Without a doubt, the most important “new” development pertaining to ADHD has been the widespread recognition that this condition does not go away at the end of childhood or adolescence. In at least two-thirds of the cases, significant symptoms continue into adult life. The symptoms may be as severe at age 45 as they were at age 5 or 10. The classical “hyperactivity” seen in most ADHD children becomes less prominent as they age, but the severe impulsivity and inatten-tiveness often continues into adulthood, frequently getting worse and even more impairing.
Another important advance in our understanding of ADHD is recognition of the familial nature of the condition. When one care-fully looks at cousins, aunts, uncles and other extended family, ADHD is far more prevalent than in the general population. While only ten years ago there were few studies of the genetics of ADHD, there are now hundreds. Another advance is the growing recognition that ADHD, Tourette’s Syndrome (TS), and Obsessive-Complusive Disorder (OCD) are, to some extent, genetically linked. In the course of evaluation of an ADHD child, it is common to find an OCD older sibling, an uncle with TS, a parent with OCD/TS, and a grandmother with ADHD/OCD.
Another advance in our understanding occurred, when, after years of study, the DSM-IV made it official –there is something called “ADHD, Inattentive Type,” without any evident hyperactivity or impulsivity. The label is confusing, since this is the condition most of us once called “A.D.D..” The new label has generated a lot of debate and criticism.
In any event, we now know that as many as 40% of all people with ADHD have the “Inattentive Type” only. In the past, children as well as adults with “Inattentive Type” were frequently criticized but rarely diagnosed. This is slowly changing.
ADHD in Adults
ADHD in Adults (all types) is a condition very few clinicians have been trained to recognize until just recently. Most adults with ADHD were mistakenly given one of these three “labels:”
1. Bipolar Disorder
2. Atypical Depression
3. Personality Disorder
Some were termed “Antisocial,” while others with untreated ADHD were given the label, “Substance Abusers.” In the counseling office, these adults usually manifest many of the following symptoms:
1. Significant impulsivity
2. A hot, quick, flaring temper
3. Forgetfulness and unreliability (e.g., appointments)
4. Restlessness and inatten-tiveness in routine interviews
5. Disruptive, intrusive behavior
6. Very poor “insight” capacity
7. Seems “uncooperative,” and determined to do things their way
8. Rarely seems to read or complete materials given to them for review
9. Exceptional impatience
10. Projection of blame onto others
11. Failure to “follow-through”
12. Unpredictable, very rapid “mood-swings”
While it is easy to confuse these symptoms with Personality Disorders, since many of the outward symptoms are similar, there are several very important differences we find in adults with ADHD.
The following information should be obtained to aid in making a diagnosis.
A. Careful reconstruction of childhood history will reveal symptom onset very early in many cases during the toddler years: always called ‘hyper,’ gave baby-sitters and day care providers fits, napped and fed poorly, and grand-parents, as well as parents, were frustrated by behavior, Many male adults will be found to have been retained as “immature” in kindergarten or first grade.
There may have been many conflicts during elementary school: Name on the board, trips to the office, suspensions, etc. Academic problems in school may have mounted over the years, and despite evident intelligence always called “off task,” “not working up to potential,” “lazy,” “unmotivated,” etc.
Adults with ADHD, especially men, tend to deny and mis-represent past history and give answers like “I did OK.” Information from their mother may reveal otherwise. One mother, after hearing her adult son say, “I did okay,” exploded in laughter and said: “Oh, yeah! How about the year you spent on a bench outside your fourth grade class!”
B. It is vital to inquire if a diagnosis of ADHD was ever suggested by teachers or family doctor, or if the parents inquired about it but were told “he is just a growing boy,” or “just all boy.” In many cases, the clinician may discover treatment was suggested but the parents declined, or medication was prescribed for a while, and helped, but was stopped at puberty (a typical practice in the 60’s and 70’s).
C. Careful inquiry about family genetic conditions. When this reveals many different family members with likely ADHD, TS, or OCD may be decisive. Obviously, given what we now know about genetics, when a grandmother has TS and a sister has OCD, then the restless, inattentive and temperamental male adult in your office is highly suspect for ADHD. In the event one or more of his children have ADHD, then given behaviors noted above he does also until proven otherwise!
D. Adults treated with medications effective for proven ADHD usually show rapid and substantial improvement in these symptoms. Those with Bipolar or Personality Disorders do not. The issue is complicated by another concern: there is an overlap between ADHD and Bipolar as well as Personality Disorders, e.g., some people have both, or even all three! In effect, these are not mutually exclusive conditions, and in the office the clinician may be confronted by a very complicated person who fits criteria for several different conditions, and thus may need multiple forms of treatment for optimal recovery.
One final point about adolescents and adults with ADHD: in women, the Inattentive Type is far more common, and by late adolescence often looks more like a mood disorder. Those with “Inattentive Type” were typically well-behaved as children, but prone to day-dreaming, incomplete work, and “poor study habits.” Commonly they became more and more forgetful, disorganized, and ineffective as they aged.
