Problems characterized as disorders of attention and hyperactivity in children have long constituted the most chronic behavior disorder and the largest single source of referrals to child mental health centers. In regards to Attention Deficit Hyperactivity Disorder (ADHD) there are few exclusionary developmental criteria and no unequivocal, positive developmental markers. ADHD is distinct from other disorders of childhood due to a difference in intensity, persistence and clustering of symptoms rather than the presence or absence of symptoms in confirming the diagnosis. ADHD reflects a biopsychosocial etiology with heredity shaping temperament and interacting with life experience to determine whether a child ultimately receives the diagnosis. These temperamental qualities result in a lack of fit between adult expectations and the child’s performance.
Although the labels used to describe this cluster of childhood problems has changed numerous times over the past 100 years, the term Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder is most familiar to educators, medical and mental health professionals. However, there continues to be a degree of disagreement in what defines this set of childhood problems and the best diagnostic label. Researchers have argued that this might be best be referred to as a reward system dysfunction, a learning disability or a self-regulatory disorder to name but a few. It is increasingly recognized that ADHD in fact does not represent a problem with faulty attention but rather represents a problem of faulty modulation and self-regulation. Individuals with ADHD when interested are sufficiently motivated to pay attention as well or nearly as well as others. It is when tasks are repetitive, effortful, uninteresting or not of their choosing that they experience greater difficulty staying focused and remaining on task. It is when consequences, either rewards or punishments, are delayed, infrequent, unpredictable or inconsistent that they experience greater difficulties than their peers. Problems with self-regulation cause difficulty managing emotions. Small events are responded to with excessive behavior and emotion. Self- regulatory problems make it difficult to develop habitual behaviors. More practice trials are needed over longer periods of time for individuals with ADHD to progress from behaviors that are governed by the outside world to behaviors that are self-governed or habitual. Negotiating the demands of every day life requires efficient self-regulation to develop the habits necessary for success.
The current Diagnostic and Statistical Manual of the American Psychiatric Association is in it’s fourth edition. Categorically ADHD contains three primary and one related diagnosis. The first contains symptoms of the inattentive type, the second, the hyperactive-impulsive type, the third a combination of the previous two and the fourth or related type, symptoms of either type one or two but of insufficient number to warrant a full syndrome diagnosis but clear impairment present. This latter diagnosis is referred to as Attention Deficit Hyperactivity Disorder – Not Otherwise Specified. It is now increasingly recognized that given these criteria, approximately 2% to 3% of the childhood and for that matter adult population meets the combined type criteria, nearly the same percentage meeting the inattentive type criteria, less than half a percent meeting the hyperactive- impulsive type criteria and no data available concerning the not otherwise specified type.
As children with ADHD grow older it often appears that the hyperactive-impulsive qualities diminish in severity and intensity, while the inattentive and disorganized patterns of behavior remain constant. It is this later pattern combined with the childhood history of inattention, hyperactivity and impulsivity which appears to best define the population of adults with ADHD. However, it should be noted that of the childhood symptoms, level of severity regarding impulsivity appears to best predict later life problems. High levels of childhood impulsivity predict more serious adult dysfunction.
Just as it took many years to recognize that depression can extend downward from adulthood into childhood, it has taken an equal amount of time to recognize that Attention Deficit Hyperactivity Disorder can extend upwards from childhood into adulthood. It is now estimated that although a third of children receiving diagnoses of ADHD may outgrow many symptoms not all symptoms are outgrown. The remaining two-thirds manifest most symptoms, may or may not meet the full diagnostic criteria, but are also characterized by mainly co-occurring or co-morbid psychiatric and life problems. Estimates suggest that among the severely effected ADHD adult population there is a high co-occurring rate of borderline and impulse personality problems, substance abuse and in recent studies a significant risk for depression and anxiety disorders.
The Social Security Act (42 U.S.C.) Provides in Titles II and XVI, for the payment of a supplemental security income to disabled persons. The disabilities covered now include Attention Deficit Hyperactivity Disorder. The disorder is defined in the Act as being manifested by developmentally inappropriate degrees of inattention, impulsiveness and hyperactivity the disorder can affect adults as well as children. The regulations allow that when medication controls the primary symptoms of the disorder attention must be focused on the functional limitations which persist despite treatment. In Aviles v. Bowen (715 F.Supp. 509 S.D.N.Y, 1989) the court held that ADHD was a functional, non-psychotic disorder with co-occurring anxiety, depression and oppositional behavior under the SSI regulations as they then stood and that a person with ADHD is entitled to payments. Further, the courts have ruled that the 1975 Individuals with Disabilities Education Act, the Rehabilitation Act of 1990 all provide protection for children and adults with ADHD.
