ADHD in Adults: It Rarely Travels Alone

Adults have lived

longer than children, and thus have had more time to develop other psychiatric

disorders. In children with AD/HD, the existence of a comorbid condition is

correlated with greater likelihood that the symptoms will persist into

adulthood. As the child moves from adolescence to adulthood, the predominant

symptoms of AD/HD tend to shift from external, visible ones to the internal

symptoms.  There seems to be a

decrease in observable symptoms of AD/HD with age. Although a given adult may

not meet DSM-IV criteria for full AD/HD any longer, he or she may still

experience impairment in certain aspects of life. The individual’s perception

of his or her degree of impairment can vary. Depending on occupation or domestic

situation, the adult may need to deal with higher-level issues that involve

executive function.

 

There has been

increasing awareness that many adults and children with AD/HD may also meet

criteria for one or more other psychiatric diagnoses. (Comorbidity means having

two or more diagnosable conditions at the same time) There is some evidence that

the incidence of comorbidity is somewhat higher in adults than in children.

However, many of the studies looking at the issue of comorbidity are difficult

to compare. Studies used different criteria for AD/HD and bipolar disorder, and

sometimes got their subjects from different populations. For example, one might

expect to see more complex types of AD/HD in specialized hospital clinics than

one would see in a door-to-door survey or in a primary care physician’s

office. Despite the differing criteria across studies, and the lack of large

general population studies of adult AD/HD, there still convincing data that

several other psychiatric diagnoses are common among adults with AD/HD.

 

Substance

Abuse: (Abuse of or

addiction to alcohol or drugs) Adult attention deficit disorder seems to be

related to earlier onset of substance abuse, a longer period of active abuse,

and a lower rate of recovery. (Wilens, Biederman and Mick, Am J Addict 1998)

The risk of substance abuse (in an adolescent prospective study) may be higher

if the individual has conduct disorder in addition to the AD/HD. Conduct

Disorder is a persistent pattern of violating rules, laws and the rights of

others.  (Milberger, Biederman,

Faraone, Wilens, Chu, Am J Addict 1997) A study by Biederman et al (Am J

Psychiatry 1995) suggested found that 52% of adults (versus 27% of controls)

with AD/HD met criteria for substance abuse. Other studies have found slightly

lower but still significantly elevated rates of abuse and addiction in AD/HD

adults. AD/HD by itself increased the chance of substance abuse, but if the

AD/HD were combined with another disorder such as Antisocial Personality

Disorder, Anxiety, Depression or Bipolar Disorder, the rates increased further.

It is possible that adults have the higher rate of substance abuse because their

AD/HD might not have been treated when they were children. A recent study in Pediatrics

showed that AD/HD children and adolescents treated with stimulant medication

were less likely to develop later problems with drugs or alcohol.

 

Antisocial

Personality Disorder: This is a personality style characterized by a tendency to violate the rights

of others, to flout societal rules, and to lack remorse for misdeeds. About

18-25% of AD/HD 25-year-olds studied were found to have this disorder. Only 2%

of the general population has Antisocial Personality Disorder (ASPD.) Children

who have AD/HD accompanied with aggressive destructive tendencies seem to be the

ones most likely to develop adult ASPD. AD/HD children lacking those tendencies

do not seem to have a greatly increased risk of developing ASPD. The individuals

with AD/HD and ASPD may end up in the penal system. An impulsive individual

might be more likely to get caught than one who plans his criminal activity more

carefully.

 

Learning

Disabilities are present in

Adults as well as children. Often they are less evident when an individual

leaves school and finds a career that matches his or her strengths and

weaknesses. However, some individuals continue to experience the effects of

learning disabilities in college and at work. When an individual has a learning

disability, he or she may have a vague sense of shame because it seems that he

or she is not able to perform certain tasks ash well as others.

 

Mood

disorders: Mood Disorders include Major Depression, Dysthymia (Chronic low-level

depression) and Bipolar Disorder (Manic Depressive Disorder.) These are present

in many individuals with AD/HD. Usually, depression starts later than the first

onset of the AD/HD. There has been some debate about the incidence of Bipolar

Disorder in individuals with AD/HD. Some might say that rapid mood shifts and

frequent irritability are characteristics of AD/HD. Others diagnose a rapid

cycling mood disorder. Recurrent major depression is more common in adults with

ADHD than in non-ADHD adults. However, one must also be aware that depression

can be a side effect of stimulants and several other medications. Because

stimulants have been known to exacerbate depression and mania, one should

usually treat the mood disorder before treating the AD/HD.

 

Diagnosing AD/HD

in adults can be quite complicated. In order to meet criteria for the diagnosis,

one should have evidence of symptoms dating back to age seven. It may be

difficult for some individuals to give an accurate, unbiased history of these

early events. Often it is useful to get outside corroboration on childhood

behavior. The high incidence of comorbid disorders also complicates the picture.

Inattention itself is a fairly non-specific finding. Even when the diagnosis of

AD/HD is clear, one must be alert for other disorders. One study found that only

12% of adults referred to their clinic had pure AD/HD without any other major

psychiatric diagnoses. 


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