

Possible predictors of ADHD continuing into adulthood include its severity in childhood and a family history of the condition. With as much as 70% of ADHD being inherited, the disorder is "highly heritable," nearly as heritable as schizophrenia, Dr. McCracken said.

Genes that may confer ADHD risk include catecholamine genes, such as DRD4, DAT1, DRD5, SNAP25, according to preliminary reports, he said.

However, several environmental factors have also been linked to ADHD risk. Chief among these is maternal smoking during pregnancy, Dr. McCracken said. Others include premature birth, lead exposure, and ischemic cerebrovascular headache, he added.

Gender and ethnicity have not so far been shown to be linked to ADHD risk, Dr. McCracken said.

The best guidelines for treating ADHD in adolescents and young adults come from the Texas Children's Medication Algorithm Project (TCMAP), said Adelaide S. Robb, M.D., of the Children's National Medical Center in Washington. Dr. Robb also spoke at the symposium.

The TCMAP guidelines are the most current, Dr. Robb said. They were updated this year, and so far they are the only ones published after the FDA approved Strattera (atomoxetine), which is indicated for ADHD in patients of all ages, she said.

In addition, the TCMAP guidelines make treatment recommendations not only for ADHD alone but for ADHD accompanied by other disorders included mood disorders or anxiety, Dr. Robb said.

For example, for ADHD accompanied by a mood disorder, the guidelines suggest treating the more severe of the two first. Only if monotherapy does not resolve both disorders should a treatment for the second condition be added, Dr. Robb noted.

For ADHD with anxiety, the guidelines offer two options. One option is to try Strattera to treat both disorders, as some studies suggest it has efficacy for both. The other option is to treat the ADHD with one of the approved stimulants then add a selective serotonin reuptake inhibitor (SSRI) for the anxiety, Dr. Robb said.

The symposium was supported by McNeil Pediatrics, a division of McNeil-PPC, Inc., of Fort Washington, Pa.