Attention Deficit Hyperactivity Disorder Through the Life Cycle: Clinical Paper

A young school boy heading into a dark tunnel

Human growth and development, with the requisite learning of skills and master of cognitive and psychosocial tasks, unfolds in endlessly fascinating, complex patterns. If the child is to develop a healthy personality, then he or she must learn how to test reality, regulate impulses, stabilize moods, integrate feelings and actions, focus attention, and plan. (Wright, 1999)

Diagnostic Features

Attention-Deficit/Hyperactivity Disorder (ADHD) often referred to erroneously as ADD, is presented in the Diagnostic and Statistical Manual of mental disorders-IV (DSM-IV) (American Psychological Association [APA], 1994, pp. 78-85) as a disorder usually first diagnosed in infancy, childhood, or adolescence. The diagnostic criteria are enumerated as follows:

  1. Either (1) or (2):
    1. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      Inattention
      1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      2. often has difficulty sustaining attention in tasks or play activities
      3. often does not seem to listen when spoken to directly
      4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
      5. often has difficulty organizing tasks and activities
      6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. is often easily distracted by extraneous stimuli
      9. is often forgetful in daily activities
    2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      Hyperactivity
      1. often fidgets with hands or feet or squirms in seat
      2. often leaves seat in classroom or in other situations in which remaining seated is expected
      3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
      4. often has difficulty playing or engaging in leisure activities quietly
      5. is often “on the go” or often acts as if “driven by a motor”
      6. often talks excessively

      Impulsivity

      1. often blurts out answers before questions have been completed
      2. often has difficulty awaiting turn
      3. often interrupts or intrudes on others (e.g. butts into conversations or games)
  2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
  5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

The DSM-IV (1994, p. 85) also defines four diagnostic categories of ADHD, based upon the impairments present. If Criteria A1 and A2 are met (inattention and hyperactivity-impulsivity), ADHD, Combined Type is appropriate. If Criteria A1 is met (inattention), ADHD, Predominately Inattentive Type is appropriate. And if Criteria A2 is met (hyperactivity-impulsivity), ADHD, Predominately Hyperactive-Impulsive Type is appropriate. The fourth category is defined as ADHD, Not Otherwise Specified (NOS), and is utilized for those who have “disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the criteria for Attention Deficit/Hyperactivity Disorder.” The diagnosis of “In Partial Remission” can also be appended if a previous diagnosis has been made, but the individual no longer meets the full criteria. Additionally, persons who have any of the subtype diagnoses, may go on to have that subtype changed (e.g. from Predominately Inattentive type to Combined type).

Important to the view of the development of person with ADHD, is the description given by Hutchins (1994), in which he describes the dichotomous symptoms of persons with and without hyperactivity-impulsivity:

Main SymptomsImpulsivityInattention
BehaviorOveractiveSluggish
ModelImpulse InhibitionOrganization
OccurrenceBoys more than GirlsBoys more or equal to Girls
Languagelanguage disorderSubtle Deficits
PeersPeer RejectionSocial Withdrawal
ComorbidityAggression, conduct disorderAnxiety, Depression
PresentationBehavior, early referralLearning, late referral
Family TypeDiscord/angerstress/Frustration
OutcomePersistenceAdjustment

And by Zgonc’s Study (as cited in Price, 1999)

TraitADHD / ImpulsivityADHD / Inattention
Decision MakingImpulsiveSluggish
BoundariesIntrusive, RebelliousHonors Boundaries, Polite, Obedient
AssertionBossy, IrritatingUnderassertive, Docile,Overly Polite
Attention SeekingShow-off, Egotistical, Best at WorstModest, Shy, Socially Withdrawn
PopularityAttracts but doesn’t BondBonds but doesn’t Attract

Cultural Considerations

In his comprehensive review of literature (approaching 100 references), Reid (1995) presents the data currently available regarding current standardized testing. It appears that in the United States, African-American Students are over-represented, and Hispanic students under-represented with respect to the ADHD diagnosis. Reid also suggests there is a higher rate of diagnosis among those with a low socioeconomic status, among whom minorities are over-represented. However, there is no firm evidence on which to base a conclusion, as the studies which have been done show conflicting results. In fact, no variations were noted by ethnic or socioeconomic status in a later study (Bussing, Schoenberg, Rogers, Zima, & Angus, 1998).

However, Reid (1995) was able to show that inter-rater reliability was a factor among cultures when children were tested within their own country, such as China (with a low mean score) versus New Zealand and South London (with higher mean scores). With this data in mind, he cautions against the use of simple standardized testing without clinical judgment in the schools until more studies are done, as fully one-third of the school population is expected to be minority by the year 2000.

