November 12, 2011

Meeting the Challenge of Adult ADHD

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Joseph V. Madia, MD By:

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Attention deficit later in life brings complicated diagnosis

James Carville, Sir Richard Branson, Michael Phelps, Howie Mandel…what do these famous people have in common? They all have attention deficit hyperactivity disorder.

ADHD is usually associated with children. And though it's true that ADHD almost always develops in early childhood, often it isn't diagnosed until much, much later. Adults can be affected by this disorder - and are, in large numbers. For those who have ADHD in childhood, up to 50 percent continue to have the condition into adulthood.

For adults struggling with ADHD, especially if they've dealt with the symptoms for years without being properly diagnosed, there are many special issues and considerations in managing the disorder in daily life.

Adult ADHD is largely misunderstood, misdiagnosed, and complicated by the overlap of other conditions such as depression, anxiety or substance abuse. Dealing with adult situations such as a job, marriage and other relationships, bills and household management, and of course your own children, can be overwhelming for people with ADHD.

"Adult ADHD is no joke," says Gina Pera, author of Is It You, Me, or Adult A.D.D? Stopping the Roller Coaster When Someone You Love Has Attention Deficit Disorder. "It is considered the most impairing outpatient psychiatric condition, even more impairing than depression and anxiety.

Left unrecognized, ADHD is associated with higher rates of substance abuse, bankruptcy, failed relationships, absentee parenting, car accidents, unemployment, and dropping out from college or high school. There can also be physical 'side effects' from unrecognized ADHD, including obesity, sleep deprivation, diabetes, and hypertension."

Originally it was thought people would "outgrow" the condition as adults, Jennifer Van Pelt, MA, writes in Social Work Today magazine. "However, 60% to 90% of adults continue to experience symptoms."

But when treated properly, adult ADHD can be managed, even to the point that it can become a driving point in a highly successful life, as those famous ADHD cases can attest.

Step One: Proper Diagnosis

According to the organization CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), over 12 million Americans have ADHD and less than 1 in 4 know it.

“A proper diagnosis can be the first step in helping people transform their lives,” explains Dr. Umesh Jain of the Canadian ADHD Resource Alliance. “I am constantly inspired by what my patients are able to achieve. The key to success with ADHD is to develop an understanding of your strengths and challenges, and then embrace those traits.”

Diagnosing an adult with ADHD consists of gathering information from clinical interviews, validated measurements such as the Conners Adult ADHD Rating Scales and the Brown ADD Scale for Adults, and other supporting evidence. A physician should also explore the onset of symptoms in childhood, says Anthony Rostain, MD, of the University of Pennsylvania School of Medicine, as well as possible comorbid conditions such as mood disorders or substance abuse.

"It's also a good idea to get records from schools," Rostain says. "Not that it always tells the story, but you'll often see teachers commenting on 'Johnny was bright but never could stay in his seat' or teachers saying 'he was always late,' etc." Rostain equates this with archeological digging, to get a full lifespan profile of the patient. "I think once you've got scales that can quantify the symptomatology and can compare the patient's profile to that of the normal population, and to make sure that you've got collateral information that's corroborating what you're hearing from the patient, then you can feel fairly comfortable that you've got somebody with the diagnosis of ADHD."

Early diagnosis is key for the most successful management, says Pera. "In ten years of talking with hundreds of adults with ADHD and their family members, I’ve not met one who didn’t wish for the knowledge earlier in life. They are so grateful to finally have an explanation for lifelong challenges and a path towards creating lasting changes. If you are thinking that you or someone you love has ADHD, it’s important to educate yourself so you can seek an expert evaluation and know for sure. Knowledge is power. The sooner you know, the sooner you can focus on strategies for success."

Step Two: A Treatment Plan

The treatment of adult ADHD is complicated by several factors. Research on adult ADHD is in a very early stage compared to the childhood emphasis, and according to three doctors with the Family Medicine of St. Louis Residency Program, the diagnostic features of ADHD take a very different form in adults.

