علوم تربیتی

Attention Deficit Hyperactivity Disorder

in Teens and Adults:

They Don’t All Outgrow It

Robert J. Resnick

Randolph-Macon College

Attention deficit hyperactivity disorder (ADHD) has been long recognized

and well established in children, but its continuation into adulthood has

only recently been supported by the research. ADHD symptoms and concerns

typically appear differently in adults, but treatment options, conceptually

at least, are similar to those used for children who have ADHD. This

article introduces the issue of Journal of Clinical Psychology: In Session

devoted to ADHD in teens and adults. It presents the prevalence and

manifestations of the disorder and then reviews the subsequent articles

on the comorbidity, evaluation, education, psychopharmacology, and

psychosocial treatments of ADHD for teens and adults. The issue concludes

with an article on neurobiofeedback, a relatively new treatment

option. © 2005 Wiley Periodicals, Inc. J Clin Psychol/In Session 61:

529–533, 2005.

Keywords: adults with attention deficit hyperactivity disorder (ADHD); teens

with attention deficit hyperactivity disorder (ADHD); diagnosis; treatment

The symptoms of attention deficit hyperactivity disorder (ADHD) have been well documented

for more than 100 years, but the nomenclature of attention deficit disorder (ADD),

now ADHD, is only about 25 years old. Only relatively recently has the conventional

belief that such disorders are experienced only in childhood and outgrown in adolescence

given way to recognition of the reality that ADHD is usually not outgrown. Symptoms

continue in most children who have ADHD into adolescence and adulthood, causing

personal, social, occupational, and even leisure time dysfunction.

Correspondence concerning this article should be addressed to: Robert J. Resnick, Ph.D., Department of Psychology,

Randolph-Macon College, Ashland, Virginia 23005; e-mail: rresnick@rmc.edu.

JCLP/In Session, Vol. 61(5), 529–533 (2005) © 2005 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20117

Until the early 1970s, there was general agreement that ADHD was outgrown during

puberty. This view was self-reinforcing as the major focus for many years was the child’s

elevated activity level in teenage years. This myopia significantly contributed to the

belief that with maturation came cure. However, by 1976 evidence demonstrated that

most children who haveADHD do not outgrow their symptoms, although symptoms may

change. Frequently their symptom presentation is altered by maturation and by improved

cognitive ability and coping. Hyperactivity is reduced in adulthood, but impulsivity and

other symptoms related to executive functions typically become more evident as the

demands for self-sufficiency increase with age. By the mid- to late-1990s, there was

general agreement that approximately one-half to two-thirds of children who haveADHD

continue to have symptoms of the disorder into their teenage years and on into adulthood.

Most teens and adults experience occasional problems with inattention, impulsivity,

distractibility, and restlessness, but individuals who have ADHD differ from others in the

frequency, intensity, and duration of these symptoms. ADHD in teens and adults is more

often manifested by numerous problems related to the executive function problems that

can lead to significant difficulties in daily life management. These populations who have

ADHD are also at risk of being misdiagnosed because presenting symptoms mimic those

of other disorders, particularly depression, substance abuse, anxiety, sleep problems, marital

distress, feeling of being overwhelmed, low motivation, and poor employment history.

Additionally, people who have ADHD may have one of several comorbid disorders,

most often depression. Academic underachievement (frequently diagnosed as learning

disability) is also a common cofinding among teens and adults who have ADHD. Indeed,

learning disabilities may be confused with ADHD symptoms and misdiagnosed: A learning

disability is the diagnosis but ADHD is the underlying cause.

This brief article outlines the symptoms and treatments of ADHD in adolescents and

adults and then introduces the subsequent articles in this issue of the Journal of Clinical

Psychology: In Session, which is devoted to this topic.

Teens Who Have ADHD

As children who have ADHD change from “tweenagers” to teenagers, their symptoms

may be different because of maturational and cognitive development. Teenagers who

have ADHD often have multiple behavioral, academic, and interpersonal problems that

unfortunately are misidentified because they are thought to have “outgrown” ADHD as

the excessive motor activity has often diminished, giving way to more subtle fidgetiness

and a sense of inner restlessness.We now know that teens who haveADHD are extremely

vulnerable to conduct problems, oppositional-defiant behaviors, and academic problems.

