Lenard Adler, MD, is director of the Adult ADHD Program at NYU School of Medicine and author of Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder. He is also the president of the American Professional Society of ADHD and Related Disorders (APSARD), an international professional organization that focuses exclusively on ADHD with the goal of improving the quality of care for patients with ADHD from childhood through adulthood. I had the opportunity to talk with Dr. Adler about the different ways symptoms of ADHD can present and cause stress into adulthood and the importance of accurate diagnosis and treatment.
Q: Let’s start with some general information about ADHD.
Dr. Adler: ADHD is a neurobiological disorder. It is the second most common mental health disorder in adults after depressive disorders. ADHD has a very high prevalence rate, occurring in about 6% to 8% of kids and 4.4% of U.S. adults. About 60% of children with the disorder go on to be adults with the disorder, so it tends to run the lifespan. It's also a disorder that we think about 85% of the transmission is familial, so it tends to run in families. In fact, if there is a child in the family with ADHD there is a 30% to 40% chance that one of the two parents will have ADHD. And that is one of the things that commonly drives adults into the doctor’s office -– because they have a child that has been recently diagnosed and they realize they’ve had similar symptoms themselves in childhood and their spouse often nudges them and says, ‘Honey, you still have these things now but they are a little different.’
Q: How are the symptoms of ADHD different in adulthood?
Dr. Adler: Well, the symptoms are similar, but changed somewhat because adults are not just grown up children. The symptoms change in several ways. One is that the inattentive symptoms become a bit more prominent in adulthood and that is probably true somewhat more for women in general. Females tend to carry a little bit higher load of the inattentive symptoms. In part that accounts for why more women present in adulthood as compared to girls, verses men to boys. Because if you are behaviorally disruptive in the classroom you’re more likely to be picked out and brought into the healthcare system as compared if you are inattentive and missing things and you may just be seen as underperforming. That is changing as we understand the inattentive symptoms better, but in general the gender distribution is a little different childhood to adulthood. It’s about 2 to 1 boys to girls in childhood, whereas it's a fairly even gender distribution 1 to 1 in adulthood.
So the symptoms change in several ways –- one is that the inattentive symptoms become more prominent. Secondly, the frank hyperactivity becomes much more felt rather than manifested –- the sense of needing to get in and out of your chair is felt. The adult doesn’t get out of the chair because they know it is very stigmatizing at a meeting if you are getting up and down. They’ll also guard against some of the impulsivity because they know if you interrupt your boss at a meeting even if that happens occasionally, it’s probably not very good for your long term survival on the job. So what happens is they may guard against interrupting and ultimately get distracted from what is being said in the meeting. I can give you an example of a mid-level executive who I take care of who described (before treatment) losing track of what was going on in meetings. It was happening anyway, but especially when he felt he had something to say and was going to interrupt. He had to guard against interrupting so much that it distracted him and he further got lost in terms of what was being said.
Q: Why do symptoms present somewhat differently for adults?
Dr. Adler: The organizational load for adults is very different. Think about what the cognitive load is like for a young elementary school child –- they have a very structured day in terms of going to school, having a set amount of homework, staying in one classroom. Then think about what it’s like as they go through middle school where you start to use a planner, change classes and have to write down homework assignments to high school where you have much more homework and you are managing larger projects and AP classes. Then off to college where the parental support that’s often there to help organize is removed and into adulthood where you have the responsibilities of family, children and work and having to manage many, many more things with less structure. What happens is the symptoms tend to change and may be brought forward at these critical changes in one’s life, these watershed areas, when you move from elementary to middle and middle to high school and then to college and then into adulthood. So the individual with ADHD, as they have higher cognitive loads, may begin to have more organizational problems.
Q: Does the criteria to make the diagnosis change from children to adults?
Dr. Adler: No, the criteria to make the diagnosis are actually the same. There are four critical elements in making the diagnosis for both kids and adults. We talked about how the symptoms change in part in presenting into adulthood, but you have to have symptoms. You have to have 6 of 9 inattentive and/or 6 of 9 hyperactive/impulsive symptoms. That’s the first criteria. If you just had symptoms -– because we all have symptoms from time to time probably not the full spectrum of symptoms, but we all have some difficulty paying attention or we may feel restless if we haven’t slept well or if we have a major stressor in our life -- if we had no impairment, you wouldn’t make a diagnosis because we don’t just treat symptoms, we treat impairment. So, the second criteria is impairment. And you have to have impairment which can be relative in terms of underperformance in school or work, home, or social settings. The third criteria is the roots of the disorder have to lie in childhood. It’s a lifetime spectrum disorder. You don’t have to be fully symptomatic in childhood, but you have to have some significant symptoms. The last criteria, you have to be sure the symptoms are from ADHD and not something else.
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