ADHD in adults: symptoms, characteristics (DSM-5 criteria)

As early as 1902, English pediatrician George Still described children with high levels of impulsivity, hyperactivity and lack of attention. What he described then is very similar to what we now call ADHD. Adult ADHD was first mentioned in psychiatric literature in 1976, but it wasn't until the 1990s that the diagnosis of ADHD in adults was thoroughly researched. The three core symptoms of ADHD "hyperactivity, impulsivity and attention problems," which are clearly expressed in children, may manifest in a different and more subtle way in adults with ADHD. Psychoeducation, medication, coaching and cognitive behavioral therapy are the basic elements of the treatment of ADHD in adults.

ADHD in adults

It has taken a long time to realize that ADHD does not simply disappear after age 18 and that adults can have ADHD, too. The three central characteristics of ADHD - attention problems, hyperactivity and impulsivity - often persist into adulthood. For some, lack of concentration is paramount and for others, hyperactivity. So not everyone with ADHD is very busy. There are also very quiet people with ADHD who mainly suffer from concentration problems and procrastination. The variation in manifestations can make a diagnosis difficult. In addition, many adults with ADHD struggle with other problems, such as sleep problems, addiction problems, gloominess, etc. It is not always clear which symptoms are most prominent. This makes making a diagnosis often no easy task.

What is ADHD?

ADHD stands for attention-deficit/hyperactivity disorder. In Dutch, it refers to attention and concentration problems, impulsivity and hyperactivity. In DSM-5, it is called attention-deficit/hyperactivity disorder. ADHD is highly heritable, but exactly how ADHD arises is still not entirely clear. However, it is already clear that it is caused by a subtly abnormal structure and functioning of a number of brain areas, which disrupts thought processes such as attention, motivation and executive functions. ADHD is therefore often called a "neurobiological disorder. Because ADHD usually manifests in childhood, it is also sometimes referred to as a developmental disorder.

ADHD: a complex interplay between genetic predisposition and environmental factors

There is probably a vulnerability in the hereditary predisposition in ADHD that is influenced by various environmental factors. These include factors during pregnancy (e.g., family strain, smoking and/or alcohol consumption during pregnancy), childbirth (a premature birth and/or oxygen deprivation during delivery may be associated with an increased risk of ADHD), and psychological and social environmental factors (e.g., an upbringing with little structure, clarity and boundaries). Although a person is born with a particular predisposition to ADHD, his or her upbringing plays a reinforcing or protective role in the subsequent course. A lack of structure and guidance, and inconsistency in parental authority, can reinforce ADHD symptoms and fuel behavioral problems. In short, it is the complex interplay between genetic predisposition and environmental factors that determines whether a person develops ADHD. Several genetic and environmental factors play a role in the development of ADHD, with heredity being dominant.

ADHD: three major groups of symptoms

The fundamental characteristics of ADHD can be clustered into three groups of symptoms:

• Attention problems: short attention span, easily distracted and bored, procrastination, frequently switching from one activity to another without really finishing something, difficulty in distinguishing main issues from side issues, getting lost in details, poor ability to plan and organize, poor ability to prioritize, chaotic, temporary over-concentration or hyper-focus which alternates with periods of strong distractibility, only being able to pay attention to things one finds interesting.

• Hyperactivity: motor restlessness, a feeling of inner turmoil, busy and talking a lot, always having to be busy with something, difficulty relaxing.

• Impulsivity: doing first and then thinking, frequently interrupting others, being impatient, impulsively spending money, impulsively starting and ending relationships and work relations.

How is ADHD diagnosed?

Diagnosis is made using the standard work for psychological and psychiatric disorders: the DSM, which stands for: Diagnostic and Statistical Manual of Mental Disorders. The English-language fifth edition of this manual from the American Psychiatric Association (APA) was published in May 2013. The Dutch translation of the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), rolled off the presses in April 2014.