In the American Family Physician journal, H. Russell Searight, Ph.D., along with John M. Burke, Pharm.D. and Fred Rottnek, M.D., report that adults often have more subtle cognitive-behavioral symptoms, they tend to try and self-diagnose, and the most effective treatment is the long-term use of a drug that has a potential for abuse. "While family physicians are knowledgeable about childhood ADHD, there is a noticeable absence of guidelines for primary care evaluation and treatment of adults with symptoms of the disorder." They add that most adults do not have a "pure" form of ADHD as well, it often being intertwined with other psychiatric disorders.

Pharmacology is a common treatment, with stimulants such as Ritalin and Dexedrine being the most commonly used type of drugs, just as with children. Antidepressants are sometimes also prescribed to battle ADHD. "Medication will be the single most effective treatment strategy for most adults with ADHD," says Pera. "Unfortunately, medication myths and misinformation dissuade some people from considering medication for ADHD. Others have tried medication but were turned off by the side effects. It’s important to be your own advocate when it comes to medication, because not all physicians are familiar with proper selection and dosing strategies."

Psychotherapy, particularly cognitive behavior therapy, is often combined with medication. And for adults, marriage or relationship counseling is often vital. Pera can attest to the negative effects on adult relationships; when she began learning about adult ADHD, she realized that it was having a huge impact on her relationship with her then-fiance.

Step Three: Life Management and Coping Strategies

Self-management strategies are vital for adults to successfully manage the condition. "Adults who are late to the ADHD diagnosis often carry around a few decades of dealing with ADHD symptoms in the best way they can — and that often includes maladaptive coping strategies," Pera says. 

Planning and organization, combined with limiting distractions and clutter, are important for the person with ADHD. J. Russell Ramsay, Ph.D. and colleague of Rostain at UPSM, says that procrastination is a prominent feature of adults with ADHD. "Patients may miss deadlines, receive incompletes in course work, have job-related problems, or miss tax filing deadlines. Accordingly, treatment strategies incorporating clear and explicit scheduling practices are particularly effective." He adds that old-fashioned pencil and paper planning is usually more effective than electronic methods, because it allows a person to clearly visualize his day and time management. "Coping mechanisms such as this are crucial to the improvement of daily functioning," Ramsay says. 

Pera offers these tips for dealing with adult ADHD in daily life:

Jettison poor coping strategies
When you’re a young college student, you can get by with waiting for the last-minute “adrenaline rush” to finish that paper. When you’re in the workforce in a tough economy, that last-minute strategy could get you fired. When you finally have an explanation for life-long challenges around organization, initiation, and motivation -- that is, an ADHD diagnosis -- you can start developing more productive strategies.

Externalize solutions
What does that mean? It means don’t count on your working memory to hold all that you need to remember. Cut down stress and improve relationships by creating supports in your environment.

Get organized
Disorganization is one of the more universal challenges among adults with ADHD. Are you always misplacing your car keys and phone, forgetting to charge your phone, and creating undue frustration for yourself? Buy a storage valet that holds keys, wallet, watch, and change and serves as a recharging station for your various electronic devices. Make the valet “home base” for all these items, resolving to not set them down anywhere else. For other organizational tips, check one of several books on the topic for adults with ADHD or consult a professional organizer.

Think through projects before jumping in
Nothing creates discord at home like the new bathroom tile that goes ungrouted for 8 months. Instead of charging enthusiastically into a home fix-it project, externalize your plans on paper first. Note the materials you will need and how long each step should take; if time estimation isn’t your strong suit, ask your partner or a friend for help. Schedule the steps on your calendar.

Focus on parenting strategies
Parents with ADHD can have a hard time finding that middle ground between being the “all fun” parent and the “all discipline” parent. If the parent with ADHD also has problems with temper (more common than most people realize), he or she might fly off the handle over a minor infraction. To help children and parents stay on the same page, household rules and the repercussions for breaking them should be written down and the parent should check the guidelines before meting out any punishment. 

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Reviewed by: 
Joseph V. Madia, MD
Review Date: 
November 9, 2011

Last Updated:
November 16, 2011