Few psychiatric/psychological disorders have generated more controversy than the diagnosis of attention deficit hyperactivity disorder (ADHD).
Recent additions to diagnostic specifications by the American Psychiatric Association specifying qualifiers for the diagnosis of adult ADHD have also been equally controversial. This article will discuss information regarding adult ADHD.
It is important to understand that diagnosing any psychological/psychiatric disorder can only be performed by a licensed mental health care professional. Anyone who believes that they have any type of psychiatric/psychological disorder should seek a formal consultation.
First, it is important to make something clear regarding the diagnosis of ADHD and individuals who talk about something called attention deficit disorder. There is no formal diagnostic category called attention deficit disorder.
The formal diagnostic specifications of ADHD also include the three subtypes of ADHD:
Predominantly hyperactive subtype: The presentation is primarily one of issues with hyperactivity and impulsivity and few issues with inattention
Predominantly inattentive subtype: The presentation is primarily one of issues with attention and concentration, and not with hyperactive behavior or impulsivity. This presentation is what many people are referring to when they refer to attention deficit disorder; however, that diagnostic label does not exist, according to APA.
Combined subtype: The presentation consists of significant issues with hyperactivity, impulsivity, and attention and concentration. This is what most people think of when they think of ADHD; however, it is but one of three different subtypes of a very heterogeneous disorder.
ADHD is a neurodevelopmental disorder, meaning that the symptoms of the disorder must occur in childhood. There are a number of potential symptoms associated with this disorder, all of which target issues with impulse control – difficulty controlling one’s movements, activity level, or ability to sit still; issues with attention; issues with memory that are related to issues with attention; and other potentially disruptive types of behaviors.
According to APA, children need to be diagnosed with six symptoms of inattention and/or six symptoms of hyperactivity/impulsivity to qualify for the diagnosis, whereas adults only need five symptoms of each. APA uses a cutoff age of 17 years old to signify the border between what is considered childhood and adolescence/adulthood in this case.
Even adults who are diagnosed with ADHD must have presented several of these symptoms prior to the age of 12. Part of the issue with this designation of a diagnosis of adult ADHD is that the term several is not specific enough to determine how many symptoms must have been present at this period in order for an individual with complaints of having adult ADHD to receive a formal diagnosis. This makes the diagnosis of adult ADHD quite slippery because one clinician may consider two or three symptoms self-reported by an adult who is trying to get a diagnosis of ADHD as significant, where another may consider more than three symptoms a sign of a valid diagnosis.
The bottom line is that ADHD is not a diagnosis that suddenly occurs in adults. It is a developmental diagnosis that must have been present before the age of 12. Adults can certainly develop symptoms that appear to be like ADHD as a result of a head injury, stroke, drug abuse, etc.; however, ADHD cannot be diagnosed in individuals who present with symptoms that are due to known causes, such as head injury, drug abuse, etc. The Diagnosis of Adult ADHD
The DSM-5 lists the same description of the symptoms as diagnostic criteria for ADHD used in both adult and childhood diagnoses. However, this does not mean that individuals who never received a diagnosis of ADHD in childhood but received a diagnosis as adults express the disorder in the same manner. Priorities change, activities change, and responsibilities change significantly from childhood to adulthood.
Most often, children with ADHD are first diagnosed around school age when their behavior interrupts or interferes with classroom activities or with their ability to learn effectively. Many adults who have finished formal schooling do not have this luxury of having a teacher notice these issues.
Issues organizing tasks at work or in daily personal life
Becoming distracted when one needs to concentrate on something
Issues with following directions
Problems getting things done on time, such as at work, in one’s personal life, or with goals and priorities
The only major problem with these above signs/symptoms is that nearly everyone has complaints in these areas to some extent. Clinicians are burdened with the task of deciding whether these types of complaints are related to a clinically significant disorder or whether they just represent normal variations in human behavior.
The issue can become clearer if it can be documented that the person:
Has a history of not doing well in school (e.g., the person was considered an underachiever or had poor grades)
Had to repeat a grade in school or dropped out of school before completing high school
Had a history of conduct problems in school
Had a number of job changes with a history of poor work performance
Has a history of being less satisfied with work and less happy in the jobs they have had
All of these above criteria are things that can be documented (except for the satisfaction issue), and this is the type of information that helps the clinician determine whether or not the person is actually expressing ADHD. It is important to understand that the self-reports of individuals who come in to be assessed with many different types of disorders, including ADHD and substance abuse, are often very unreliable. It is extremely important for clinicians to get corroboration and verification of issues occurring in the past before making formal diagnoses. Unfortunately, this doesn’t always happen.
ADHD, even adult ADHD, is diagnosed in a small proportion of the population. The DSM-5 lists the prevalence of ADHD as being present in about 5 percent of all children and in about 2.5 percent of all adults. This indicates that this disorder is relatively rare. The ratio of adult ADHD is about 1.6:1 males to females in adults and 2:1 males to females in children. The most prominent presentation of ADHD is the predominantly inattentive type, which is also the most commonly diagnosed type in adults. The most difficult subtype to deal with is the combined subtype due to the number of symptoms and related issues.
Individuals with ADHD face various problems. These problems cover a number of different issues and indicate that ADHD is a disorder that affects many different areas of functioning in both children and adults. A great deal of empirical research has looked at the complications of ADHD in adults who are either diagnosed with ADHD as children or as adults.
Have significantly more issues with driving, such as getting more speeding tickets, being more likely to be involved in traffic accidents, and being far more likely to have their driver’s license suspended or revoked
Are more likely to have less status or achievements as adults, such as being part of lower socioeconomic statuses, being unemployed, needing government assistance, etc.
Are more likely to seek treatment for marital problems or to be separated or divorced
Have more issues with anxiety and depression and are significantly more often diagnosed with anxiety disorders or major depressive disorder
Substance use disorders in adults with ADHD are likely to include issues with alcohol use disorders, tobacco use disorders, cannabis use disorders, and even stimulant use disorders as stimulants are known to treat the symptoms of ADHD in both children and adults. Stimulant abuse can range from abusing drugs like Ritalin or Adderall all the way to the use of highly dangerous and illicit drugs, such as cocaine and cocaine derivatives. Individuals diagnosed with co-occurring ADHD and substance use disorders require that both disorders be treated concurrently in order for any success to be realized in addressing these conditions.
Treatment of Adult ADHD
The treatment for adult ADHD is similar to the treatment for ADHD in children. Various medications can be used, such as stimulant medications (e.g., Ritalin, Adderall, Concerta, Vyvanse, etc.), nonstimulant medications (e.g., Strattera, Intuniv, and Kapvay), and other medications, such as antidepressants and even benzodiazepines to address symptoms of depression or anxiety. Stimulant medications and benzodiazepines need to be used judiciously in people who also have substance abuse issues, as there is an abuse and addiction potential with these medications.