How and Why Treatments for ADHD Differ in Adults and Children

How and Why Treatments for ADHD Differ in Adults and Children1

How and Why Treatments for ADHD Differ

in Adults and Children

Rabeea Saleem

How and Why Treatments for ADHD Differ in Adults and Children2

ADHD is a neuropsychiatric disorder with cognitive and

behavioral components, characterized by symptoms such as

impulsivity, hyperactivity, inattention and various educational,

social and functional deficits. This disorder is most prevalent

among kids aged 4 to 17 years old(Boston.com, 2014). The

American Psychiatric Association states in the Diagnostic and

Statistical Manual of Mental Disorders (DSM-5) that 5% of

children have ADHD (Cdc.gov, 2014).  However, studies in the US

have estimated higher rates in community samples. It is

estimated to affect 3 to 5 percent of school-age children and

occurs three times more often in boy than in girls (“Prevalence

and Incidence of Attention Deficit Hyperactivity Disorder”,

2014). ADHD is the most widely studied childhood disorder. A

substantial amount of literature is available about treating

childhood ADHD and research on treating ADHD in adulthood is

expanding. I will start by examining the symptom profiles of

ADHD in adults and children, then discuss the treatment options

for ADHD in both, adults and children, and compare their

How and Why Treatments for ADHD Differ in Adults and Children3

efficacy in relation with the manifestation and symptom variance

of the disorder that is observed in children and adults.

Initially, ADHD was regarded as exclusively a childhood disorder

which was considered to resolve itself in adolescence but recent

statistics show this not to be the case. A survey by Kessler et

al. (2012) revealed that 36.3% of children meeting the criteria

for ADHD continued to meet full diagnostic criteria for the

disorder as adults and about two thirds of all children with ADHD

continue to have residual symptoms into adolescence and adulthood

(Faraone et al., 2006). DSM-V, released in May 2013, recognizes

this and hence, has included descriptions to show how ADHD might

look like at older ages and for adolescents older than 17 yrs.

DSM V now considers ADHD as a chronic neurodevelopmental disorder

with onset in the developmental period, with impairments that

often persists into adulthood.

ADHD in Children

ADHD is one of the most prevalent psychiatric disorders in

children with estimates suggesting that it affects approximately

How and Why Treatments for ADHD Differ in Adults and Children4

4% to 12% of school-aged children worldwide (Timothy et al,

2010). During the past decade, epidemiological studies have found

high rates of concurrent psychiatric and learning disorders among

individuals with ADHD (Timothy et al, 2010). Comorbidity has

become an important area of research and studies reveal that

children with ADHD also have other disorders such as oppositional

defiant disorder (ODD), conduct disorder, mood and anxiety

disorders, and cigarette and substance use disorders.

There are three different categories of ADHD symptoms in children:

inattention, impulsivity and hyperactivity. Inattention may not

become evident until a child enters the demanding environment of

school. Symptoms of inattention in kids include distractibility,

making careless mistakes in school, producing messy and careless

work, difficulty finishing schoolwork, frequent shifts in

conversation and forgetfulness. Hyperactivity symptoms may be

apparent in very young preschoolers and are nearly always present

before the age of seven. Symptoms include fidgeting and

squirming, running or climbing excessively, talking excessively,

having difficulty engaging in quiet leisure activities and always

How and Why Treatments for ADHD Differ in Adults and Children5

being on the go. ‘Hyperactivity may vary with age and

developmental stage. Toddlers and preschoolers with ADHD tend to

be constantly in motion, jumping on furniture, and having

difficulty participating in sedentary group activities. For

instance, they may have trouble listening to a story. School-age

children display similar behavior but with less frequency. They

are unable to remain seated, squirm a lot, fidget, or talk

excessively. Impulsivity may lead to accidents such as knocking over

objects or banging into people. Children with ADHD may also

engage in potentially dangerous activities without considering

the consequences. For instance, they may climb to precarious

positions (“Attention Deficit Hyperactivity Disorder: Symptoms of

ADHD”, 2013).

ADHD in Adults

Contrary to earlier assumptions, ADHD is no longer considered a

disorder exclusive to childhood. A survey by Kessler et al.

(2005) revealed that 36.3% of children meeting the criteria for

ADHD continued to meet full diagnostic criteria for the disorder

How and Why Treatments for ADHD Differ in Adults and Children6

as adults and about two thirds of all children with ADHD continue

to have residual symptoms into adolescence and adulthood (Faraone

et al., 2006).According to Retz (2012), considering the

prevalence of adult ADHD and the negative impact its symptoms may

have on different domains of the patient’s life, it should be

recognized as a significant mental disorder requiring accurate

diagnosis and treatment (Rosler et al, 2010a).ADHD may manifest

differently in adults which is why it is quite a challenge, given

that identification of adult ADHD is a recent development, to

correctly recognize the disorder in adults and treat it. Symptom

expression of ADHD is markedly different in adults. Inattention

tends to persist through childhood and adolescence and on into

adulthood, while hyperactivity tends to diminish with age.

