by Wasserstein, Jeanette - Wasserstein, Adella - Wolf, Lorraine E.
Attention deficit hyperactivity disorder (ADHD) is a common childhood neuropsychiatric disorder affecting 3-10% of children that often remains unrecognized or "hidden" in adulthood. Although ADHD was once thought to disappear as children grew up, data suggest that one to two thirds of children with ADHD continue to have significant symptoms throughout life (Wender, Wasserstein, & Wolf, 2001). Adult prevalence estimates vary widely. Conservatively, 1-6% of adults are believed to meet formal diagnostic criteria.
The core symptoms of ADHD-hyperactivity, inattention, and impulsivity-change as the child grows older. Research suggests that hyperactivity declines with age, attentional problems remain fairly constant, and executive function problems increase in adulthood. Coexisting psychiatric conditions, learning disabilities, and social difficulties are common. The persistence of ADHD into adulthood first became apparent in the 1970's, but is only recently becoming more generally known in the adult mental health field (Wender, Wolf, and Wasserstein, 2001).
MBD, HYPERACTIVITY, ADD, ADHD, AND LD: HOW DO THEY RELATE?
While there is agreement that ADHD occurs in adults, the terminology and our understanding of its underlying pathology are still emerging. The names and criteria for this syndrome have changed frequently over time, reflecting shifts in prevailing thinking about key symptoms or underlying mechanisms (see Wender et al., 2001, for review). Originally designated as "minimal brain dysfunction" (MBD), the terms "hyperactivity" and/or "hyperkinesis" were used in the 1960's, "attention deficit disorder (or ADD), with or without hyperactivity" in the 1980's, and finally "attention deficit hyperactivity disorder" (or ADHD) currently. These changes in terms reflect changes in thinking away from a focus on structural brain damage (e.g., MBD) toward a focus on symptoms or behavior, such as excessive activity and inattention. The terminology is likely to continue to change as we further develop our understanding of what we have come to call "ADHD."
The shift away from the original MBD label also signaled an emerging recognition of the difference between disorders of behavior (i.e., in activity level or attention) and specific disorders of learning (i.e., learning disabilities such as dyslexia, dyscalculia or dysgraphia). These cognitive and behavioral problems often coexist, but are now believed to be based on different genetic clusters and mechanisms (Farone et al., 1993).
SYMPTOMS OF ADHD
The American Psychiatric Association (1994) recognizes three types of ADHD: ADHD Predominantly Hyperactive Impulsive Type, characterized by motor and impulse control problems; ADHD Predominantly Inattentive Type, problems in attention or arousal; and ADHD Combined Type, significant problems in both areas. It is still unclear whether these subtypes reflect a common neuropathology or whether they represent distinct disorders (Faraone, Biederman & Friedman, 2000). It has also been argued that these categories, which were created primarily for children, may not apply equally for adults (Wolf & Wasserstein, 2001).
Children with ADHD are often overactive, impulsive, and inattentive. In order to be diagnosed in adulthood, it is essential that some level of these core symptoms were present during childhood. Over activity generally decreases by adolescence and is often replaced by fidgetiness and/or cognitive restlessness. More recently, researchers are focusing on self-regulation (i.e., problems with executive functions), rather than attention or activity level as the main deficit in ADHD (e.g., Barkley, 1997). Associated features in both children and adults may include moodiness, poor social relationships with peers, and a variety of different learning problems. Other psychiatric conditions are often also present, clouding the picture (e.g., see Marks, Newcorn & Halpern, 2001 for review).
WHAT ARE THE PERTINENT ADULT PROBLEMS?
* Substance abuse, antisocial behavior, and even criminality are among the better-known problems of some adults with ADHD (Hechtman, Weiss, & Perlman, 1984). However, these issues are hardly universal, and may be more likely in some groups of patients. Poor social skills or deficits in self-awareness are also frequent.
* When unrecognized, and therefore untreated, ADHD occurs along with other psychiatric conditions, it can contribute to the failure of medication and psychotherapy. This is because the "comorbid," or coexisting, conditions are then the only focus of treatment (Ratey, Greenberg, Bemporad, & Lindem, 1992).
* Problems with independent adaptive functioning are among the most common complaints of adults who have ADHD and seek therapy (Silver, 2000). For example, they may have difficulty finding and keeping jobs, trouble maintaining routine and organization, and problems with self-discipline. In contrast, behavior control issues are the more usual complaints in children with ADHD. The difference between children and adults may reflect the fact that parents, teachers, and society can provide external forms of regulation for children, but cannot fulfill that role for adults. Additionally, the tasks of adulthood generally require more self-regulation, thereby making deficits in this area more apparent.
Problems with social skills and adaptive functions can be very stressful to relationships. Adults with ADHD may thus have a greater likelihood of family violence, divorce, and multiple marriages.
RECOGNIZING ADHD IN ADULTS
There are two main groups of adults with ADHD: (1) those who were diagnosed as children and still have symptoms, and (2) those who were never diagnosed. The second group may be more likely to include females. When looking at childhood symptoms, it is important to consider that a highly organized home life can mitigate the expression of ADHD symptoms. Pronounced difficulties may only emerge during higher education, or even later in the work world, when environmental demands become more complex. Often there is also a strong family history of ADHD, learning disabilities, or both.
There is no definitive diagnostic test for ADHD, although standardized ADHD scales are extremely helpful in understanding current (and past) symptoms. Examining for comorbid psychiatric conditions and ruling out alternative psychiatric problems that can resemble ADHD (such as depression or anxiety disorders) is essential. The goal of assessment is to understand the individual's unique pattern of strengths and weaknesses in order to design appropriate interventions (whether medical, psychosocial, or remedial). Fear of stigma, shame, and denial can interfere with seeking help.
As is the case for children, the best treatment involves both drug and psychosocial interventions. Among drugs, stimulant medications, such as Ritalin, are usually tried first. Individuals who do not respond to stimulants, or who have comorbid substance abuse problems or depression, may be treated with antidepressants. Generally, medications are better at addressing inattention and hyperactivity than impulsivity. Comorbid illness, if present, affects the choice of drugs.
Psychosocial treatment is also key. These interventions typically involve (1) psychotherapy addressing how the ADHD affects the person's life (relationships and functioning), and (2) education about the disorder. Technologies helpful for ADHD include structured external supports like day planners, computers, and coaching, as well as some specialized forms of cognitive remediation (see Wasserstein, Wolf & Lefever, 2001, Part V; Nadeau, 1997).
ADHD IN ADULT EDUCATION AND EMPLOYMENT
Adults with ADHD often face their biggest challenges in higher education and later in the work world. Executive and planning abilities are extremely challenged in the young person with ADHD who is making the transition from the structured environments of high school and home to an unstructured life at college. Similarly, working adults need to create multiple layers of structure at work, and they must manage to integrate work demands with competing personal responsibilities. In other words, adults need to plan and execute their own internal structure, which is especially difficult for those with ADHD. Poor time management, chronic lateness, and difficulties completing paperwork and meeting deadlines are exceedingly common work-related problems of adults with ADHD.
Some students and/or employees with ADHD may be eligible for supports and/or accommodations. Students and employees who are disabled by ADHD may be covered under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act in school and work settings. These laws prohibit discrimination on the basis of disability and guarantee equal access to programs and facilities. All adults with ADHD and clinicians evaluating them should become familiar with these statutes in order to evaluate their need, and eligibility, for services (Wolf, 2001).
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