Contributed by: Terry Matlen, MSW, ACSW
Attention deficit/hyperactivity disorder (AD/HD) is a lifelong, genetic disorder. (Barkley 2002) Parents of children who have been diagnosed should be screened for AD/HD. Adults with this disorder often experience difficulties in relationships, on the job and in other life areas. The problems of raising a child with special needs are exacerbated by undiagnosed AD/HD in one or both of the parents. Fortunately, the majority of adults respond well to treatment.
It is estimated that between 1% and 6% of the adult population has AD/HD. (Wender) Forty percent of children who have AD/HD have at least one parent who also meets the criteria for diagnosis. (Zeigler) AD/HD affects up to 7.5% of school-aged children, or between one to three students in every classroom. (Barbaresi, et al) For various reasons, AD/HD in adults often goes undiagnosed. Thus, these parents are trying to carry out adult responsibilities without the benefit of appropriate treatment for their own AD/HD. Undiagnosed AD/HD in parents affects the entire family. These adults typically exhibit emotional labiality and tend to have higher rates of depression, substance abuse disorders, and other co-morbidities.
Adults with AD/HD are less likely to graduate from college and even less likely to obtain advanced educational degrees. Like most adults with AD/HD, these parents face uncertain career prospects. Although they may be intelligent and enthusiastic workers, they often have difficulties keeping a job. (Pary) Social skills deficits are common among this population. AD/HD can interfere with the ability to establish and maintain close relationships and may contribute to an unstable home environment.
Parents of a child who has AD/HD are three times as likely to separate or divorce as parents of non-AD/HD children. (Barkley 1995) Simply put, the parent may not have the emotional tools needed to effectively support the special needs of the AD/HD child. Parents who do not have AD/HD report that these children are often far more challenging to parent than their non-AD/HD siblings. The adult with AD/HD faces the already formidable task of raising a difficult child while at the same time trying to cope as best they can with their own AD/HD. If the parents' own AD/HD issues are not addressed, these adults can have tremendous difficulties fulfilling their roles as parents.
Evaluating the Parent
Parents may be unaware that they exhibit behaviors that would indicate the presence of AD/HD. Furthermore, AD/HD has been long considered a childhood disorder. It was not until the mid-1980's that researchers began to acknowledge that AD/HD indeed lasted into adulthood. Parents may be under that mistaken belief that they outgrew their AD/HD while in fact it continues to affect their life. When treating a child who has AD/HD, the physician should discuss with the parent the genetics of AD/HD and inquire if a parent might be struggling with symptoms too. Physicians (i.e. pediatricians) who are uncomfortable or unable to evaluate the adult should then refer parents to another health care provider for an AD/HD evaluation. Should the parent show resistance to the idea, the physician might discuss the difficulties of raising an AD/HD child if ones own AD/HD is not addressed and treated. One or both of the parents may indicate that they faced many of the same problems when they were a child. The parent may recall that school was difficult, although he or she had the intellectual capabilities to do well. There may be family stories of hyperactivity or behavioral problems during the parent's childhood.
Mothers or fathers may see in the opposite sex parent many of the same behaviors now being exhibited by their child. Often is the case when one parent will turn to the other and say, "I know where it comes from. You're the exact same way!" Physicians may want to ask about the behaviors of other family members as well, to better ascertain the possibility of undiagnosed AD/HD in the family. These kinds of questions can bring up a plethora of information pointing to the possibility that the parent, too, might have the disorder.
Research on AD/HD and behavioral disorders is fairly recent and may not have been attributed to AD/HD when the parent was a child. The astute physician will take a patient history by posing questions in terms of behavior and not necessarily in terms of any specific diagnosis. How does this affect the physician's role in evaluating and treating their young patients? Treating the parent is an important part of improving the quality of life for the child. One can see that an impulsive, distracted parent might have problems remembering to give a youngster his/her medication. Adults with AD/HD tend to be disorganized and often have difficulty maintaining a home. These adults have trouble keeping appointments, getting the child ready and off to school in time, and performing other basic parenting duties.
