Issues in ADHD in Adults
by J. Russell Ramsay, Ph.D. and Anthony L. Rostain,
MD
As clinician?researchers interested in the
assessment and treatment of adults with ADHD, our
reaction to the DSM?IV?TR is akin to Winston
Churchill's observation on democracy: ?[It] is the
worst form of government except all the others that
have been tried.? Albeit a valuable tool for
classifying, studying, and validating mental
disorders, the current incarnation of the DSM
remains seriously flawed in its handling of
developmental disorders such as ADHD, particularly
as they affect adults. With the DSM?V committees
tentatively scheduled to begin deliberations in
2007, the committee dealing with ADHD may wish to
consider addressing some major issues with direct
relevance to that diagnosis in adults, namely (1)
creating a new axis for developmental disorders; (2)
identifying developmentally sensitive diagnostic
criteria for adults suspected of having ADHD; (3)
modifying the ?age of onset? criterion; (4)
clarifying the criteria for ?impairment?; (5)
developing additional subtypes that capture the
clinical realities of adult patients; and (6)
revising the category of ADHD?NOS to include
?acquired? ADHD.
Developmental Disorders ? Axis 1.5?
The multi?axial system of DSM is one of its
strengths. However, it is clear that the
developmental disorders currently listed in Axis I
are a distinctive subgroup insofar as they do not
resemble psychopathological conditions (like
schizophrenia or bipolar disorder). Instead, they
are disorders of neurodevelopment leading to a wide
variety of functional impairments in thinking,
feeling, acting, and learning that extend over the
entire life cycle. They resemble Axis II disorders
insofar as they are enduring conditions that can
affect all aspects of adaptation, but yet they are
not bona fide personality disorders. ADHD has been
described as an ?Axis 1.5? disorder (Ramsay &
Rostain, 2003) to illustrate how the effects of
executive dysfunction fall somewhere between these
two axes, a conceptualization that has been useful
with other developmental disorders affecting adult
patients (e.g., Asperger Syndrome, Ramsay et al.,
2005). Thus, the creation of a separate diagnostic
subgroup for all lifespan developmental disorders
(including ADHD) would serve to highlight the
long-term impact of these conditions. Moreover, such
a categorization would facilitate the introduction
of developmentally sensitive diagnostic criteria for
adult ADHD (e.g., Brown, 2005; McGough &
Barkley, 2004).
Developmentally Sensitive Diagnostic
Criteria for ADHD Adults
The current symptom list for ADHD includes
several items that are specific to the childhood
manifestations of ADHD and are not developmentally
appropriate for young adults and adults with ADHD
(McGough & Barkley, 2004). This is not
surprising as the original criteria were developed
for children and adolescents, ages 4 to 17 years
old. Rather than ?growing out of? ADHD, many
affected individuals simply outgrow the limited
definition of symptoms while continuing to
experience developmentally inappropriate problems
related to poor self?regulation. Thus, there is a
need to provide separate diagnostic criteria to
adequately reflect the symptomatology of adults with
ADHD.
Many of the current diagnostic criteria may be
easily modified to reflect the symptoms experienced
by adults with ADHD. In fact, many good examples of
adult ADHD symptoms are already captured by various
diagnostic instruments (e.g., Brown, 1996; Conners
et al., 1999). Specific symptoms reflecting the
degree of functional difficulties that interfere
with role performance experienced by adults with
ADHD might include the following:
- Difficulty initiating and following through on
important though manageable tasks or activities
despite deadlines or potential negative
consequences.
- Recurring problems learning and remembering
important information or details in daily life.
- Persistent difficulties managing tasks or
materials (e.g., bills, files, or tools at work or
home) and time (e.g., lateness for scheduled
meetings) that are not the result of environmental
interference.
