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##  Adults with Attention Deficit Hyperactivity Disorder (ADHD). ERIC               Digest.                                                                      

Attention deficit hyperactivity disorder (ADHD) is a common                     childhood neuropsychiatric disorder affecting 3-10% of children that            often remains unrecognized or "hidden" in adulthood. Although ADHD              was once thought to disappear as children grew up, data suggest that            one to two thirds of children with ADHD continue to have significant            symptoms throughout life (Wender, Wasserstein, & Wolf, 2001). Adult             prevalence estimates vary widely. Conservatively, 1-6% of adults are            believed to meet formal diagnostic criteria. 
The core symptoms of             ADHD-hyperactivity, inattention, and impulsivity-change as the child            grows older. Research suggests that hyperactivity declines with age,            attentional problems remain fairly constant, and executive function             problems increase in adulthood. Coexisting psychiatric conditions,              learning disabilities, and social difficulties are common. The                  persistence of ADHD into adulthood first became apparent in the                 1970's, but is only recently becoming more generally known in the               adult mental health field (Wender, Wolf, and Wasserstein,                       2001). MBD, HYPERACTIVITY, ADD, ADHD, AND LD: HOW DO THEY                     RELATE?While there is agreement that ADHD occurs in adults, the             terminology and our understanding of its underlying pathology are               still emerging. The names and criteria for this syndrome have                   changed frequently over time, reflecting shifts in prevailing                   thinking about key symptoms or underlying mechanisms (see Wender et             al., 2001, for review). Originally designated as "minimal brain                 dysfunction" (MBD), the terms "hyperactivity" and/or "hyperkinesis"             were used in the 1960's, "attention deficit disorder (or ADD), with             or without hyperactivity" in the 1980's, and finally "attention                 deficit hyperactivity disorder" (or ADHD) currently. These changes              in terms  reflect changes in thinking away from a focus on                      structural brain damage (e.g., MBD) toward a focus on symptoms or               behavior, such as excessive activity and inattention. The                       terminology is likely to continue to change as we further develop               our understanding of what we have come to call "ADHD." 
The shift              away from the original MBD label also signaled an emerging                      recognition of the difference between disorders of behavior (i.e.,              in activity level or attention) and specific disorders of                       learning (i.e., learning disabilities such as dyslexia, dyscalculia             or dysgraphia). These cognitive and behavioral problems often                   coexist, but are now believed to be based on different genetic                  clusters and mechanisms (Farone et al., 1993). SYMPTOMS OF                    ADHDThe American Psychiatric Association (1994) recognizes three            types of ADHD: ADHD Predominantly Hyperactive Impulsive Type,                   characterized by motor and impulse control problems; ADHD                       Predominantly Inattentive Type, problems in attention or arousal;               and ADHD Combined Type, significant problems in both areas. It is               still unclear whether these subtypes reflect a common neuropathology            or whether they represent distinct disorders (Faraone, Biederman &              Friedman, 2000). It has also been argued that these categories,                 which were created primarily for children, may not apply equally for            adults (Wolf & Wasserstein, 2001). 
Children with ADHD are often               overactive, impulsive, and inattentive. In order to be diagnosed in             adulthood, it is essential that some level of these core symptoms               were present during childhood. Over activity generally decreases by             adolescence and is often replaced by fidgetiness and/or cognitive               restlessness. More recently, researchers are focusing on                        self-regulation (i.e., problems with executive functions), rather               than attention or activity level as the main deficit in ADHD (e.g.,             Barkley, 1997). Associated features in both children and adults may             include moodiness, poor social relationships with peers, and a                  variety of different learning problems. Other psychiatric conditions            are often also present, clouding the picture (e.g., see Marks,                  Newcorn & Halpern, 2001 for review). WHAT ARE THE PERTINENT ADULT             PROBLEMS?* Substance abuse, antisocial behavior, and even                   criminality are among the better-known problems of some adults with             ADHD (Hechtman, Weiss, & Perlman, 1984). However, these issues are              hardly universal, and may be more likely in some groups of patients.            Poor social skills or deficits in self-awareness are also                       frequent. 
