Adult ADHD – A Common Disorder, Often MissedADHD
by Steve Baskin MD, Psychiatrist
Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric diagnosis in children, but until 10 to 15 years ago, its validity as an adult diagnosis was controversial. We now know that most childhood ADHD continues into adulthood and remains present throughout the life cycle. Recent studies from 2005 show that adult ADHD effects 4.4% of the U.S. population and 4.2% of the population in developing countries worldwide. This means that approximately 8 to 10 million people in the United States alone have adult ADHD- a much higher figure than what was previously thought. To give this perspective, the prevalence of bipolar spectrum disorder in the United States is 1% (and 1% worldwide) and that of schizophrenia is also 1% in the United States (and 1% worldwide). Mental health practitioners have just started to realize how vast a problem this is and how important it is to recognize, diagnose and treat adult ADHD as early as possible. Adult ADHD has, so to speak, “come out of the closet” in the last 5 to 10 years. It is a disabling condition that most often, when untreated, has devastating effects on the individual’s work, school, family and social life.
Most adults with ADHD go undiagnosed. An estimated 90% of adults with ADHD are never treated. These individuals are going through life, coping as best they can but with a severe disorder of attention. They often cannot sustain focus on any subject for more than a brief period of time- sometimes as brief as 1-2 minutes.
Adult ADHD has three groups of symptoms- inattention, hyperactivity, and impulsivity. Almost all adults with ADHD have inattention as the main symptom and it is the primary reason they are seeking treatment. The most common symptoms of inattention in ADHD that are tested for are a) easy distractibility (trouble focusing attention and a tendency to tune out or drift away in the middle of a page or conversation, b) difficulty getting organized (their desks, work places, and home spaces are disorganized and often filled with piles of paper, books, etc.), c) chronic procrastination and difficulty getting started, d) multiple projects going, a difficulty in following through and completing things (this includes commitments to others).
Other common symptoms of inattention that can raise a red flag, and alert the therapist to possible ADHD are: a) frequently losing, forgetting or misplacing important objects (i.e. keys, wallet, glasses), b) a history of repeated work failures, career changes or moving their place of residence,
c) difficulty remembering verbal or written directions or instructions even when repeated several times, d) poor reading comprehension- must re-read the paragraph 2-3 times to retain the information, e) frequently getting traffic tickets for excessive speed or involved in multiple auto accidents that are their fault.
In addition, most adults with ADHD have executive function deficits. Executive functions are thought to be localized primarily in the prefrontal lobes of the cerebral cortex. Executive functions that are most often compromised are planning, prioritizing, shifting tasks, working memory, and time management. Russell Barkley uses the phrase “ time blindness” in reference to ADHD adults’ difficulties with time management. They cannot estimate the time it will take to complete a task or to get somewhere. Due to this, they often miss deadlines, are late with assignments, and completely miss appointments.
Common symptoms of hyperactivity are: difficulty sitting still, fidgeting while sitting, and difficulty waiting ones turn. Common symptoms of impulsivity are: a tendency to say what comes to mind without considering the timing or appropriateness of the remark, interrupting people, and intruding on others’ privacy.
The current challenge is how to find the 90% of adults who go undiagnosed and untreated. Many adults with ADHD experience a worsening of their symptoms to crisis proportions when they leave home entering the work force or college. They don’t have the structure that was provided by their family and cannot get by on just basic intelligence as many of them did in high school. Their difficulties with distractibility, procrastination, and organization can often lead them to seek counseling if they are lucky enough to have such services available to them. If not, they may never come to the attention of a mental health practitioner. (Many therapists in practice currently have an undiagnosed ADHD adult in their practice. These individuals are often in treatment for another diagnosis (i.e. depression, anxiety, or bipolar disorder).)
Stated again, the consequences of untreated ADHD for the individual are huge. They do not fulfill the level of their potential in school or careers due to their inattention symptoms. They are often undereducated, dropping out of high school or college, and if in college, they are often unable to complete degrees and frequently take twice as long as others to do this. They gravitate towards lower level jobs and are economically compromised in terms of income. They are also socially compromised often with repeated failures in relationships (they have difficulty listening to or paying attention to others). If they also have hyperactivity or impulsive symptoms in addition to inattention, they are further disabled in the areas of work and relationships because others find it difficult to be around people who are hyperactive (constantly moving, fidgeting, unable to wait their turn), or impulsive (talking excessively, interrupting others, blurting out answers).
