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Assessing Attention Deficit Hyperactivity Disorder (ADHD) in Adults

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ADHD is not just a disorder of childhood. The majority of adults who were diagnosed in childhood are likely to continue to struggle with symptoms of ADHD as adults. According to Russell Barkley, only 20-35 percent of adults who were diagnosed with ADHD as children no longer have any ADHD symptoms which impair their functioning.

How does ADHD manifest itself in adulthood

Adults with ADHD typically struggle with time management, have difficulties sticking with and completing tasks, tend to procrastinate and may be prone to poor decision making. Often their lives seem chaotic and poorly organized, as they struggle to stay on top of responsibilities. Work and relationships may suffer because of difficulties staying focused on and completing tasks, forgetfulness, and impatience. Finally, adults with ADHD often are at risk for significant emotional distress. They may become depressed and doubt themselves, because of their struggles, or they may become anxious and worry about their abilities to manage their responsibilities.

Myths about Adult ADHD

There is not an ADHD personality type. Adults, adolescents and children with ADHD are as different as adults with blue, brown and green eyes. There are adults with ADHD who are laid back and easy going, while there are others who are driven and quick to anger. Folklore has suggested that somehow adults with ADHD can be more creative, spontaneous, or energetic. Research clearly indicates that there is no evidence that ADHD conveys any advantage (see Russell Barkely’s work on ADHD). The truth is that ADHD makes life more difficult. Research has found that adults with ADHD tend to have more accidents and speeding tickets, more job changes and more firings, and lower levels of occupational achievement (when compared to siblings without ADHD). Finally, adults with ADHD have been found to have high rates of depression and substance abuse, and many report problems with anxiety and low self-esteem.

Assessing ADHD in adults

Part of what makes assessing ADHD difficult is that the symptoms of ADHD are typical behaviors most of us occasionally experience. Who does not sometimes forget or misplace something, have difficult staying focused or become impatient? The key in assessing ADHD symptoms is determining that symptoms are typical of the person’s functioning and significantly interfere with important life responsibilities: the person whose attention occasionally wanders versus the person who cannot read books or documents because his/her attention consistently wanders; or the person who forgets one or two appointments versus the person who regularly forgets or is chronically late for appointments.

A second factor that makes the assessment of ADHD in adults difficult is that the diagnostic criteria for ADHD was developed for children. Thus, evaluators need to reasonably and appropriately modify these criteria, translate them so they apply to adult behavior, in order to assess ADHD in adults. For example, while difficulties remaining seated is not often seen in adults, subjective feelings of restlessness are the adult manifestation of that symptom. Similarly, significant problems with time management is often an adult ADHD symptom, but is not something that is considered an issue with children.

A third challenge in assessing ADHD in adults is that adult symptoms may be more subtle. Children may frequently get out of their seats, disrupt class, blurt out answers, while adults may struggle to complete work projects on time, have to work twice as hard and twice as long on a project to complete it, and may be prone to procrastinating and running late.

Fourth, adults are more likely to have co-morbid (other disorders) along with ADHD, or may have other disorders that have similar symptoms. For example, difficulties with concentration and a lack of motivation may reflect problems with depression. These symptoms can easily be mistaken for difficulties with sustained attention and task completion. Similarly, irritability, a symptom of depression, can be confused with poor frustration tolerance. Finally, irritability and reckless behavior can be suggestive of either ADHD or bi-polar disorder.

Fifth, adults may find themselves in jobs or other situations where the demands are beyond their abilities/skills, or where the job demands are simply unrealistic. Thus, evaluation needs to involve a detailed examination of the difficulties an individual is experiencing to make sure that difficulties are not reflective of a poor job fit, but truly are ADHD symptoms.

ADHD is not an all or nothing condition. People with ADHD can pay attention, exercise self-control, and complete tasks. If a person with ADHD is faced with a deadline, has a highly rewarding and interesting task to complete, or is under close scrutiny their performance may be quite good. The key in diagnosing ADHD is determining whether symptoms are typically (not always present) and whether symptoms are more pronounced when there is less external structure and demand.