Prevalence

It is generally accepted that between approximately 3% and 5% of the child population in the United States is affected by clinically diagnosable ADHD (American Psychiatric Association, 1994; Bussing, Schoenberg, Rogers, Zima, & Angus, 1998; Reid, 1995), with the peak at around ages 8-9 years old (Szatmari, Offord, & Boyle, 1989) and roughly 50% of the cases diagnosed before age 4 (American Psychiatric Association, 1994). This translates into between 1.2 and 2 million children in 1995, and is the most commonly diagnosed childhood disorder (Epstein, Shaywitz, Shaywitz, & Woolston, 1991; Nolan, Volpe, Gadow, & Sprafkin, 1999), accounting for nearly one-half of all referrals to child mental health clinics (Lerner & Lerner, 1991).

The younger the child, the greater chance of hyperactivity-impulsivity type of ADHD, with teens having predominately inattentive-type. Males are generally perceived to be at a higher risk for ADHD, although the ratio of male to female (3:1) did not vary by diagnosis type. (Nolan, Volpe, Gadow, & Sprafkin, 1999). A ratio of 4:1 to 9:1 is reported by the American Psychiatric Association (1994). It is reported otherwise that females who are afflicted appear to be at greater risk for going undetected (Bussing, Schoenberg, Rogers, Zima, & Angus, 1998) due to the belief that girls generally have a higher incidence of the inattentive type of ADHD, which does not show overt signs (behavior), and may be less obvious to parents and educators. It is more likely that females are less likely to be represented due to the view that ADHD is viewed as a “male” problem, as it was shown that the females who were referred were more severely impaired (Gaub, & Carlson, 1996; Nolan, Volpe, & Gadow, 1999).

Reporting rates were shown to vary along ethnic lines as noted by Bussing, Schoenberg, Rogers, Zima and Angus (1998), with African-American parents less likely to apply a medical label to their child than those of Caucasian descent, instead categorizing them as a “behavior problem” or “bad child”. Hispanic children appear to diagnosed with ADHD at a lesser rate (Reid, & Maag, 1994), although the cause of this is not known.

It is believed that approximately 40% of those with a diagnosis of ADHD in childhood will still retain the qualifications for that label in adulthood (Klein, & Mannuzza, 1991), although this number ranges to 70% as noted later.

Comorbidity

It has been found that children with ADHD have a high level of comorbidity with other psychiatric illnesses. In a general study, (ADHD children at higher risk, 1996), disorders in behavioral, mood, family, anxiety, cognitive social and school functioning increased markedly from baseline in a 4 year longitudinal analysis. These primarily occur with the ADHD-Combined Type (ADHD-C), and with older children.

There is a significant correlation between ADHD-C and behavior such as conduct disorder and oppositional defiant disorder, much more so than those in the ADHD- Inattentive type (ADHD-I) (Nolan, Volpe, & Gadow, 1999). Brown (1997) notes that 45% of those with ADHD will exhibit symptoms of oppositional defiant disorder, and 25% those of conduct disorder. This compares to 16% and 10% respectively in the general population.

All subtypes of ADHD showed correlation with generalized anxiety disorder, though ADHD-C had the highest severity. The younger children also showed higher levels of Social phobia than elementary and adolescent children. This contrasts to dysthymia and and major depressive disorder, (Brown (1997) estimates this at up to 70%) which showed an increase in both comorbity and severity in the older children. (Nolan, Volpe, & Gadow, 1999). As a result of this, it was found that 10% of all ADHD afflicted persons had attempted suicide in the last 3 years (Seay, 1998).

Substance abuse has also been found to be common, with 75% of boys with ADHD that were not on medication, and 25% of boys with ADHD on medication having at least one substance abuse disorder, compared to 18% of the boys without. They note that adults with ADHD developed substance abuse disorders at nearly twice the rate of their non-ADHD peers (Study: Use of Ritalin for ADHD, 1999).

Learning Disabilities are also notable among those with ADHD (Halpern, Gittleman, Klein, & Rudel, 1984; Shaywitz, & Shaywitz, 1988, 1993).

Learning and Standardized Test Performance

Learning Disabilites can be shown through the results of Weschler Intelligence Scales for Children-III (WISC-III). Children with ADHD show at least one standard deviation between their two strongest and two weakest subtest scores 66% of the time, as compared to 22% of the time for the general population, and 25% versus 2% when 2 standard deviations are looked at (Reid, & Maag, 1994). According to Pineda, Ardila and Rosselli (1999), ADHD children show lower scores in most WISC-R subtests, with the exception of similarities, comprehension and picture completion, in which they scored higher. Overall, however, the full scale IQ was a mean of only 3 points lower in children with ADHD. They also showed that the children with ADHD under-perform on memory, constructional, and fluency tests. In all, normal children outperformed those with ADHD on 31 separate neuropsychological variables.

Adults with ADHD also fare poorly on intelligence tests such as the Weschler Adult Intelligence Scales-III (WAIS-III), with 87% falling outside of 1 standard deviation, versus 20% of the general population when the two highest and two lowest subtests are again compared. Those with ADHD also show marked differences when comparing verbal IQ to verbal memory, 64% with one standard deviation and 30% with two standard deviations compared to 19% and 3.6% of the general population (Brown, 1997).

