Potential ADHD Adults Should Seek Diagnosis

Learn about the characteristics of adults with ADHD, what causes ADHD, and the importance of adults with ADHD getting a diagnosis.

Diagnosis Is Critical: You Could Have Adult ADHD and Not Know It

ADHD has been recognized and treated in children for almost a century, but the realization that ADHD often persists into adulthood has only come over the last few decades.

The prevailing belief among professionals for many years was that children and adolescents would outgrow their symptoms of ADHD by puberty, and certainly by adulthood. However, contemporary research has shown that as many as 67 percent of children diagnosed with ADHD will continue to have symptoms of the disorder that significantly interfere with academic, vocational or social functioning in their adult lives. ¹

The core symptoms of ADHD: inattention, impulsivity and hyperactivity appear in childhood (usually by age seven) and result in a chronic and pervasive pattern of impairment for most. ADHD in adults is sometimes viewed as a "hidden disorder" because the symptoms of ADHD are often obscured by problems with relationships, organization, mood disorders, substance abuse, employment or other psychological difficulties. It is a complex and difficult disorder to diagnose, and should only be diagnosed by an experienced and qualified professional.

ADHD is first recognized in some adults because of problems with depression, anxiety, substance abuse or impulse control. Others recognize that they may have ADHD only after their child is diagnosed. Despite increased awareness and identification of the disorder in adults, many adults remain unidentified and untreated.

Characteristics of Adults with ADHD

The growth of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and a renewed interest in research have contributed to the increased recognition of this disorder in both children and adults. Still, many adults grew up at a time when clinicians, educators, parents and the general public knew very little about ADHD or its diagnosis and treatment. Consequently, greater public awareness has led to an increased number of adults seeking evaluation and treatment for ADHD and its associated symptoms.

The current diagnostic criteria for ADHD (reworded slightly to be more appropriate for adults) according to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are:

1. Fail to give close attention to details or make careless mistakes at work
2. Fidget with hands or feet or squirm in seat
3. Have difficulty sustaining attention in tasks or fun activities
4. Leave seat in situations where seating is expected
5. Don't listen when spoken to directly
6. Feel restless
7. Don't follow through on instructions and fail to finish work
8. Have difficulty engaging in leisure activities quietly
9. Have difficulty organizing tasks and activities
10. Feel "on the go" or "driven by a motor"
11. Avoid, dislike, or are reluctant to engage in work that requires sustained mental effort
12. Talk excessively
13. Lose things necessary for tasks and activities
14. Blurt out answers before questions have been completed
15. Easily distracted
16. Have difficulty awaiting turn (impatient)
17. Forgetful in daily duties
18. Interrupt or intrude on others

Although other symptom checklists are sometimes used in assessing adults for ADHD, the above DSM-IV criteria are currently considered the most empirically valid. These core symptoms of ADHD frequently lead to associated problems and consequences that often co-exist with adult ADHD. These may include:

1. Problems with self-control and regulating behavior
2. Poor working memory
3. Poor persistence of efforts toward tasks
4. Difficulties with regulation of emotions, motivation and arousal
5. Greater than normal variability in task or work performance
6. Chronic lateness and poor time perception
7. Easily bored
8. Low self-esteem
9. Anxiety
10. Depression
11. Mood swings
12. Employment difficulties
13. Relationship problems
14. Substance abuse
15. Risk-taking behaviors
16. Poor time management

The impairment from both the core symptoms and associated features of ADHD can range from mild to severe in its impact on academic, social and vocational domains, and in daily adaptive functioning. Since the symptoms of ADHD are common to many other psychiatric and medical conditions and some situational/environmental stressors, adults should never self-diagnose and should seek a comprehensive evaluation from a qualified professional.

Who Receives an ADHD Diagnosis?

Research indicates that ADHD occurs in approximately three to five percent of school-age children and approximately two to four percent of adults. Among children, the gender ratio is approximately 3:1, with boys more likely to have the disorder than girls. Among adults, the gender ratio falls to 2:1 or lower. The disorder has been found to exist in every country in which it has been studied, including North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the Middle East. The disorder may not have the same name in these countries, and may be treated differently, but there is little doubt that the disorder is virtually universal among human populations.

What Causes ADHD?

There are no definitive answers as yet. To date, there are no biological, physiological or genetic markers that can reliably identify the disorder. However, research has demonstrated that ADHD has a very strong biological basis.

Although precise causes have not yet been identified, there is little question that heredity makes the largest contribution to the expression of the disorder in the population. In instances where heredity does not seem to be a factor, difficulties during pregnancy, prenatal exposure to alcohol and tobacco, premature delivery, significantly low birth weight, excessively high body lead levels, and postnatal injury to the prefrontal regions of the brain have all been found to contribute to the risk for ADHD to varying degrees.

Research does not support the popularly held views that ADHD arises from excessive sugar intake, food additives, excessive viewing of television, poor child management by parents, or social and environmental factors such as poverty or family chaos.

Diagnosis of ADHD in Adults

A clinician or a team of clinicians who have experience and expertise in ADHD and related conditions should make a comprehensive evaluation. This team may include a behavioral neurologist or psychiatrist, a clinical psychologist or an educational psychologist.