Given these complexities careful and detailed assessment is needed before making a diagnosis of ADHD.

Significant problems in a major life area: a necessary criteria for the diagnosis of ADHD in adulthood

Barkley and other experts argue that to diagnosis ADHD as present a person must have real impairments in major areas of functioning: job loss, severe marital conflict, demotion, probation at work, or frequent traffic violations. Perceived impairment does not equal real impairment. For example, the adult in an MBA program who feels he must struggle to keep on top of his studies while working and participating in family life, would not be considered as having a real impairment versus the individual who was fired from a supervisor job for failing to repeatedly turn in time sheets and complete reports. Thus, it is critical to carefully examine the problems an adult is struggling with before making a diagnosis of ADHD.

Establishing childhood onset – A critical and neglected issue

ADHD is clearly a disorder that people are born with. Thus, unlike other disorders, there is no adult or late onset ADHD. We cannot “get” ADHD as an adult. Therefore, a critical component in assessing ADHD in adults is determining that there is a history of ADHD symptoms dating back to childhood. A number of experts have suggested that failing to establish early onset of symptoms is one of the most overlooked steps in the diagnostic process (Murphy and Gordon, 1998, in Barkley’s Handbook on ADHD). Obviously, establishing childhood onset can be a daunting task. Establishing a clear picture of how an individual functioned as a child or adolescent is difficult because memory is subjective and memories can fade with time. However, establishing childhood onset is critical for making a diagnosis of ADHD. Thus, careful interviewing is needed. Examining a history of school performance and looking for problems such as inconsistent academic achievement and school related behavior problems is often helpful. It is often very useful to involve an adult’s parents or older siblings in the evaluation process, as they may be able to share relevant information. Similarly, archival records (school records, results of previous treatment/evaluations) can also be very helpful in working to ascertain early onset of ADHD symptoms. Finally, symptoms need to persist throughout the life span. Therefore, when adults are assessed for ADHD their functioning as a child, adolescent, and younger adult needs to be considered.

Evaluating for other disorders, symptoms and explanations

ADHD symptoms are not only common behaviors that many of us exhibit occasionally, but they are also behaviors which can be signs and symptoms of other disorders or problems (when occurring frequently). Thus, a careful and thorough evaluation to rule out other disorders or problems that might better account for current symptoms is crucial. It is also important to determine if other disorders are present because there is evidence that many adults with ADHD may also suffer from problems with depression, bipolar disorder, anxiety or substance abuse, in addition to ADHD.

Thus, a thorough evaluation includes a complete mental health history, assessment for substance abuse, assessment for mood and anxiety disorders, and a review of current life stresses. Detailed interviewing and rating scales are the most appropriate tools for such an assessment.

In conclusion: ADHD in adults is a real disorder

ADHD is a disorder that is more likely to go undiagnosed in adults than in children or adolescents. All too often parents will bring children for evaluation, and disclose that they or their spouse were “just like that” as a child. ADHD can hamper the quality of life and significantly interfere with people living up to their potential. Thus, it is just as important that adults struggling with ADHD symptoms receive help.

Bibliography and resources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association, l994.

Barkley, R.A., Attention-deficit Hyperactivity Disorder: A Handbook for diagnosis and treatment, 2nd, Guilford Press, N.Y., 1998.

Barkley, R.A., ADHD and the Nature of Self Control. Guildford Press, N.Y., 1997.

Conners, C.K., & Jett, J.L., ADHD in Adults and Children: The Latest Assessment and Treatment Strategies. MHS, North Tonowanda, N.Y., 1999.

Helpful websites include:

www.chadd.org – Children and Adults with Attention Deficit/Hyperactivity Disorder, (CHADD), a national advocacy group’s website offering information, newsletters and support group listings.

www.psychcentral.com – Site established to review mental health websites. Provides ratings of and links to sites. Frequently updates information.

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