In their study, Reid and Maag (1994) also note that nearly 50% of ADHD children studied had reading difficulties, nearly 40% had mathematical difficulties, and 30% presented with both mathematical and reading difficulties. Speech and expressive difficulties were found, in this same study, to be present in children with ADHD at a higher rate than normal children.

Some of the other issues that can effect academic achievement include: Starting skills, completing skills, making transitions, following through on directions, producing work consistently, organizing multi-step activities, low metacognition and motivation (Munoz, Smeal, David, & Wittig, 1999).

As a result of these lowered academic and standardized test scores, a high number of ADHD children are placed in special education settings. However, it has not been defined as to whether these children are in need of special education due to their ADHD or a comorbid condition.

Finally, Weiss (1996) classifies those with ADHD as trainable, not educable, with the difference being that those that are educable can learn by being told, and those that are trainable learn by doing with repetition.

Social Skills

When “Social skills were defined as cognitive and overt behaviors a person uses in interpersonal interactions and can range from simple nonverbal behaviors such as eye contact and head nods to the complex verbal behavior of offering a compromise that will meet everyone’s needs” (Schumaker, & Deshler, 1995), children with learning disabilities, including ADHD, were found to be behind their peers.

This does not imply that they engage in less social interactions overall, but instead focuses on the quality of those interactions. It was found, in fact, that they initiate 5% more interactions. However, they engage in organized, extracurricular and sport activities that require complex social activities less often. They also tend to jump to a solution in social situations, rather than using problem solving behaviors, and use fewer nonverbal and verbal social skills than same-age peers.

The hierarchy proposed by Guevremont and Dumas (1994) shows four domains in which children of ADHD have social difficulty:

High-rate intrusive behavior

  • Excessive talking, Interruptions, Noisy interactions, Dominating activities Monopolizing discussions, Obnoxious behavior

Deficient communication skills

  • Limited turn-taking during conversations, Less responsive to others’ initiations, Likely to ignore peers’ questions, Problems shifting roles between giving and receiving information, Inappropriate or disagreeable verbal exchange, Difficulty remaining on topic, Poor eye contact and motor regulation

Biased and deficient social cognitive skills

  • Decreased self-awareness, Less knowledgeable about appropriate behavior, Deficient social problem-solving skills, Biased attributions of others’ intentions, Inattentive to social cues

Poor emotional regulation

  • Aggressive behavior, Temper outbursts, Overreaction to minor events, Excitability, Poor transitioning from one activity to another

The generalization of social skills from a taught singular situation to larger settings is also decreased. As a result of these lack of skills, the tendency to is to act in an antisocial as opposed to prosocial manner. More specifically, Hubbard and Newcomb (1999) showed that when ADHD children were in play groups with normal children, the rates of solitary play increased, and the rate of verbalization decreased. However, the team of Schumaker and Deshler (1995) did show that these skills are teachable, with a high rate of success when done properly.

Diagnosis vs. Label

Buonomano (1999) wonders whether the term ADHD is a medical diagnosis or a label applied under social pressure to remove responsibility from society at large. He notes that the diagnosis is rarely used in the rest of the world, yet 1.3 million children in the United States have been labeled as such (It should be noted, that in many countries, the term “minimal brain dysfunction” or “hyperkinetic disorder” may be used, however, encompassing the same general criteria, which would skew this comparison).

Robison, Sclar, Skaer and Galin (1999) disagree with this, noting that dependent upon the population, prevalence rates of 1.7% – 16% have been noted in other countries. This places the United States at the low end of prevalence. Vonnegut (as cited in Buonomano, 1999) tells us that

“The diagnosis of ADHD tells us more about ourselves than we want to know…[Parents] truly believe their child is suffering from an inability to learn or fit in, and without treatment will suffer peer rejection or academic failure…That these children are diagnosed because they are in conflict with adults…ADHD offers an explanation that absolves parents and teachers of having any responsibility for the conflict.”

Smelter and Rasch (1996) note “the insulation that such diagnosis affords the patient from paying the price for poor behavior at school.”

In the latest reports in this controversy, the National Institutes of mental health (NIMH) has issued a report indicating that ADHD is a medical disorder, although it can be affected by the environment (Eskenazi, 1999). Regardless of the reason however, the results are real, as shown in the following sections. Whether the sufferer needs assistance in school or social situations, the diagnosis of ADHD affords us the ability to identify those persons with whom we need to focus extra energy.

