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August 2, 2010

Adult ADHD — Hidden Diagnosis
By Jennifer Van Pelt, MA
For The Record
Vol. 22 No. 14 P. 24

Adult ADHD is often obscured by comorbid conditions such as depression, anxiety, and substance abuse.

Adult ADHD is rarely recognized in the workplace, and those with the condition may be labeled as poor employees or fired, making career advancement or simply maintaining consistent employment difficult.

Impulsivity, distractibility, disorganization, restlessness, emotional outbursts. In children, a teacher would recognize these symptoms, and the parents would be referred to a medical professional for an attention-deficit/hyperactivity disorder (ADHD) evaluation. In adults, these symptoms may lead to people getting fired, filing for divorce, or simply being labeled as lazy or irrationally angry.

A recent World Health Organization (WHO) study estimated that 3% to 4% of adults worldwide have ADHD, with a rate of 4.5% in the United States.1 Of those, a large number—possibly 8 million to 10 million—are undiagnosed. Millions more do not receive appropriate treatment.2 The WHO study also reported that adults with ADHD miss an average of more than three weeks in workplace productivity yearly. The Centers for Disease Control and Prevention has estimated the costs of such work loss at $3.7 billion.3

“Adult ADHD is chronically misunderstood. A multitude of patients have spent years spinning their wheels in psychotherapy without having had their ADD diagnosed or treated,” says Roslyn Ross Steeler, MSW, LCSW, a therapist for 28 years. She has focused on the treatment of adult ADHD for the last 10 years after she and both of her children were diagnosed with the condition.

“When we were diagnosed and treated, I began to ask more questions of my patients and found that many of them had ADHD as their underlying problem yet had been diagnosed or presented with depression or anxiety along with relationship, marital, and job issues. Since then, I have focused on the understanding and treatment of adult ADHD,” Steeler explains.

“ADHD is often a hidden disability in adults,” says Leslie Rouder, LCSW, a therapist with more than 12 years of experience treating adult ADHD and as an ADHD coach.

ADHD is a common neurobiological condition usually diagnosed in childhood. Originally it was thought people would “outgrow” the condition as adults; however, 60% to 90% of adults continue to experience symptoms.1,2 In the past, ADHD was not studied as extensively or diagnosed as often as it is now in children, resulting in a high percentage of undiagnosed adults. Symptoms may have been present but were likely dismissed as just bad behavior. An ADHD diagnosis can still be difficult for adults and children since no single medical test exists for reaching that conclusion. An accurate diagnosis depends on a thorough clinical history and evaluation. In adults especially, an ADHD diagnosis can easily be missed due to comorbid depression, anxiety, substance abuse disorders, and/or other psychiatric conditions. And when an adult exhibits symptoms, employers, primary care physicians, and family members do not usually consider ADHD.

“When I think of the problems associated with adult ADD/ADHD, I think of that line from a TV advertisement for a credit card—‘It’s everywhere you want to be.’ ADD/ADHD has the potential to interfere with virtually any adult role,” says J. Russell Ramsay, PhD, an assistant professor of psychology and psychiatry at the University of Pennsylvania School of Medicine and clinical psychologist for Penn’s Adult ADHD Treatment & Research Program.

Problems associated with the condition most commonly occur in college, work, and relationships, he says. Specifically, ADHD seems to interfere with the individual’s sense of self-control and self-efficacy, thereby affecting his or her ability to establish and follow through on reasonable goals and to manage the various distractions involved with reaching those goals. “The specific small problems that lead to the larger problems in life domains are procrastination, poor time management, disorganization, distractibility, and poor emotional regulation,” Ramsay notes.

At work, symptoms of adult ADHD can translate to a messy work area, trouble starting and finishing projects, chronic lateness, underestimating the time needed to complete tasks, an inability to focus and listen during meetings, and forgetting or missing deadlines. In addition to the common symptoms of distractibility and impulsivity, problems in the area of executive functioning can manifest as an impaired ability to plan and prioritize work duties, says Rouder.

Workers with ADHD are rated lower on work performance, more likely to be disciplined by supervisors, paid lower salaries, and produce lower-quality work.2,4 Adult ADHD is rarely recognized in the workplace, and those with the condition may be labeled as poor employees or fired, making career advancement or simply maintaining consistent employment difficult. Paradoxically, employees with ADHD may also be viewed as hard workers due to a symptom called hyperfocus, a tendency to become overly absorbed in one task. Actually a coping mechanism for distraction, hyperfocus causes the individual to become oblivious to his or her surroundings to the extent that he or she loses track of time and neglects other duties. Hyperfocus at work may be viewed as productivity but, if left unmanaged, can become problematic if the worker neglects other tasks.