How AD/HD Symptoms Compare in Adults and Children
The same symptoms that apply to children with AD/HD also apply to adults; however, the symptoms may be manifested in a number of ways. Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse. (Searight)
The primary symptoms of AD/HD are inattention, impulsivity and hyperactivity. The adult versions of these symptoms often have severe consequences. Inattentive children are reprimanded for daydreaming in class. Inattentive adults neglect their spouses, forget directions, and crash their automobiles. Impulsive children often make bad choices. Impulsive parents also make bad decisions. Consequently, they may face huge credit card bills, marital strain and other negative consequences. Hyperactive children are always moving. Hyperactive adults may feel restless and are drawn to high-risk behaviors. Other behaviors that are common to children who have AD/HD are also seen in adults with the disorder. Children with AD/HD will procrastinate, turning in homework late, if at all. Their work is often sloppy. Procrastination in adults results in paperwork and work-related projects being completed late or not at all. Bills go unpaid not because there is no money, but because the adult simply never gets around to mailing in the payment.
Other common symptoms include not living up to one's potential, hypersensitivity to stimuli, emotional reactivity, and poor short term memory. Any one of these behaviors presents a problem for an adult. Taken as a group, they represent a potentially disabling condition.
Consider the following challenges:
Treatment for Adults
Adults with AD/HD respond well to treatment. Appropriate management of adult patients with AD/HD is multimodal and should include psychoeducation, counseling, supportive problem-directed therapy, behavioral intervention, coaching, and cognitive remediation. Couples or family therapy may be indicated to help the parent learn better parenting strategies for raising the AD/HD child. (Wender)
Stimulant medications are the first line of treatment for adults with AD/HD. Stimulant use among patients with a history of substance abuse should be closely monitored to ensure that no abuse occurs. Approximately 70% of adults who have been treated with stimulant medication show a reduction of symptoms. The antidepressant medication Bupropion has also been shown to be effective in treating adults with AD/HD. (Kuperman) Atomoxetine, a non-stimulant medication which is a highly selective inhibitor of the norepinephrine transporter, appears to be an efficacious treatment for adult AD/HD. Its lack of abuse potential may be an advantage for many patients. (Michelson)
Once effective treatment is in place, adults with AD/HD usually do quite well. Paired with the other interventions, medication can provide the parent with the tools he or she needs to improve the quality of life for the family.
Because AD/HD is a genetic disorder, screening the parent of the AD/HD patient is imperative as part of the overall medical/psychological management of the child. Appropriate and effective treatments are available to both child and parent and should be considered for both in order for families to live successful, healthy lives.
References Barbaresi, W., Katusic, S., Colligan, R., Pankratz, V., Weaver, A., Weber, K,. Mrazek, D., Jacobsen, S. "How Common Is Attention-Deficit/Hyperactivity Disorder? Incidence in a Population-Based Birth Cohort in Rochester, Minnesota" Archives of Pediatrics and Adolescent Medicine, Vol. 156 No. 3, March 2002 Barkley, R. "International Consensus Statement on AD/HD" January 2002 Barkley, R. Taking charge of ADHD. NY: Guilford Press. 1995 Kuperman S, Perry PJ, Gaffney GR, Lund BC, Bever-Stille KA, Arndt S, Holman TL, Moser DJ, Paulsen JS. "Bupropion SR vs. methylphenidate vs. placebo for attention deficit hyperactivity disorder in adults." Annals of Clinical Psychiatry 2001 Sep; 13(3):129-34 Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke J, Dietrich A, Milton D. "Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies." Biol Psychiatry 2003 Jan 15; 53(2):112-20 Pary R, Lewis S, Matuschka PR, Rudzinskiy P, Safi M, Lippmann S. "Attention deficit disorder in adults." Annals of Clinical Psychiatry 2002 Jun; 14(2):105-11 Searight HR, Burke JM, Rottnek F., "Adult ADHD: evaluation and treatment in family medicine." American Family Physician 2000 Nov 1; 62(9):2077-86, 2091-2 Wender PH, Wolf LE, Wasserstein J. Adults with ADHD. An overview. Annals of the New York Academy of Science 2001 Jun;931:1-16 Zeigler, Chris. Teaching Teens with ADD and ADHD, Dendy, November 2000 2003