Attention Deficit Hyperactivity Disorder (ADHD) has long been recognized and accepted as a diagnosis for children. As more children were followed long-term, it was noted than many children continued to have symptoms during adolescence. The prevailing conventional wisdom was that ADHD was “outgrown” during adolescence but by the early 1970’s it was apparent that ADHD symptoms were reaping havoc on the personal, vocational, educational and even leisure time activities of adults (Resnick, 2000). We should note that the reasons that contributed to this false belief that with maturation came cure was two fold: First, maturation often did produce a reduction in the overt hyperactivity witnessed in many ADHD children. In its place was a much more subtle fidgetiness and a sense of inner restlessness. And secondly, with maturation, also came improved cognitive skills and strategies that masked, making less overtly visible, ADHD symptoms and behaviors (Resnick, 2005).

ADHD in Adults

As Wasserstein (2005) points out DSM-IV criteria are not adult friendly. The criteria used are based on children 4-17. She further notes that newly diagnosed adults are much more likely to be diagnosed as “inattentive” as they did not present with conduct problems as children thus flying under the radar of school officials. Symptom presentation in adults usually will include difficulties with procrastination, disorganization, forgetfulness and feelings of boredom and dysphoria, Newly diagnosed adults are more likely to be women as men tend to view adult ADHD symptoms differently, i.e., more normal. Women as, Taylor (2006) has demonstrated are more sensitive to health issues both physically and psychologically. Culture, ethnicity, parents, socioeconomic class and school shape the threshold for the identification of ADHD symptoms (Resnick, 2005). Barkley (2006) and Wender (2000) rigorously reviewed of prevalence data and concluded that ADHD can be found in 2%-7% of the adult population and that 4% is the generally accepted rate. While the gender of about 6 to 1 boys over girls; in adults, the incidence rate is be 2 to 1 with some data suggesting it approaches 1 to 1 (Resnick, 2005).

Perhaps, the best way to conceptualize adult ADHD is around executive functioning. Problems with self-control, delay of gratification, affect regulation, planning, organizing and selecting, dividing, and sustaining attention are often the bane of ADHD adult’s life.

The Work-Up

There is no adult onset for ADHD though there is often adult initial diagnosis of ADHD and the presence of ADHD symptoms in childhood may or may not be documented making this diagnosis is a challenging endeavor. As there is a strong genetic component to ADHD a careful family history is an important place to start. It would not be unusual to find learning problems and/or psychiatric disorders in the pedigree. A developmental and childhood history is important as well. Another part of the history taking should include a close examination of the patient’s school history including a review of available report cards with teacher commentaries, programmed testing completed by school systems. Reflections by patient, spouse/significant other and parents, if possible, on the academic experience should be collected. Not only grades, but behavior—daydreaming, not completing assignments on time, not turning in homework, poor reading comprehension, to name a few. Often the question of learning disability can be answered if academic records reveal normal intelligence and appropriate achievement scores. As you trace the developmental history be mindful of changes in behavior and/or grades with the transition from elementary to middle to high school to college. Moving up the academic ladder requires more independent work and being better organized.

A rigorous mental status examination should be completed to rule out other disorders that can mimic ADHD, e.g., depression, anxiety, and substance abuse. Your history should also rule-out a history of, sleep apnea, head trauma, lead toxicity, and seizures disorders as they can mimic ADHD. But, also, be sensitive to the co-morbids masking 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. As you complete your evaluation probe the following areas:

1. Does the person describe difficulties that can be conceptualized as problems in self-control, and self-regulating behavior?
2. Does the person have a poor working memory and accesses it inconsistently; is the person
   forgetful—even for pleasant and desirable things or events?
3. Are there organizational problems in the symptom presentation?
4. Does the person have poor persistence in task effort?
5. Is the person often late and have poor time perception?
6. Does the person say they are easily bored?

