Table Of ContentAttention-Deficit Hyperactivity Disorder (ADHD) in Adults
Key Issues in Mental Health
Vol. 176
Series Editors
A. Riecher-Rössler
Basel
M. Steiner
Hamilton
Attention-Deficit
Hyperactivity Disorder
(ADHD) in Adults
Volume Editors
Wolfgang Retz
Homburg/Saar
Rachel G. Klein
New York, N.Y.
9 figures and 18 tables, 2010
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Key Issues in Mental Health
Formerly published as ‘Bibliotheca Psychiatrica’ (founded 1917)
Prof. Dr. Wolfgang Retz Rachel G. Klein, MD
Institut für Gerichtliche Department of Child and
Psychologie und Psychiatrie Adolescent Psychiatry
Universitätskliniken des New York University
Saarlandes Child Study Center
Kirrberger Strasse New York, N.Y. (USA)
Homburg/Saar (Germany)
Library of Congress Cataloging-in-Publication Data
Attention-deficit hyperactivity disorder (ADHD) in adults / volume editors,
Wolfgang Retz, Rachel G. Klein.
p. ; cm. -- (Key issues in mental health, ISSN 1662-4874; v. 176)
Includes bibliographical references and indexes.
ISBN 978-3-8055-9237-6 (hardcover : alk. paper)
1. Attention-deficit disorder in adults. I. Retz, Wolfgang. II. Klein,
Rachel G. III. Series: Key issues in mental health, v. 176. 1662-4874;
[DNLM: 1. Attention-Deficit Disorder with Hyperactivity--diagnosis. 2.
Adult. 3. Attention-Deficit Disorder with Hyperactivity--therapy. W1 BI429
v.176 / WM 190 A883 2010]
RC394.A85A884 2010
616.85(cid:2)89--dc22
2009037557
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ISSN 1662–4874
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Contents
VII Preface
Retz, W. (Homburg/Saar); Klein, R.G. (New York, N.Y.)
Chapter 1
1 Attention-Deficit Hyperactivity Disorder in Adults: An Overview
Wender, P.H. (Boston, Mass.); Tomb, D.A. (Salt Lake City, Utah)
Chapter 2
38 Family and Twin Studies in Attention-Deficit Hyperactivity Disorder
Freitag, C.M. (Frankfurt); Retz, W. (Homburg/Saar)
Chapter 3
58 Molecular Genetics of Attention-Deficit Hyperactivity Disorder
Retz, W. (Homburg/Saar); Freitag, C.M. (Frankfurt)
Chapter 4
78 Neurophysiology of Adult Attention-Deficit Hyperactivity Disorder
Baehne, C.G.; Fallgatter, A.J. (Würzburg)
Chapter 5
88 Brain Imaging in Adult Attention-Deficit Hyperactivity Disorder
Schneider, M. (Venray); Rösler, M.; Retz, W. (Homburg/Saar)
V
Chapter 6
105 Attention-Deficit Hyperactivity Disorder in Adults: Diagnosis and Prevalence
Stieglitz, R.-D. (Basel)
Chapter 7
126 Comorbidity in Adult Attention-Deficit Hyperactivity Disorder
Klein, R.G.; Mannuzza, S. (New York, N.Y.)
Chapter 8
144 Adult Attention-Deficit Hyperactivity Disorder – Functional Impairment,
Conduct Problems and Criminality
Rösler, M. (Homburg/Saar)
Chapter 9
159 Psychotherapy in Adult Attention-Deficit Hyperactivity Disorder
Philipsen, A.; Richter, H.; Matthies, S.; Hesslinger, B. (Freiburg)
Chapter 10
174 Psychopharmacological Treatment of Attention-Deficit Hyperactivity
Disorder in Adults
Trott, G.-E. (Aschaffenburg)
187 Author Index
189 Subject Index
VI Contents
Preface
Despite a long research history and robust findings about genetics, life course, and
treatment of attention-deficit hyperactivity disorder (ADHD), the disorder remains
a matter of public controversies and scientific debates. Descriptions of children suf-
fering from developmentally inadequate inattention, motor overactivity and impul-
sivity by European as well as American physicians go back to the 19th century. In the
20th century, empirical studies across the world substantially advanced our knowl-
edge of epidemiology, etiology, pathophysiology and treatment of the syndrome.
Nevertheless, controversy about the diagnosis remains, as evidenced by different
diagnostic standards in the Diagnostic and Statistical Manual of the American
Psychiatric Association (4th ed.; DSM-IV), and the International Classification of
Diseases (10th ed.; ICD-10), which is more restrictive and is the obligatory diagnos-
tic standard for European psychiatrists. Due to the immense international scientific
support for the DSM-IV approach to the diagnosis of ADHD, it is applied in this vol-
ume of Key Issues in Mental Health.
