Attention Deficit Hyperactivity Disorderin Teens and Adults:They Don’t All Outgrow It

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Robert J. Resnick

Randolph-Macon College

Attention deficit hyperactivity disorder (ADHD) has been long recognizedand well established in children, but its continuation into adulthood hasonly recently been supported by the research. ADHD symptoms and con-cerns typically appear differently in adults, but treatment options, concep-tually at least, are similar to those used for children who have ADHD. Thisarticle introduces the issue of Journal of Clinical Psychology: In Sessiondevoted to ADHD in teens and adults. It presents the prevalence andmanifestations of the disorder and then reviews the subsequent articleson the comorbidity, evaluation, education, psychopharmacology, andpsychosocial treatments of ADHD for teens and adults. The issue con-cludes with an article on neurobiofeedback, a relatively new treatmentoption. © 2005 Wiley Periodicals, Inc. J Clin Psychol/In Session 61:529–533, 2005.

Keywords: adults with attention deficit hyperactivity disorder (ADHD); teenswith attention deficit hyperactivity disorder (ADHD); diagnosis; treatment

The symptoms of attention deficit hyperactivity disorder (ADHD) have been well docu-mented for more than 100 years, but the nomenclature of attention deficit disorder (ADD),now ADHD, is only about 25 years old. Only relatively recently has the conventionalbelief that such disorders are experienced only in childhood and outgrown in adolescencegiven way to recognition of the reality that ADHD is usually not outgrown. Symptomscontinue in most children who have ADHD into adolescence and adulthood, causingpersonal, social, occupational, and even leisure time dysfunction.

Correspondence concerning this article should be addressed to: Robert J. Resnick, Ph.D., Department of Psy-chology, Randolph-Macon College, Ashland, Virginia 23005; e-mail: rresnick@rmc.edu.

JCLP/In Session, Vol. 61(5), 529–533 (2005) © 2005 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20117

Until the early 1970s, there was general agreement that ADHD was outgrown duringpuberty. This view was self-reinforcing as the major focus for many years was the child’selevated activity level in teenage years. This myopia significantly contributed to thebelief that with maturation came cure. However, by 1976 evidence demonstrated thatmost children who have ADHD do not outgrow their symptoms, although symptoms maychange. Frequently their symptom presentation is altered by maturation and by improvedcognitive ability and coping. Hyperactivity is reduced in adulthood, but impulsivity andother symptoms related to executive functions typically become more evident as thedemands for self-sufficiency increase with age. By the mid- to late-1990s, there wasgeneral agreement that approximately one-half to two-thirds of children who have ADHDcontinue to have symptoms of the disorder into their teenage years and on into adulthood.

Most teens and adults experience occasional problems with inattention, impulsivity,distractibility, and restlessness, but individuals who have ADHD differ from others in thefrequency, intensity, and duration of these symptoms. ADHD in teens and adults is moreoften manifested by numerous problems related to the executive function problems thatcan lead to significant difficulties in daily life management. These populations who haveADHD are also at risk of being misdiagnosed because presenting symptoms mimic thoseof other disorders, particularly depression, substance abuse, anxiety, sleep problems, mar-ital distress, feeling of being overwhelmed, low motivation, and poor employment his-tory. Additionally, people who have ADHD may have one of several comorbid disorders,most often depression. Academic underachievement (frequently diagnosed as learningdisability) is also a common cofinding among teens and adults who have ADHD. Indeed,learning disabilities may be confused with ADHD symptoms and misdiagnosed: A learn-ing disability is the diagnosis but ADHD is the underlying cause.

This brief article outlines the symptoms and treatments of ADHD in adolescents andadults and then introduces the subsequent articles in this issue of the Journal of ClinicalPsychology: In Session, which is devoted to this topic.

Teens Who Have ADHD

As children who have ADHD change from “tweenagers” to teenagers, their symptomsmay be different because of maturational and cognitive development. Teenagers whohave ADHD often have multiple behavioral, academic, and interpersonal problems thatunfortunately are misidentified because they are thought to have “outgrown” ADHD asthe excessive motor activity has often diminished, giving way to more subtle fidgetinessand a sense of inner restlessness. We now know that teens who have ADHD are extremelyvulnerable to conduct problems, oppositional-defiant behaviors, and academic problems.Additionally, teen girls who have ADHD are likely to have worsening of symptomsbecause of the hormonal changes at puberty and are at increased risk for unplanned andunwanted pregnancies, among other problems, than their unaffected counterparts. Teenswho have ADHD are more likely to drink coffee to excess and to smoke, probably becauseboth caffeine and nicotine may increase arousal in underactive parts of the brain. Addi-tionally, adolescents who have ADHD also have more traffic accidents, speeding cita-tions, and academic difficulties than their peers (Cox, Merkel, Penberthy, Kovatchev, &Hankin, 2004).

