Most kids don’t outgrow ADHD

Doctors once thought that children who suffered from attention deficit hyperactivity disorder (ADHD) would outgrow the condition once they reached adulthood. It’s now clear, however, that most of these children continue to experience ADHD-related difficulties later in life.

“About two-thirds of children with ADHD go on to be adults with ADHD,” said Lenard Adler, director of the Adult ADHD Program at New York University School of Medicine. According to recent estimates, nearly 4% of U.S. adults have the disorder.

Research shows, however, that only about one in five adults with ADHD is properly diagnosed and treated. One reason the diagnosis of ADHD often is missed in adults: Many doctors are uncomfortable making it. “There’s a lack of understanding and training about adult ADHD among healthcare providers,” Adler said.

In a recent survey of primary-care physicians, only 35% reported feeling comfortable diagnosing and treating adult patients with ADHD, although their comfort levels with other conditions that affect mental function, including depression (92%) and anxiety (85%), were much higher.

Also, the diagnosis of ADHD is not always clear-cut, particularly in adults. There are no objective measures, such as blood tests or X-rays, on which to base this diagnosis. Instead, doctors must rely on subjective criteria such as what patients say they’re feeling and experiencing.

Adults with ADHD may complain of difficulty managing their day-to-day responsibilities, such as paying bills or completing household tasks; they might report feeling stressed because they’re unable to finish work or tasks; or they could experience overwhelming feelings of frustration because they are simply unable to organize themselves. Some report difficulties managing time efficiently, or complain that they are easily distracted.

Since most adults experience similar problems at one time or another, it often is difficult for physicians to differentiate people with actual ADHD from those who don’t have it. “It’s really a question of degree,” says Jeanette Wasserstein, assistant clinical professor of psychiatry at Mount Sinai School of Medicine in New York. To justify a diagnosis of adult ADHD, the symptoms must cause actual impairment at work, at home or in social settings. Symptoms must also be more or less continuous from childhood. (Even if a patient was not actually diagnosed with ADHD as a child, some symptoms must have been present then.)

Another factor in diagnosis is that outward signs of the problem tend to become less noticeable over time. Hyperactive and impulsive behaviors, for instance, typically wane. “While they may still feel restless, they’re less likely to get up out of their chair or climb onto their desk” than a child with the condition might be, Adler said.

In adults, difficulty maintaining attention and focus are the predominant symptoms. Because they tend to be more difficult to recognize than problems with hyperactivity and impulse control, they’re more likely to be missed or blamed on a lack of will or effort. (For instance, a child who is constantly disruptive in class is more likely to be identified as potentially having ADHD than a child who simply doesn’t pay attention.)

The diagnostic challenge is further complicated by the fact that people with ADHD frequently have psychiatric disorders with overlapping symptoms. About half of all adults with ADHD have conditions such as depression, anxiety, manic depression and substance abuse problems that can mask the presence of the disorder.

In spite of all these difficulties, a brief questionnaire created by the World Health Organization has been found to be highly effective in identifying people at risk for having adult ADHD. The six-item questionnaire consists of four questions related to inattentiveness and two related to hyperactivity and impulsivity. In a recent study conducted at Harvard Medical School, individuals who screened positively on the questionnaire had a 93% chance of actually having ADHD.

“The cost of not diagnosing and treating the disorder is substantial,” Adler says. Divorce rates and unemployment are higher among adults with untreated ADHD. When properly identified, the symptoms can generally be well managed with medications. For many adults, just getting a diagnosis brings relief because it helps explain the difficulties they experienced since childhood.

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Indicators of adult ADHD

A self-test developed by the World Health Organization can help identify behavior consistent with adult ADHD. Four or more choices of Sometimes, Often or Very Often indicate the potential benefit of an in-depth evaluation with a health care provider.

In the last six months:

1. How often do you have trouble wrapping up the final details of a project once the challenging parts have been done?

Never; Rarely; Sometimes; Often; Very often

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

Never; Rarely; Sometimes; Often; Very often

3. How often do you have problems remembering appointments or obligations?

Never; Rarely; Sometimes; Often; Very often

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

Never; Rarely; Sometimes; Often; Very often

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

Never; Rarely; Sometimes; Often; Very often

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Never; Rarely; Sometimes; Often; Very often

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Source: World Health Organization

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Dr. Valerie Ulene is a board- certified specialist in preventive medicine practicing in Los Angeles.