|
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.
|