Physical Development

Jaquith (1996) notes that there are three major aspects of physical development that are affected in the child with ADHD. These are the processing of input through the five sensations, proprioception (spatial knowledge of ones body) and establishment of dominance. A child who has not developed tactility (touch) fully, may be more interactive with their environment to gain needed physical stimuli. Decreased auditory and visual processing may result in difficulty with short-term memory, difficulty following through on instructions, ease of distraction, and rapidly shifting attention. Proprioception that has not fully developed can lead to a child who may bump into objects and have decreased coordination. Additionally, they may engage in activities which are physically dangerous, as the development of exactly what the body is capable of is not yet clear. Finally, Jaquith notes that the establishment of dominance is important in the acts of reception, processing, storage and utilization of information. If the child has not yet established a dominant side, then the child may not utilize their brain in the most effective manner in the processing of outside stimuli.

Psychological Development

The early psychological development of the child with ADHD (through elementary school) is affected to a great deal by their disorder as noted by Wright (1999). As an infant, the task of learning to calm and regulate themselves is compounded by their overflow and sensitivity to environmental stimuli. They may be unable to organize sensations properly, reacting adversely to stimuli that would be calming to other infants.

As a toddler, in order to gain separation, he must learn to tolerate frustration and overcome stress of disappointments. Instead, parents describe these children as “all-or-nothing”, being emotionally over-reactive, and having a tendency to fall apart easily.

As the pre-school age approaches, the child faces the tasks of individuation, identity, and self-concept. Instead of forming a single image of themselves, these children may be fearful, confused, manipulative, and avoidant as a result of the mixed message they receive to their behavior, which is, without their control, chaotic. These early problems are strong contributors to later emergence of anxiety disorders in children with ADHD.

Finally, in elementary school, the child should be consolidating the results of previous stages, and learning social interactions. However, their social deficits, particularly in processing social information and cues, inhibits this. Additionally, they are very sensitive to the feedback from others, and the shunning by peers, criticism from teachers and parents, lead the child to begin developing a negative self-image, low self-esteem and feelings of depression and anger.

Environmental Interaction

This section could be more appropriately termed, to use a computer phrase, GIGO (Garbage In = Garbage Out). This is essentially what Seay (1999) describes in his overview of the interaction of the person with ADHD and the world at large. He discusses that children with ADHD are considered fidgety. They rock their chairs, bounce their leg or drum their fingers in an attempt to quell the hyperactivity they crave. He says that the child with ADHD also doesn’t “realize that others around him literally do not think as he does; he only know that he often feels out of place or different. At the same time, he often is unaware or unable to verbalize, his unique perceptions of the world around him.”

Seay (1999) notes many of the cognitive symptoms that are prevalent among children (as well as adolescents and adults), that contribute to the more widespread problems. These include “blinking”, “scanning”, “multi-tracking”, “flooding”, “radial thinking” and “hyper-focus”.

“Blinking” is the quick loss of focus and then refocus on a discussion or task. If this occurs during a conversation, or in school, the child will have missed content. They are faced with the task of asking for the person to repeat themselves, or not understanding the person or lesson.

“Scanning” is when the mind does not filter environmental stimuli. The child may be overwhelmed with input from a teacher, the fly in the room, another child talking, the sound of the chalk. They may be unable to pick out a single item to give their attention to. This can lead to being perceived as not paying attention, to not being interested in a person or subject.

“Multi-tracking” is similar to “scanning”, in that multiple stimuli are affecting the child. The difference lies in that the child is able to follow one of the stimuli instead of being overwhelmed, but jumps back and forth between them. This results in disjointed conversation with others, and loss of continuity in work.

“Flooding”, can be described as “The pourous system of the ADDer instantly absorbed all that is in his environment, in such an intense and pervasive way that it floods the person, causing them to overreact when compared to most people” (Seay, 1999). This results in the person pushing away from a situation that is painful or too stimulating, whether it is perceived as such by others.

“Radial thinking” is where the person with ADHD connects topics laterally rather than in a sequential fashion. They may begin new topics unannounced based on a thought that was generated by a single word in a conversation. When attempting to communicate ideas to others, this makes understanding difficult, and raises frustrations among both the person with ADHD and their listener.

Finally, “hyper-focus” is the reverse of what ADHD is normally perceived as. When a person with ADHD is able to focus on a topic, they may become so immersed in it that they have no time for any other pursuits, sometimes not even sleep. As a result, family and friends, other projects, are all pushed aside in the singular pursuit of one project.

Childhood

In Childhood, the effects of ADHD are far-reaching, touching every aspect of the child’s life. Social skills are decreased, learning ability is lessened, and self-esteem is lowered.

Gresham (1988) notes that ability to successfully interact socially is one of the most important aspects of a child’s development. Berndt (in Guevremont, & Dumas, 1994) makes this more explicit, stating that positive peer relationships play a “prominent role in the development of (a) self-control of aggressive impulses, (b) feelings of acceptance and belonging, (c) morality, (d) stress resistance, (e) self-esteem, and (f) cooperative social-exchange skills.” However, socially, children with ADHD are affected due to their decreased appropriate interactions, and anti-social behavior.