Given these legal safeguards combined with the increased recognition that ADHD in adults represents a very real and, for a significant minority, debilitating disorder, disability consultants are increasingly likely to be asked to evaluate and provide treatment plans for this population. The following offers a brief set of guidelines for evaluation and treatment planning.
Assessment
At the present time assessment of ADHD in adults is in it’s infancy. As a behavioral disorder, the evaluation of ADHD is most valid when direct history and observation data can be obtained. Often with adults, however, direct observation in a classroom or work setting is not possible. Thus, history takes on increasing importance. It is critical when taking a history to attempt to communicate with the patient’s spouse and even parents concerning reported symptoms. A number of self-report, spousal report and parent report questionnaires are now available for the assessment of adults with ADHD. Normative data for these questionnaires continues to be collected and, therefore, unlike the diagnosis with children, the evaluator must more heavily rely on qualitative rather than quantitative interpretation of these questionnaires. The keys to making diagnosis must include a childhood history of ADHD symptoms or a diagnosis of ADHD, continued adult complaints related to inattention, disorganization and to a lesser extent restlessness and impulsivity. However, most critical is careful evaluation of alternate causes for these symptoms. Symptoms of stress intolerance, impulsivity, inattention and disorganization are extremely common and appear to present across a variety of internalizing and externalizing psychiatric disorders. Thus, differential diagnosis is critical when attempting to identify symptomatic problems stemming from ADHD as opposed to other disorders.
Some researchers have suggested that certain patterns on the Wechsler Adult Intelligence Scale (e.g., Bannatyne factors: verbal much strong than sequential or perceptual) may also aid in the diagnosis. An increasing number of computerized instruments based upon the continuous performance tasks are now being marketed and some include adult data. However, evaluators must be aware that current research data suggests these instruments may identify problems with impulsivity and difficulty sustaining attention while performing a boring task, but they also result in a high rate of false negatives and as yet are not considered essential in the diagnostic process. Finally, an assessment of personality utilizing instruments such as the MMPI or Millon is also critical in providing the evaluator with an overview of the adult’s personality and current psychiatric status.
Treatment
There is a growing body of research suggesting that adults with ADHD respond extremely well to stimulants and antidepressants at a rate almost similar to the childhood ADHD population. Further, counseling to develop increased awareness of ineffective habits as well as activities to build organizational and planning skills at this juncture hold intuitive appeal as beneficial for this population. It has yet to be demonstrated scientifically, however, that counseling or organizational skills building is of very much direct benefit for ADHD symptoms. Given the current state of research with the childhood ADHD population it is likely that further adult studies will find that counseling and cognitive skill building, though helpful for secondary adjustment problems in this population, on a scientific basis likely will not yield very much demonstrated, direct benefit for ADHD symptoms.
Conclusions
It is important for developmental consultants to recognize that between 30 to 70% of children diagnosed with ADHD will continue to experience at least some, if not the full syndrome, of symptoms into adulthood. Given that at least half of these individuals are at significantly increased risk for other co-morbid problems including personality disorders, emotional problems, alcoholism, work related problems and even accidents it is a fairly common phenomena for consultants to be faced with an individual presenting a history of ADHD symptoms. In many situations ADHD symptoms may not be the reason for adult referral. They may, however, pre-date an accident or current trauma and must be understood in regard to the potential contribution they make to the individual’s past and current functioning.
It still remains the case that most adults with ADHD are undiagnosed, untreated, and unaware that help is available. Their symptoms occur in varying type and severity. They may cause significant impairments in interpersonal relations, marriage, emotional well-being, employment and daily adaptive functioning. It is also not surprising that for many, after years of frustration, even for those vocationally successful, strong feelings of low self-esteem may underlie their adjustment and personality. These individuals often possess a sense of knowing something is wrong but never knowing exactly what it is or what to do. The developmental consultant can play an important role in accurately identifying and diagnosing this disorder, providing educational information to the ADHD adult and offering assistance with treatment planning.
