AD/HD in Adults
AD/HD in Adults - Fact Sheet #7
AD/HD has been recognized and treated in children for almost a century, but
the realization that AD/HD often persists into adulthood has only come over
the last few decades. The prevailing belief among professionals for many
years was that children and adolescents would outgrow their symptoms of
AD/HD by puberty, and certainly by adulthood. However, contemporary research
has shown that as many as 67 percent of children diagnosed with AD/HD will
continue to have symptoms of the disorder that significantly interfere with
academic, vocational or social functioning in their adult lives.1 The core
symptoms of AD/HD ¾ inattention, impulsivity and hyperactivity ¾ appear in
childhood (usually by age seven) and result in a chronic and pervasive
pattern of impairment for most. AD/HD in adults is sometimes viewed as a
“hidden disorder” because the symptoms of AD/HD are often obscured by
problems with relationships, organization, mood disorders, substance abuse,
employment or other psychological difficulties. It is a complex and
difficult disorder to diagnose, and should only be diagnosed by an
experienced and qualified professional. AD/HD is first recognized in some
adults because of problems with depression, anxiety, substance abuse or
impulse control. Others recognize that they may have AD/HD only after their
child is diagnosed. Despite increased awareness and identification of the
disorder in adults, many adults remain unidentified and untreated.
Characteristics of Adults with AD/HD
The growth of Children and Adults with Attention-Deficit/Hyperactivity
Disorder (CHADD) and a renewed interest in research have contributed to the
increased recognition of this disorder in both children and adults. Still,
many adults grew up at a time when clinicians, educators, parents and the
general public knew very little about AD/HD or its diagnosis and treatment.
Consequently, greater public awareness has led to an increased number of
adults seeking evaluation and treatment for AD/HD and its associated
symptoms. The current diagnostic criteria for AD/HD (reworded slightly to be
more appropriate for adults) according to the most recent Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) are:
Fail to give close attention to details or make careless mistakes at work
Fidget with hands or feet or squirm in seat
Have difficulty sustaining attention in tasks or fun activities
Leave seat in situations where seating is expected
Don’t listen when spoken to directly
Feel restless
Don’t follow through on instructions and fail to finish work
Have difficulty engaging in leisure activities quietly
Have difficulty organizing tasks and activities
Feel “on the go” or “driven by a motor”
Avoid, dislike, or are reluctant to engage in work that requires sustained
mental effort
Talk excessively
Lose things necessary for tasks and activities
Blurt out answers before questions have been completed
Easily distracted
Have difficulty awaiting turn (impatient)
Forgetful in daily duties
Interrupt or intrude on others
Although other symptom checklists are sometimes used in assessing adults for
AD/HD, the above DSM-IV criteria are currently considered the most
empirically valid. These core symptoms of AD/HD frequently lead to
associated problems and consequences that often co-exist with adult AD/HD.
These may include:
- Problems with self-control and
regulating behavior
- Poor working memory
- Poor persistence of efforts toward tasks
- Difficulties with regulation of
emotions, motivation and arousal
- Greater than normal variability in task
or work performance
- Chronic lateness and poor time
perception
- Easily bored
- Low self-esteem
- Anxiety
- Depression
- Mood swings
- Employment difficulties
- Relationship problems
- Substance abuse
- Risk-taking behaviors
- Poor time management
The impairment from both the core symptoms and associated features of
AD/HD can range from mild to severe in its impact on academic, social and
vocational domains, and in daily adaptive functioning. Since the symptoms
of AD/HD are common to many other psychiatric and medical conditions and
some situational/environmental stressors, adults should never
self-diagnose and should seek a comprehensive evaluation from a qualified
professional.
Research indicates that AD/HD occurs in approximately three to five
percent of school-age children and approximately two to four percent of
adults. Among children, the gender ratio is approximately 3:1, with boys
more likely to have the disorder than girls. Among adults, the gender
ratio falls to 2:1 or lower. The disorder has been found to exist in every
country in which it has been studied, including North America, South
America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the
Middle East. The disorder may not have the same name in these countries,
and may be treated differently, but there is little doubt that the
disorder is virtually universal among human populations.
What Causes AD/HD?
There are no definitive answers as yet. To date, there are no biological,
physiological or genetic markers that can reliably identify the disorder.
However, research has demonstrated that AD/HD has a very strong biological
basis. Although precise causes have not yet been identified, there is
little question that heredity makes the largest contribution to the
expression of the disorder in the population. In instances where heredity
does not seem to be a factor, difficulties during pregnancy, prenatal
exposure to alcohol and tobacco, premature delivery, significantly low
birth weight, excessively high body lead levels, and postnatal injury to
the prefrontal regions of the brain have all been found to contribute to
the risk for AD/HD to varying degrees. Research does not support the
popularly held views that AD/HD arises from excessive sugar intake, food
additives, excessive viewing of television, poor child management by
parents, or social and environmental factors such as poverty or family
chaos.