Counterbalancing these severe consequences of untreated ADHD is the positive fact that once ADHD is diagnosed, individuals have a good prognosis. Medication is still the hallmark of treatment. It does not cure ADHD, but often improves the basic inattention symptoms in the range of 40% to 60%. With a good response, most people in treatment can come close to living a normal life. They are able to finish college, get degrees, hold onto the jobs they get and have successful relationships. They are able to achieve higher levels of education, career satisfaction and the ability to have normal, stable relationships.
Diagnosis: In terms of diagnosis, the key feature about adult ADHD is that it presents with chronic problems of inattention and or hyperactivity/impulsivity that go back to childhood, usually before age 12 to 16. If the patient cannot give a clear history, the family can be used as another source. Parents, teachers, report cards, etc., usually will help fill out an accurate history.
Children who are hyperactive and impulsive are more commonly and easily diagnosed because their behavior is a problem to others. The children who have pure inattentive ADHD are daydreaming or spacing out part of the time and are less obvious to teachers, principals, and adults in general. They are less likely to get diagnosed in childhood.
Sixty percent of adults I see in my practice have pure inattentive ADHD – the other 40% have adult ADHD combined type with inattention plus hyperactivity and/or impulsivity.
ADHD is a strongly inherited condition – approximately 35 to 40 percent of people with it have a first-degree relative who also has ADHD. Many adults with ADHD are poor historians and it is often important or helpful to have a second source of information- this can be the individual’s partner, spouse or a member of the family.
The psychiatrist who evaluates an ADHD adult for treatment must do a thorough evaluation. They must take a thorough family history, medical history and medication history. A key point is that 60% to 80% of adults with ADHD have a second co-morbid diagnosis. To be specific, 18.6% of adults with ADHD have major depressive disorder and 19.4% of adults with ADHD have bipolar disorder. Some 47.1% of adults with ADHD have a major anxiety disorder (PTSD, OCD, panic attacks, social anxiety disorder and GAD), 15.2% of adults with ADHD have substance abuse disorder and 10% of adults with ADHD have a learning disability.
Due to the strong element of co-morbidity (more than one diagnosis), psychiatrists must take time to evaluate further the above-mentioned co- morbid conditions. Most often, these conditions need to be treated first and stabilized before you treat the ADHD. In actual practice, we treat the more severe disorder first. Once co-morbid conditions are stabilized, then the patient can be treated for ADHD. Sometimes, the patient will say, “If I could only concentrate and finish my assignments at work or school, I would not be depressed or anxious.” The clinician has to delineate between anxiety and depression that both seem secondary to ADHD versus anxiety and depression that are independent of ADHD. In most patients, if depression and anxiety are secondary to ADHD symptoms, I will treat ADHD first, but if the depression and anxiety are not caused by ADHD, I will treat the more severe co-morbid disorder first. In terms of a full evaluation, a psychiatrist must rule out any history of cardiovascular or heart disease, hypertension or narrow angle glaucoma – as these are the three medical conditions that make the use of stimulants contraindicated. Stimulants are still at this time considered one of the first line treatments for ADHD.
The psychiatrist, after ruling out co-morbid conditions and taking a full history including patient’s use of drugs, stimulants (such as caffeine and nicotine), and drug allergies- then does testing for the presence of symptoms of ADHD. There are a number of very good rating scales available. In the office, I usually use a 20 question symptom rating scale that covers inattention, hyperactivity and impulsive symptoms of ADHD and I follow it up with a 60 question more detailed ADHD symptom review questionnaire that the patient takes home and brings back on the second visit. There are also several physical tests that are used to help diagnose ADHD. The quantitative EEG is a test that when positive is 90% diagnostic for adult ADHD. It is a special type of EEG that shows, when positive, an increase in slow theta brainwaves over the frontal cortex (a pattern of under arousal). This test costs $1200 to $1500 in the Bay Area and is too expensive to use regularly. (It is only used regularly in a few clinics in the United States including Hallowell and Ratey’s Clinic in Massachusetts). The SPECT scan shows decreased blood flow, decreased dopamine and decreased dopamine receptors in the prefrontal lobe of the cerebral cortex, but this test is only a research tool at this time.
