Saturday, January 16, 2010

ADHD in Adulthood

Attention Deficit/Hyperactivity Disorder (often referred to as ADHD, AD/HD or ADD) is a chronic neuro-behavioral disorder, usually first diagnosed in childhood.  The DSM-IV has described ADHD as having three subtypes: predominantly hyperactive-impulsive, predominantly inattentive and combined hyperactive-impulsive and inattentive.

For the predominantly hyperactive-impulsive subtype, most of the symptoms (six or more) are in the hyperactivity-impulsivity categories.  Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.  Symptoms of hyperactivity in children may include:
  • Fidget and squirm in their seats
  • Talk nonstop
  • Dash around, touching or playing with anything and everything in sight
  • Have trouble sitting still during dinner, school, and story time
  • Be constantly in motion
  • Have difficulty doing quiet tasks or activities.
and symptoms of impulsivity in children may include:
  • Be very impatient
  • Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
  • Have difficulty waiting for things they want or waiting their turns in games
For the predominantly inattentive subtype, the majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.  Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing.   Symptoms of inattention in children may include:
  • Be easily distracted, miss details, forget things, and frequently switch from one activity to another
  • Have difficulty focusing on one thing
  • Become bored with a task after only a few minutes, unless they are doing something enjoyable
  • Have difficulty focusing attention on organizing and completing a task or learning something new
  • Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
  • Not seem to listen when spoken to
  • Daydream, become easily confused, and move slowly
  • Have difficulty processing information as quickly and accurately as others
  • Struggle to follow instructions
For the combined hyperactive-impulsive and inattentive subtype, six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.  Most children with ADHD have the combined type.

Estimates of ADHD have varied, but it is believed that it affects between 3% and 5% of children.  Although it has previously been thought of as a disorder of childhood, it is now understood that ADHD often continues well into adulthood.  In fact, it is believed that as many as 30% to 70% of children with ADHD may continue to experience symptoms as an adult.  Like ADHD in children, adult ADHD is not indicative of the person's creative capacity or intellectual abilities.  In fact, people with all levels of talent and IQ may struggle with ADHD.

There are many adults who have never been identified as having ADHD in childhood, yet they present with difficulties and behaviors in adulthood that are suggestive of an undiagnosed and untreated ADHD.   These difficulties and behaviors are often difficult to identify as ADHD because they are often mistaken for other things, such as stress and coping problems, substance abuse or other psychological problems. ADHD is not often recognized in these adults until they seek help with one of these conditions.  In fact, many adults may first realize they have ADHD only when their own children or another family member are diagnosed with the condition.

Thomas E. Brown, Ph.D., an expert in the area of ADHD, and author of the highly recommended book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults, suggests that ADHD reflects a developmental impairment of executive function.  He noted that ADHD adults typically present with a variety of complaints, including concentration problems, disorganization or distraction, and difficulty initiating tasks, working consistently, and attending to detail.  As a consequence, Dr. Brown identified six symptom clusters that were consistently reported by those with ADHD.  These included problems in:
  1. Activation: organizing tasks and materials, estimating time, prioritizing tasks, and getting started on work tasks. Patients with ADHD describe chronic difficulty with excessive procrastination. Often they will put off getting started on a task, even a task they recognize as very important to them, until the very last minute. It is as though they cannot get themselves started until the point where they perceive the task as an acute emergency.
  2. Focus: focusing, sustaining focus, and shifting focus to tasks. Some describe their difficulty in sustaining focus as similar to trying to listen to the car radio when you drive too far away from the station and the signal begins fading in and out: you get some of it and lose some of it. They say they are distracted easily not only by things that are going on around them, but also by thoughts in their own minds. In addition, focus on reading poses difficulties for many. Words are generally understood as they are read, but often have to be read over and over again in order for the meaning to be fully grasped and remembered.
  3. Effort: regulating alertness, sustaining effort, and processing speed. Many with ADHD report they can perform short-term projects well, but have much more difficulty with sustained effort over longer periods of time. They also find it difficult to complete tasks on time, especially when required to do expository writing. Many also experience chronic difficulty regulating sleep and alertness. Often they stay up too late because they can't shut their head off. Once asleep, they often sleep like dead people and have a big problem getting up in the morning.
  4. Emotion: managing frustration and modulating emotions. Although DSM-IV does not recognize any symptoms related to the management of emotion as an aspect of ADHD, many with this disorder describe chronic difficulties managing frustration, anger, worry, disappointment, desire, and other emotions. They speak as though these emotions, when experienced, take over their thinking as a computer virus invades a computer, making it impossible for them give attention to anything else. They find it very difficult to get the emotion into perspective, to put it to the back of their mind, and to get on with what they need to do.
  5. Memory: utilizing working memory and accessing recall. Very often, people with ADHD will report that they have adequate or exceptional memory for things that happened long ago, but great difficulty in being able to remember where they just put something, what someone just said to them, or what they were about to say. They may describe difficulty holding one or several things "on line" while attending to other tasks. In addition, persons with ADHD often complain that they cannot pull out of memory information they have learned when they need it.
  6. Action: monitoring and regulating self-action. Many persons with ADHD, even those without problems of hyperactive behavior, report chronic problems in regulating their actions. They often are too impulsive in what they say or do, and in the way they think, jumping too quickly to inaccurate conclusions. Persons with ADHD also report problems in monitoring the context in which they are interacting. They fail to notice when other people are puzzled, or hurt or annoyed by what they have just said or done and thus fail to modify their behavior in response to specific circumstances. Often they also report chronic difficulty in regulating the pace of their actions, in slowing self and/or speeding up as needed for specific tasks.
These problems often result in difficulties in many areas of the person's life.  Adults with ADHD may demonstrate chronic problems which impact their career development, their relationships and their general functioning.  Research has found that the most common behaviors in the ADHD adult that have a negative impact on relations are:
  • doesn’t remember being told things
  • saying things without thinking (sometimes resulting in social inappropriateness)
  • “zoning out” in conversations
  • problems dealing with frustration
  • trouble getting started on a task (procrastination)
  • underestimating time needed to complete a task (poor planning, time management)
  • leaving a mess and being disorganized (can include a messy or disorganized home, office)
  • forgetting special dates, meetings or always being late
  • not finishing a project
As a consequence of all of the above, the ADHD adult can be experienced as unmotivated, lazy or immature.  They may be experienced as requiring constant encouragement or supervision in order to remain focused or complete role appropriate tasks.  They may be experienced as unreliable or insensitive.  Their verbal impulsivity can make other people feel uncomfortable. People with ADHD may often enjoy vigorous conversation as a source of stimulation, however may struggle to recognize that others may not share this enjoyment,  As a result, while others in similar situations may know to tone down the argument and move onto another topic, the ADHD adult may persist in the conversation, leading to social unpleasantness.

