Adult ADHD

Type of psychology: Biological bases of human behavior; Clinical; Cognition; Counseling; Developmental; Psychopathology; Psychotherapy; School

Attention deficit/hyperactivity disorder (ADHD) is often erroneously assumed to be a specifically childhood condition, but it exists in the adult population as well. Adult ADHD requires identification and assessment and frequently involves medication, counseling, and management issues. As society has become more complex and technologically sophisticated, it is imperative to have a keen understanding of adult attention deficit disorder and related problems such as hyperactivity and impulsivity.

Introduction

The construct of attention deficit/hyperactivity disorder (ADHD) has existed for decades. "Attention-deficit disorder (ADD) with or without hyperactivity" was first defined in the third edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (1980), or DSM-III. Its definition has evolved since then. The name ADD was changed to ADHD in the revised edition of the DSM-III-R (1987). In 1998, the National Institutes of Health (NIH) held a Consensus Development Conference on the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. While most experts supported the ADHD diagnosis criteria, the final report noted a need for further research into the validity of the diagnosis.

Quite often, this diagnosis is perceived as one that affects only children. However, studies suggest that about half of children diagnosed with ADHD continue to experience ADHD symptoms as adults—and that the majority do not receive any treatment for them. There are also many adults with ADHD—particularly women—who were not diagnosed as children. The DSM-5, published in 2013, updated the definition of ADHD to reflect the growing body of evidence that shows the condition can last beyond childhood in order to help clinicians diagnose and treat adults with ADHD.

The general public is keenly aware of ADHD, and though there is some controversy over diagnosis and potential overtreatment, there is broad consensus that this condition does exist and can interfere with learning and other aspects of life. Many children received identification, medication, and accommodations and modifications in school. Many of these individuals learn to cope with this disorder as children, but others, for various reasons, continue into adulthood still struggling with the signs and symptoms of adult ADHD.

One reason for this struggle is that symptoms that are not especially problematic in school and thus were not addressed may become more of an issue in adult life. As people with ADHD enter adulthood, the demands of a full-time job and perhaps a full-time relationship may become problematic. Parenting is another realm that requires patience, compassion, empathy, warmth, and prioritization. For the adult with ADHD, some of these qualities are in short supply. Further, some adults with ADHD may be at greater risk of automobile accidents and other difficulties working with machines and other electrical and mechanical devices.

Diagnosis

The DSM-5 provides the criteria for ADHD. For inattention, the individual must manifest five of the nine criteria relative to inattention (six of nine needed in childhood and adolescence) and five of the nine criteria for hyperactivity and impulsivity (six of nine needed in childhood and adolescence). Hyperactivity and impulsivity are not separated in the DSM-5. Further, the clinician establishes the severity (mild, moderate, or severe) and specifies if it is a combined presentation (predominately inattentive or predominately hyperactive/impulsive).

Adults with ADHD are often keenly aware of their limitations surrounding attention span and impulsive behavior. They may have sublimated their energy if they participate in sports, jogging, or other activities which provide an outlet for their energy. Without an outlet, others may cause consternation to those around them in the work or familial environment.

Counseling issues

An adult with ADHD may be frustrated and exasperated as they may have believed that ADHD problems would resolve themselves upon reaching adulthood. Those who are undergraduate or graduate students may need to request accommodations and modifications from a disabilities service office. In terms of differential diagnosis, the adult student may need further testing for a learning disability inasmuch as while they may have received a medical diagnosis of ADHD, psychoeducational assessment may not have been done and a learning disability in reading, spelling, written expression, or mathematics may not have been identified. Thus, the adult with ADHD has further adjustment to make and may need additional consultation and assistance as they progress through college.

Interpersonal issues may also be problematic as the expectations for sexual and interpersonal intimacy may be different than the expectation of an adolescent.

Often, an individual with adult ADHD will also present with low frustration tolerance, irritability, and/or mood lability. These may present in the work environment, home environment, or academic environment.

Late identification

If the individual has not been previously diagnosed with ADHD, a comprehensive workup is appropriate. There are several computerized tests such as the Test of Variables of Attention (TOVA) which can specify if the attentional problems are in the visual or auditory realm or both. Further, the TOVA can differentiate between impulsivity, hyperactivity, and inattention. Due to concerns around childhood misdiagnosis of ADHD, such comprehensive testing may also be required for adults who were diagnosed with ADHD as children if they wish to obtain medication or school or workplace accommodations.

Treatment

Some adults with ADHD are maintained on a dosage of ADHD medication—most commonly psychostimulants such as methylphenidate (Ritalin), extended-release dexmethylphenidate (Focalin), and amphetamines (Adderall)—that will allow them to function well in the work and familial environment. Often the dosage needs to be titrated as the individual ages. Traffic violations and automobile accidents are more likely to occur if the individual is not on medication or has forgotten to take medication. In some instances, ongoing physical examinations and blood/urine analysis is recommended in order to rule out other difficulties and for general optimal functioning.

In addition to medication, adults with ADHD often find other educational and management strategies helpful. Different kinds of behavioral and time management practices can be effective at improving organization. Formal or informal coaching can also be useful for some patients. Similarly, mental health counseling, which may include techniques such as cognitive therapy and family therapy, is often recommended as part of a broad support strategy.

Misdiagnosis

Often individuals with adult attention deficit disorder that have not been diagnosed in childhood or adolescence are incorrectly diagnosed. It may be problematic for adult psychiatrists to correctly diagnose adult ADHD and signs and symptoms of ADHD may be confused with borderline personality disorder or narcissism. However, adult ADHD individuals do not engage in the self-injurious behavior or extreme ambivalence seen with personality disorders. Mood disorders and anxiety disorders have some symptomatic overlap with ADHD; they are also commonly comorbid with ADHD, so it may be the case that the individual has been correctly diagnosed with a mood or anxiety disorder but that some of their symptoms, such as restlessness or emotional lability, are attributable instead to overlooked ADHD.

Prognosis

With medication, counseling, and educative therapy, the individual with adult ADHD can live a potentially happy life, using skills and coping strategies to assist them with their occupation and interpersonal relationships. Supportive counseling is obviously an additional benefit. Activities that require sustained attention for long periods of time may be problematic and the individual should be encouraged to break attentional tasks into smaller components and be aware that others may be perturbed by inattentive behaviors which could be construed as being negligent of or ignoring other individuals.

Bibliography

"Adult ADHD (Attention Deficit Hyperactivity Disorder)." Anxiety and Depression Association of America, adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhd. Accessed 16 June 2021.

"Adult Attention-Deficit Hyperactivity Disorder." Mayo Clinic, 22 June 2019, www.mayoclinic.org/diseases-conditions/adult-adhd/symptoms-causes/syc-20350878. Accessed 16 June 2021.

"Attention-Deficit/Hyperactivity Disorder in Adults: What You Need to Know." National Institute of Mental Health, US National Institutes of Health, 2021, www.nimh.nih.gov/health/publications/adhd-what-you-need-to-know/#pub1. Accessed 16 June 2021.

Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington: American Psychiatric Association, 2013. Print.

"For Adults: Overview." CHADD, chadd.org/for-adults/overview/. Accessed 16 June 2021.

Ramsay, J. Russell, and Anthony L. Rostain. The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out. New York: Routledge, 2015. Print.

"Symptoms and Diagnosis of ADHD." Centers for Disease Control and Prevention, 21 Sept. 2020, www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed 16 June 2021.