Adults Who Have ADHD

Although there cannot be an adult onset of ADHD, quite commonly the diagnosis ofADHD is not made until adulthood. ADHD is probably a disorder one is born with, but

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childhood symptoms are frequently overlooked or misdiagnosed. Individuals who havehyperactive/impulsive ADHD accompanied by disruptive behavior are more likely to beidentified in childhood. Children whose ADHD is less disruptive, who have more inatten-tiveness symptoms, may not be diagnosed until adolescence or adulthood. One cannot,however, have ADHD as an adult without having ADHD (though not always identified)as a child. Parents, culture, socioeconomic class, schools, and ethnicity contribute to thevariability in the tolerance level (and thus, intervention) of ADHD symptoms (Resnick,2000). Wender (1995, 2000), in his rigorous reviews of prevalence data, concludes thatthe incidence of ADHD in adulthood is 2%–7% and that 4% is the generally acceptedrate. The ratio of men to women has been reported to be between 2:1 and 1:1 (Resnick,2005). The nearly equal number of males and females in adulthood strongly suggests asignificant underdiagnosis of ADHD among girls, as reflected by childhood gender ratiostypically reported at 3:1 or greater.

The diagnosis of ADHD in adults, as in children, can be one of three types: attentiondeficit hyperactivity disorder primarily hyperactive-impulsive type; attention deficit hyper-activity disorder primarily inattentive type; or attention deficit hyperactivity disorder,combined type (hyperactive-impulsive and inattentive). The diagnostic manual (Diag-nostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision, 2000)provides diagnostic criteria; however, they are essentially the symptoms of ADHD chil-dren, more specifically of male children. Thus, many of the criteria need to be modifiedto be applicable to adults (see Resnick, 2000).

Often the symptoms of adults who have ADHD cluster around procrastination, dis-organization, and forgetfulness—even for those activities they are motivated to do andenjoy. Hyperactivity is more likely to be experienced as a feeling of tension or restless-ness in adults who have ADHD. Stress intolerance, affective lability, and living by “avoid-ance” of deadlines are frequent concomitant findings. Interpersonal confrontations areoften brief and intense for adults who have ADHD

Treatments

Treatment for teens and adults who have ADHD, like ADHD children, is multifacetedand individualized to meet the needs of the patient. Patient and family education thatexplains the ADHD diagnosis, its lifetime course, and treatment options is the first inter-vention. Medication management is often used, but the response rate is lower and lessrobust compared to that of children. Stimulants have been the drug of choice for decadesand continue to be the most used class of medications. Antidepressant medication is asecond-tier drug used for ADHD among teens and adults and may also be more oftenused when there is a cofinding of depression or anhedonia. Recently, nonstimulant drugs(norepinephrine reuptake inhibitors), similar in chemical structure to antidepressants,have been marketed specifically to treat ADHD. Medication management for womenwho have ADHD is more challenging because of reproductive issues and the potentialimpact of menstrual cycles on drug effectiveness. For ADHD, adolescents and adultsrarely need long-term, insight-oriented psychotherapy, except for a comorbid condition,but focused psychotherapy around life-span issues (e.g., marriage, job change, parent-hood) is both common and effective. Intermittent treatment may include improvement ofsocial skills, teaching of self-advocacy, bibliotherapy, self-help groups (e.g., Childrenand Adults with Attention Deficit Disorders [CHADD] and the Attention Deficit Disor-ders Association [ADDA]), stress reduction, environmental manipulation, work assis-tance, and school-based interventions. Other strategies may include marital/couples therapy,

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coaching, visual prompts (sticky notes, personal digital assistants, to-do lists), advocacyfor the adult who has ADHD, and ongoing treatment of comorbid conditions.

