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Adult ADHD: Is it Real?
They have been flooding into your office: grown-ups who believe that they have ADHD. Some are referred to you by their exasperated spouses (“my wife gave me an ultimatum…”), some recognize themselves in their hyperactive children (“I tried his ritalin one day, and I’ve never been more focused in my life”), and some are swept into treatment by the media tidal wave (“I saw this doctor, Ed Hallowell, interviewed on TV…”). Whatever the reason, there they are, often expecting an official “test” for ADHD and a subscription for Ritalin.
Most of us are, in fact, convinced that ADHD occurs in adults, primarily because we’ve seen dramatic treatment responses to stimulants with our own eyes. But there is an undercurrent of skepticism as well. The “diagnosis-dujour” nature of adult ADHD is irritating; also, the fact that so many of these patients come into our offices self-diagnosed and asking for “speed” makes us think twice. No psychiatrist wants to be a pusher.
In order to prove that a given diagnosis like ADHD is valid, you must be able to: (1) reliably describe ADHD and to distinguish it from other syndromes with ADHD-like traits (“descriptive validity”); (2) show that ADHD has a predictable course, outcome, and treatment response (“predictive validity”); and (3), it has some recognized cause, be it neurobiological or environmental (“etiologic validity”).
Descriptive Validity. The first issue: Can adult ADHD be described reliably? Yes, but it tends to be a different creature from ADHD in kids. Inattention is much more prominent than hyperactivity or impulsivity. And whereas questions about “paying attention” are useful in kids, adults respond more to questions about organizing themselves and negotiating the complexities of their lives. They talk about feeling “overwhelmed” and “scattered”, they procrastinate, they mismanage money, they are chronically late (chances are they arrived late to your appointment!), they make careless errors at work or at home, etc…. Yes, we have all experienced such traits on bad days, but ADHD patients experience them almost every day.
What about “hyperactivity/impulsivity”? No, adults aren’t running around the classroom or jumping out of their seats. But they do lose their temper, have a hard time relaxing, and feel like their thoughts (rather than their legs) are racing. And how do you differentiate these symptoms from hypomania or anxiety disorders? Very carefully: there are no tricks here, just good old-fashioned diagnostic questioning. This takes time, which is why most authorities scoff at the idea that you can diagnose adult ADHD in one initial evaluation session.
Predictive Validity. The diagnosis of ADHD should allow one to predict a certain natural history and treatment response. To some extent, this is built into the DSM-IV criteria: In order to make the diagnosis in adults, you have to document that the patient had the disorder before age 7, and that it has persisted since then. Unless your patient has a photographic memory, there’s no way to accomplish this without interviewing parents and spouses, so this should be a part of your assessments.
Roughly 50% of kids with ADHD will grow out of it (1), but that still leaves a lot of adults with the condition. Studies of the course of ADHD in adults show that it leads to a number of predictable problems (2): such patients are rated by employers as having poorer job performance, are three times more likely to be fired from a job than controls (due primarily to inattention), and seven times more likely to have car accidents (due to both inattention and impulsivity).
Etiologic Validity. A “real” disorder should be demonstrated to have some sort of a cause, although this criterion for diagnostic validity is the weakest of all, since many “real” disorders in medicine and psychiatry have no established cause (eg., essential hypertension, migraine headaches, bipolar disorder). Surprisingly, ADHD is somewhat ahead of the game here, in that there is solid evidence that it is largely a genetic disorder. Twin studies have shown that 75% of ADHD transmission is genetic (3). Compare this with the heritability of schizophrenia (75%) and depression (40%), and it is clear that ADHD is among the most genetically determined of any condition in medicine.
So, are you convinced that ADHD in adults is real? Or do you suspect that we are drugging overly spirited people who enjoy the amphetamine high? TCR believes it is real enough to treat, as long as you take the time necessary to ascertain its origin and persistence since the early years. Which is no small feat.
TCR VERDICT:
ADHD: Not just for children anymore
1. Spencer T, Biederman J, Wilens TE, et al. Adults with attentiondeficit/ hyperactivity disorder: a controversial diagnosis. J Clin Psych. 1998; 59[Suppl 7]:59-68.
2. Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder.. J Clin Psych. 2002; 63[Suppl 12]:10-15.
