Dr Birgit Amann

Challenges as adolescents with ADHD approach young adulthood

Delegates at MoM VIII had options to attend a range of clinical seminars, including one on the management of ADHD in adolescents and early adulthood, led by Dr Birgit Amann (Behavioral Medical Center, Troy, Minnesota, USA) and Professor Peter Hill (independent child and adolescent psychiatrist, London, UK).

During this seminar, Dr Amann and Professor Hill considered how ADHD symptoms evolve over the lifespan, with accompanying changes in patient goals, priorities and awareness of symptoms. They particularly focused on the transition from adolescence to young adulthood, drawing attention to the environmental demands on this population, specifically the need to:1

  • Establish lasting personal relationships outside of immediate family
  • Become more financially independent, and responsible for personal structure/time management
  • Choose a career/occupation.

The seminar also highlighted how these demands may be further compounded by a lack of societal accommodations for ADHD in the workplace, a shortage of specialists in the treatment of adult ADHD, and the desire to move out of the parental home.

Dr Amann described how adolescents with ADHD need to balance these demands with appropriate resources, including the development of personal self-management skills and external support from family and friends. She emphasised that psychoeducation and behavioural interventions were crucial in this regard.

Professor Philip Asherson

Presentation of ADHD in adulthood

In another clinical seminar, Professor Philip Asherson (King’s College London, UK) described how the diagnosis of adult ADHD can be complicated by the presence of comorbidities and symptoms not easily identifiable during patient interview (e.g. distractibility). In addition, he noted that, in his experience, common symptoms of adult ADHD can mimic symptoms of other psychiatric conditions:

Emotional instability Can also be suggestive of bipolar disorder or borderline personality disorder
Sleep problems/initial insomnia Can be confused with symptoms of bipolar disorder or depression
Talking excessively or tangentially Can be confused with symptoms of chronic hypermania
Low self-esteem Can be confused with symptoms of depression
Concentration difficulties Common across many different psychiatric conditions

Audience questions: differentiating between ADHD and bipolar disorder
In response to audience questioning about how to differentiate between ADHD and bipolar disorder, Professor Asherson noted that:

  • ADHD involves chronic traits, whereas bipolar disorder has an episodic course
  • Patients with ADHD often have sleep problems despite wanting to sleep, whereas patients with bipolar disorder typically do not feel like they want/need to sleep.

Dr Larry J Klassen (Eden Mental Health Centre, Winkler, Manitoba, Canada) highlighted similar points in a clinical seminar on the differential diagnosis of adult ADHD.2,3

Professor Asherson particularly emphasised mind wandering and ceaseless mental activity as central characteristics of adult ADHD that can be helpful indicators of the possible diagnosis. He noted the Mind Excessively Wandering Scale (MEWS), which has been shown to differentiate between adults with ADHD and control subjects.4

Professor Asherson: “One of the most prominent features of ADHD: adults complaining that their thoughts are constantly on the go, jumping or flitting from one topic to another, and multiple lines of thought at one time. These can be quite distressing to patients and very much part of the impairment.”

‘Late-onset ADHD’

In a plenary session, Dr Luis Rohde (Hospital de Clinicas de Porto Alegre, Brazil) considered whether adult ADHD is only a childhood-onset neurodevelopmental disorder, or whether ‘late-onset ADHD’ is a valid concept. He presented data from two longitudinal cohort studies suggesting that adult ADHD may be diagnosed in adults who had no symptoms in childhood.5,6 However, he noted the importance of considering differences between population-based cohorts and clinical samples (e.g. less comorbidity in population samples7), and suggested that ‘late-onset ADHD’ may just be ADHD that emerges later, when demands on patients have increased.

Audience questions: ‘late-onset ADHD’ as a distinct diagnosis
In response to audience questioning, Dr Rohde suggested that more research is needed before it is possible to determine whether ‘late-onset ADHD’ represents a separate disorder to childhood-onset ADHD.

  1. Turgay A, Goodman DW, Asherson P, et al. Lifespan persistence of ADHD: the life transition model and its application. J Clin Psychiatry 2012; 73: 192-201.
  2. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Toronto: CADDRA, 2011.
  3. Geller B, Williams M, Zimerman B, et al. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. J Affect Disord 1998; 51: 81-91.
  4. Mowlem FD, Skirrow C, Reid P, et al. Validation of the Mind Excessively Wandering Scale and the Relationship of Mind Wandering to Impairment in Adult ADHD. J Atten Disord 2016; Epub ahead of print.
  5. Agnew-Blais JC, Polanczyk GV, Danese A, et al. Evaluation of the persistence, remission, and emergence of attention-deficit/hyperactivity disorder in young adulthood. JAMA Psychiatry 2016; 73: 713-720.
  6. Caye A, Rocha TB, Anselmi L, et al. Attention-deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort supporting a late-onset syndrome. JAMA Psychiatry 2016; 73: 705-712.
  7. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry 1999; 40: 57-87.