Additionally, teen girls who have ADHD are likely to have worsening of symptoms

because of the hormonal changes at puberty and are at increased risk for unplanned and

unwanted pregnancies, among other problems, than their unaffected counterparts. Teens

who haveADHD are more likely to drink coffee to excess and to smoke, probably because

both caffeine and nicotine may increase arousal in underactive parts of the brain. Additionally,

adolescents who have ADHD also have more traffic accidents, speeding citations,

and academic difficulties than their peers (Cox, Merkel, Penberthy, Kovatchev, &

Hankin, 2004).

Adults Who Have ADHD

Although there cannot be an adult onset of ADHD, quite commonly the diagnosis of

ADHD is not made until adulthood. ADHD is probably a disorder one is born with, but

530 JCLP/In Session, May 2005

childhood symptoms are frequently overlooked or misdiagnosed. Individuals who have

hyperactive/impulsive ADHD accompanied by disruptive behavior are more likely to be

identified in childhood. Children whoseADHD is less disruptive, who have more inattentiveness

symptoms, may not be diagnosed until adolescence or adulthood. One cannot,

however, have ADHD as an adult without having ADHD (though not always identified)

as a child. Parents, culture, socioeconomic class, schools, and ethnicity contribute to the

variability in the tolerance level (and thus, intervention) of ADHD symptoms (Resnick,

2000). Wender (1995, 2000), in his rigorous reviews of prevalence data, concludes that

the incidence of ADHD in adulthood is 2%–7% and that 4% is the generally accepted

rate. The ratio of men to women has been reported to be between 2:1 and 1:1 (Resnick,

2005). The nearly equal number of males and females in adulthood strongly suggests a

significant underdiagnosis ofADHD among girls, as reflected by childhood gender ratios

typically reported at 3:1 or greater.

The diagnosis of ADHD in adults, as in children, can be one of three types: attention

deficit hyperactivity disorder primarily hyperactive-impulsive type; attention deficit hyperactivity

disorder primarily inattentive type; or attention deficit hyperactivity disorder,

combined type (hyperactive-impulsive and inattentive). The diagnostic manual (Diagnostic

and Statistical Manual of Mental Disorders, fourth edition, Text Revision, 2000)

provides diagnostic criteria; however, they are essentially the symptoms of ADHD children,

more specifically of male children. Thus, many of the criteria need to be modified

to be applicable to adults (see Resnick, 2000).

Often the symptoms of adults who have ADHD cluster around procrastination, disorganization,

and forgetfulness—even for those activities they are motivated to do and

enjoy. Hyperactivity is more likely to be experienced as a feeling of tension or restlessness

in adults who haveADHD. Stress intolerance, affective lability, and living by “avoidance”

of deadlines are frequent concomitant findings. Interpersonal confrontations are

often brief and intense for adults who have ADHD

Treatments

Treatment for teens and adults who have ADHD, like ADHD children, is multifaceted

and individualized to meet the needs of the patient. Patient and family education that

explains the ADHD diagnosis, its lifetime course, and treatment options is the first intervention.

Medication management is often used, but the response rate is lower and less

robust compared to that of children. Stimulants have been the drug of choice for decades

and continue to be the most used class of medications. Antidepressant medication is a

second-tier drug used for ADHD among teens and adults and may also be more often

used when there is a cofinding of depression or anhedonia. Recently, nonstimulant drugs

(norepinephrine reuptake inhibitors), similar in chemical structure to antidepressants,

have been marketed specifically to treat ADHD. Medication management for women

who have ADHD is more challenging because of reproductive issues and the potential

impact of menstrual cycles on drug effectiveness. For ADHD, adolescents and adults

rarely need long-term, insight-oriented psychotherapy, except for a comorbid condition,

but focused psychotherapy around life-span issues (e.g., marriage, job change, parenthood)

is both common and effective. Intermittent treatment may include improvement of

social skills, teaching of self-advocacy, bibliotherapy, self-help groups (e.g., Children

and Adults with Attention Deficit Disorders [CHADD] and the Attention Deficit Disorders

Association [ADDA]), stress reduction, environmental manipulation, work assistance,

and school-based interventions. Other strategies may include marital/couples therapy,

ADHD in Teens and Adults 531

coaching, visual prompts (sticky notes, personal digital assistants, to-do lists), advocacy

for the adult who has ADHD, and ongoing treatment of comorbid conditions.