Many times, adults with ADHD might unconsciously seek relationships with those who act as organizers for them - disciplined, controlled people who 'loan' their organizing functions to the ADHD adult from time to time.  While this may often result in a cooperative and supportive relationship, frustrations in the relationship may exist as the ADHD adult may be experienced as needing a lot of management, and as being demanding and immature.  The partner may find that they are constantly nagging the ADHD adult to get up, to tidy up, to get organized, and to take care of business. The ADHD adult may be constantly misplacing their keys or forgetting to do important tasks.  In addition, the partner may sometimes feel hurt that their ADHD adult loved one doesn’t seem to listen to them, blurts out hurtful things, and leaves them with the bulk of the responsibility for organizing and planning.

The ADHD adult may struggle in making career decisions, in being disciplined in ways that allow for the successful development of a career, or may demonstrate impulsivity resulting in frequent career changes.  At work, they may be disorganized, may procrastinate or may be verbally impulsive which may negatively impact relationships at work. They may demonstrate difficulty concentrating, completing tasks, listening, and relating to others which can also lead to trouble at work. They may make frequent errors in writing and spelling which they do not notice soon enough.  In their personal lives, managing finances may be a concern. The ADHD adult may find him or herself struggling to pay bills, losing paperwork, missing deadlines, or be in debt due to impulsive spending.  Their inattention and impulsivity may lead to frequent clumsiness or an increased risk for car accidents or traffic tickets.

Impulsivity and trouble with organization in the ADHD adult can also lead to problems with health, such as compulsive eating or reaching for unhealthy foods, a reinforcing cycle of alcohol and drug abuse, or trouble making appointments or forgetting medication for a chronic condition.  Many ADHD adults may self medicate with chronic marijuana use (or other substances) in their unconscious attempts to increase their focus or regulate their affect.

Structure and organization can significantly improve the life of the ADHD adult.  Personal aids such as PDAs and other organizers can be invaluable in keeping the ADHD adult on track and on task.  Developing consistent schedules for everything, including eating and sleeping can also be important in regulating affect and behavior.  However, medication intervention, coupled with the above changes, has often been the most effective treatment for the ADHD adult.  Adults who might suspect a diagnosis of ADHD are encouraged to obtain a proper assessment such as psychodiagnostic testing by a skilled psychologist, to properly confirm the diagnosis of ADHD.

    Sunday, January 10, 2010


    'Tweenager' is a deliberately created word.  Marketing professionals recognized something important about the psychology of children (girls, in particular)  in the stage between youth and teenager.  They understood that these children, although a unique group, had a striving to be like their older counterparts, but also had a certain naivete that could be exploited.  Thus, the creation of the word 'tweenager' provided for the pre-teen an identity that acknowledged their relative youth status, but connected them to the older girls/guys they were aspiring to be.  The 'tweenage' stage, between the age of 10 years and 14 years, is an important period of cognitive, social, moral and sexual development that can present some challenges for both the child and the parents.