Emergence of “depression” symptoms in adolescents is a very common report, and they may indeed look depressed in the office. Inquiry about their child-hood history of “dreamy,” “off task” behavior in class, and especially their problems with completion of homework during elementary and middle school, may be the only immediate cues to ADHD symptoms, but of course when a family history reveals ADHD, TS, or OCD in family members then ADHD Inattentive Type should be strongly suspected.
Women with this condition often are a conundrum for clinicians because they are more forgetful, disorganized, and “dysfunctional” than one would expect given their education and family background, and their symptoms of depression may be quite unusual or atypical. “Atypical depression” should always trigger an ADHD inquiry.
PTSD and ADHD
PTSD and ADHD are often concurrent. This co-morbidity is clearly evident now in offices where children and families are seen for evaluation and treatment. Unfortunately, in some clinical settings the ADHD aspect of the situation is ignored, while in other settings the PTSD issues are overlooked.
Cuffe recently summarized the issues related to these concurrent conditions. ADHD children are, of course, more prone to risk-taking behaviors than “normal” children, and are more exploratory, curious, and “disinhibited” than others. They are also, as Barkley has often stressed, less “rule conscious” than normal children. For example, when repeatedly taught never to talk with strangers they fail to remember the rule when new and interesting situations arise. They tend to plunge into trouble without adequate foresight, just as they are prone to dash across the street without looking out for traffic.
These children often are born into families in which one or more parents and other family relatives have ADHD-based impulse control problems, e.g. The parents and other family members have problems in self-control similar to the children. The uncle who drops in and spends a week or so before moving on may be very impaired by ADHD and/or substance problems, left in charge of a highly disinhibited, risk-prone child, and sexual and/or physical abuse may be the result.
PTSD may, in itself, impair the ability to concentrate and induce hyper vigilance, creating an ADHD mimicking syndrome, at least temporarily. Clinicians are advised to carefully evaluate the pre morbid history for any symptoms of ADHD, as well as the family history, in any case of PTSD. Attributing school problems, concentration difficulties, mood swings, and episodic anger to a residual of PTSD is often incomplete; many of these children and adults will also have ADHD symptoms requiring treatment.
Evaluation of ADHD and PTSD
Guidelines for this dual-track evaluation of ADHD and PTSD are easy to write about, but, of course, often present significant challenge in the clinician’s office! The guidelines can be summarized as follows:
- When all evidence points to a child being a reasonably well-adjusted, well-behaved youngster at home and in school prior to a traumatic incident such as molestation or physical abuse, then current symptoms are likely primarily sequelae of trauma.
- When there is a history of over-activity, disruptive behaviors, substantial “temper” problems, difficulties following directions, and inattentiveness, then when these symptoms become worse after traumatic incidents it is probable both ADHD and PTSD conditions are involved.
- It is always important, when there is a clear possibility of combined conditions, to take a very careful genetic history of the family.
- Abuse and neglect, like ADHD, is often multi-generational. The lethal combination of ADHD and abuse is a strong suspect when therapeutic efforts to help resolve the emotional damage from abuse appears insufficiently effective.
- Although both conditions may lead to significantly disturbed behavior in the school setting, in most cases of abuse/PTSD that behavior will be relatively transient or temporary, lasting weeks or a month or two, but not many months or years! This is especially true when therapy is being provided for the traumatic issues, and the child or adolescent seems to be making progress dealing with these issues yet the disruptive acting out at school continues. In the case of PTSD children and adolescents with ADHD-Inattentive Type, symptoms of their ADD may be confined to inattention, excessive daydreaming, poor completion of homework, difficulty concentrating in class, and declining effort and grades.
- It is important to re-emphasize that “mood” problems are often found in children and adolescents with ADHD, and in many settings may be more prominent than are typical ADHD symptoms. Con-current, effective treatment for both ADHD and PTSD provides children and adolescents with the best possible chance of full recovery and successful adjustment.
We now know this is also the case for adults as well. Effective treatment will usually require a combination of parent/client education, psychotherapy, medication, and when the client is a child, some special attention to modification of educational programs in school when necessary.
ADHD and Other Conditions
Co-morbidity is an area of increasingly intensive interest and research. “Co-morbidity” is a term for concurrent or associated conditions. In many clients with ADHD, one of the most important questions is: “OK, you evidently have ADHD, and what else?”
While we often see ADHD in younger children uncomplicated by other significant conditions, by ages 10 or 11, it is routine to discover the presence of Depression or dysthymia, Bipolar Disorder, OCD, TS, Panic or other Anxiety Disorders, and many Adjustment Disorders. As clients with ADHD age, it becomes increasingly uncommon to encoun-ter a person with ADHD as the only problem requiring treatment. By age 25 or so, the overwhelming majority of people with ADHD have one or more associated conditions.