The diagnostic criteria of ADHD according to DSM-5, are:

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2).

(1) Inattentiveness: Six (or more) of the following symptoms have been present for at least six months to an extent that is inappropriate and adversely affects social, school or occupational activities and is not developmentally appropriate. Note: Symptoms are not simply a manifestation of oppositional behavior, defiance, hostility or an inability to understand tasks or instructions. Older adolescents and adults (17 years and older) must meet at least five symptoms. The individual: (a) often fails to pay adequate attention to details or carelessly makes mistakes in schoolwork, work, or other activities (b) often has difficulty maintaining attention in tasks or play (c) often appears not to listen when addressed directly (d) often fails to follow directions and often fails to complete schoolwork, chores, or meet obligations at work (not the result of oppositional behavior or inability to understand directions) (e) often has difficulty organizing tasks and activities (f) often avoids, dislikes or is unwilling to engage in tasks that require sustained mental effort (such as school or homework) (g) often loses things needed for tasks or activities (e.g., toys, homework, pencils, books or tools) (h) is often easily distracted by external stimuli (i) is often forgetful in daily activities

(2) Hyperactivity and impulsivity: six (or more) of the following symptoms have been present for at least six months to an extent that is inappropriate and adversely affects social, school or occupational activities and is not developmentally appropriate. Note: Symptoms are not simply a manifestation of oppositional behavior, defiance, hostility or an inability to understand tasks or instructions. Older adolescents and adults (17 years and older) must meet at least five symptoms. The individual: (a) frequently moves restlessly with hands or feet, or twists in his/her chair (b) often stands up in class or other situations where one is expected to remain seated (c) often runs around or climbs on everything in situations where this is inappropriate (in adolescents or adults this may be limited to subjective feelings of restlessness) (d) has difficulty playing quietly or engaging in relaxing activities (e) is often "on the go" or "rambles on" (f) often talks on and on (g) often blurts out answers before questions have been completed (h) often has difficulty waiting his/her turn (i) often disrupts others' activities or intrudes (e.g., interferes casually in conversations or games)

B. Some symptoms of hyperactivity-impulsivity or inattention causing impairment were present before age 12.

C. Some impairments from the group of symptoms are present in two or more areas (for example, at school (or work) and at home).

D. There must be clear evidence of significant limitations in social, school or occupational functioning.

E. The symptoms do not occur exclusively in the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not previously attributable to another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

DSM-5 distinguishes three subtypes of ADHD:

314.01 Combined picture: If during the past six months both criteria A1 (inattentiveness) and A2 (hyperactivity-impulsivity) are met.

314.00 Predominantly inattentive picture: If during the past six months criterion A1 (inattentiveness) is met, but not criterion A2 (hyperactivity-impulsivity).

314.01 Predominantly hyperactive-impulsive picture: If during the past six months criterion A2 (hyperactivity-impulsivity) is met, but not criterion A1 (inattention).

Comorbidity

Most adults with ADHD also have other mental health problems. In addition to depressive symptoms, anxiety disorders and addictive behaviors are often a concern. Adults with ADHD are at increased risk for nicotine, alcohol and drug abuse, antisocial behavioral problems, and mood disorders.

Prevalence

Research shows that between 1 and 7 percent of adults have ADHD. The ratio of males to females with ADHD is more balanced among adults than among children. ADHD is more common in boys than girls, but that difference decreases as people age.

Treatment

Treatment of ADHD in adults often includes a combination of psychoeducation, medication, coaching and cognitive behavioral therapy. These treatments aim to improve symptoms and increase quality of life.

Conclusion

ADHD in adults is a complex and multifaceted problem that can manifest itself in a variety of ways. Understanding the symptoms, diagnostic criteria and treatment options is essential for effective management. Due to a combination of genetic and environmental factors, ADHD plays a significant role in adult life, and it is important that diagnosis and treatment be carefully tailored to the individual needs of the patient.