Although disbelieved for many decades, longitudinal studies performed since the
1970s in the USA, Canada and other countries have clearly shown that ADHD per-
sists into adulthood and is associated with high risk for comorbid psychiatric disor-
ders and social impairment. Until recently, in Germany and other European
countries, the lifespan perspective of this disorder has failed to be recognized. In the
last decade, scientific and clinical interest in ADHD have increased dramatically in
Germany, but there remains a deep transatlantic gap regarding treatment opportuni-
ties, and views about the benefits of treatment, for adult ADHD patients, in spite of
ample empirical evidence supporting treatment efficacy.
In this volume of Key Issues in Mental Health, we have brought together scientists
from the USA and Germany to provide an overview about several important aspects
VII
of ADHD across the lifespan. The topics include epidemiology, neurobiology, psy-
chopathology, longitudinal course, comorbidity and social impairment. Moreover,
diagnostic problems and therapeutic options regarding this disorder are discussed.
In the first chapter, Paul H. Wender and David A. Tomb give a synopsis of adult
ADHD from the authors’ extended work at the University of Utah. Formal and mole-
cular genetic studies are reviewed by Christine M. Freitag and Wolfgang Retz in chap-
ters 2 and 3, followed by chapter 4, where Christina G. Baehne and Andreas J.
Fallgatter report findings from neurophysiological studies of adult ADHD. An
overview of morphological and functional imaging studies in adult ADHD is pro-
vided by Marc Schneider and coworkers in chapter 5. The subsequent chapters refer
to clinical aspects of ADHD in adults, starting with diagnostic issues of adult ADHD,
presented in chapter 6 by Rolf-Dieter Stieglitz. The very important issue of comor-
bidity in adult ADHD is reviewed by Rachel G. Klein and Salvatore Mannuzza in
chapter 7, and in chapter 8 aspects of social dysfunctioning in adults with ADHD are
discussed by Michael Rösler. The last two chapters give insights into therapeutic
approaches in adult ADHD. In chapter 9, Alexandra Philipsen and coworkers report
on psychotherapeutic approaches for adults with ADHD, with a main focus on the
development of a group therapy in Germany, and in chapter 10 Götz-Erik Trott sum-
marizes options of pharmacological treatment.
In order to continue the tradition of Key Issues in Mental Health, the editors and
contributing authors endeavored to give an overview of the most relevant research
and treatments in an important field of contemporary psychiatry. We hope that this
volume will be a useful tool for physicians and therapists who work with ADHD
patients.
Wolfgang Retz
Rachel G. Klein
VIII Preface
Chapter 1
Retz W, Klein RG (eds): Attention-Deficit Hyperactivity Disorder (ADHD) in Adults.
Key Issues in Mental Health. Basel, Karger, 2010, vol 176, pp 1–37
Attention-Deficit Hyperactivity Disorder in
Adults: An Overview
Paul H. Wendera (cid:2) David A. Tombb
aDepartment of Psychiatry, Harvard Medical School, Boston, Mass., and bDepartment of Psychiatry, University of
Utah School of Medicine, Salt Lake City, Utah, USA
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a common, genetically transmitted neurological
disorder, with onset in childhood, probably mediated in part by decreased brain dopaminergic func-
tioning. The first author and colleagues were among the earliest (1976) to describe the persistence
of symptoms into adulthood and to perform a methylphenidate trial. Prevalence and natural history
data suggest that of the 3–10% of children diagnosed with ADHD, one- to two-thirds continue to
manifest appreciable ADHD symptoms as adults. This chapter reviews how ADHD in adults can be
readily diagnosed and treated using the Wender Utah diagnostic criteria to identify adult character-
istics of the disorder. Stringent diagnosis is key to determining effective treatment. This chapter also
addresses core hypotheses of etiology and treatment. Dopamine agonist stimulant medications
appear to be the most effective in treating ADHD. About 70% of patients receiving stimulant medi-
cation have shown moderate to marked improvement, as compared with 20% of those receiving
placebo. The core symptoms of hyperactivity, inattention, mood lability, temper, disorganization,
stress sensitivity, and impulsivity have been shown to respond to treatment with stimulant medica-
tions more than to other drugs. Appropriate management of adult patients with ADHD includes
psychoeducation and counseling when necessary while the roles of supportive problem-directed
therapy, behavioral intervention, coaching, and couples and family therapy remain to be evaluated.
Copyright © 2010 S. Karger AG, Basel
Attention-deficit hyperactivity disorder (ADHD) is very likely the most common and
undiagnosed psychiatric disorder of adult life. Increasingly recognized only since the
1970s, ADHD had previously been believed to diminish in adolescence and disappear
in adulthood. About 30 years ago, the senior author noted that the parents of ADHD
children described similar problems in their own childhood and for many these prob-
lems had continued throughout life. A frequent comment by a spouse was: ‘What do
you mean used to have?’ The senior author was then faced with two primary ques-
tions: [1] what clinical features characterize ADHD in adults (this work antedated
DSM-III) and [2] how does one determine if the adults would have met the criteria
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