Depression and Dysthymia
Depression and Dysthymia are the most common of these problems. While medication may adequately treat core ADHD symptoms, clients will often need psychotherapy for these or other mood disorders. Many will benefit from additional medications such as Prozac, Paxil, Zoloft, Luvox, Effexor or Serzone along with psychotherapy to effectively relieve depression and dysthymia.
ADHD and PMS
Women with ADHD often report especially severe PMS, and their spouses and children may be very troubled by their exceptional irritability and impatience during this time of the month. Medi-cations such as those mentioned above, as well as Buspar are often extremely effective in relieving PMS symptoms.
ADHD and BiPolar Disorder
Intensive research is now underway to sort out the relationship between ADHD and Bipolar Disorder. These conditions share many symptoms, and differential diagnosis is often difficult. Further, there are clearly some people with both ADHD and Bipolar Disorder. The combination may generate a clinical pattern of exceptional severity, and is evident occasionally in relatively young children as well as in adolescents and adults. Extreme over-reaction to limit setting, severe temper “fits,” episodes of violent or assaultive behavior, and very wide fluctuations of mood tend to be characteristic of children, adolescents and adults with ADHD-Bipolar Disorders.
Although we almost always see some over-reaction to limit setting, some temper tantrums and “fits,” some violent ideas and occasional actions, and some mood fluctu-ation in all ADHD children, especially boys, when these symptoms are extreme, associated Bipolar Disorder is always an important diagnostic consideration. Clinical experience suggests combined treatment is quite effective, e.g. with a stimulant for ADHD plus Depakote, Tegretol or Lithium for Bipolar symptoms.
Children and adolescents with a history of brain injury, brain infections, drug or alcohol exposure during fetal development, and/or very impaired cognitive ability periodically appear to have symptoms much like those with ADHD/Bipolar combinations, and may respond well to similar treatment efforts. It is important to emphasize how at risk these children are for severe abuse. Terrific temper fits, violent actions, stubborn refusal to cooperate with parental rules, extreme hostility, and moody or angry defiance obviously are behaviors which provoke the most irrational and poorly controlled of all parental responses.
The parent being provoked the most is often a young adult himself or herself, severely impaired with residual ADHD or ADHD/Bipolar symptoms, thus prone to irritability, impatience, rages and violent reactions when even minimally stressed. This parent is periodically incapable of the restraint and judgment we would expect.
Given the genetic and familial context in which these often-severe conflicts arise, it should be obvious conjoint treatment of all affected parents as well as children is the only prudent course. We most strongly urge very careful diagnostic and intensive multi-modal treatment efforts be extended to parents, and other important relatives, as well as to children with these conditions. Analysis of “treatment failures” often reveals, in our experience, minimal effort extended to provide effective diagnostic and comprehensive treatment services for parents and other family members.
ADHD, especially when combined with Bipolar Disorder, can generate an “abusive environment” with contributions from many family members. The family environment can be greatly improved with effective treatment of all affected family members.
Panic Disorder, with or without Agoraphobia, and Generalized Anxiety Disorder
Panic Disorder, with or without Agoraphobia, and Generalized Anxiety Disorder may be diagnosed in as many as 25-30% of all adolescents and adults who also have ADHD, and in some children as well. Further, it is not uncommon to see some of the typical symptoms of these conditions reverberate in ways which aggravate each other, e.g. a person who is chronically late, forgetful and lost experiences increased anxiety while trying to drive to an appointment, thus triggering increasing fear, panic or phobic symptoms, which then may blossom into a full-blown panic attack..
Clients with anxiety conditions, meanwhile, have difficulty with adjusting to residual ADHD symptoms since anxiety increases dis-organization, inattention to details, forgetfulness and impairs focus on essential tasks of daily living.
These concurrent conditions are now found far more commonly than previously thought, and there may be some genetic/familial con-tribution. ADHD, Panic Disorder and other Anxiety Disorders tend to have a strong familial history, as is the case with Depression and Bipolar Disorder as well. Again, careful assessment and treatment for both conditions affords the client his/her best opportunity for effective recovery.
Finally, we should mention it is always wise to carefully consider ADHD whenever the clinician encounters a person with an evident Adjustment Disorder. The reason is simple: people with ADHD, young and old, are highly volatile and tend to behave in a fashion which brings about many changes, often adverse, and they very commonly have exaggerated symptoms as a result of the change. This situation is most commonly encountered when parents split up and a child has evident adjustment problems.
In cases of this kind, and many others, it is frequently discovered that disputes over child-rearing were generated by ADHD symptoms in one of the children, and aggravated by undiagnosed or untreated ADHD symptoms in one of the parents. The child may be more moody and testy at school as a consequence of the separation, but treatment only for the adjustment issues will address only one facet of the child’s condition.