Evaluation for ADHD should include a comprehensive clinical interview surveying past and present ADHD symptomatology, developmental and medical history, school history, work history, psychiatric history; including any medications prescribed, social adjustment and general day-to-day adaptive functioning (i.e., ability to meet the demands of daily life).

The interview is intended first to identify evidence of core ADHD symptoms (hyperactivity, distractibility, impulsivity) and then to ensure that the history of these symptoms is both chronic and pervasive. This should not simply be a brief, surface-level exam. It usually requires one or two hours at minimum. Ideally, the interview should rely on several informants (a parent if possible, or a significant other,) and survey behavior from multiple settings (i.e., school, work, home). It is also imperative that the clinician attempt to rule in or rule out other psychiatric diagnoses that may better explain presenting symptoms.

An adult evaluation should also use the DSM-IV ADHD symptom rating scales, review any available past objective records such as report cards, transcripts or prior testing/evaluation reports, and in some cases use psychological testing to determine any cognitive or learning weaknesses that may underlie functional impairment.

A comprehensive evaluation is needed for three reasons:

1. to establish an accurate diagnosis
2. to evaluate for the presence of co-existing medical or educationally disabling conditions
3. to rule out alternative explanations for behaviors and/or relationship, occupational or academic difficulties.

Why Identify ADHD in Adults?

Growing up with undiagnosed ADHD can have devastating effects on the adult. For some, the diagnosis and education that follows an evaluation can be a profoundly healing experience. Proper diagnosis can help adults put difficulties in perspective and better understand the reasons for many lifelong symptoms.

Adults with ADHD have often developed negative perceptions of themselves as "lazy," "stupid," or even "crazy." Proper diagnosis and effective treatment can help improve self-esteem, work performance and skills, educational attainment and social competencies.

Many adults with ADHD are offered protection under the Americans with Disabilities Act of l990, which prohibits discrimination in employment and public accommodations against any individual who has a physical or mental impairment that substantially limits one or more major life activities, including learning and working, or who has a record of such impairment.

After Adult ADHD Diagnosis, What Then?

Although there is no cure for ADHD, many treatments can effectively assist in managing its symptoms. Chief among these treatments is the education of adults with ADHD and their family members about the disorder's nature and management.

However, well-controlled research comparing different types of treatment has found overwhelmingly that the greatest improvement in the symptoms of ADHD results from treatment with stimulant medication combined with counseling. Evidence shows that some tricyclic antidepressants may also be effective in managing symptoms of ADHD as well as co-existing symptoms of mood disorder and anxiety.

Just as there is no single test to diagnose ADHD, no single treatment approach is appropriate for everyone. Treatment needs to be tailored to the individual and should address all areas of need. There may be a variety of behavioral, social, academic, vocational or relationship concerns for the adult with ADHD. For some, just getting the diagnosis and understanding that there was a reason for many past difficulties can be extremely helpful.

Adults with ADHD may also benefit from counseling about the condition, vocational assessment and guidance to find the most suitable work environment, time management and organizational assistance, coaching, academic or workplace accommodations, and behavior management strategies.

In summary, some common components of treatment plans for adult ADHD include:

1. Consultation with appropriate medical professionals
2. Education about ADHD
3. Medication
4. Support groups
5. Behavior skill-building such as list-making, day planners, filing
6. systems and other routines
7. Supportive individual and/or marital counseling
8. Coaching
9. Vocational counseling
10. Assistance with making appropriate educational and vocational choices
11. Perseverance and hard work
12. Appropriate academic or workplace accommodations

A multimodal treatment plan combining medication, education, behavioral and psychosocial treatments is thought to be the most effective approach. Although there has yet to be a large volume of research on psychosocial treatment of adult ADHD, several studies suggest that counseling which offers support and education can be effective in treating adults with ADHD. A combined treatment approach, maintained over a long period of time, can assist in the ongoing management of the disorder and help these adults lead more satisfactory and productive lives.

This article first appeared as CHADD Fact Sheet No. 7, Spring 2000. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) is a national organization with local support groups in many communities..

Suggested Reading

Barkley, R.A. (1998). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.New York: Guilford Press.

Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence and Adulthood. A Guide for Practitioners. New York: John Wiley & Sons, Inc.

Nadeau, K.G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults: Research Diagnosis and Treatment. Brunner/Mazel.

Hallowell, E.M., and Ratey, J. (1994). Driven to Distraction. New York: Pantheon.

Murphy, K.R., and LeVert, S. (1995). Out of the Fog: Treatment Options and Coping Strategies for Adult Attention Deficit Disorder. New York: Hyperion.

Solden, S. (1995). Women with Attention Deficit Disorder. Grass Valley, CA: Underwood Books.

1. Barkley, RA, Fischer, M., Fletcher, K., & Smallish, L. (2001) Young adult outcome of hyperactive children as a function of severity of childhood conduct problems, I: Psychiatric status and mental health treatment. Submitted for publication.

next: Impact of ADHD on Adults
~ adhd library articles
~ all add/adhd articles