In summary, the personal experience of the psychiatrist or psychologist using a variety of standardized rating scales for ADHD symptom reporting is how the diagnosis is made. The diagnosis is confirmed when the patient gets a positive response to medication. Adults who do not have ADHD will not get dramatically improved attention symptoms on stimulants, or other medications. This is an important point. Only adults with ADHD will respond to stimulants or other drugs with benefits in the three symptom area.
Treatment: ADHD is a very rewarding condition to treat because almost everyone gets better. There are a number of ways to treat adult ADHD including nutrition, (especially omega-3 fatty acids), physical exercise, neurobiofeedback, specific brain exercises, cerebeller stimulating exercises and others. So far, however, none of these natural methods of treatment have proven to be nearly as effective as medication. Medication remains the hallmark of treatment although psychotherapy and coaching are also often important components of the treatment plan.
In terms of medication and the current state of the art of treatment for ADHD, approximately 70% of adults do best on stimulant medications and approximately 30% of adults do best on antidepressant and other medications. The three stimulant medications are Ritalin, Dexedrine and Adderall – each has a short-acting form, lasting approximately four hours and a long acting form lasting approximately 8 to 12 hours. The stimulant medications are in general very safe and effective when monitored correctly and on the condition that the patient does not have cardiovascular disease, hypertension or narrow-angle glaucoma. Ritalin and Dexedrine have actually been available since the 1930s. All three stimulants are used at times as augmenting agents for patients with major depression. Almost all the drugs that work for ADHD increase dopamine and/or norepinephrine in several areas of the brain especially in the pre-frontal cerebral cortex. The 30% of patients who do not tolerate or do well on the stimulants often get dramatic benefits on one of the antidepressants or other drugs listed here. The antidepressants and other drugs in the order I usually prescribe them are: Wellbutrin, desipramine, Strattera, Provigil, guanfacine, clonidine and amantadine. This order in part reflects side effect potential and tolerability. The stimulants are all controlled substances and have to be written on a special controlled substance form. The other 30% of medications are not controlled substances and can be called in easily to any pharmacy.
Many adults with ADHD need psychotherapy and/or coaching. They often have had years of failure. Some of them have been called” lazy”, or told that “they are not working hard enough”, that they are “underachievers” and that they are “not doing the best they can”. These patients often have shame and low self‑esteem because of past failures and negative feedback from teachers and family. When diagnosed, they are extremely relieved to find that they have a treatable condition- that it is not their fault that they have under-achieved in their own or others estimation. It is important that the patient have a therapist who has knowledge of ADHD in order to help these patients deal with their specific problems. Therapists work on general issues as mentioned above, self-esteem, relationship issues, acceptance of the diagnosis whereas ADHD coaches work on day‑to‑day strategies to help the patient gain benefits in one or more of the inattention areas or executive function areas listed above.
This article is meant mainly to be an introduction to the subject of Adult ADHD for psychologists and therapists who have not been exposed to this information before. If you are interested in finding out more, which I hope you are, I recommend the book Delivered from Distraction (published in 2005) by Ed Hallowell, M.D. and John Ratey, M.D., two psychiatrists at Harvard who have ADHD. Their first book, Driven to Distraction, published in 1994, is a classic and also a great book. These two books are easy to read and full of accessible information to help you get a feel for the subject matter fairly quickly. Another book I recommend is Women with Attention Deficit Disorder by Sari Solden. Also, if you are interested in screening your own patients, but do not have a lot of experience with adult ADHD rating scales, I have put together a seven-question brief screening test that covers the primary inattention symptoms, hyperactive and impulsive symptoms, as well as how to score the test. If you would like a copy of this screening test, I will be happy to send you one, just e-mail my office manager at firstname.lastname@example.org.
Dr. Steve Baskin is a psychiatrist in private practice in Berkeley since 1985. The evaluation, diagnosis and treatment of adult ADHD is one of Dr. Baskin’s specialties.