Attention deficit hyperactivity disorder (ADHD) is a neuro-behavioural disorder that can be classified into three groups: inattention, impulsivity and hyperactivity. There can be sub-types: the combined type (inattention, impulsivity and hyperactivity), the predominantly inattentive type, and the predominantly hyperactive-impulsive type. Since ADHD is known to be a lifelong disorder, the symptoms for adolescence and adulthood are very similar to those that manifest themselves in younger children – except they appear to be less severe.
No Clinical Scientific Test Exists for Diagnosing ADHD
Despite a plethora of research, no clinical scientific test exists that can confirm or disconfirm ADHD. C. Keith Conners, Professor Emeritus of Medical Psychology in the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, together with Diane E Johnson Ph.D. point this out throughout their chapter: "The Assessment Process: Conditions and Comorbidities," in Clinician’s Guide to Adult ADHD, 2002.
According to Johnson and Conners, there are risk factors that can cause ADHD to be more symptomatic including genetics; however, no single genetic marker has yet been discovered. Some other risk factors they mention are:
- toxins
- temperament
- complications in pregnancy
- birth problems
- illnesses causing development delay
- environmental stress
Identifying ADHD in Adults
At present, ADHD can only be identified using a battery of tests and by looking for certain characteristic behaviours. This neurological problem is generally diagnosed according to the level and occurrence of these behaviours in a number of different settings. Thus, any kind of assessment of ADHD tends to be subjective and integrates what Johnson and Conners refer to as, “information across informants and domains.”
All things considered, generating a conclusive diagnosis is problematic. According to the researchers, there is also little consistency of the assessment of the disorder due to changing diagnostic criteria and differences in the view points between the USA and Europe.
One of the diagnostic tools available and used with adults is the well-known CAADID "Conners’ Adult ADHD Diagnostic Interview for DSM-IV," authored by Jeff Epstein, Ph.D., Diane E. Johnson, Ph.D., and C. Keith Conners, Ph.D.
ADHD Rarely Occurs Alone
Johnson and Conners call attention to the fact that besides the inconsistencies in diagnostic criteria, to complicate matters further, there is a high rate of comorbidity or appearance of other conditions along with ADHD, including:
- learning disabilities
- mood and anxiety disorders
- conduct disorders
- substance related disorders
Furthermore, there are psychiatric and medical conditions that show similar symptoms, such as:
- borderline personality disorder
- frontal, parietal or temporal tumours
- depression
- substance abuse
More importantly, the normal ageing process and environmental stress may also cause organisational and inattention deficits.
No Official Diagnostic Criteria for ADHD in Adults
The diagnostic criteria for ADHD, published by the APA, The American Psychiatric Association, found in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR, 2000, are based on the symptoms that children present. The DSM-IV-TR does not list full criteria for adults since the original version was published in 1994 when there was still a lot of ambiguity around this disorder. The TR-revised edition, published in 2000, does not provide clear guidelines either. The DSM-V, due to be published in 2010, may redefine this disorder and list more exact diagnostic guidelines.
Some of the indicators mentioned in the DSM-IV-TR for ADHD are:
For attention:
- Appears spacey, daydreaming tuned out, not listening
- Seems to be forgetful and disorganised and tends to lose things
- Appears to have a short attention span, and is easily distracted
- Often fails to finish things
For impulsivity:
- Is easily frustrated and abandons tasks easily
- May interrupt and have difficulty waiting turn
- May seem excitable and volatile
- May not anticipate the consequences of their behaviour or actions
For hyperactivity:
- Appears to have high energy levels
- Cannot keep still, always seems to moving some part of their body
- May have difficulty staying seated, may have to get up and walk around
The DSM-IV-TR also states that the:
- problems should have started before age seven
- the behaviour should take place in a number of settings
Although this manual states that the symptoms causing impairment should have started before the age of seven, adults may have difficulty defining the time when their symptoms began and it may be impractical and unrealistic to contact those who may have a retrospective viewpoint.
In addition, it is noted in the DSM-IV-TR that there should be clear evidence in impairment of ability to function:
- in social environments
- in learning or work situations
Presently, helpful articles concerning ADHD are available from the AACAP (American Academy of Child and Adolescent Psychiatry) but they also do not offer an updated defined list of adult symptoms.
ADHD Differs Across the Life Span
Johnson and Conners state that the above mentioned behaviours can present themselves not only in adults with ADHD but in every human and characterise themselves differently across the life span. For example, in “ADHD in Children: Clinical Observations, Consensus in Child Neurology – ADHD," Journal of Child Neurology, 1998, P. Accardo mentions that hyperactivity tends to decline one year after the adolescent growth spurt and disruptive behaviours also decrease. Johnson and Conners also point out that DSM-IV-TR is not designed to cope with variations or development changes in symptoms and thus diagnosis of the disorder is very much left to the judgment of the assessor.
Together with the unavailability of scientific measures, lack of criteria, inconsistent diagnostic assessment guidelines, the changing in physiology over time and the difficulties posed when trying to collect historical behavioural information, another point of contention that Conners and Johnson highlight regarding the assessment of ADHD in adults is impairment. How can one evaluate impairment? Unfortunately, the DSM- IV-TR does not provide operational guidelines for measuring this construct.
Assessors Cautious of Over-Diagnosing ADHD
Finally, because of the above evaluation and diagnostic shortcomings, assessors and practitioners have to be careful not to over diagnose ADHD in adults and must be attentive of adults who are looking for “performance enhancement” or in some ways wish to gain from a positive diagnosis of ADHD.
Sources:
Accardo, P., "ADHD in Children: Clinical Observations, Consensus in Child Neurology – ADHD," Journal of Child Neurology, pp. 4-8, 1998.
Johnson, D., and Conners, C.K., “The Assessment Process: Conditions and Comorbidities,” Clinician’s Guide to Adult ADHD, Sam Goldstein, Anne Teeter Ellison, Chapter 4, 72-82. Elsevier, Academic Press, Florida, 2002.
Lesley Lanir - Freelance writer, lecturer and teacher trainer Lesley Lanir, writes on foreign language learning disorders, linguistics, and literature.
