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ADHD in Adults:  Maybe its not only your kid?

Barkley (2006) and Wender (2000) carefully looked at data across numerous studies and concluded that ADHD can be found in 2%-7% of the adult population, with 4% being the generally accepted rate.  While the gender ratio in children is about 6 to 1, boys over girls, in adults, the incidence rate has been reported to be 2 to 1 with some suggesting it approaches 1 to 1 (Resnick, 2005).

So what accounts for this dramatic change in how ADHD affects children as compared with adults.  Do boys grow into it or grow out of it? Maybe girls grow up and develop it?  Perhaps, the best way to conceptualize adult ADHD is to utilize concepts associated with executive functioning.  Problems with self-control, delay of gratification, affect regulation, planning, organizing and selecting, dividing, and sustaining attention often impact the ADHD adult’s life.  Maybe it’s the demands on adults, different than those on children that account for the change.

Whether I work with children or adults, I always conduct a careful mental status examination to rule out disorders that can mimic ADHD, e.g., depression, anxiety, and substance abuse.  Other considerations are the possibility of sleep apnea, head trauma, lead toxicity, and seizure disorders as they can mimic ADHD.  Further, there can be co-morbid conditions that mask underlying ADHD.  Women, for example, are frequently treated for depression without detecting the underlying ADHD.  Women with ADHD are more likely to report dysphoria while men are more likely to report conduct problems (Quinn, 2005).  Anxiety, stress and bi-polar disorder can also mask ADHD.  Questions that might need to be asked in an Adult ADHD evaluation include:

1. Does the person describe difficulties with problems in self-control, and self-regulating behavior?

2. Does the person have poor working memory and access it inconsistently?

3. Is the person forgetful – even for pleasant and desirable things or events?

4. Are there organizational problems?

5. Does the person have poor persistence in task effort?

6. Is the person often late and have poor time perception?

7. Does the person say they are easily bored?

Some other areas to think about that may be the result of adult ADHD include:

1. Reactivity:  does the person over or under react to the environment?

2. Risk Taking:  does the person not tolerate low stimulation and/or crave novelty?

3. Is the person prone to temper outbursts, with a quick “on” or a slow “off”?

4. Is the person struggling to sustain motivation?

5. How are their social skills and social judgment?

6. How is their sleep, e.g., restless, or trouble falling or staying asleep?

7. How is their frustration tolerance?

8. How forgetful are they?

ADHD adults in my practice receive coaching more often than psychotherapy, and often the treatment is intermittent rather than ongoing.  Many of the adults that I see derive benefit from psychostimulants.  All stimulants are either dextro amphetamine or methylphenidate molecules.  The 14 products on the market differ in the delivery system and the length of time that the drug is effective.  Side effect profiles are similar with the most common being a loss of appetite, insomnia, and stomach discomfort.  All stimulants, if effective, are immediately effective (though further titration of dose is often necessary) and have no cumulative therapeutic effect.  Rather, each does is a discrete event.

ADHD adults may require cognitive-behavioral therapy to help them change the negative messages from others in the past to more realistic and positive thoughts.  Neutralizing these old experiences inspires hope as well.  Marital therapy is also often an adjunct component of treatment. 

Treatment plans are often multi-modal and frequently need to change over time.  Adults who think they may have ADHD are encouraged to seek an evaluation and get help with the symptoms with which they may have been struggling for a very long time.

References

Barkley, R.A. (2006). Attention deficit hyperactivity disorder:  A handbook for diagnosis and treatment.  New York:  The Guilford Press.

Resnick, R.J. (2005).  Attention deficit hyperactivity disorder in teens and adults:  They don’t all outgrow it.  Journal of Clinical Psychology:  In Session, 61, 529-534.

Wender, P.H. (2000).  ADHD:  Attention-deficit hyperactivity disorder in adults. New York:  Oxford University Press.

September 2006