Guevremont and Dumas (1994) estimate that 50% of children with ADHD have significant difficulties in peer and social relationships, and it has been noted in many articles that the child with ADHD may be viewed negatively by their peers (Schumaker, & Deshler, 1995; Wheeler & Carlson, 1994). The causes of this are numerous, including aggressiveness, being “socially salient and intense, and their high level of vigor is typically inappropriate in social situations” (Sheridan, & Dee, 1996), or troublesome, noisy, sad or unhappy (Sheridan, & Dee, 1996) (dependent upon the subclassification). Additionally, lack of impulse control resulting in physically inappropriate actions such as pushing, hitting or grabbing other children deter appropriate interactions (Schwiebert, & Sealander, 1995).

Classrooms with a child having ADHD have greater overall rates of negative teacher-child interactions with normal children, and decreased time spent with the normal children as more energy is spent on the child with ADHD (Wheeler, & Carlson, 1994).with the result of negative attitudes towards the child with ADHD, consciously or unconsciously. In fact, disruptive behavior in the classroom was cited in one study by Campbell and Paulauskas (as cited in Wheeler, & Carlson, 1994), as causing nearly 70% of normal students to use this as a reason for dislike of the child with ADHD.

The social deficiencies have been noted to be “consistently linked to higher incidences of school maladjustment, suspensions (14% vs. 2% in the general population (Goldstein, 1997))/expulsions, delinquency and childhood psychopathology.” (Gresham, 1988).

Whether this is a result of poor interactions with peers or poor self-esteem is of question, however. With either cause, the two do seem to feed negatively upon one another. Boys with ADHD were rated to be more unpopular by their peers, and scored significantly higher on tests of depression and poor self-concept than did normal children. This does imply that children with ADHD are not blind to their status with peers (Wheeler, & Carlson, 1994). In everyday activities, however, these children may not show overt signs of low self-esteem. In fact, they may present them selves as having a self-perception as high, or higher than that of other children, and “Their distorted perceptions may serve as a buffer to shield them from some of the negative effects surrounding their frequent failure” (The self-perceptions, 1996). It is also suggested, that to shield themselves from an impending failure, children with ADHD may increase their distractions (an unconscious coping tool) to divert attention away from the task (Shaughnessy, & Martin, 1999).

Children with ADHD are placed in alternative educational settings within the schools, depending on criteria that varies from district to district. This has the potential to further demoralize a student, and lower their self-esteem more, and facilitate the ongoing under-education of these students.

Adolescence

As the children enter adolescence, a change in the symptoms of ADHD occur. Shaughnessy and Martin (1998) indicate that this may be due to the hormonal changes occurring during puberty. The ADHD is persistent, though the diagnosis appears to change from ADHD with Hyperactivity or Combined, to ADHD with Inattentiveness (Robison, Sclar, Skaer, & Galin, 1999), with only 70% – 80% still meeting the full criteria (Guervemont, & Dumas, 1994), resulting in 1%-2% of the teenage population (Crist, 1999).

However, all of these teens are still at risk, as shown by Swanson and Seargant (1998), who demonstrated in a longitudinal study that adolescents with ADHD-C or ADHD-H as a child were at greater risk for later psychiatric diagnosis, oppositional or antisocial behavior, and social and peer problems. These oppositional and antisocial tendencies may manifest more in the teenage years as the adolescent enters middle and high school, with an increased workload and less support (Crist, 1999), resulting in frustration and feelings of inadequacy (Driggs, 1995). When examined, again longitudinally, by Guervemont and Dumas (1994), remarkable stability in the ratings of social competence by themselves, parents, peers and teachers was demonstrated, with lower scores than those of normal peers. Mendelson, Johnson, and Stewart (as cited n Guervemont, & Dumas, 1994) also support this, with over 50% of studies individuals in each category reporting they were not liked, loners with no friends, or were involved in frequent fighting.

At this stage of life, the social rejection and incompetence may be felt most heavily, when acceptance is so crucial. This is as a result, the factor contributing most heavily to continued depressed moods, decreased self-esteem, and the emergence or worsening of antisocial behavior. Additionally, over 75% of the studied teens continued to have problems with school, home and community (social) adjustment as they entered adolescence, and nearly 30% failed to complete high school (Lambert, 1988; Lambert, Sassone, Hartsough & Sandoval, 1987; Weiss & Hechtman, 1993 (as cited in Sheridan, & Dee, 1996).

One of the major academic hardships reported by teens was the task of listening to an instructor and attempting to take notes at the same time. They find that their attention, when divided in that manner allows them to gain very little from a class (Living with ADD, 1996). Some students can utilize their status as learning disabled to get assistance in taking notes, or pay a person to take notes for them. While allowing them to gain more information from a class, however, this does take a toll on the self-image, and only serves to accentuate their differences.

