ADHD in Adulthood
Description, Evaluation, and Treatment
ATTENTION DEFICIT IN ADULTHOOD: THE HIDDEN DISORDER
Have you or anyone you know ever felt like Ann? Ann describes her life in this way. I grew up not feeling very good about myself. In school, it was hard for me to stay on the subject or to finish anything. When I didn't finish my school work, I'd get spankings at home. Teachers would be on my back. I tried so hard, but I just couldn't finish anything. I couldn't concentrate. I couldn't take notes even if I really tried. I was distracted very easily by practically everything. If someone sneezed, I'd look at him and my mind would go off in a million directions. I'd look out the window, wondering why he had sneezed.
People would say, "If you'd just try," but I was worn out from trying. It made me irritable. I felt like a failure.
The situation has persisted into adulthood. I'm very disorganized. Take housekeeping, for example. After dinner, when I start the dishes, I'll wash a little, then run and wipe off the table, wipe the cabinet, talk on the phone, and never get anything completed. My closet and drawers are still a mess, just like when I was a kid. What's really hard is to stay with any kind of paper work, bills, for example.
I'm the most impulsive person. If I see something I know I shouldn't buy, I'll buy it anyway. Or, I'll say something that I know the minute it comes out of my mouth I'm going to regret. It's like a little monster. I'm bad about interrupting people. It seems like I have to get out what I'm going to say in a hurry.
I can't sit still. During TV commercials I'm usually up fixing popcorn, getting something to drink, talking on the telephone, or wiping off the coffee table. Here is someone who went from childhood to adulthood with no understanding of the cause of her problems.
Now listen to how another adult, Jeremy, describes his life. On days I have to do paperwork, I make myself sit at my desk and try to get organized. My desk is piled high. I pick up a bill, make it out, and start to put a stamp on it. But the stamps are next to the paper clip box and I think it should go in the desk, so I put it in the desk. And I see more pencils than I need, so I throw two of them out. Then the phone rings, and while I'm on the phone I start throwing out junk mail, and there are magazines on the desk, so I take them to the bookcase. In the bookcase there's an old magazine I don't need anymore so I throw that away. Then I realize that the waste basket is full so I empty it. When I go outside to empty the waste basket, I see that there's something going on in the kitchen, so I do something in there. It's like I'm following a trail from one thing to another.
I can't get anything done because I can't concentrate on any one task. I can't seem to determine that, ok, this is the time to get the file cabinet straightened out. My motivation is always crisis. What gets done is what has to get done. The invoices I have to send out to get paid get sent out. The bills I have to pay so the insurance company and light company don't shut off services get paid. I'm always late for appointments. Bills get paid at the last moment, usually, like reports in school were done at the last minute. I pushed the limits then, and I still push the limits. But if I had my druthers, I wouldn't push the limits. I'd rather not file two extensions every year on my income tax.
ADD can create great stress in relationships. A woman brought her son in to see me for an evaluation. As we discussed symptoms she not only confirmed ADD in her son, but also suspected it in her husband. John came in some months later. A major problem for him was procrastination. He never seemed to finish tasks around the house. He got bored doing repair work in his business and put off jobs. As a child he would start and stop sports because he got bored. His father would have to stay on him about his homework. He would get it done, but at the last minute. He did a lot better with deadlines. He was diagnosed with ADD. The symptoms were causing marital difficulties, and he and his wife were separated at the time.
Have you ever lost your car keys? More than once? Are you a fast talker? Do you interrupt others? Do you do 3 or 4 things at once? Do you like spinach? Just kidding.
Research indicates that 3 to 5% of children may have Attention Deficit Disorder (ADD), and 50% of them will continue to have symptoms in adulthood. ADD is a term which refers to a group of symptoms which in adults includes difficulty sustaining attention in tasks (especially those which the person finds uninteresting), inability to keep one's mind on a conversation, difficulty remaining seated for very long, and fidgeting. Also common are the tendencies to be impulsive, to interrupt others, to be disorganized, and to have mood swings. Individuals with ADD tend to be frustrated easily and may have a short and explosive temper.
It has been the general opinion of professionals in the past that ADD resolved itself in adolescence or adulthood. Researchers now realize that this is not always true. For at least half of those with ADD in childhood, the symptoms only change their presentation in adulthood. Hyperactive children may become fidgeting adults who are always on the go.
Often adult ADD sufferers are being identified when their children are referred by the schools for evaluation. As they talk about and learn of the pattern of behaviors that characterize ADD, they realize that they had the same behaviors when they were children. One study reported that approximately 30% of hyperactive children had a formerly hyperactive parent.