Diagnosis of AD/HD in Adults
A clinician or a team of clinicians who have experience and expertise in
AD/HD and related conditions should make a comprehensive evaluation. This
team may include a behavioral neurologist or psychiatrist, a clinical
psychologist or an educational psychologist. Evaluation for AD/HD should
include a comprehensive clinical interview surveying past and present
AD/HD symptomatology, developmental and medical history, school history,
work history, psychiatric history ¾ including any medications prescribed,
social adjustment and general day-to-day adaptive functioning (i.e.,
ability to meet the demands of daily life). The interview is intended
first to identify evidence of core AD/HD symptoms (hyperactivity,
distractibility, impulsivity) and then to ensure that the history of these
symptoms is both chronic and pervasive. This should not simply be a brief,
surface-level exam. It usually requires one or two hours at minimum.
Ideally, the interview should rely on several informants (a parent if
possible, or a significant other,) and survey behavior from multiple
settings (i.e., school, work, home). It is also imperative that the
clinician attempt to rule in or rule out other psychiatric diagnoses that
may better explain presenting symptoms. An adult evaluation should also
use the DSM-IV AD/HD symptom rating scales, review any available past
objective records such as report cards, transcripts or prior
testing/evaluation reports, and in some cases use psychological testing to
determine any cognitive or learning weaknesses that may underlie
functional impairment. A comprehensive evaluation is needed for three
reasons: to establish an accurate diagnosis, to evaluate for the presence
of co-existing medical or educationally disabling conditions, and to rule
out alternative explanations for behaviors and/or relationship,
occupational or academic difficulties.
Why Identify AD/HD in Adults?
Growing up with undiagnosed AD/HD can have devastating effects on the
adult. For some, the diagnosis and education that follows an evaluation
can be a profoundly healing experience. Proper diagnosis can help adults
put difficulties in perspective and better understand the reasons for many
lifelong symptoms. Adults with AD/HD have often developed negative
perceptions of themselves as “lazy,” “stupid,” or even “crazy.” Proper
diagnosis and effective treatment can help improve self-esteem, work
performance and skills, educational attainment and social competencies.
Many adults with AD/HD are offered protection under the Americans with
Disabilities Act of l990, which prohibits discrimination in employment and
public accommodations against any individual who has a physical or mental
impairment that substantially limits one or more major life activities ¾
including learning and working ¾ or who has a record of such impairment.
After Diagnosis, What Then?
Although there is no cure for AD/HD, many treatments can effectively
assist in managing its symptoms. Chief among these treatments is the
education of adults with AD/HD and their family members about the
disorder’s nature and management. However, well-controlled research
comparing different types of treatment has found overwhelmingly that the
greatest improvement in the symptoms of AD/HD results from treatment with
stimulant medication combined with counseling. Evidence shows that some
tricyclic antidepressants may also be effective in managing symptoms of
AD/HD as well as co-existing symptoms of mood disorder and anxiety. Just
as there is no single test to diagnose AD/HD, no single treatment approach
is appropriate for everyone. Treatment needs to be tailored to the
individual and should address all areas of need. There may be a variety of
behavioral, social, academic, vocational or relationship concerns for the
adult with AD/HD. For some, just getting the diagnosis and understanding
that there was a reason for many past difficulties can be extremely
helpful. Adults with AD/HD may also benefit from counseling about the
condition, vocational assessment and guidance to find the most suitable
work environment, time management and organizational assistance, coaching,
academic or workplace accommodations, and behavior management strategies.
In summary, some common components of treatment plans for adult AD/HD
include:
Consultation with appropriate medical professionals
Education about AD/HD
Medication
Support groups
Behavior skill-building such as list-making, day planners, filing systems
and other routines
Supportive individual and/or marital counseling
Coaching
Vocational counseling
Assistance with making appropriate educational and vocational choices
Perseverance and hard work
Appropriate academic or workplace accommodations
A multimodal treatment plan combining medication, education, behavioral
and psychosocial treatments is thought to be the most effective approach.
Although there has yet to be a large volume of research on psychosocial
treatment of adult AD/HD, several studies suggest that counseling which
offers support and education can be effective in treating adults with
AD/HD. A combined treatment approach, maintained over a long period of
time, can assist in the ongoing management of the disorder and help these
adults lead more satisfactory and productive lives.
This article first appeared as CHADD Fact Sheet No. 7, Spring 2000.
Suggested Reading
Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook
for Diagnosis and Treatment.New York: Guilford Press.
Goldstein, S. (1997). Managing Attention and Learning Disorders in Late
Adolescence and Adulthood. A Guide for Practitioners. New York: John Wiley
& Sons, Inc.
Nadeau, K.G. (1995). A Comprehensive Guide to Attention Deficit Disorder
in Adults: Research Diagnosis and Treatment. Brunner/Mazel.
Hallowell, E.M., and Ratey, J. (1994). Driven to Distraction. New York:
Pantheon.
Murphy, K.R., and LeVert, S. (1995). Out of the Fog: Treatment Options and
Coping Strategies for Adult Attention Deficit Disorder. New York:
Hyperion.
Solden, S. (1995). Women with Attention Deficit Disorder. Grass Valley,
CA: Underwood Books.
References
1. Barkley, RA, Fischer, M., Fletcher, K., & Smallish, L. (2001) Young
adult outcome of hyperactive children as a function of severity of
childhood conduct problems, I: Psychiatric status and mental health
treatment. Submitted for publication.
Need more information about AD/HD or the national organization dedicated
to helping children and adults with AD/HD succeed?
Call Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
at 800-233-4050,
fax (301) 306-7090
write CHADD at 8181 Professional Place, Suite 201, Landover, MD 20785
or visit our website at www.chadd.org
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