    In terms of cognitive development, during the tweenage period, the child moves from the Concrete Operations stage to the Formal Operations stage, as described by renown developmental psychologist, Jean Piaget.  During the Concrete Operations stage which occurs between the ages of 7 and 12 years, the tweenager begins thinking logically about concrete events, but may still have difficulty understanding abstract or hypothetical concepts.  As she/he moves into later tweenagehood and into Formal Operations, skills such as logical thought, deductive reasoning, and systematic planning begin to emerge.  Therefore, even though the tweenager may have the appearance, at times, of being an emerging adolescent, he/she may not have the cognitive sophistication to take on the complex decisions of adolescence.

    Changes in social development are also evident as the child moves through tweenagehood.  Renown developmental psychologist Erik Erikson described the social developmental process in eight stages.  Each stage is regarded by Erikson as a "psychosocial crisis," which arises and demands resolution before the next stage can be satisfactorily negotiated.  Erikson believed that the fourth psychosocial crisis was handled during what can now effectively be called the 'tweenage' period.  During this fourth stage, the issue of competence is central.  The tweenager, therefore,  is learning to master the more formal skills of life such as relating with peers according to rules, progressing from free play to play that may be elaborately structured by rules and may demand formal teamwork, and mastering important academics and increasing self-discipline in homework.  If all has gone relatively well for the child to this point, she/he will emerge feeling  competent and will be trusting, autonomous, and full of initiative and will learn easily enough to be industrious. However, this is also the period during which self-doubt, and feelings of shame, guilt and inferiority may be expressed when the child does not achieve this feeling of competence.

    The tweenager period ends when the child emerges out of this psychosocial crisis where struggles around competence is central and enters into the fifth psychosocial crisis (adolescence, from about 13 or 14 to about 20). Now an emerging adolescent, the tweenager begins to learn how to answer the question  "Who am I?"  During this period,  some role identity diffusion occurs and many may experiment with minor delinquency and rebellion.  However, it is also a critical period when this late tweenager may experiment with different - usually constructive - roles rather than adopting a "negative identity" (such as delinquency).  However, tweens sometime consolidate their identities through the formation of cliques.  Tween girls, in particular, as seen to be highly susceptible to forming cliques which, although can be a source of support and identity, can sometimes result in the phenomenon where tween girls may cruelly exclude their peers.  Both tween boys and girls also sometimes engaging in problematic bullying.

    Changes in moral development are also evident in the tweenager.  According to psychologist Kohlberg's theory of moral development, a change from a pre-conventional morality to a conventional morality typically begins during the tweenager stage.  The pre-conventional level consists of the first and second stages of moral development, and is solely concerned with the self in an egocentric manner. A child with pre-conventional morality has not yet adopted or internalized society's conventions regarding what is right or wrong, but instead focuses largely on external consequences that certain actions may bring.  As a result, if there are no negative consequences to their behavior, or if some positive comes of it, the tweenager may struggle to fully appreciate the inappropriate of his or her behavior. 

    As the tweenager develops, a shift towards a conventional level of moral reasoning is seen in the later tweenager stage.  This level of moral reasoning is typical of adolescents and adults. Those who reason in a conventional way judge the morality of actions by comparing them to society's views and expectations. The conventional level consists of the third and fourth stages of moral development. Conventional morality is characterized by an acceptance of society's conventions concerning right and wrong. At this level an individual obeys rules and follows society's norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid, however, and a rule's appropriateness or fairness is seldom questioned.

    For more and more, tweenagehood marks the onset of puberty and sexual development.  Girls usually experience the changes associated with puberty between the ages of 10-12 and it tends to happen a bit later for boys (between 12-15 years of age). Like any developmental milestone, there is a wide range of "normal."  Typically, however, these changes in sexual development are likely occurring in the context of changes in concrete cognitive operations, struggles around competence and pre-conventional morality, all of which may not optimally be in sync.

    Parents may notice changes in their tweenager as the changes in their cognitive, social, moral and sexual development converge.  For example, tweenagers may demonstrate new concerns or fears.  They may increasingly have a fear of kidnappings, rapes, and scary media events, as opposed to fantasy things such as witches, monsters, ghosts.  They may also have a more developed sense of looking into the future and seeing effects of their actions (as opposed to early childhood where children often do not worry about their future).  Parents may also notice that their tweenagers may begin to view human relationships differently.  They may notice the flawed, human side of authority figures, including their parents, whom they previously may have wholly embraced without question.  They may start caring about what they look like and what they are wearing.  In fact, alarmed parents may see their tween dressing like a teenager but still be unable to make the more sophisticated cognitive, social and moral decisions, which could leave the tweenager very vulnerable.  While they are trying out at being teenager by engaging in teenager behaviors, they may not have the emotional capacity to deal with the consequences of these choices.  Sometimes this includes the beginning of sexual experimentation.

    Parents must be prepared for the major shifts that are occurring in their children and be prepared to help them navigate through the changes in their cognitive, social, moral and sexual development.  Ultimately, like all periods of development, there is an eventual movement on to the next stage.  If sufficient support and understanding exists for the tweenage period, successful navigation into teenagehood will bring new and exciting challenges for all.