Ginsberg and Sartain (1996), make some very telling comments from their personal experiences with ADHD in school. Especially as they entered middle school and beyond, and teachers were less knowledgeable and tolerant of students with ADHD (they have to learn to function in society!) one has had a teacher say “Look, I know you’re… retarded or something, but..” and feel that teachers are measuring their disability rather than the quality of their work. They note that papers would be turned in late because they were misplaced, or a name was forgotten, and a zero would be given. Under these circumstances, they have seen any number of teens “feel that ADHD is a license to stop trying because their efforts will be fruitless.”

As they enter later adolescence, teens begin to drive. With the well reported statistics about the high incidence of accidents of teens with ADHD (3 times higher risk for accidents) (Barkley, & Murphy, 1998), who have had their licenses suspended or revoked more often, and drove without a license at a rate 9 times that of the general population (Goldstein, 1997), they often have to drive under rules that other teens don’t. These may include restrictions such as: no music in the car, no more than one passenger, they have to take their Ritalin first. While this does allow them the freedom of a vehicle, it again underscores for them their differences, and embarrassment when they are unable to comply with the various requests of passengers.

Teenage girls face a unique set of crises. While boys with hyperactivity can be somewhat socially tolerated, girls are not. As children, they have been scolded and derided. As they enter the teenage years, they may begin to join those detractors and talk down about their previous and present behavior, blaming themselves and creating a sense of shame (women and ADD, 1999).

Teens with ADHD, predominantly males, also have a higher incidence of incarceration in Juvenile facilities, at a ratio of 5:1 compared to the general population.

Therapy, which may have been started in childhood or adolescence will average over 16 months of attendance for approximately 63% those in their late teen years (Thompson, 1996). While the therapy alone does not present a favorable prognosis, it is reasonable to assume that those that have undergone therapy also were taking pharmacological medications at the same time, which has recently been shown to be the most effective treatment modality (Marcus, 1999).

Within this age range, adolescents are able to become more active participants in taking ownership of their disorder, including the use of non-professional support groups, which have been shown to “help foster healthy self-esteem by learning to think about themselves in a positive way.” (Timmer, 1995)

Both individual and group therapy can assist in what may be that one of the major milestones to be accomplished, which often occurs during these years: “Probably the hardest part of having ADHD is accepting the diagnosis… The disorder is part of who you are and, yes, you have to control it, but it doesn’t define you. It’s okay to have attention deficit disorder, as long as you know what to do about it.” (Farley, 1997) This acceptance may be the key to overcoming many of the perceived failings, and resultant psychosocial issues such as lowered self-esteem and depression.

Adulthood

They may be the ‘eccentrics’ whose behavior seem unconventional, or the ‘terrible-tempered’ who are painfully bewildering, or the ‘explosive types’ with whom reasoning is difficult. They may be victims of a disorder that is not for children only – (Coming, 1992).

Entering adulthood, the estimates of those persisting with diagnosable ADHD vary from approximately one-third of those diagnosed with ADHD in childhood still meeting the criteria in adulthood (Robison, Sclar, Skaer, & Galin 1999; Swanson, & Sergeant, 1998), 50% (Shaughnessy, & Martin, 1998) to nearly 70% (Barkley, 1998; Driggs, 1995). Shaughnessy & Martin (1998) also believe that those who do not “outgrow” ADHD by adulthood have a considerable lessening of the hyperactivity portion of their disease.

Shaffer (1994) (as cited in Smith, Everett, & Johnson, 1998) reports that “Adult ADHD has become the foremost self-diagnosed condition in my practice.” researchers at Johns Hopkins also found that they were receiving more self referrals for ADHD than for depression, but the rate of actual diagnosis in these individuals was less than 15% (Self-referred, 1997).

The most current DSM – DSM-IV – is the first revision to address ADHD in adults (Weiss, 1996). In 1994, ADHD was in fact the fastest growing diagnostic category for adults (Wiggins, Singh, Getz, & Hutchins (1999). This may require major life-outlook alterations. For many adults, this is a first diagnosis, and they view themselves as having a stigma attached. For others, they may be been treated for depression, anti-social personality disorder (seven times more likely than the general population (Goldstein, 1997)) or character disorder (Adults with Attention, 1999). They report subjective stress 79% of the time, and interpersonal problems 75% of the time (Fargason & Ford, 1994).

The newly diagnosed adults (as well as those with an existing diagnosis) must “acknowledge that he or she needs to make accommodatons for the ADD symptoms, to take responsibility for seeking professional help when necessary, and never use their ADD symptoms as excuses for lack of responsibility or relationship problems” (Jaksa, 1999).

As adults, our personality is relatively defined. Robin, Tzelepis, and Bedway (1998) in their study of newly diagnosed adults with ADHD were able to classify them into two distinct categories, with comparison to controls. They found that 50% had a negative world-view, with passivity, disorganization, self-centeredness, and introversion, while only 4% of controls had these features. Nearly 50% of those with ADHD were in the bipolar opposite, a positive world-view, while 88% of controls fell into this category. This was characterized by extroversion, nurturance of others, assertiveness and less disorganization. Only a slight percentage of each fell into a mixed category. Unfortunately, with their current research, they were unable to draw conclusions as to the causes of these dichotomous personalities.