On occasion certain provisions of two federal laws may assist adults who have ADHD.First, the Individuals with Disabilities Educational Act (IDEA) mandates a free and pub-lic education until age 21. Second, the Americans with Disabilities Act (ADA) requiresemployers who have at least 15 employees to make “reasonable accommodations” for aperson who has ADHD who is “otherwise qualified” to perform the job functions. Thismandate includes schools as well.

Outcome

Treatments are effective and can bring about significant improvement in the life qualityof persons suffering with ADHD. However, ADHD is rarely cured; the realistic aim isto manage it. Treatments must be individualized, integratinging treatment of the inter-fering symptoms with the strengths and needs of the ADHD patient. Many adolescentsand adults who have ADHD have difficulty accepting the help of others, viewing it asevidence of their personal shortcomings. The ADHD therapist, coach, spouse, and friendmust try to keep the person focused on goals, not necessarily on how goals are achieved.The goals are to make the world more ADHD-friendly (Nadeau, personal communica-tion, 1999) and to introduce a degree of order, peace, and happiness to the affectedadult’s life.

An Update on ADHD in Adolescents and Adults

In order to increase awareness of this overlooked diagnosis and to highlight diagnosticand treatment resources, we asked leading authorities on ADHD to contribute their knowl-edge to this issue of the Journal of Clinical Psychology: In Session. They have graciouslygiven their expertise. Jeanette Wasserstein reviews the diagnostic assessment of atten-tional deficits in teens and adults. She describes the significant areas to be covered in adiagnostic interview, the use of questionnaires, and the indications for neuropsycholog-ical testing. Kathleen G. Nadeau addresses workplace and career concerns that ADHDimpacts in teens and adults. Carol Ann Robbins examines the social and relational travailsrelated to ADHD in teens and adults. She emphasizes how to educate individuals, cou-ples, and families so that they will be better informed about the debilitating effects ofADHD and communicate more effectively by using Imago Therapy. Patricia Quinn reviewsthe diagnosis and treatment of ADHD in female teens and adults, underscoring the impactof hormonal fluctuations on ADHD symptoms as well as the social challenges faced bywomen who have ADHD.

From diagnosis we move to treatment. William W. Dodson provides a practitioner-friendly review of pharmacotherapy for ADHD for teens and adults. In his article onpsychosocial treatment, Kevin Murphy describes various psychological and behavioralinterventions that have been successful for teen and adult ADHD. He also reviews federalstatutes that can be used to manage treatment in educational and employment settings.Concluding the issue is an article by Steven M. Butnik, who presents information and acase study on using neurobiofeedback: a relatively new diagnostic and treatment strategy.

Select References/Recommended Readings

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th ed., Text Revision). Washington, DC: Author.

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Cox, D.J., Merkel, R.L., Penberthy, J.K., Kovatchev, B., & Hankin, C.S. (2004). Impact of methyl-phenidate delivery profiles on driving performance of adolescents with attention-deficit/hyperactivity disorder: A pilot study. Journal of the American Academy of Child and AdolescentPsychiatry, 43, 269–275.

Jackson, M.T. (1997). The adult attention deficit disorders intervention manual. Columbia, MO:Hawthorne Educational Services.

Kolberg, J., & Nadeau, K.G. (2002). ADD-friendly ways to organize your life. New York:Brunner-Routledge.

Nadeau, K.G. (1996). Adventures in fast forward: Life, love, and work for the ADD adult. NewYork: Brunner-Mazel.

Ramsay, J., & Rostain, A. (2003). A cognitive therapy approach for attention deficit hyperactivitydisorder. Journal of Cognitive Psychotherapy, 17, 319–334

Resnick, R.J. (2000). The hidden disorder: A clinician’s guide to attention deficit hyperactivitydisorder in adults. Washington, DC: American Psychological Association.

Resnick, R.J. (2005). Attention-deficit/hyperactivity disorder in adults. In C.B. Fisher & R.M.Lerner (Eds.), Encyclopedia of applied developmental science (Vol. 1, pp. 129–131). Thou-sand Oaks: Sage Publications.

Weis, M.D., & Weis, J.R. (2004). A guide to the treatment of adults with ADHD. Journal of ClinicalPsychiatry, 65, 27–37.

Wender, P.H. (1995). Attention-deficit hyperactivity disorders in adulthood. New York: OxfordUniversity Press.

Wender, P.H. (2000). ADHD: Attention-deficit hyperactivity disorder in children and adults. NewYork: Oxford University Press.

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