Hyperactivity might be manifested as feelings of restlessness and

difficulty engaging in quiet, sedentary activities. As they grow

older, some teens that had ADHD may experience periods of anxiety

and depression. According to Rostain (2012), ADHD in adults is

related to impairments in educational, occupational,

neuropsychological and social functioning in adults.

How and Why Treatments for ADHD Differ in Adults and Children7

Treatments

Although the hyperactive syndrome was first described more than

100 years ago, there is controversy regarding the most effective

treatment for ADHD.As ADHD is the most widely-studied childhood

disorder, there are many different treatments that have been

proven to be effective for ADHD. However, as ADHD in adults has

only been recently recognized, there is dearth of longitudinal

research targeting specifically adult ADHD. As there is variance

in the symptom profiles of children and adults with ADHD, there

cannot be a ‘one-size-fits-all’ treatment for ADHD.

According to Barkley (2013), the treatments of children and

adults vary largely because of the age difference and who is to

implement the treatment. Treatments also differ because the

symptom patterns and functional deficits are very different in

adults and children.

Treatments for children

The longest-used medications for ADHD are stimulants which have

been used in the management of childhood ADHD since the 1930s

How and Why Treatments for ADHD Differ in Adults and Children8

(Bradley 1937), as claimed in a study by Retz et al, (2012).

According to the study, stimulants have become the first line

pharmacological treatment for ADHD in view of their favorable

efficacy profiles and are recommended as one component of

multimodal therapy by several evidence-based guidelines (Ebert et

al. 2003; Nutt et al. 2007;NICE 2008). Survey has show that 40

percent of junior high school children and 15 percent of high

school children with ADHD are prescribed medication, mostly

Ritalin which is an amphetamine (Butcher, Mineka & Hooley, 2014).

Other ADHD medications include methylphenidate, atomoxetine and

dexamphetamine (Didoni et al, 2011). Stimulant treatment have

been shown to be beneficial, consistently, in improving the core

systems of ADHD like hyperactivity and inattention, but evidence

supporting long term gains is scarce ( Zoëga et al, 2012). Also,

while stimulants do improve the core symptoms, no clear effect is

found on academic performance (Prasad et al, 2013). Additionally,

concerns regarding the numerous side effects of medication and

drug dependence, and abuse have led to many parents seeking

alternative, non-pharmacological treatments for ADHD.

How and Why Treatments for ADHD Differ in Adults and Children9

Some authorities favor psychological interventions to be used in

conjunction with medications (Mariani and Levin, 2007).

Longitudinal studies (Rostain, 2012) have shown that

pharmacotherapy is only one facet of treatment and without

behavioral interventions, child’s difficulties at school and home

are likely to endure. Effective behavioral approaches to treat

ADHD involves the use of behavior therapy which consists of

employing positive reinforcement immediate feedback about their

performance and structuring of tasks in a way that minimizes

errors and maximizes success (Frazier & Merrill, 1998). While

medication eliminates the problematic symptoms of ADHD, it does

not modify behavior. Moreover, medication does not work on over

20% of the ADHD patients. For those it works for, the effect is

short-term and chances of ‘rebound’ are high, once the medication

is discontinued. Behavioral therapy fills in these blanks and

teaches such children alternative and productive behaviors. Other

behavioral interventions include selective reinforcement in the

class room (DuPaul et al,. 1998) and family therapy (Everett &

Everett,2001). According to APA, for children with ADHD who are

How and Why Treatments for ADHD Differ in Adults and Children10

under 5 years old, behavior therapy should be the first line of

treatment.

Psychosocial treatment for ADHD has shown promising results

(Pelham &Fabiano2008: Corcoran, 2011). Youth with ADHD have

trouble controlling their impulses, concentrating and behaving,

therefore, their parents have to learn elementary techniques to

manage their challenging behaviors. “Using techniques such as

positive reinforcement, rewards, response cost, punishments,

contracts, token economies, extinction procedures, environmental

manipulation and stimulus controls, parents can be taught to

exert a positive in uence on behavior” (Rostain,2012). fl

Psychosocial treatment has proven to be the most successful for

kids who exhibit low to moderate ADHD symptoms.

An unconventional treatment for ADHD in children was investigated

in a study by Klaus et al (2013) which studied the effectiveness

of individualized homeopathic treatment of children diagnosed

with ADHD, over a 10 year period. The findings reported

How and Why Treatments for ADHD Differ in Adults and Children11

clinically significant positive effects of the homeopathic

therapy, persistent over 10 years.

There are several different approaches to treating ADHD but

research suggests that for most children, multimodal approach is

the best way to manage their symptoms. Multimodal treatment

typically includes medication, behavioral therapy, educational

and family support and psychotherapy. Results from a cross-

national workshop (Hinshaw et al., 2011), which enlisted

international leading psychiatrists and psychologists of

developmental psychopathology, indicates that prevalence of

medication treatment varies greatly both within and across

nations. In addition, the ways in which school settings perceive

and react to ADHD symptoms of children differ widely between

countries. Social context greatly influences assessment and

treatment of ADHD around the world.