There is no dearth of suppositions regarding this, however. Driggs (1995) offers the supposition that the accumulated psychological effects of unrecognized ADHD are worse than the original limitation of the disorder. Guevremont and Dumas (1994) and Wheeler and Carlson (1994) indicate that the worse the peer relationships in childhood and adolescence, and/or childhood diagnosis of ADHD-H, the greater the possibility of poor social adjustment and mental health problems in the adult with ADHD. Jackson and Farrugia (1997) believe that this negative world-view comes because the adult with ADHD will

“Perceive that nobody understands how difficult it is for them to work steadily, become organized, keep friends and set goals for themselves. They become even more discouraged when people around them give advice on how they ‘should’ act and who they ‘should’ be.”

Also, as noted before, adults with ADHD are also at increased risk for anti-social behavior disorders and substance abuse (up to 1/3 abuse alcohol and 1/5 substances (Goldstein, 1997)) (Heilingenstein, Guenther, Levy, Savino, & Fulwiler (1999). Jackson and Farrugia (1997) estimate that 14% -33% of substance abusers have ADHD, and 20% – 45% will manifest antisocial, conduct or oppositional defiant disorders, both well above the percentage of those with ADHD in the general population.

Bemporad (1998) suggests that these adults can benefit from psychotherapy in order to heal old scars, and develop appropriate coping techniques.

Hayes (1999) states that “adults with learning disabilities find, too, that their successes or failures in their personal lives or jobs are more affected by their social skills than by their academic learning.” Some of the social issues that were able to be downplayed in the teenage years come to a head in the adult world, if they have not been taught earlier. These include perception of others facial expression and vocal cues, language and social conventions, vocal monitoring (volume of one’s own voice), skills in asking for help in receiving information, body awareness skills (proprioception), organizational skills, and personal space awareness.

It is believed that adults with ADHD have learned to mask some of the symptoms of the disease, at least in parts of their life. They over-rely on other assets such as intelligence to get by (Driggs, 1995), or develop other traits such as obsessive-compulsive behaviors (Shaugnessy, & Martin, 1998), as well as controlling their environment to either decrease or increase stimulation as needed. Shaughnessy, & Martin also indicate that the developed coping strategies work well enough that roughly 50% can largely discontinue medication treatment.

This is not to disallow the problems that do occur in the adult with ADHD. In 10- and 15-year follow up studies, Guevremont and Dumas (1994) found that those with ADHD-H as children, no matter their current state of diagnosis, showed more difficulty in heterosocial situations and decreased performance on job interviews and assertion, while Barkley (1998) showed that those no longer fitting the clinical description of ADHD still had significant adjustment problems in work, school, and social settings. Bemporad (1998) suggests that even those with coping techniques may be performing far below their capabilities. This may be due to, in part, the inability to develop adequate coping mechanisms for prioritizing many tasks and viewing them as individual pieces rather than the whole. Hallowell and Ratey (1992) (as cited in Munoz, Smeal, David, & Wittig, 1999) say that the adult with ADHD can quickly come to feel inadequate, “embarrassed and humiliated” by their inability to cope.

Heilingenstein, Guenther, Levy, Savino, and Fulwiler (1999), in their study of college students with no previous history of academic problems found that these students were at much higher risk for academic problems in college, including lower grade point average and academic probation. They hypothesis that adults are at additional risk due to loss of family structure and the absence of individualized education plans.

Work, the major aspect of the adult life outside of family, also can suffer for the adult with ADHD. Nadeua (1995) (as cited in Carroll, & Ponterotto, 1998) states “The manifestations of attention deficits in adults are most evident in the workplace environments”. Occupational underachievement and job dissatisfaction are common among adults with ADHD, and they had a significantly lower occupational ranking (Carroll, & Ponterotto, 1998). “It is not uncommon for persons with ADHD to lose jobs due to poor performance, organizational problems, or problems in interpersonal relationships” according to Drehmer and LaVan (1999) (as cited in Munoz, Smeal, David, & Wittig, 1999).

One problem that arises is that when a person with ADHD is given multiple jobs, they may just end up shuffling papers due to divided attention (Munoz, Smeal, David, & Wittig,1999). Other factors in job difficulty include cognitive deficits in academic, language and verbal learning; short term memory difficulties; restlessness, distractibility, impatience; and a low tolerance for frustration (Parker, 1999). Those with AHDH-H are viewed as having a significantly worse work status, had more frequent job changes, and were laid off or quit more often than other ADHD group and controls (Carroll & Ponterotto, 1998). It is suggested that some may quit out of boredom when faced with repetitive tasks (Adults with Attention, 1999). The importance of finding a job that fits the strengths of the adult with ADHD is paramount to success and job fulfillment (Fellman, 1999; Parker, 1999). Carroll & Ponterotto (1998) found that this was usually a job with high personal interest, with the ability to “be their own boss” and have substantial flexibility and decision-making ability.