3. Spencer T, Biederman J, Wilens TE, et al. Overview and neurobiology of attention-deficit/hyperactivity disorder. J Clin Psych. 2002; 63[Suppl 12]:3-9.
General PsychiatryMost of us are, in fact, convinced that ADHD occurs in adults, primarily because we’ve seen dramatic treatment responses to stimulants with our own eyes. But there is an undercurrent of skepticism as well. The “diagnosis-dujour” nature of adult ADHD is irritating; also, the fact that so many of these patients come into our offices self-diagnosed and asking for “speed” makes us think twice. No psychiatrist wants to be a pusher.
In order to prove that a given diagnosis like ADHD is valid, you must be able to: (1) reliably describe ADHD and to distinguish it from other syndromes with ADHD-like traits (“descriptive validity”); (2) show that ADHD has a predictable course, outcome, and treatment response (“predictive validity”); and (3), it has some recognized cause, be it neurobiological or environmental (“etiologic validity”).
Descriptive Validity. The first issue: Can adult ADHD be described reliably? Yes, but it tends to be a different creature from ADHD in kids. Inattention is much more prominent than hyperactivity or impulsivity. And whereas questions about “paying attention” are useful in kids, adults respond more to questions about organizing themselves and negotiating the complexities of their lives. They talk about feeling “overwhelmed” and “scattered”, they procrastinate, they mismanage money, they are chronically late (chances are they arrived late to your appointment!), they make careless errors at work or at home, etc…. Yes, we have all experienced such traits on bad days, but ADHD patients experience them almost every day.
What about “hyperactivity/impulsivity”? No, adults aren’t running around the classroom or jumping out of their seats. But they do lose their temper, have a hard time relaxing, and feel like their thoughts (rather than their legs) are racing. And how do you differentiate these symptoms from hypomania or anxiety disorders? Very carefully: there are no tricks here, just good old-fashioned diagnostic questioning. This takes time, which is why most authorities scoff at the idea that you can diagnose adult ADHD in one initial evaluation session.
A valid diagnosis should have three qualities:
- Descriptive validity
- Predictive validity
- Etiologic validity
Predictive Validity. The diagnosis of ADHD should allow one to predict a certain natural history and treatment response. To some extent, this is built into the DSM-IV criteria: In order to make the diagnosis in adults, you have to document that the patient had the disorder before age 7, and that it has persisted since then. Unless your patient has a photographic memory, there’s no way to accomplish this without interviewing parents and spouses, so this should be a part of your assessments.
Roughly 50% of kids with ADHD will grow out of it (1), but that still leaves a lot of adults with the condition. Studies of the course of ADHD in adults show that it leads to a number of predictable problems (2): such patients are rated by employers as having poorer job performance, are three times more likely to be fired from a job than controls (due primarily to inattention), and seven times more likely to have car accidents (due to both inattention and impulsivity).
Etiologic Validity. A “real” disorder should be demonstrated to have some sort of a cause, although this criterion for diagnostic validity is the weakest of all, since many “real” disorders in medicine and psychiatry have no established cause (eg., essential hypertension, migraine headaches, bipolar disorder). Surprisingly, ADHD is somewhat ahead of the game here, in that there is solid evidence that it is largely a genetic disorder. Twin studies have shown that 75% of ADHD transmission is genetic (3). Compare this with the heritability of schizophrenia (75%) and depression (40%), and it is clear that ADHD is among the most genetically determined of any condition in medicine.
So, are you convinced that ADHD in adults is real? Or do you suspect that we are drugging overly spirited people who enjoy the amphetamine high? TCR believes it is real enough to treat, as long as you take the time necessary to ascertain its origin and persistence since the early years. Which is no small feat.
TCR VERDICT:
ADHD: Not just for children anymore
1. Spencer T, Biederman J, Wilens TE, et al. Adults with attentiondeficit/ hyperactivity disorder: a controversial diagnosis. J Clin Psych. 1998; 59[Suppl 7]:59-68.
2. Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder.. J Clin Psych. 2002; 63[Suppl 12]:10-15.
3. Spencer T, Biederman J, Wilens TE, et al. Overview and neurobiology of attention-deficit/hyperactivity disorder. J Clin Psych. 2002; 63[Suppl 12]:3-9.
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