During the assessment, it is very helpful to obtain an “objective” measure of current symptoms. This can be accomplished by using a rating scales; reliability is frequently increased by having others who are knowledgeable about the patient complete the measure as well. Wasserstein (2005) has pointed out that the Brown Scales and the Conners Scale are the two most widely used in clinical practice. The former looks at executive functioning symptoms and the latter at DSM-IV diagnostic criteria. Both have been able to discriminate ADHD adults from those without the disorder. It may be useful to use both as Wasserstein (2005) reports that the Brown is more sensitive to inattention problems and the Connors more sensitive to impulsive and hyperactive symptoms. During the mental status exam or some other section of the assessment, there are symptoms that should be explored to aid in the diagnosis or exclude the diagnosis of adult ADHD. I have called these “trickle down” symptoms:

1. Reactivity: does the person over or under react to the environment?
2. Risk Taking: may not tolerate low stimulation and/or crave novelty.
3. Inability to sustain effort once started
4. Temper outbursts: quick “on” with quick or slow “off”
5. Lack of, or unable to sustain, motivation even in some things patient has great interest.
6. Poor social skills, verbally invasive, or poor social judgment
7. Disturbances in sleep: restless, delayed onset, early morning awakening
8. Low frustration tolerance
9. Poor attention to health issues: non-compliant with needed medication regime, failure to keep health care appointments.
10. Forgetful even in the things they are interested in like family, leisure time activities.
11. Difficulty maintaining exercise plan.

Clearly, these trickle downs are not unique to ADHD but they are an excellent guide as you go through your “rule in” and rule out” diagnostic consultation.

I would, also, suggest the use of computerized assessment of attention. These are tests that measure attention and impulsivity. The Conners Continuous Performance Test II and the Test of Variable Attention are two examples. My view is that more data is better than less data as the preponderance of ADHD evidence may carry the day. The tests take about 20 minutes to complete and provide age and gender normed data regarding attention, inattention and impulsivity.

Treatment

The treatment of ADHD is most often multimodal and intermittent as opposed ongoing when compared to other disorders or co-morbid diagnoses. Psychoeducation usually is the first component. Often this is done with spouses, partners or significant others. A lengthy and detailed explanation of the etiology and impact of ADHD on the patient and others must be provided. Some discussion of reasons for the “late” diagnosis and the neurobehavioral underpinnings are important components of this discussion. Empowerment is a significant piece of the treatment paradigm and websites to national support groups (CHADD and ADDA) are provided along with several recommendations of “self-help” books. A good source is ADDWarehouse.com. The bibliotherapy is, also, a useful adjunct to psychotherapy and the psychoeducation. A very important part of this process is giving hope as this along with understanding the disorder as this sets the stage for all other treatments.

Phamacotherapy

Pharmacotherapy has been a successful treatment for ADD/ADHD symptoms since 1937(Dodson, 2005). All stimulants are either an amphetamine or methylphenidate molecules and 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 identical with loss of appetite, insomnia, and stomach discomfort as the most common. All stimulants, if effective, are immediately effective (though further titration of dose if often necessary) and have no cumulative therapeutic effect. Thus, each dose is a discrete event. Second line medications for ADHD are, most often, an anti-depressant. In adults, Bupropion Wellbutrin) seems to be the most effective. Pemoline (Cylert), though not an antidepressant is, also, used as a second tier pharmacological agent. For a thorough discussion of the pharmacology in adult ADHD see Dodson, 2005.

Psychological and Psychosocial

Psychosocial interventions are geared toward learning to cope with, and manage the symptoms of ADHD. As, Murphy (2005) points out, psychosocial interventions are more successful if they are viewed as managing a chronic disability as there is no cure for ADHD. In that respect, it is like managing any other chronic condition, e.g., hypertension, poor eyesight, diabetes, etc. Cognitive-behavior therapy is particularly well suited for ADHD patients 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, after the educational process for the spouse, can be quite productive as renewed hope for lasting change is quite possible.