Treatments for Adults

The prevalence of adult ADHD is estimated to be roughly 7-9%.

With DSM V making the move towards establishing a more adult-

How and Why Treatments for ADHD Differ in Adults and Children12

tailored criterion for ADHD, it is evident that the operational

definition of ADHD has changed from being a childhood disorder to

a chronic, developmental disorder. In recent years, the

recognition and diagnosis of ADHD in adults have been increasing

although treatment of adults with ADHD continues to lag

substantially behind that of children (Wilens, 2010).In addition,

epidemiological studies in the past decades have documented high

rates of concurrent learning and psychiatric disorders in

individuals with ADHD. In particular, adult ADHD is highly co-

morbid with a variety of disorders including antisocial, mood,

impulse control, bipolar disorders and anxiety symptoms (Kessler,

Adler, Barkley et al., 2006). The presence of these co-morbid

symptoms confounds the assessment and diagnosis for adult ADHD.

Treatment guidelines for adults with ADHD are still progressing,

but there is a growing consensus that multimodal approaches

similar to those used with children and adolescents are the most

likely to address the “multiplicity of issues that these patients

present to clinicians” (Rostain, 2012).

How and Why Treatments for ADHD Differ in Adults and Children13

Pharmacotherapy for ADHD in adults is not aswell-researched as in

children and adolescents, but the American Academy of Child and

Adolescent Psychiatry guidelines endorse the use of both

stimulant and non-stimulant medications, like atomoxetine

depending upon patient variables (Rostain, 2012). Combining SSRIs

with stimulants can be used safely for adults with ADHD and

comorbid anxiety r depression. As adults have a different symptom

profile than children, recent pharmacological trials deduced that

methylphenidate treatment showed decline of not only the core

symptoms of ADHD but also, different measures of emotional

dysregulation, oppositional symptoms and disorganization in

adults with ADHD (Reimherr et al. 2007; Rösler et al. 2009,

2010b; Marchant et al. 2010)(Retz et al., 2012).

Despite their success rate, there are many reasons

pharmacotherapy is less successful for adult ADHD than it is for

children. As with children, medications have a lot of adverse

side effects for adults as well. While growth suppression is not

an issue for adults, effects on the cardiovascular system are

more significant in adults than in children. Stimulants are known

How and Why Treatments for ADHD Differ in Adults and Children14

to increase heart rate and blood pressure, and those with long-

term, heavy recreational use are at increased risk of myocardial

infarction and stroke(Moncrieff and Timimi, 2011). According to

Wim J. C. Verbeeck and Siegfried Tuinier(2011), adults with ADHD

often suffer from a comorbid disorder for which stimulant drugs

may be inappropriate. Psychostimulants are also contraindicated

in patients with glaucoma, hyperthyroidism, and current use of

monoamine oxidase (MAO) inhibitors, symptomatic cardiovascular

diseases, uncontrolled hypertension, and drug dependence

(Greenhill et al., 2002) as Referenced by Buitelaar, Kan&Asherson

(2011). In view of these facts, many adults with ADHD choose to

go for non-pharmacotherapy, alternative treatments.

There is a growing line of research which highlights the efficacy

of cognitive behavioral treatment for adults with ADHD who are on

medication and manifest residual ADHD symptoms. Coaching therapy

is another treatment which aims to design a plan of action to

improve performance of the patient in day to day. The coaching

also has a CBT component to it and has been proven to be

successful in treating adult ADHD and helping patients maintain a

How and Why Treatments for ADHD Differ in Adults and Children15

healthy self-esteem (Ryfel, 2011). Effectiveness of another

alternative mode of treatment was demonstrated in a study by

Rucklidge et al., (2014) which showed that micronutrient

treatment induced statistically robust improvement in ADHD

symptoms, as well as normal functioning for ADHD adults.

This paper examined the difference in symptom profiles of

children and adults with ADHD and explored the differences in the

treatments for both. It can be safely concluded that treatments

of adults and children differ because of the demands of symptom

self-management, age differences, comorbidity and difference in

domains of impairments. Moreover, who is implementing the

treatment is another critical factor. With children it is mostly

their parents and/or teachers who are implementing the treatment

which is why behavioral modification works for them. It is not as

effective for adults as they must institute such contingency

management strategies themselves (Barkley, 2014). Cognitive

behavioral therapy is more effective with adults when it focuses

on their executive deficits, such as in time management and

emotional self-regulation, but is not effective when used

How and Why Treatments for ADHD Differ in Adults and Children16

directly with children, probably because of their more limited

mental and executive functioning development (Barkley, 2014).

Medications are effective for both groups but presence of higher

co morbidity in adults can hinder its effectiveness. Multimodal

treatments are the only ones that have been proven to be equally

successful in adults and children, both. More longitudinal

studies are required to investigate the etiology and core

symptoms of adult ADHD to better manage and tailor the treatment

to meet the individual needs as ADHD affects every person

differently. Carefully controlled research is necessary to study

where the treatment for ADHD in adults converges and where it

digresses from that of children.

How and Why Treatments for ADHD Differ in Adults and Children17

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