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Section 15
Diagnostic Issues with Clients with Adult ADD

Question 15 found at the bottom of this page
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Mary had been treated for bipolar disorder, but still suffered from extremes of distractibility, impulsivity and agitation/hyperactivity. John was a mental health professional with excellent clinical skills, but was severely behind with his patient charts and necessary paper work. Sue was a brilliant college student who somehow never recognized the need to regularly attend classes, read assignments, or write papers. All turned out to be adults with previously unrecognized ADHD whose lives were greatly improved with appropriate diagnosis and subsequent treatment. All had also been given other diagnoses in the past, and had been treatment failures, as is often the case when ADHD is missed in adults (Ratey, Greenberg, Bemporad, & Lindem).

Attention deficit hyperactivity disorder (ADHD) is a complex neuropsychiatric syndrome (or syndromes) that is among the most common of childhood disorders. Once thought to disappear as children matured, ADHD, as current data indicate, changes form but remains clinically significant in many of the grownups who had it as children. The exact rate of persistence is a controversial subject. Outcome data suggest that anywhere from 5% to 75% still show significant levels of symptoms into adulthood, depending on who are used as informants and where the diagnostic cutoff point is set. For example, self-report of symptoms yields lower persistence rates than parent report among adolescents or young adults. Adult prevalence rates vary, but anywhere from 1% to 6% of the general population are believed to meet the strict DSM-IV diagnostic criteria for ADHD (Wender).

The core childhood symptoms of ADHD are hyperactivity, inattention, and impulsivity. However, Paul Wender, who originally created awareness of the continued adult form, drew attention to frequently associated features and subjective symptoms also seen in ADHD adults. These included affective lability, hot temper (with explosive and short-lived outbursts), emotional overreactivity (leading to poor tolerance of stress), and disorganization. Research suggests that the core childhood symptoms shift with development, sometimes dramatically: hyperactivity often declines by adolescence, attentional problems appear to remain more constant, and impulsivity may transform into more overt difficulties in executive functions. It is tempting to speculate that deficits in executive functions may account for many of Wender’s additional observations. Executive functions are an evolving construct, which have become a shorthand for complex regulative processes. Many other terms are used interchangeably with executive functions. These include self-reflection, self-control, planning, forethought, delay of gratification, anticipatory set, future orientation, working memory, planning, set shifting, selecting, dividing and sustaining attention, affect regulation, resistance to distraction, and metacognition. Strictly speaking, from a neuropsychological perspective, executive functions originally referred to a more narrow set of fundamental neurological processes necessary for “independent” and “socially responsible” living (Lezak). These usually denoted problems with initiation, inhibition, shifting, sequencing, planning, and self-awareness. Failures in inhibition, as well as in attention regulation, are likely to compromise other derivative executive/regulative abilities indirectly (see Barkley; Brown).

As a result of executive deficits in adults, adults with adaptive functioning may be as frequent as, if not more frequent than, problems with disruptive behaviors or inattention. Consequently, difficulty in keeping jobs and maintaining routine and poor organization of time and/or money are common (Wolf &Wasserstein). For example, individuals may report frequent missing of appointments or work deadlines, repeated failure to file taxes, poor tracking of bill payments and even bankruptcy, as well as restlessness and difficulty in unwinding and subtle forms of motor fidgeting such as pacing, leg shaking, playing with rubber bands, or rustling papers while talking. Complex presentation is the rule in adults and adolescents. That is, the ADHD is usually nestled with other comorbid psychiatric conditions, such as substance abuse, antisocial behavior, residual learning disabilities, conduct disorders, and/or mood and anxiety disorders (Brown). In adult patients, the ADHD may be missed because the comorbidities are the more common focus of attention of mental health professionals. In adolescents the ADHD may be the treatment focus, while the comorbidities may not be recognized and addressed. Last, frequent problems with social skills and adaptive functions can be very stressful to relationships. Consequently, divorce and multiple marriages are not uncommon among these adults. I have also found that some adults who have ADHD form codependent relationships wherein they become overly submissive to a controlling and highly organized partner. With the right balance such a relationship can be adaptive for the dyad, but mutual resentment and misunderstanding of the underlying forces frequently occur.

Adults and adolescents who have ADHD may show stimulus-seeking behaviors, which may lead to poorer health, criminal records, more serious motor vehicle accidents, less education, and lower occupational achievement. Nevertheless, anecdotally, success in risky and exciting occupations (e.g., entrepreneurial ventures and sales) has been reported (Weiss & Murray). Others have speculated that aspects of ADHD can be channeled into creative productivity, with the right supports and nurturance (Wolf & Wasserstein).

Recognizing ADHD in Adult Patients
The DSM currently recognizes three types of ADHD: ADHD Predominantly Hyperactive Impulsive Type, characterized by motor and impulse control problems; ADHD Predominantly Inattention Type, characterized by problems in attention and arousal; and ADHD Combined Type, characterized by problems in both areas. Unfortunately, the fixed symptom threshold that was created was based on children (ages 4–17); while the diagnostic criteria are used for all ages. Additionally, many items are not entirely applicable to adults. Examples include behaviors such as often runs about or climbs excessively, often has difficulty playing or engaging in leisure activities quietly, or often avoids or strongly dislikes tasks that require sustained mental effort, such as schoolwork or homework. Thus a priori, fewer items can be used to rate adults, and fewer chances to meet criteria result. Moreover, because ADHD is conceptualized as a developmental disability, target symptoms must be age-inappropriate relative to peers. These sorts of considerations argue that current DSM standards are less appropriate for adult sufferers, who may still have relative deficits and show many ADHD-based problems but do not fully meet criteria (Barkley). That is, they may have “outgrown” the normative sample, but not the disorder. The existing DSM standards must be nevertheless considered, although there are no formal guidelines regarding such subthreshold presentations. In such cases I often use ADHD: not otherwise specified (NOS), although the DSM again provides no definite criteria. Incidentally, I have found that low self-esteem, against a backdrop of many solid abilities, is a good marker for diagnostic risk. In order to make the diagnosis, it is essential that the core symptoms were present during childhood. Given the strong genetic contribution in this condition (e.g., Wender,; Levy, Hay, McStephen,Wood, &Waldsman), I stress examination of family history, especially in borderline presentations. For example, it is quite common for adults to seek evaluation when their own children have been diagnosed. It is also not unusual to find a strong family history of learning disabilities or other psychiatric disorders in a true proband. If I see no family history, I am much less likely to make the diagnosis, unless there have been perinatal or other risk factors for acquired symptoms.

There are two main groups of adolescents/adults who have ADHD: (1) Those who were originally diagnosed as children and (2) those who were never diagnosed. The first group is easier to recognize and often includes men or those who were hyperactive as children. The second group is more likely to include females and/or the inattentive subtype, because they were less likely to have been disruptive during their childhood. That is, the true inattentive type children are often not identified during childhood.
- Wasserstein, Jeanette; Diagnostic Issues For Adolescents And Adults With ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p 535

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about diagnostic issues with clients with adult ADD.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
According to Wasserstein, why are the current DSM symptom thresholds for ADD inappropriate for diagnosing ADD in adult clients? Record the letter of the correct answer the Answer Booklet.