Because undiagnosed and untreated ADD can lead to many other problems including poor academic achievement, low self-esteem, job instability, relationship problems, or depression, it is often a relief for adults to learn that there is a biologically induced disorder which has caused their life-long frustrations. Many adults just attribute their problems to personal inadequacy when, in fact, they have had little chance to control what now appears to be a neurological abnormality in brain chemistry.
Other adults were diagnosed and treated as children, but treatments were discontinued in the teen years even though academic, behavioral, and social problems persisted at a less obvious but more insidious level.
Research is pointing toward biological causes of ADD. Although hyperactivity and attention problems can result from chaotic family situations, the full symptom picture and diagnosis does not result from family problems alone. A couple of recent reports serve as examples of the evidence for this hypothesis.
The Single Photon Emission Computed Tomography (SPECT) of brain imaging has been used to measure brain activity. Normal children tend to have increased activity in the frontal lobes of the brain during an intellectually stimulating task. Children with ADHD show a decrease in frontal lobe activity during these tasks. This research demonstrates a neurological basis to the different behavior seen in children with ADHD.
NEED FOR IDENTIFICATION PROPER EVALUATION AND TREATMENT
It is extremely important that a person suspecting ADD in themselves or a relative seek out a competent professional who is knowledgeable in the differential diagnosis of ADD and who will perform a thorough evaluation of his or her symptoms and difficulties. The reasons for the thorough evaluation are twofold:
(1) Individuals with ADD diagnosed in childhood are at risk for developing symptoms of depression, anxiety, substance abuse, explosive and violent outbursts, and anti-social behavior. In addition, individuals with ADD are at a higher risk for associated learning disabilities. Therefore identification and proper treatment of concurrent symptoms is necessary.
(2) The symptoms of ADD are also symptoms of many other psychiatric disorders and medical diseases. That is, a person may not have ADD, but rather another disorder which would require a different treatment approach. One study found that a number of teens previously diagnosed and treated for ADD and conduct disorder had manic depressive illness. One of my clients met criteria for ADD, but was found to have a thyroid disorder.
By this time you're probably wondering what an evaluation is like. It should include a clinical interview by someone licensed to make psychiatric diagnoses. Information from a parent, if possible, and at least a spouse or other close relative should be obtained. The evaluation should also include a test of attention, and questionnaires to assess not only ADD symptoms, but other symptoms and causes. A medical examination should be requested to rule out other medical causes. If learning disability is suspected, an educational evaluation may also be necessary.
In my practice I use a computerized test of the mental handicaps usually found in ADD: inattention, impulsivity, long reaction time, and variability of reaction time. The Connors Continuous Performance Test, developed by Keith Connors, Ph.D., is a 14 minute visual continuous performance test that resembles a computer game. Norms are available for children and adults.
Follow-through to complete tasks has been difficult so ask for reminders and remind yourself.
Use lists and schedules.
Break each job into small, manageable segments.
Give yourself a break to do something not connected to the job.
Set up a work space separated from the surrounding environment so that it blocks out noise and keeps visual distractions to a minimum.
It's helpful for you to be able to move from one area of work to another during your time-out breaks.
Have something to keep your hands busy.
Use sound screens: discuss TV, radio, fan, etc.
Use checklists to keep up with jobs and set regular patterns of tasks.
Use an appointment book or daily schedule.
Since ADD causes overreactivity and temper outbursts, decide on a time out signal and when you feel you are getting too frustrated, call time out. Identify the underlying feeling and use words to express it. Support groups
PROFESSIONAL HELP FOR ADULTS WITH ADD
Individual and group counseling with focus on:
Time management and self-organization
Self control training
Vocational assessment and counseling
WHAT TYPE IS PROVIDED ONLY BY A MEDICAL DOCTOR?
Research has shown that the stimulant medications, Ritalin or Methylphenidate, Cylert or Pemoline, and Dexedrine or d-amphetamine have been effective in reducing the symptoms of ADD in adults. These are the same medications used in childhood ADD. Approximately 60 to 80 percent show a positive response. Adults who have ADD do not develop a tolerance to the drugs and do not report euphoric effects, so drug addiction is not seen as a problem. Here again, a thorough evaluation is necessary before treatment should be initiated because these drugs can be abused if the diagnosis is not correct or if the person has a history of drug abuse. There are side effects. These include insomnia, appetite suppression, weight loss, abdominal pain, headaches, and growth suppression in the short term. A person with a tic disorder or seizure disorder may not be able to take the drugs.
Other medications are available when stimulants are inappropriate. The newest medication on the block at the time of this writing is Strattera. It is not a stimulant medication. It lasts up to 24 hours in the body, so it can give full day coverage. This medication has been recommended for adults. Medications used to treat depression have also been found to improve the symptoms of ADD. Dilantin, a medication for seizures, has been found effective in also improving ADD symptoms. Other medications are available, so consult your physician.