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Listen to thisWithout doubt the most important "new" development pertaining to ADHD has been the now-widespread recognition that this is a condition which does not somehow go away at the end of childhood or adolescence. In at least 2/3 of cases significant symptoms continue into adult life and may be as severe at age 45 as they once were at age 5 or 10. It is evident the classical "hyperactivity" we see in most ADHD children is less and less prominent as they age, but severe impulsivity and inattentiveness not only often continues in force, but in many adults gets worse and even more impairing.
Another important advance in our understanding of ADHD is recognition of the familial nature of the condition. While only 10 years ago there were few studies of the genetics of ADHD, there are now hundreds, and the Human Genome Project is actively pursuing the identification of genes which govern development of this condition, and when one carefully looks at cousins, aunts, uncles and other extended family ADHD is far more prevalent than in the general population.
A further advance, during the past few years, is the growing recognition that ADHD, TS, and OCD are evidently, to some extent, genetically linked. In the course of evaluation of an ADHD child, it is common to find an OCD older sibling, and uncle with TS, a parent with OCD/TS, and a grandmother with ADHD/OCD. When the clinician then carefully evaluates cousins, a sprinkling of these related conditions is often quickly identified.
Finally, after years of study, DSM-IV has made it official that there is something called ADHD, Inattentive Type, without any evident hyperactivity or impulsivity. This is now coded as 314.00. The label is confusing, since for most of us this is the condition we once called "A.D.D.," and the new coding has generated a lot of debate and criticism. In any event, we know as many as 40% of all people with ADHD have the Inattentive Type only. In the past, children as well as adults with this condition were frequently criticized but rarely diagnosed.
Adults
ADHD IN ADULTS is a condition very, very few clinicians have been trained to recognize until just recently. Most adults with ADHD have been given one of the three different "labels:" 1)Bipolar Disorder; 2)Atypical Depression; 3)Personality Disorder. Some have been termed "Antisocial," and since untreated ADHD often results in drug abuse, "Substance Abusers."
In the counseling office, these adults usually manifest many of the following symptoms ...
These are characteristic features of adults with ADHD-Residual Type. While it is easy to confuse these symptoms with Personality Disorders, since so many of the outward symptoms are so similar, there are several very important differences we find in adults with ADHD:
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 daycare providers fits, napped and fed poorly, and
grandparents were frustrated by behavior, as well as parents. Many male
adults will be found to have been retained as "immature" in Kindergarten or
1st Grade. There may well 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
misrepresent past history and give answers like "I did OK." Information from
their mother may reveal otherwise; in one such case after hearing her son
say this the mother exploded in laughter and said: "Oh, yeah! Like how about
the year you spent on a bench outside your 4th Grade class!"
It is always 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 stopped at puberty (a typical practice in the 60's and 70's).
Familial factors
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 on page 1 he does also until proven otherwise!
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. These are people who are well-behaved as children, but prone to daydreaming, incomplete work, "poor study habits," and more and more forgetful, disorganized, and ineffective as they age. Emergence of "depression" symptoms in adolescents is a very common report, and they may indeed look depressed in the office. Inquiry about their childhood 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 confuse the clinicians because they are more forgetful, disorganized, and "dysfunctional" than one would imagine given their education and family background, and their symptoms of depression may be quite unusual or atypical. "Atypical depression" should always trigger ADHD inquiry.
Concurrent conditions
PTSD & ADHD are often concurrent. This co-morbidity is clearly evident now in offices where children and families are seen for evaluation and treatment, but in some settings the ADHD aspect of the situation is ignored, while in others the PTSD issues are ignored.
A recent paper by Cuffe summarizes some of the issues and concepts related to these concurrent conditions. ADHD children are, of course, more prone to risk-taking behaviors than are "normal" children, and are more exploratory, curious, and "disinhibited" than others. They are also, as Barkley has so often stressed, less "rule conscious" than normal children; when repeatedly taught never to talk with strangers they fail to remember the rule when new and interesting situations arise, and they tend to plunge into trouble without adequate foresight, just as they are prone to dash across the street without looking out for traffic.
Meanwhile, these children often live in families in which one or more parents have ADHD-based impulse control problems, and are relatively often especially prone to similar difficulties. 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.
As Cuffe and his associates suggest, and others have in many related
publications, PTSD and ADHD are often concurrent; treatment for ADHD may
help improve rule consciousness and ability to follow directions. PTSD may
in itself impair ability to concentrate and induce hyper-vigilance, creating
an ADHD-mimicking syndrome at least temporarily. The long-term case history,
as well as the familial history, will usually be most instructive
diagnostically.
Clinicians are well-advised to carefully evaluate the
pre-morbid history for symptoms of ADHD, as well as the family history, in
any case of PTSD. Attributing school problems, concentration difficulties,
mood swings, and episodic anger merely to residual of PTSD is often
incomplete; many of these children and adults will also have ADHD symptoms
requiring treatment.
Guidelines for proceeding with this kind of dual-track evaluation are easy to write about, but of course often present significant challenge in a counseling office! These can be summarized as follows ...
Abuse and neglect, like ADHD, is often multigenerational, and 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 remains problematic. In the case of children and adolescents with
ADHD-Inattentive Type, symptoms 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. Concurrent, 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 – OTHER CONDITION 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 do often see ADHD in younger children uncomplicated by other significant conditions, by ages 10 or 11 – and sometimes earlier – 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 encounter 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 are by far the most common of these problems, and while medication may adequately treat core ADHD symptoms, clients will often need psychotherapy for these or other mood disorders. Many will benefit from medications such as Prozac, Paxil, Zoloft, Luvox, Effexor, Remeron or Serzone as well as psychotherapy to effectively relieve Depression and Dysthymia.
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 period. Medications such as those mentioned above, as well as Buspar, are often extremely effective in relieving PMS symptoms.
Intensive research is now under way trying to tease out the relationship between ADHD and Bipolar Disorder. These conditions share many symptoms we find in clients; 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 fluctuation 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 will 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 commonly these children are at grave risk for abuse. Terrific temper fits, violent actions, stubborn refusal to cooperate with parental rules, extreme hostility, and moody/angry defiance obviously are behaviors which provoke the most irrational and poorly controlled of all parental responses. Further, 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, and thus periodically incapable of the restraint and judgment we expect from parents.
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, and we would 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 in cases of this type. ADHD, especially combined with Bipolar Disorder, can generate an "abusive environment" with contributions from many family members, and it can be greatly improved with effective treatment of all affected family members.
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 manners 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 because anxiety increases disorganization, 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 contribution: like 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 on the part of one of the children, and aggravated by undiagnosed/untreated ADHD symptoms affecting 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.
Reference: ADD Clinic at http://www.addclinic.com/