Our suggestions above are, in fact, rather
similar to the empirically developed and tested set
of items set forth by Barkley and Murphy (2006) in a
prior issue of this newsletter (Vol. 14, 4), and
reprinted here with their permission. That list
consisted of:
- Is often easily distracted by extraneous
stimuli
- Often makes decisions impulsively
- Often has difficulty stopping my activities or
behavior when I should do so
- Often starts a project or task without reading
or listening to directions carefully
- Often shows poor follow through on promises or
commitments I may make to others
- Often has trouble doing things in their proper
order or sequence
- Is o ften more likely to drive a motor vehicle
much faster than others (excessive speeding)
- Often has difficulty sustaining attention in
tasks or play activities
- Often has difficulty organizing tasks and
activities
Barkley and Murphy recommended a threshold of 6
out of 9 of these symptoms as being the most
accurate for classifying adult cases of ADHD
relative to their clinical and community control
groups.
Age of Onset Criterion
Requiring evidence of impairment in childhood
prior to age seven is overly restrictive and results
in many impaired adults with ADHD not receiving the
diagnosis. Many individuals may have benefited from
supportive, structured environments in childhood
that allowed them to function adequately despite the
presence of symptoms. But, as they were expected to
take greater responsibility for their academic,
social, and personal activities with fewer
environmental supports, these individuals became
more impaired by their long-simmering ADHD symptoms.
Viewing ADHD within a developmental framework and
acknowledging that symptoms change with increased
age, it would seem that clinically significant
symptoms and impairment may not emerge until later
in life when the demands of the environment exceed
one's executive functioning in terms of the ability
to adapt, cope, and compensate.
A later age of childhood onset, say 12 years of
age, has been suggested as a reasonable adjustment
(McGough & Barkley, 2004), though many
individuals initially diagnosed with ADHD as adults
describe their symptoms as first causing noticeable
difficulties for them during middle school or early
high school. In a recent phone survey of adults with
ADHD, 12 was the median age of diagnosis for the
sample, but 35% of the sample were not diagnosed
until after reaching age 18 (Faraone &
Biederman, 2005). What is more, recent research
comparing adults with ?late onset? ADHD (e.g., meets
all childhood criteria except for age of onset) and
adults fulfilling the full diagnostic criteria
indicated that there are no differences between
these groups of ADHD adults in various measures of
functioning (Faraone, 2006). On the basis of both
clinical and empirical evidence, a recommended
revision of the DSM would be the guideline that a
diagnosis of ADHD in adulthood requires
retrospective evidence of the emergence of symptoms
by 16 years of age, as recommended by Barkley and
Murphy (2006) in an earlier issue of this
newsletter.
Symptoms and Impairment
The definition of what constitutes impairment has
been a tricky one in the field of ADHD (e.g.,
Barkley et al., 2006; Gordon et al., 2005). Because
adults are expected to assume more responsibility
for their behaviors, to function relatively
consistently in these roles over an extended period
of time (rather than getting a fresh start at the
end of an academic term), and are more likely to
have others dependent on their performance in
various life roles (e.g., co?worker or employer,
spouse, parent), the negative effects of ADHD in any
single domain of life may be severe enough to create
impairment warranting clinical attention. Hence, the
requirement of impairment in two or more settings
should be reduced accordingly for adults.
But what is a reasonable definition of
impairment? One that is too lenient runs the risk of
overdiagnosing individuals as having ADHD who may,
in fact, be experiencing transient adjustment
problems. On the other hand, a definition of
impairment that is too strict runs the risk of
excluding individuals who experience problems
directly related to ADHD. As it is currently
written, the diagnosis of ADHD is an
?all?or?nothing? category--either you have it or you
do not. Clinicians and researchers seem to agree
that ADHD symptoms fall along a continuum of
severity, reflecting a dimensional approach rather
than a categorical one. As such, it would seem
appropriate to include a diagnostic specifier to
indicate mild, moderate, or severe impairment, as is
already done with many other disorders. The appeal
of this approach would be to allow for the fact
there are varying degrees of impairment and, thus, a
severity level could be established to warrant
appropriate accommodations and other services for
adults, while acknowledging the presence of milder
forms of ADHD requiring treatment. This issue is
dealt with in considerably more detail in the
article by Lewandowski and associates.
