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Manual of Articles Sections 15 - 28
Mary had been treated for bipolar disorder, but still suffered from extremes of distractibility, impulsivity and agitation/hyperactivity. John was a mental health professional with excellent clinical skills, but was severely behind with his patient charts and necessary paper work. Sue was a brilliant college student who somehow never recognized the need to regularly attend classes, read assignments, or write papers. All turned out to be adults with previously unrecognized ADHD whose lives were greatly improved with appropriate diagnosis and subsequent treatment. All had also been given other diagnoses in the past, and had been treatment failures, as is often the case when ADHD is missed in adults (Ratey, Greenberg, Bemporad, & Lindem).
Attention deficit hyperactivity disorder (ADHD) is a complex neuropsychiatric syndrome (or syndromes) that is among the most common of childhood disorders. Once thought to disappear as children matured, ADHD, as current data indicate, changes form but remains clinically significant in many of the grownups who had it as children. The exact rate of persistence is a controversial subject. Outcome data suggest that anywhere from 5% to 75% still show significant levels of symptoms into adulthood, depending on who are used as informants and where the diagnostic cutoff point is set. For example, self-report of symptoms yields lower persistence rates than parent report among adolescents or young adults. Adult prevalence rates vary, but anywhere from 1% to 6% of the general population are believed to meet the strict DSM-IV diagnostic criteria for ADHD (Wender).
The core childhood symptoms of ADHD are hyperactivity, inattention, and impulsivity. However, Paul Wender, who originally created awareness of the continued adult form, drew attention to frequently associated features and subjective symptoms also seen in ADHD adults. These included affective lability, hot temper (with explosive and short-lived outbursts), emotional overreactivity (leading to poor tolerance of stress), and disorganization. Research suggests that the core childhood symptoms shift with development, sometimes dramatically: hyperactivity often declines by adolescence, attentional problems appear to remain more constant, and impulsivity may transform into more overt difficulties in executive functions. It is tempting to speculate that deficits in executive functions may account for many of Wender’s additional observations. Executive functions are an evolving construct, which have become a shorthand for complex regulative processes. Many other terms are used interchangeably with executive functions. These include self-reflection, self-control, planning, forethought, delay of gratification, anticipatory set, future orientation, working memory, planning, set shifting, selecting, dividing and sustaining attention, affect regulation, resistance to distraction, and metacognition. Strictly speaking, from a neuropsychological perspective, executive functions originally referred to a more narrow set of fundamental neurological processes necessary for “independent” and “socially responsible” living (Lezak). These usually denoted problems with initiation, inhibition, shifting, sequencing, planning, and self-awareness. Failures in inhibition, as well as in attention regulation, are likely to compromise other derivative executive/regulative abilities indirectly (see Barkley; Brown).
As a result of executive deficits in adults, adults with adaptive functioning may be as frequent as, if not more frequent than, problems with disruptive behaviors or inattention. Consequently, difficulty in keeping jobs and maintaining routine and poor organization of time and/or money are common (Wolf &Wasserstein). For example, individuals may report frequent missing of appointments or work deadlines, repeated failure to file taxes, poor tracking of bill payments and even bankruptcy, as well as restlessness and difficulty in unwinding and subtle forms of motor fidgeting such as pacing, leg shaking, playing with rubber bands, or rustling papers while talking. Complex presentation is the rule in adults and adolescents. That is, the ADHD is usually nestled with other comorbid psychiatric conditions, such as substance abuse, antisocial behavior, residual learning disabilities, conduct disorders, and/or mood and anxiety disorders (Brown). In adult patients, the ADHD may be missed because the comorbidities are the more common focus of attention of mental health professionals. In adolescents the ADHD may be the treatment focus, while the comorbidities may not be recognized and addressed. Last, frequent problems with social skills and adaptive functions can be very stressful to relationships. Consequently, divorce and multiple marriages are not uncommon among these adults. I have also found that some adults who have ADHD form codependent relationships wherein they become overly submissive to a controlling and highly organized partner. With the right balance such a relationship can be adaptive for the dyad, but mutual resentment and misunderstanding of the underlying forces frequently occur.
Adults and adolescents who have ADHD may show stimulus-seeking behaviors, which may lead to poorer health, criminal records, more serious motor vehicle accidents, less education, and lower occupational achievement. Nevertheless, anecdotally, success in risky and exciting occupations (e.g., entrepreneurial ventures and sales) has been reported (Weiss & Murray). Others have speculated that aspects of ADHD can be channeled into creative productivity, with the right supports and nurturance (Wolf & Wasserstein).
Recognizing ADHD in Adult Patients
There are two main groups of adolescents/adults who have ADHD: (1) Those
who were originally diagnosed as children and (2) those who
were never diagnosed. The first group is easier to recognize and often includes
men or those who were hyperactive as children. The second group is more likely
to include females and/or the inattentive subtype, because they were less likely
to have been disruptive during their childhood. That is, the true inattentive
type children are often not identified during childhood.
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