* When unrecognized, and therefore untreated, ADHD                  occurs along with other psychiatric conditions, it can contribute to            the failure of medication and psychotherapy. This is because                    the "comorbid," or coexisting, conditions are then the only focus of            treatment (Ratey, Greenberg, Bemporad, & Lindem, 1992). 
* Problems            with independent adaptive functioning are among the most common                 complaints of adults who have ADHD and seek therapy (Silver, 2000).             For example, they may have difficulty finding and keeping jobs,                 trouble maintaining routine and organization, and problems with                 self-discipline. In contrast, behavior control issues are the more              usual complaints in children with ADHD. The difference between                  children and adults may reflect the fact that parents, teachers, and            society can provide external forms of regulation for children, but              cannot fulfill that role for adults. Additionally, the tasks of                 adulthood generally require more self-regulation, thereby making                deficits in this area more apparent. 
Problems with social skills              and adaptive functions can be very stressful to relationships.                  Adults with ADHD may thus have a greater likelihood of family                   violence, divorce, and multiple marriages. RECOGNIZING ADHD IN                ADULTSThere are two main groups of adults with ADHD: (1) those              who were diagnosed as children and still have symptoms, and (2)                 those who were never diagnosed. The second group may be more likely             to include females. When looking at childhood symptoms, it is                   important to consider that a highly organized home life can mitigate            the expression of ADHD symptoms. Pronounced difficulties may only               emerge during higher education, or even later in the work world,                when environmental demands become more complex. Often there is also             a strong family history of ADHD, learning disabilities, or                      both. 
There is no definitive diagnostic test for ADHD, although               standardized ADHD scales are extremely helpful in understanding                 current (and past) symptoms. Examining for comorbid psychiatric                 conditions and ruling out alternative psychiatric problems that can             resemble ADHD (such as depression or anxiety disorders) is                      essential. The goal of assessment is to understand the individual's             unique pattern of strengths and weaknesses in order to design                   appropriate interventions (whether medical, psychosocial, or                    remedial). Fear of stigma, shame, and denial can interfere with                 seeking help. TREATMENTAs is the case for children, the best              treatment involves both drug and psychosocial interventions. Among              drugs, stimulant medications, such as Ritalin, are usually tried                first. Individuals who do not respond to stimulants, or who have                comorbid substance abuse problems or depression, may be treated with            antidepressants. Generally, medications are better at addressing                inattention and hyperactivity than impulsivity. Comorbid illness, if            present, affects the choice of drugs. 
Psychosocial treatment is               also key. These interventions typically involve (1) psychotherapy               addressing how the ADHD affects the person's life (relationships and            functioning), and (2) education about the disorder. Technologies                helpful for ADHD include structured external supports like day                  planners, computers, and coaching, as well as some specialized forms            of cognitive remediation (see Wasserstein, Wolf  & Lefever, 2001,               Part V; Nadeau, 1997). ADHD IN ADULT EDUCATION AND                            EMPLOYMENTAdults with ADHD often face their biggest challenges              in higher education and later in the work world. Executive and                  planning abilities are extremely challenged in the young person with            ADHD who is making the transition from the structured environments              of high school and home to an unstructured life at college.                     Similarly, working adults need to create multiple layers of                     structure at work, and they must manage to integrate work demands               with competing personal responsibilities. In other words, adults                need to plan and execute their own internal structure, which is                 especially difficult for those with ADHD. Poor time management,                 chronic lateness, and difficulties completing paperwork and meeting             deadlines are exceedingly common work-related problems of adults                with ADHD. 
Some students and/or employees with ADHD may be                    eligible for supports and/or accommodations. Students and employees             who are disabled by ADHD may be covered under Section 504 of the                Rehabilitation Act and the Americans with Disabilities Act in school            and work settings. These laws prohibit discrimination on the basis              of disability and guarantee equal access to programs and facilities.            All adults with ADHD and clinicians evaluating them should become               familiar with these statutes in order to evaluate their need, and               eligibility, for services (Wolf, 2001). REFERENCESAmerican                Psychiatric Association. (1994). Diagnostic and statistical manual              of mental disorders (4th ed.) Washington, DC: American Psychiatric              Association. 