Group therapy is another treatment option, as ADHD adults often feel alone, isolated, frustrated and misunderstood. The group offers the ADHD adults a place where they are accepted for who and what they are and is often a positive experience to see how others are handling the daily struggles of ADHD. Groups seem to work best when they are time limited, semis structured with specific goals and themes for each session (e.g., organizational skills, medication, social skills, etc). A word of caution: such group work in the hands of the inexperienced, can lead to chaos (Murphy, 2005)

Personal coaching has become a popular and effective treatment. Coaching is about putting the person’s goals into action; it is not about insight, process or understanding. It is a practical, “get it done” approach to daily problems. It is about what needs to be done, how is the person going to do it and when will it be done. “Why” is not relevant. This treatment is, however, only effective when the patient is ready and willing to work with a coach to set goals, strategies and deadlines (see Ratey, 2002 for a full discussion).

The use of external aids or prompts is particularly helpful intervention: post-its, PDA’s, email prompts, “to-do” lists, bulletin boards, color coding, multiple sets of keys, bills paid automatically from checking account or credit card, etc are all geared to making the ADHD adults life more manageable and less overwhelming by making the world a little more ADHD friendly. Frequently, ADHD adults shut down when feeling overwhelmed and/or stressed out. So the overarching strategy for virtually all psychosocial interventions is: find out what isn’t working and help the patient develop better coping strategies. The ADHD patient and the therapist must be active in this kind “what’s broken, let’s fix it” treatment.
Treating ADHD adults may require some career counseling and advocacy. ADHD adults need to advocate for themselves. Being able to describe accurately their ADHD and, also, being able to discuss their strengths and weaknesses to others are critical components to self-advocacy. There may be occasions where you will advocate for your patients particularly around workplace and academic accommodations.

Treatment plans are often multi-modal and frequently change over time and should always be made in concert with the ADHD respecting their wishes regarding various interventions, e.g., medication management. And to reiterate, psychological interventions are more likely to be intermittent rather than on going as the ADHD person’s life changes with new stressors and challenges, e.g., marriage, children, promotion, relocation, etc.

A developing treatment option worth mentioning is the use of biofeedback. Using this technique of immediate feedback, ADHD persons can learn to regulate their brain activity. Successful patients increase the amount of focused activity and decrease the amount of “off-task” activity (Butnik, 2005). Biofeedback parameters are also being used as a diagnostic procedure.

A Concluding Comment

Psychologists possess all the basic skills to be successful working with ADHD adults. The diagnosis and treatment of ADHD adults can be a challenging and satisfying part of one’s practice. It could easily become a specialty practice because ADHD people improve, they appreciate your efforts and they tell others!

References

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

Butnik, S. M. (2005). Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder. Journal of Clinical Psychology: In session, 61, 621-625.

Dodson, W.W. (2005). Pharmacotherapy of Adult ADHD. Journal of Clinical Psychology: In Session. 61,589-606.

Murphy, K. (2005). Psychosocial treatments for ADHD in teens and adults: A practice-friendly Review. Journal of Clinical Psychology: In Session, 61, 607-619.

Quinn, P.O. (2005) Treating girls and women with ADHD: Gender-specific issues. Journal of Clinical Psychology: In Session, 61, 579-588.

Ratey, N.A. (2002). Life coaching for adult ADHD In S. Goldstein & A. Teeter Ellison (eds.), Clinician guide to adult ADHD: Assessment and intervention. San Diego: Academic 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.

Resnick, R. J. (2000). The hidden disorder: A clinician’s guide to attention deficit hyperactivity disorder in adults. Washington, DC: American Psychological Association.

Taylor, S. (2006). Health Psychology. 6th Edition, New York: McGraw-Hill

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

Wasserstein, J. (2005). Diagnostic issues for adolescents and adults with ADHD. Journal of Clinical Psychology: In session, 61, 535-548.

Robert J. Resnick, Ph.D., ABPP(rresnick@rmc.edu) is a former president of Division 42 and APA. He maintains a specialty practice of ADHD through the life span.