Counseling Points - Family/Pediatric Nurse 11/08 - (Page 9)

Co-morbid Bipolar Disorder. It is often quite challenging to differentiate between symptoms of ADHD and a mood disorder such as bipolar disorder, because both disorders have overlapping symptoms of inattention, hyperactivity, and impulsivity.5 If a child’s diagnosis is not clear or if there are complicating factors, the child needs to be referred to a specialist for further evaluation. Co-morbid Substance Abuse Disorders. In children and adolescents with ADHD and a co-morbid substance abuse disorder, difficulties in daily functioning may persist into adulthood resulting in poor academic and occupational achievement, social impairment, and an increased rate of separation and divorce.23 Health care professionals need to remember that ADHD symptoms may interfere with substance abuse interventions. Individuals with ADHD and a co-morbid substance abuse disorder should be referred to a mental health specialist in substance abuse disorders.They should be carefully and closely monitored and participate in a substance abuse cessation program in addition to receiving pharmacological treatment. Co-morbid Sleep Disorders. Recently, there has been an increased awareness of the co-morbidity of ADHD with sleep disorders. Sleep dysregulation may be related to the ADHD or to use of medications such as psychostimulants. From clinical experience, we have observed that changes in sleep patterns can cause cognitive impairments as well as attention and memory issues. It is important to take a thorough sleep history and educate individuals and families about sleep hygiene techniques to diminish insomnia. In addition, clinical experience suggests that the effects of some of the long-acting stimulants may last up to 12 hours; therefore they should be given early in the morning to decrease the likelihood of insomnia. If sleep dysregulation persists, it may be important to refer the child or adolescent with ADHD to a sleep specialist and further evaluate him or her. inattentive symptoms. In addition, symptom presentation changes somewhat over the lifespan. It is anticipated that the DSM Task Force of the American Psychiatric Association will adjust the diagnostic criteria for adults in the DSM V, due for publication in 2012, helping to clarify diagnosis in adults. Adult Symptomatology In young adults, ADHD presents with inattentiveness, impulsivity, difficulty focusing, and hyperactivity (a more common symptom in young males than in females). The most hyperactive children, especially males, by adolescence or young adulthood may have come into conflict with school authorities or with law enforcement, or may have suffered a higher than average incidence of serious accidents. ADHD adolescent males in particular tend to be exaggerated risk-takers. Even without engaging in risky behaviors, the inattentiveness and distractibility of ADHD can result in a higher frequency of automobile accidents for these individuals.21 As individuals with ADHD mature, hyperactivity tends to calm down or to become less visible to others; adults with ADHD tend to be more internally restless or fidgety than hyperactive.They may experience difficulty relaxing, concentrating, or persisting with sedentary activities, have poor organizational skills, be chronically late, often lose things, and be serious procrastinators.They may complain of being energetic project starters, but not “deal closers.” They may abuse substances, and can be chronically bored, moody, or short-tempered. In the adult health care setting, people with ADHD frequently present with mood disorders, alcohol and drug abuse, or injuries from accidents or physical confrontations. Women particularly (for whom inattention is more common than hyperactivity) tend to present with anxiety, depression, or a feeling of being overwhelmed. It can be challenging to determine if these individuals are constitutionally depressed along with their ADHD, or if depression reflects the social and intellectual demoralization of a lifetime of feeling inadequate and “not quite knowing” what is wrong. This is a typical pattern described by adult women. Because distraction and school or work difficulties can also be the result of mood instability, substance use, medication interaction, neurological compromise, learning disabilities, or life events, diagnosis in adults is complex. Adults, after all, are not brought to our office by parents frightened by disruptive behaviors. Instead, they refer 9 NOVEMBER 2008 ADHD in Adults The research literature on ADHD in adults is sparse, so we must rely largely on clinical expertise and patient presentation, along with extrapolations from child research for guidance. Because we often lack early childhood records for adults with ADHD, it is difficult to document an adult’s earliest demonstration of impulsive or

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