On occasion certain provisions of two federal laws may assist adults who haveADHD.

First, the Individuals with Disabilities Educational Act (IDEA) mandates a free and public

education until age 21. Second, the Americans with Disabilities Act (ADA) requires

employers who have at least 15 employees to make “reasonable accommodations” for a

person who has ADHD who is “otherwise qualified” to perform the job functions. This

mandate includes schools as well.

Outcome

Treatments are effective and can bring about significant improvement in the life quality

of persons suffering with ADHD. However, ADHD is rarely cured; the realistic aim is

to manage it. Treatments must be individualized, integratinging treatment of the interfering

symptoms with the strengths and needs of the ADHD patient. Many adolescents

and adults who have ADHD have difficulty accepting the help of others, viewing it as

evidence of their personal shortcomings. The ADHD therapist, coach, spouse, and friend

must try to keep the person focused on goals, not necessarily on how goals are achieved.

The goals are to make the world more ADHD-friendly (Nadeau, personal communication,

1999) and to introduce a degree of order, peace, and happiness to the affected

adult’s life.

An Update on ADHD in Adolescents and Adults

In order to increase awareness of this overlooked diagnosis and to highlight diagnostic

and treatment resources, we asked leading authorities onADHD to contribute their knowledge

to this issue of the Journal of Clinical Psychology: In Session. They have graciously

given their expertise. Jeanette Wasserstein reviews the diagnostic assessment of attentional

deficits in teens and adults. She describes the significant areas to be covered in a

diagnostic interview, the use of questionnaires, and the indications for neuropsychological

testing. Kathleen G. Nadeau addresses workplace and career concerns that ADHD

impacts in teens and adults. Carol Ann Robbins examines the social and relational travails

related to ADHD in teens and adults. She emphasizes how to educate individuals, couples,

and families so that they will be better informed about the debilitating effects of

ADHD and communicate more effectively by using Imago Therapy. Patricia Quinn reviews

the diagnosis and treatment ofADHD in female teens and adults, underscoring the impact

of hormonal fluctuations on ADHD symptoms as well as the social challenges faced by

women who have ADHD.

From diagnosis we move to treatment. William W. Dodson provides a practitionerfriendly

review of pharmacotherapy for ADHD for teens and adults. In his article on

psychosocial treatment, Kevin Murphy describes various psychological and behavioral

interventions that have been successful for teen and adult ADHD. He also reviews federal

statutes that can be used to manage treatment in educational and employment settings.

Concluding the issue is an article by Steven M. Butnik, who presents information and a

case study on using neurobiofeedback: a relatively new diagnostic and treatment strategy.

Select References/Recommended Readings

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(4th ed., Text Revision). Washington, DC: Author.

532 JCLP/In Session, May 2005

Cox, D.J., Merkel, R.L., Penberthy, J.K., Kovatchev, B., & Hankin, C.S. (2004). Impact of methylphenidate

delivery profiles on driving performance of adolescents with attention-deficit/

hyperactivity disorder:Apilot study. Journal of the American Academy of Child and Adolescent

Psychiatry, 43, 269–275.

Jackson, M.T. (1997). The adult attention deficit disorders intervention manual. Columbia, MO:

Hawthorne Educational Services.

Kolberg, J., & Nadeau, K.G. (2002). ADD-friendly ways to organize your life. New York:

Brunner-Routledge.

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Wender, P.H. (1995). Attention-deficit hyperactivity disorders in adulthood. New York: Oxford

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