Terms of Impairment: Underperformer or Adult ADHD?

By: Christine Haran
It?s not that hard to identify attention deficit hyperactivity disorder (ADHD) in a kid who is jumping up and down on the school desk or flitting from one activity to another. But ADHD can be harder to pick up in adults, who have figured out ways to cope with many of their symptoms but are often still struggling to juggle the responsibilities of modern life.
Even though the condition will persist into adulthood for about 60 percent of kids with ADHD, many people still think of ADHD as a childhood disorder. According to a recent study by the Harvard School of Public Health, ADHD affects 4 percent of the U.S. adult population, or 8 million adults. Yet, 80 percent of those 8 million don?t know they have ADHD and aren?t treated.

"Most primary care physicians haven?t been trained to see it in adults." says Leonard Adler, MD, director of the Adult ADHD Program at the New York University (NYU) School of Medicine. "The impairments from the disorder are clear in terms of their impact on the workplace, the family and society." Below, Dr. Adler talks about how to recognize ADHD in adults and explains how treatment can help people with ADHD hold their jobs and families together.

What is ADHD?
ADHD is attention deficit hyperactivity disorder, which is a term we use to encompass all attention deficit disorders. It?s a very common impairing neuro-psychiatric disorder that affects individuals throughout the lifespan.


How is ADHD diagnosed?
For a diagnosis of ADHD, you have to be experiencing either inattentive symptoms (and if you have those, then you?re the inattentive subtype) or hyperactive/impulsive symptoms (and those would be the hyperactive/impulsive subtype). You may have both and have the combined subtype, which is the most common.

The second thing is that the symptoms must cause trouble. The impairment must occur in at least two settings, be that at school or work, at home or in social settings.

The third thing is that symptoms have to begin in childhood. That doesn?t mean that you have to have the diagnosis as a child, all of the symptoms, nor the level of impairment that you see as an adult. Many bright individuals have symptoms that start in childhood, but in childhood, we have structure provided by our parents and school. As we get older, we go from being managed by others to managing ourselves or managing others.

The fourth thing is that the symptoms have to be from ADHD and not another disorder.

Why do people think of ADHD as a childhood disorder?
One reason may be that the criteria that are in the Diagnostic and Statistical Manual of Mental Disorders uses childhood symptoms, so if you don?t think about how the symptoms may change throughout life, you won?t know that an adult has ADHD. For example, inattentive symptoms become much more prominent for adults as compared to the hyperactive-impulsive symptoms. Adults know that it?s not appropriate to climb on top of their desk and "runs about and climbs" is one of the childhood symptoms. No adult does that because that would be very stigmatizing.
How do people tend to cope with symptoms at work?
Adults have had a lifetime of coping with their symptoms and it?s important to look at how they?re coping. They may select jobs that allow them to deal with some of their symptoms better. For example, if you have a lot of symptoms of restlessness and you pick a job that allows you to be physically active, that will be much more in line with your symptoms than if you have a nine-to-five, buttoned-down job sitting at a desk all day. People will tend to find jobs that allow them to move from one activity to another.

You not only want to look at coping strategies but you want to look at impairment. Impairment can be relative. You may look at an individual with ADHD and say, "How in the world can this individual have ADHD? They?re an executive." The reality is that they can?t function without their executive assistant. They have to be organized by someone to function.

They may be working very, very long hours and everything is going up until the last minute. That?s relative impairment, which can be quite costly to the individual, because if they?re working long hours, there?s not a lot of time left for themselves or their family. It can spill over to difficulties in family life.


How does ADHD affect other aspects of life?
Untreated adults with ADHD are more likely to underperform academically. They?re more likely to change jobs, underperform on the job and more likely be fired. They?re about twice as likely to smoke cigarettes. If untreated, they?re more likely to use substances.

In terms of the family, they?re more likely to be divorced or separated. A number of patients who have come to our center have been in a family crisis. The spouse will complain that the individual who?s being considered for ADHD isn?t listening and is not following through on tasks. They may be seen as unreliable. There have been a number of marriages that have been on the precipice that have been pulled back with one of the two parties getting treated for ADHD.
Do symptoms tend to be different in men and women?
Women and girls tend to have more of the inattentive symptoms, which, in part, have led to some of the under-recognition. Historically, if you were behaviorally disruptive and in and out of your chair in childhood, you were more likely to be identified as having ADHD than if you were, let?s say, daydreaming and not attending to the task. This, in part, led to girls not being identified, though they are a little bit more likely to be recognized as having ADHD as adults. If you look at the gender split in childhood and adulthood, it?s four boys to every one girl and about two men to every one woman.
Are parents with ADHD likely to pass it on to their kids?
This is a familially transmitted disorder. If there?s a child in the family with ADHD, there?s about a 40 percent chance that one of the two parents will have ADHD and there?s about a 25 percent chance that a first-degree relative, such as a sibling, will have it.

One of the most common ways adults will present with ADHD is that they have a child who has been diagnosed and they?ve realized that they had the symptoms themselves in childhood. Their spouse will sort of nudge them and say, "Honey, you have them now, too."

What conditions are sometimes confused with ADHD?
There are a number of disorders that can appear ADHD-like. It?s important to remember that we?re looking at symptoms throughout the course of one?s life. That?s one way to establish what may be ADHD and what may be a mood disorder, such as depression. There are many disorders that co-travel with ADHD, like depressive disorders, bipolar disorder, anxiety disorders and learning disabilities. But it?s important to remember that mood disorders tend to come and go, whereas with ADHD, the symptoms are more or less present all the time.


These generally co-traveling disorders tend to present in families of people with ADHD, too. But for some, the anxiety disorders and maybe the chronic depression arise when the ADHD is not getting treated.

How is ADHD treated?
For adults and for children, medications play a role in treating the ADHD. The medications are the tools. The cognitive behavioral therapy or coaching will help individuals on medication to implement change. There have been a number of studies that have shown that either stimulants or non-stimulant medications can be quite effective in treating adults with ADHD. There is about a 70 percent chance of getting better with the first medicine you take, pretty good numbers in medicine.

We tend to use the longer-acting versions of the stimulants. The only stimulant that?s approved for ADHD in adults is Adderall XR, which is an amphetamine preparation. Ritalin-type stimulants, such as Ritalin LA, Metadate CD and Concerta, are also used. The non-stimulant medication that?s approved for ADHD in both kids and adults is Strattera.

People will stay on their medication long term. That doesn?t always mean forever. We evaluate the need for medications on an ongoing basis.

If you think you or a loved one has ADHD, what are the signs you should look for?
You want to look for the inattentive symptoms: trouble paying attention, distractibility, organizational difficulties, misplacing things, trouble with time management, restlessness, difficulty waiting, interrupting others when talking. You want to see if those symptoms cause trouble for the individual and also whether there?s some sense that the symptoms go back to childhood.

There is a screening tool copyrighted by the World Health Organization, that has the six symptoms that are most predictive for adults of having the disorder. It?s on the NYU website. If you have at least four of the six symptoms, you should be evaluated by your doctor to see if you have it. This is a screening tool that?s meant to identify individuals at risk for ADHD. It?s not meant to provide a formal diagnosis.

This is a disorder that?s clearly common. This is a disorder that can be diagnosed by sitting down with your doctor and going over your history. We have good screening tools. We also have good treatments and people can get better.