Barkley, R.A. (1997). ADHD and the nature of                     self-control. New York: Guilford. 
Faraone, S.V., Biederman, J., &             Friedman, D. (2000). Validity of DSM-IV subtypes of                             attention-deficit/hyperactivity disorder: A family study                        perspective. Journal of the American Academy of Child and Adolescent            Psychiatry, 39, 300-307. 
Faraone, S.V., Biederman, J., Lehman,                B.K., Keenan, K., Norman, D., Seidman, L.J., Kolodny, R., Kraus, I.,            Perrin, J., & Chen, W.J. (1993). Evidence for independent familial              transmission of attention deficit hyperactivity disorder and                    learning disabilities: Result from a family genetic study. American             Journal of Psychiatry, 150, 891-895. 
Hechtman, L, Weiss, G., &                Perlman, T. (1984). Hyperactives as young adults: Past and current              substance abuse and antisocial behavior. American Journal of                    Orthopsychiatry, 54, 415-425. 
Marks, D.J., Newcorn, J.H., &                   Halpern, J.M. (2001). Comorbidity in adults with attention                      deficit/hyperactivity disorder. Annals of the New York Academy of               Sciences, 931, 216-238. 
Nadeau, K. (1997). Adventures in Fast                 Forward. New York: Brunner/Mazel. 
Ratey, J., Greenberg, S.,                   Bemporad., J.R., & Lindem, K. (1992). Unrecognized attention-deficit            hyperactivity disorder in adults presenting for outpatient                      psychotherapy. Journal of Child and Adolescent Psychopharmacology,              4, 267-275. 
Silver, L. (2000). Attention deficit/hyperactivity in             adult lives. Child & Adolescent Psychiatric Clinics of North                    America, 9, 511-523. 
Wasserstein, J., Wolf, L.E., & LeFever,                  F. (Eds.) (2001). Attention deficit disorder:  Brain mechanisms and             life outcomes. New York: The New York Academy of Sciences. 
Wender,            P.H., Wolf, L.E., & Wasserstein, J. (2001). Adults with ADHD. An                overview. Annals of the New York Academy of  Sciences, 931,                     1-16. 
Wolf, L.E. (2001). College students with ADHD and other                 hidden disabilities. Annals of the New York Academy of Sciences,                931, 385-395. 
Wolf, L.E. & Wasserstein, J. (2001). Adult ADHD:                concluding thoughts. Annals of the New York Academy of Sciences,                931, 396-408. 
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ERIC Digests are in the public domain and               may be freely reproduced and disseminated, but please acknowledge               your source. This digest was prepared with funding from the Office              of Educational Research and Improvement (OERI), US Department of                Education, under Contract No. ED-99-C0-0026. The opinions expressed             in this publication do not necessarily reflect the positions of OERI            or the Department of Education.                                              **Title:** Adults with Attention Deficit Hyperactivity Disorder (ADHD). ERIC               Digest.                                                                      **Note:** Digest number E622.                                                          **Document Type:** Information Analyses---ERIC Information Analysis Products (IAPs) (071); Information Analyses---ERIC Digests (Selected) in Full Text (073); **Available From:** ERIC Clearinghouse on Disabilities and Gifted Education, Council for            Exceptional Children, 1110 North Glebe Rd., Arlington, VA                       22201-5709. Tel: 800-328-0272 (Toll Free); Fax: 703-620-2521;                   e-mail: [email protected]. For full text: http://www.ericec.org.           **Descriptors:** Adults,  Attention Deficit Disorders,  Behavior Problems,  Clinical             Diagnosis, Coping, Hyperactivity,  Individual Characteristics,                  Intervention,  Symptoms (Individual Disorders),  Work Environment            **Identifiers:** ERIC Digests                                                                 
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