Adults with Attention Deficit Hyperactivity Disorder
(ADHD). ERIC Digest.
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, &
* 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).
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.) Washington, DC: American Psychiatric
Barkley, R.A. (1997). ADHD and the nature of self-control. New York:
Faraone, S.V., Biederman, J., & Friedman, D. (2000). Validity of
DSM-IV subtypes of attention-deficit/hyperactivity disorder: A family study
perspective. Journal of the American Academy of Child and Adolescent Psychiatry,
Faraone, S.V., Biederman, J., Lehman, B.K., Keenan, K., Norman, D.,
Seidman, L.J., Kolodny, R., Kraus, I., Perrin, J., & Chen, W.J. (1993).
Evidence for independent familial transmission of attention deficit hyperactivity
disorder and learning disabilities: Result from a family genetic study.
American Journal of Psychiatry, 150, 891-895.
Hechtman, L, Weiss, G., & Perlman, T. (1984). Hyperactives as young
adults: Past and current substance abuse and antisocial behavior. American
Journal of Orthopsychiatry, 54, 415-425.
Marks, D.J., Newcorn, J.H., & Halpern, J.M. (2001). Comorbidity
in adults with attention deficit/hyperactivity disorder. Annals of the
New York Academy of Sciences, 931, 216-238.
Nadeau, K. (1997). Adventures in Fast Forward. New York: Brunner/Mazel.
Ratey, J., Greenberg, S., Bemporad., J.R., & Lindem, K. (1992).
Unrecognized attention-deficit hyperactivity disorder in adults presenting
for outpatient psychotherapy. Journal of Child and Adolescent Psychopharmacology,
Silver, L. (2000). Attention deficit/hyperactivity in adult lives. Child
& Adolescent Psychiatric Clinics of North America, 9, 511-523.
Wasserstein, J., Wolf, L.E., & LeFever, F. (Eds.) (2001). Attention
deficit disorder: Brain mechanisms and life outcomes. New York: The New
York Academy of Sciences.
Wender, P.H., Wolf, L.E., & Wasserstein, J. (2001). Adults with
ADHD. An overview. Annals of the New York Academy of Sciences, 931, 1-16.
Wolf, L.E. (2001). College students with ADHD and other hidden disabilities.
Annals of the New York Academy of Sciences, 931, 385-395.
Wolf, L.E. & Wasserstein, J. (2001). Adult ADHD: concluding thoughts.
Annals of the New York Academy of Sciences, 931, 396-408.