ADHD symptoms in adults can also include low self-esteem, memory problems, agitation or a short temper, reckless behavior, risk taking, and a lack of motivation. In addition to workplace problems, these symptoms can lead to financial difficulties, physical and mental health problems, and relationship difficulties. “Adult ADHD can cause problems in all realms and facets of a person’s life. Accurate diagnosis is essential,” Steeler says.

For example, one of Ramsay’s clients, Ralph, had been fired from nine different jobs during the first five years of his marriage and was unemployed for two years before seeking help. He started treatment when his wife threatened to divorce him due to his unemployment, forgetfulness in paying bills, and frequent embarrassing behaviors in social situations. Ralph admitted to experiencing feelings of being a failure, being incompetent, and pessimism about his ability to make changes in his life. Diagnosed with ADHD as a child, Ralph stopped taking medications in college and was ashamed to let employers know about his condition.5

Relationship problems such as the ones Ralph experienced are common for adults with ADHD. For those with undiagnosed ADHD, a pattern of being in bad relationships may develop as a result of underlying self-mistrust, says Steeler. And problems between adults with ADHD and their partners are also common.

Rouder frequently works with partners of adults with ADHD, receiving hundreds of calls and e-mails asking for help with managing the aspects of ADHD affecting the quality of their lives and relationships. “Many people are attracted to individuals with ADD for their zany sense of humor, imagination, creativity, charm, and ‘out-of-the-box’ thinking,” she says. “But for many couples, those attractive qualities can sometimes fade in the light of untreated ADD. Sadly, untreated ADD is a primary factor in many divorces and breakups between couples.”

Relationship problems may be magnified when couples seek help from someone who is not well versed in adult ADHD, and more damage to the relationship may occur. When an ADHD diagnosis is made and the symptoms are clearly understood, more effective counseling and therapy can be applied to the individual with ADHD, his or her partner, and the relationship so that healing can occur, Rouder says.

A Multifaceted Treatment Approach
For children with ADHD, medications are a primary, and often the only, method of treatment. For adults, medications are often insufficient treatment and if there is symptom relief, it may not translate into work and relationship improvements, says Ramsay. Because ADHD affects each adult differently, what works best for most patients is a treatment combination customized to their individual needs, including education about the condition, medications, psychotherapy, couples therapy, group therapy, vocational counseling, and/or coaching.

Cognitive behavioral therapy (CBT) is emerging as an effective treatment for adults with ADHD, and evidence supporting its value is increasing, Ramsay says. CBT can help adults with ADHD identify, for example, self-defeating behaviors and thought processes and assist them in implementing effective coping strategies and behavioral changes.4 In Ralph’s case, Ramsay and a psychiatrist combined a pharmacotherapy regimen, which helped him focus and complete tasks, with weekly CBT sessions to reach specific behavioral goals. Ralph’s CBT included using daily thought records to develop alternatives to pessimistic thoughts and role-playing to improve communication with his wife. Marital counseling was also eventually added into the treatment plan.5

But CBT is only one tool, says Steeler. Another valuable treatment involves identifying and building on a patient’s strengths. “One of the most important treatments is to help the patient identify their passions—and what they are good at—and to focus on developing these passions and strengths,” Steeler says. This technique positively redirects the ADHD symptom of hyperfocus, often enabling an adult with ADHD to be very successful. She cites the examples of Olympic swimmer Michael Phelps, whose hyperfocus helped his swimming career, and Albert Einstein, suspected to have ADHD with a hyperfocus on physics.

“When an adult with ADHD is able to identify and focus on their strengths and talents, instead of continuously shoring up their weaknesses, almost anything is possible,” says Rouder.

— Jennifer Van Pelt, MA, is a Reading, Pa.-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.


• Children and Adults With Attention-Deficit/Hyperactivity Disorder: www.chadd.org

• Help for Adults With ADHD: www.addadults.net

1. de Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: Results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008;65(12):835-842.

2. Barkley RA, Murphy KR, Fischer M. ADHD in Adults: What the Science Says. New York: Guilford; 2008.

3. Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD). Data & statistics. March 13, 2009. Available at: http://www.cdc.gov/ncbddd/adhd/data.html.

4. Ramsay JR. CBT for adult ADHD: Adaptations and hypothesized mechanisms of change. J Cogn Psychother. 2010;24(1):37-45.

5. Rosenfield BM, Ramsay JR, Rostain, AL. Extreme makeover. The case of a young adult man with severe ADHD. Clin Case Stud. 2008;7(6):471-490.