Part 2 of a 3 part series by Constant Mouton.
“Just when I think I have learned the way to live, life changes” – Hugh Prather.
For many of us, ADHD conjures up stereotypes from TV, films or books. We might think of Jim Carrey in Bruce Almighty, Tigger from Winnie the Pooh or Dory from Finding Nemo. Of course these stereotypes are well researched and often spot on for certain types of ADHD. The problem though is that they are just that – stereotypes.
The definition of ADHD is constantly being revised as more becomes known about this condition. The APA (American Psychiatric Association) first classified ADHD in 1987, and has defined ADHD in its currently recognised form since only 2000. It is only recently that ADHD is becoming recognised as a disorder seen not only in childhood, but which also occurs in adulthood and even the elderly. Because we all change throughout our lives, it is comprehensible that ADHD can present variously throughout the lifespan.
This second article in the series on ADHD and addiction, provides a brief overview of the different symptoms, consequences and co-occurring conditions of ADHD throughout the lifespan in order to assist those working in addiction services or other settings where ADHD frequently occurs, to recognise ADHD.
When looking at the occurrence of ADHD throughout the lifespan, it is important to remember the three core clusters of symptoms in ADHD:
It is equally important to compare comorbidity and its consequences throughout the lifespan.
The best known presentation of ADHD is probably the image of hyperactive, sometimes destructive children often labelled as “naughty” or sometimes as having a “learning disability”. Hyperactivity in this age group most commonly expresses itself as restlessness, difficulty in remaining seated or still for any length of time, fidgeting, running or climbing. Impulsivity is expressed as blurting out answers in the classroom, interrupting others, talking excessively and acting without thinking of the potential consequences. Inattention is expressed as daydreaming, not listening, not finishing assignments or working slowly.
In childhood, ADHD results in behavioural disturbances, academic problems, difficulty socialising and low self-esteem.
It is often associated with comorbidity of oppositional defiant syndrome, conduct disorder, learning disability, anxiety and depression.
During this transitional stage between childhood and adulthood, the individual becomes more independent, but also starts to re-examine his or her identity. Without going into the details of the Ericksonian phase of “identity versus role confusion”, it is understandable that the ADHD symptoms during this turbulent phase of life becomes somewhat more complicated.
Although the symptoms appear to be similar to those seen in childhood, hyperactivity seems to be less prominent than in childhood with impulsivity and inattention remaining equally present.
As in childhood, ADHD in adolescence can result in academic underachievement, difficulty socialising and low self-esteem. Problems with the law, smoking, experimental substance use and physical injury due to recklessness are more prominent if ADHD is left untreated.
The comorbidity seen in this phase of life corresponds mainly with that seen in childhood, with the addition of substance use disorders and possibly behavioural addictions such as internet gaming disorder.
During adulthood, hyperactivity and impulsivity may still be present, but it is mainly inattention that causes problems for individuals. Because it is not as easily observed as hyperactivity, this “silent disorder” can linger on undiagnosed for longer than necessary, potentially causing more damage to the lives of sufferers.
Inattention is mostly expressed as procrastination, being late for meetings or missing appointments, being forgetful and disorganised. Making careless mistakes in traffic can lead to road accidents, a risk which is increased further if combined with driving at high speed due to hyperactivity. If present in adulthood, hyperactivity symptoms are difficulty relaxing, being restless, excessive talking, difficulty waiting in the line, and engaging excessively in sporting activities. Impulsivity typically results in frequently quitting jobs, starting (but not finishing) multiple projects, promiscuity, impulsive spending, and outbursts of anger.
External stimuli can be very disturbing to an ADHD sufferer who struggles to filter a conversation from sounds in the background, and experiences difficulty focusing on one thing at a time. This results in sufferers tiring and oversleeping.
The hyperactivity and impulsivity can also manifest as great creativity or enthusiasm for new tasks, as well as talking excessively or interrupting others.
A frequently seen consequence of ADHD in adulthood, is underachievement academically, at work or in relationships. If untreated in adulthood, ADHD leads to an increased likelihood of unemployment, an increase in absence due to sickness, and increased risk of criminal conviction.
Disorders commonly co-occurring with ADHD in adulthood are addiction (chemical or behavioural addiction), mood disorder (both depression and bipolar disorder), generalised anxiety disorder, post traumatic stress disorder and personality disorders.
Very little is known about elderly patients and ADHD. However, it seems that while the symptoms are often similar to those found in younger adults, the consequences are more pronounced. Important in the occurrence of undiagnosed ADHD in later life, is that patients have usually found different ways to cope with the symptoms themselves: substance use disorder as a means to self-medicate is frequently seen. Sufferers may have a history of years of alcohol or stimulant addiction as a way of self-medicating, with significant histories of addiction to stimulant drugs earlier in life. Psychiatric histories can include depression, anxiety and post traumatic stress disorder. In addition, personal histories often reveal many job changes and relationship problems together with a life of underachievement, financial difficulties and personal adversity.
In addition to known comorbidity in adulthood, cognitive problems such as dementia can aggravate the symptoms of ADHD, with sufferers having greater difficulty in coping with typical phase of life problems such as the loss of loved ones. If ADHD is left untreated, physical illness can be more severe in the elderly due to an increase in lifelong substance use and risk taking behaviour present in earlier life.
Who should be aware?
Unfortunately the responsibility for recognising ADHD still lies primarily with child psychiatrists and paediatricians. Even though an initial diagnosis and treatment is best left to the specialist, the recognition of ADHD seems to have become the responsibility of many more professions. During school years the sufferer may express symptoms to a teacher, paediatrician, general practitioner, school nurse or school psychologist. During adolescence and younger adulthood, in addition to the general practitioner, the drug counsellor, internist, adult psychiatrist, neurologist, obstetrician or lecturer might be the first to recognise symptoms. Later in life, an employer, spouse, child, medical or legal specialist, addiction specialist or even geriatrician may be the first to recognise ADHD traits.
The recognition is higher in children than in older adults, mainly because more is known about ADHD in children, than in adults. The problem of underdiagnosing and undertreating ADHD throughout the lifespan is that as age increases, so does the severity of co-morbidity as well as the burden on the individual and society.
Even though this series of articles focuses primarily on addiction and ADHD, it is not only the addiction counsellor, but also the partner, employer, health care provider and educator who should have more knowledge about ADHD in order to recognise and promptly refer to the mental health setting for accurate diagnosis and treatment.
Part III of this series will reveal more about how a diagnosis is made, and how to connect the dots in obtaining a clear and comprehensive clinical picture.
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- Wilson TW, Wetzel MW, White ML, Knott NL. Gamma-frequency neuronal activity is diminished in adults with attention-deficit/hyperactivity disorder: a pharmaco-MEG study. (2012) J Psychopharmacol. 2012;26(6):771-777.
- Stahl, S. M., and Meghan M Grady. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide. 4th ed. Cambridge, UK ; New York: Cambridge University Press, 2011.
See below for more information on Constant Mouton and his talk at iCAAD London May 1-3 2017