ADHD Across The Lifespan
by Robert Molpus, MD

Historically, Attention Deficit-Hyperactivity Disorder (ADHD) was thought to be primarily a condition of school-age boys. In the last 15 years it has been established that it is present in older adolescents and adults, both male and female. Symptoms of inattention are more common than hyperactivity. It is the lack of overt symptoms of hyperactivity that probably led to the disorder not being recognized outside of hyperactive boys.

ADHD is a neurological condition with behavioral, emotional and cognitive symptoms. On PET scans, ADHD brains use different, less efficient pathways and have different patterns of functioning than normal brains performing the same activities. With ADHD, the prefrontal cortex (the front part of the brain) does not work properly due to problems with dopamine levels. Thus, executive functions such as organizing, prioritizing, focusing and maintaining attention, regulating alertness, managing frustration, regulating emotional responses and behavior, using working memory, and accessing recall suffer. When the prefrontal cortex is not functioning appropriately, it is less efficient at performing these executive functions.

ADHD is highly heritable, meaning that most of what creates ADHD is not the environment. Heritability is estimated to be anywhere between 65 and 90 percent. Most children with ADHD have at least one parent with ADHD. Affected adults often come to clinical attention when their children are diagnosed. Given its genetic and functional origins, one would expect ADHD to be a life-long condition.

In older adolescents and adults the symptoms persist in modified forms. Hyperactivity tends to calm down, but a significant sense of restlessness remains. Physical impulsivity may become verbal impulsivity and impulsive decision-making. Inattention, however, tends to persist as inattention. The impaired executive function leads to an interest-based mode of function, rather than an importance-based mode of function. Whatever grabs the attention of the person becomes the most important thing, regardless of its actual importance. This becomes more evident with increasing age, as the environment becomes less structured and there is a greater need for self-direction and self-sufficiency.

Untreated ADHD leads to multiple consequences when compared to the general population. Those with ADHD are more likely to have:
• Unintended pregnancies and sexually transmitted diseases
• Legal problems and incarceration
• Financial problems and bankruptcies
• Speeding, reckless driving, “road rage,” and multiple violations
• Substance use disorders
• Multiple relationships and marriages; more likely to be separated or divorced
• Parenting difficulties
• Multiple job changes, to have been fired or laid off, performance below potential
• Poor social skills, problematic relationships (non-romantic)

Poor self-esteem, which begins in childhood, persists into adolescence and adulthood and worsens with multiple failure experiences. The theme of performing below capability that starts in childhood continues into adulthood. Time management and organizational skills do not develop properly. ADHD children often miss critical developmental windows related to social interaction. These social skills can be learned later, but are never automatic or fully mastered.

Diagnosis in later adolescence and adulthood can be problematic. Our current diagnostic criteria (DSM-IV-TR) were developed on and for children. Many of them don’t translate well to describe the adult experience of ADHD. As people grow, they are able to make some accommodations for their symptoms, making the disorder less obvious, but often not any less disabling. Denial in the affected individual can delay treatment. Also, there is the real concern of adolescents and adults “faking” ADHD in order gain inappropriate access to stimulant medication. Co-morbid disorders are more common than not. Alcohol and substance abuse affect as much as 50% of the adult population. Anxiety disorders (32%-50%) and depression (19%-37%) are common. Antisocial behavior is present in about 18%-28% of the ADHD population.

ADHD is a clinical diagnosis, meaning it is based on presenting symptoms and history. There is no test that is diagnostic of ADHD. For example, a scale for inattention given to someone with major depression, but not ADHD, likely would be positive.

However, scales can be helpful in screening. Evaluating presenting symptoms is just the first step in diagnosis. It is critical to examine the pervasiveness of the symptoms over time and the extent to which they are impairing. There should be a more or less continuous history of symptoms and impairment. Since the disorder is based in brain dysfunction, which is a continuous state, the disorder is continuous, rather than episodic. An episodic presentation implies a co-morbid condition or a different diagnosis altogether.

Like any other psychiatric disorder, ADHD presents on a spectrum of severity. Treatment will vary based on severity. Those with mild symptoms and minimal impairment should respond to behavioral therapy, social skills training, and organization and time-management training. For moderate to severe impairment, medication usually is necessary. These patients often are too distracted and disorganized to participate in therapy effectively. Proper medical treatment will allow them to engage in therapeutic interventions. Always remember, “Pills do not equal skills.” (Gabriel Weiss).

Prior to joining CNS Healthcare, Dr. Robert Molpus was the Medical Director of Behavioral health Services at Orlando Regional Medical Center.

Dr. Molpus earned his medical degree from the UF College Of Medicine. Dr. Molpus is well known and respected in the Orlando medical community through his 16 years of private practice as well as the numerous roles he has held in hospitals and community mental health centers.