As teenage girls had their own special circumstances, so do women. Not only do they leave their family support system, they move into marriage where the societal roles seem to conspire against them. They are often unable to build a support system, being expected to be the support system. Additionally, regardless of whether they work or not, they are largely expected to “keep house”. These added stressors can place them in a psychological state of maladjustment. They also have to contend with hormonal changes with their menstrual cycle, which can cause their ADHD to reach “crisis proportions” (women and ADD, 1999).

Men, predominantly, also have a unique problem. In a recent study McCallon (1998) asked “If he outgrew it (ADHD), what is he doing in my prison?”, when he found that 40% of residents in a medium security prison were diagnosable as ADHD. This equates to over 600,000 prisoners in the United States. When released and given a 30 day supply of medication, links to support groups, counselors and physicians, there was only a 10% recidivism rate for this group. This compares to a 53%-58% nationwide rate of recidivism. In support of this, Goldstein (1997) notes that those with ADHD have a higher rate of adversarial contact with the police than the general population, at a ration of 19:3.

Family Effects

There are many myths regarding the cause of ADHD. The most common of which is that parents feel as if they are failing or have failed. Parents may criticize their child for not trying hard enough to stay under control, and are in turn criticized for being ineffective (Wright, 1999). These create untold stresses on the family structure.

When a child is diagnosed with ADHD, therefore, it is not only important to treat the child, but to also treat and educate the family. Family life with a child with ADHD can be described as “attempting to outlast the disruption…. central to the experience of living in a family with an ADHD child…. with as few secondary effects as possible” with disruption centered around the ADHD child a way of life (Kendall, 1998). Brown (1997) also describes the atmosphere in these families as having chronic stress and frustration, social isolation, an air of blame and guilt, and polarized child-parent and parent-parent roles.

The primary source of the disruption, not surprisingly, is the ADHD child doing something that needs attention, or affecting someone else. The secondary disruption arising from this includes younger siblings mimicking disruptive behavior, sibling (and occasionally parents) taking revenge on the child with ADHD, the breakdown of effective communication patterns into yelling, fighting, avoiding, etc. (Kendall, 1998).

The end goal, if the family unit is able to survive the pre-school and adolescent years (considered the most disruptive (Kendall, 1998)), is the eventual reinvestment with the family. This includes the acceptance of their “real” child with ADHD, rather than their “expected” normal child (Kendall, 1998).

Within a family structure including an adult with ADHD, there are also spousal and child conflicts. The spouse may feel resentful, as if they are parenting an entertaining but irresponsible child. They may instead feel rejected and angry if the sufferer engages in actitivies outside the house or hyper-focuses inside the house (Bemporad, 1998). The spouse also can feel the adult with ADHD does not care about the family when they fail to complete household tasks continuously (Jaksa, 1999).

Children may be confused due to conflicting rules and expectations, not only between parents, but between the ADHD parent themselves at different times. They also may experience a fear reaction, that they are not allowed to do anything wrong due to their parent’s low frustration level and impatience (Jaksa, 1999).

These actions, and the subsequent failures to keep promises to themselves and their families that it won’t happen again, can leave the ADHD adult feeling frustrated, guilty, and as a failure (Jaksa, 1999). In turn, this can lead to further withdrawl from the family circle. For these reasons, marital counseling, and individual counseling are often a necessary part of the multi-modal treatment necessary for the adult sufferer of ADHD.

Conclusion

ADHD affects the sufferer throughout the lifespan, from home-life to academics to social contacts, to risks for other conditions, and finally to self-worth. Whether it is a label or a medical diagnosis, we have the capability to treat this condition through the use of psychoactive medications and therapy, individual, marital, and group.

We need to allow the ADHD sufferer to access this care in order to provide a fuller life for themselves, and for those around them, while lessening the stigma that is still attached to this disorder.

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Derek Wood is a Nationally Board Certified Psychiatric/Mental Health Nurse, and holds a Master's degree in Psychology. His experience in the online arena of mental health can be traced back to 1997, when he was a host for Online Psych on AOL. He joined Get Mental Help, Inc. as Clinical Content Director for Mental Health Matters. Derek, with his wife Lisa, developed the original version of psychTracker (then called A Mood Journal), after his diagnosis with Schizo-Affective Bipolar, when they could not find a system available that was robust enough to help him effectively manage his symptoms and accurately interpret his charting. Derek has worked in the field of mental health since 2001, as a Unit Manager of an adult long-term treatment facility, a charge nurse in an adolescent short-term inpatient facility and long-term residential facility, and as a School Psychologist. He has also written several articles which are being used as CEU for nurses and educators.

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