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).
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).
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).
* 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.
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.
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).
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).
Barkley, R.A. (1997). ADHD and the nature of self-control. New York: Guilford.
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, 39, 300-307.
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, 4, 267-275.
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.
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