By Ira S Halper M.D
Many children and adolescents who suffer from obsessive-compulsive disorder also meet criteria for attention-deficit/hyperactivity disorder. OCD and ADHD can coexist in adults as well. Attention-deficit/hyperactivity disorder is a neuropsychiatric disorder of executive functions that can affect attention, memory, organization, planning, and emotional regulation. It used to be believed that ADHD was a childhood disorder that faded during adolescence. We now know that hyperactivity tends to fade, but inattention and impulsivity tend to persist into adulthood. As many as two thirds of individuals diagnosed with ADHD as children show at least subtle signs of attention-deficit/hyperactivity disorder as adults. Hyperactivity may persist in the form of fidgeting or an inner sense of restlessness.
The diagnosis of ADHD is most often made during the early years of school, when hyperactive behavior is disruptive, and inattention interferes with learning. However, there are exceptions. A significant number of children with this disorder have predominantly inattentive symptoms. If a child is not exhibiting hyperactive and impulsive behavior that disrupts the class, the diagnosis may be overlooked. This is particularly likely to happen if the child is bright and has a good memory. These children may be able to get by without doing much homework and still do more or less satisfactory work in school. Nevertheless, they pay a price. On some level they realize they are bright and they should be achieving at a higher level in school, but they can never figure out how. They may be told by teachers and parents that they are lazy and that they are not working up to their potential. The damage to their self-esteem can be substantial. Anxiety and depression is common in these individuals, and undiagnosed ADHD can have a negative effect on major areas of their lives.
Some individuals with mild forms of attention-deficit/hyperactivity disorder are able to figure out techniques for dealing with their weaknesses in executive functions on their own and are able to function successfully at a high level. Others are not as fortunate. Educational problems are common, and individuals with undiagnosed ADHD may have difficulty finishing college. Occupational difficulties are also common, including problems getting along with others, being fired, or quitting jobs because of boredom. Individuals suffering from undiagnosed ADHD often experience financial problems, impulsive buying, excessive use of credit, and financial stress. An increased risk of accidents and unsafe driving habits are also seen.
The diagnostic criteria for attention-deficit/hyperactivity disorder in DSM-V, the official diagnostic manual of the American Psychiatric Association, have limitations in that they were originally established for children and adolescents. Dr. Russell Barkley, a leading authority on ADHD, has developed a set of criteria for adults that may be more useful. The criteria include being easily distracted by extraneous stimuli, impulsive decision making, difficulty stopping activities when the individual should do so, starting tasks without reading or listening to directions carefully, poor follow-through on promises or commitments, trouble doing things in their proper order, and excessive speeding when driving. Because attention-deficit/hyperactivity disorder is a neurodevelopmental disorder, a clinician should be able to reconstruct with the patient a childhood history of inattention, hyperactivity, and/or impulsivity. Parents can be helpful in reconstructing these histories.
The diagnosis of ADHD is sometimes missed in childhood, but the disorder can also be over diagnosed. It is easy to confuse the concentration difficulties experienced by anxious individuals and the problems with memory and concentration seen in depressed individuals, with symptoms of ADHD. One should be skeptical about the diagnosis of ADHD without a history of symptoms in childhood or at least in early adolescence.
Genetic factors contribute heavily to the development of attention-deficit/hyperactivity disorder. It is likely that multiple genes contribute to the risk of ADHD. Neuropsychological research and functional neuroimaging are beginning to reveal the neurological basis of this disorder. While genetic factors play a large role in the development of ADHD, a significant minority of cases may develop from adverse environmental factors, in particular, complications of pregnancy and prenatal exposure to toxins, such as lead. The evidence that psychosocial factors such as bad parenting contribute to ADHD is weak. Much of the negative behavior of the mothers of these children appears to be a response to the difficult behavior of the children.
Fortunately, biology is not destiny, and attention-deficit/hyperactivity disorder in adults is very treatable. Medication is the cornerstone of treatment for ADHD, but for most individuals with this disorder psychoeducation and psychosocial treatments are also necessary for the best results. Stimulants are the best-studied and most frequently prescribed class of drugs for ADHD. Methylphenidate and amphetamine both increase the concentration of neurotransmitters at important sites in the brain, but they act in somewhat different ways. Some patients respond selectively to one drug or the other. Both methylphenidate and amphetamine are available in long-acting preparations, making once a day dosing possible. Other pharmacologic agents are available for those patients who don’t respond adequately to stimulants or for whom stimulants are contraindicated.
Pharmacologic treatment can be very helpful to individuals suffering from ADHD in adulthood, but there is no medication that can eliminate all the weaknesses in executive functions seen this disorder. Nor can medication alone successfully treat the low self-esteem, the social anxiety, the depression, and the other psychological problems that accompany ADHD in adults. There are evidence-based cognitive-behavioral protocols that have demonstrated efficacy in randomized controlled trials. One such protocol, developed at the Massachusetts General Hospital, is available with a therapist guide and a user-friendly client workbook.
Many individuals whose symptoms of ADHD persistent into adulthood lack a clear understanding of their disorder, even if they are bright, well-educated, and on medication. The Massachusetts General Hospital protocol begins with educating the patient about the nature of attention-deficit/hyperactivity disorder and its effect on the lives of adults. It is important for patients to understand that they are neither lazy nor stupid, but rather, they have weaknesses in executive functions. Paradoxically, a good result requires that patients accept the fact that they have a disability, often a mild one. If they can accept this reality, they can make a commitment to learn the behavioral and cognitive strategies necessary to compensate for residual deficits. A symptom self-report form filled out weekly assists patients in charting their progress and reminds them to adhere to the protocol.
A calendar, a notebook, and a task list with priority ratings are the foundation of the successful management of ADHD in adults. Smart phone technology has made the use of these tools much easier. With the help of the clinician, patients learn problem-solving skills and how to manage overwhelming tasks by breaking them down into smaller pieces. Individuals with attention-deficit/hyperactivity disorder often have problems organizing papers and need assistance in sorting mail and developing a filing system. With practice, patients can learn to delay distractibility; the alarm available on smart phones is helpful in this exercise. The alarm can also be set to go off at regular intervals to help patients stay on task. Patients learn how to reduce the distractions in their environment. Telephones can be turned to voice mail. Computers can be a challenge, particularly if the use of a computer is an important part of a patient’s job. Nevertheless, patients can learn how to avoid responding instantly to every e-mail.
Maladaptive thoughts are common in ADHD in adults, particularly negative thoughts about themselves and anxious thoughts about their ability to cope with challenges. Cognitive therapy techniques are employed to assist patients to identify their dysfunctional thoughts and their characteristic cognitive distortions. With the help of the clinician they are able to develop more rational and adaptive responses.
Procrastination is often a problem for adults with ADHD, and the protocol includes a section on dealing with this habit. Procrastination has advantages, for example, the avoidance of anxiety, but of course it also has negative consequences. Patients learn to more carefully weigh the pros and cons of procrastination and make more appropriate decisions.
After completing the above protocol, patients usually feel better and function better, but the anxiety and depression that accompany ADHD in adults often require treatment as well. Other evidenced-based cognitive-behavioral protocols are available to treat these disorders, and antidepressant medication may be necessary in some cases.
A good resource for adults with attention-deficit/hyperactivity disorder and their families is CHADD, Children and Adults with Attention-Deficit/Hyperactivity Disorder www.chadd.org. CHADD is a non-profit organization serving individuals and families affected by ADHD.
Dr. Halper is the Director of the Cognitive Therapy Center in the Department of Psychiatry at Rush University Medical Center in Chicago. His website is www.irahalpermd.com.