Subtypes and Comorbidities of ADHD
The subdivision of ADHD into combined,
inattentive, and hyperactive?impulsive subtypes is
helpful insofar as it points to the heterogeneity of
presentations seen in patients with the disorder. As
noted in the lead article of this special issue by
Pliszka, it appears that an aggressive subtype may
exist that is being considered for DSM?V, which
makes sense given the high rates of externalizing
problems seen in children and adolescents. This
subtype could also be applied to adults who have
trouble controlling their temper and/or who are
prone to impulsive verbal or physical aggression.
Three additional subtypes could be considered for
inclusion in the DSM?V to further refine
descriptions of the diverse clinical presentations
of adults with ADHD: disorganized, anxious, and
mood?labile.
1. Many adults seeking help with ADHD symptoms
have an extremely difficult time keeping track of
the details of their lives and are extremely
disorganized. They may be able to focus (or even
hyper?focus) on tasks requiring attention, but they
exhibit slow cognitive processing and their
problem?solving style is chaotic. They appear to be
similar to that subset of children with ADHD having
sluggish cognitive tempo, or SCT (Milich,
Ballantine, & Lynam, 2001).
2. Another group of ADHD patients exhibits
performance anxiety when facing tasks that require
sustained mental effort. They do not meet criteria
for Generalized Anxiety Disorder, but there is a
clear and consistent pattern of nervousness and
apprehension when they confront everyday chores,
jobs, studies, and other duties, the performance of
which are made difficult by the effects of executive
dysfunction. This anxiety tends to further impair
the ability to stay focused and is often associated
with maladaptive procrastination and avoidance.
3. Finally, a fairly sizeable group of adult
patients with ADHD report fluctuating moods that
interfere with daily functioning, characteristics
first noted in Wender and colleagues' Utah criteria
(see Wender, 1987). Although not meeting criteria
for a bipolar spectrum disorder, these individuals
often become extremely angry or saddened with even
the slightest frustration or minor setback. They
find it difficult to modulate their affect, and
often express their feelings in ways that are
considered immature or dysfunctional. The major
distinction between the mood lability of ADHD and
that of bipolar spectrum disorders appears to be the
temporal dimension. Mood swings in the ADHD group
tend to be quickly triggered, brief, and are
responsive to cognitive?behavioral strategies.
ADHD Not Otherwise Specified
The diagnostic category ADHD ?Not Otherwise
Specified? (NOS) has been clinically useful for
individuals presenting with subthreshhold symptoms.
However, individuals whose symptoms fall within this
category have not been well studied. Recent research
indicates that individuals with subthreshhold
symptoms may differ from individuals with late onset
and full ADHD (Faraone, 2006). The DSM?V committee
may wish to consider expanding this diagnostic
category to also include individuals with atypical
patterns of onset (e.g., following traumatic brain
injury or in association with prolonged substance
abuse). ?Acquired? ADHD (as opposed to
developmentally based ADHD) requires additional
research to be validated, but given its relatively
frequent occurrence, ADHD NOS can be used to capture
this patient population.
Summary
Used as designed, the DSM can be an effective
tool for helping mental health professionals
determine the nature of difficulties encountered in
the clinical practice of psychology and psychiatry.
There have been many advances in the research and
treatment of adult ADHD in the decade or more since
the last major revision of the DSM. Further
modifications of the DSM?V in light of the distinct
clinical issues and symptomatology associated with
adult ADHD would reflect these advances and result
in a useful resource for practicing clinicians and
researchers.
Drs. Ramsay and Rostain are with the Adult
ADHD Treatment and Research Program at the
University of Pennsylvania School of Medicine.
Address correspondence to: J. Russell Ramsay, Ph.D.,
3535 Market St., 2 nd Floor, Philadelphia, PA
19104?3309, or e?mail: ramsay@mail.med.upenn.edu.
References
Barkley, R. A., Cunningham, C., Gordon, M.,
Faraone, S., Lewandowski, L., & Murphy, K.
(2006). ADHD symptoms vs. impairment: Revisited.
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Brown, T. E. (1996). Brown attention deficit
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Corporation.
Brown, T. E. (2005). Attention deficit
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Conners, C. K., et al. (1999). Conners' adult
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Reprinted with permission from ADHD Report, Guilford
Publications, Inc.,
December 2006, Volume 14 No. 6
