The purpose of this article is to alert the older adult population to the symptoms that result from AD/HD. Older adults who believe they have AD/HD should find a clinician with experience in adult AD/HD and also in geriatrics.
When treatment for older adults is sought for depression, anxiety or other conditions such as obsessive/compulsive behavior or substance abuse, few medical and mental health professionals consider AD/HD. Their symptoms are often attributed to aging problems such as stress from losses, retirement and memory decline.
Adults with AD/HD are often misdiagnosed and treated for anxiety disorder or other psychiatric conditions, which can worsen AD/HD symptoms.
Until1980, AD/HD was considered a childhood disorder normally outgrown by adolescence. Even today, many continue to believe that only children have AD/HD; however, it is present in an estimated two to four percent of the adult population, or 2 to 5 million people (Khouzam, Hanri R., 1997). Recent surveys show that 30 to 70 percent of children with AD/HD will continue to have symptoms into adulthood.
AD/HD in adults has many of the same clinical features as the childhood disorder; therefore counseling and psychopharmacology are as essential in treating adults as they are in treating children with AD/HD. Many of the similar symptoms include:
• difficulty sustaining attention and concentration,
• frequent mood swings and short tempers, and
• an inability to organize or plan ahead.
Adults often experience career difficulties. Some of them learn to adapt to their disability and harness the energy and creativity that often accompany the disorder, so they thrive professionally. Many are successful entrepreneurs.
Joseph Biederman (1998) describes a 55-year-old father of two boys, general manager of a biotechnology company and how he was diagnosed with AD/HD. After medical treatment and psychotherapy, he said, "Since I have been taking methylphenidate, I have noticed I am more focused and can stick to a project and complete it."
In the 1950s, the general public was not widely aware of AD/HD, and although I studied psychology, I had no idea it existed. When our son's kindergarten teacher told us he
wouldn't sit still, we took him to our family physician who prescribed a medication typically used to treat seizures. Our son eventually was able to control himself enough to stay in school, but no one knew the cause of his behavior. Until I started my doctorate program in psychology and took a course on AD/HD, I had no idea my son had the disorder. And although I had experienced similar symptoms throughout my life, it never occurred to me that I might have AD/HD even though I now am in my 60s.
I started personal counseling because I felt that anyone providing professional counseling should go through the process. As counseling progressed, I was diagnosed as having an anxiety disorder, unspecified. But after taking the course, I began to understand why I had trouble reading, had to repeat the fourth grade and could never memorize music or anything else. My counselor and co-author of this article at first said he did not think I had AD/HD, most likely because I had developed so many coping skills. He did, however, suggest that I fill out a questionnaire for adult AD/HD, which indicated I had the symptoms.
I then made an appointment with a psychiatrist for further assessment and diagnosis. She agreed with the diagnosis of AD/HD and prescribed methylphenidate. Once on the medication, my entire world changed. My wife noticed that I could now listen without interrupting. I was able to sit still. I could continue one task for long periods of time whereas before, I changed tasks about every 15 minutes. I had recently started taking piano lessons, but had found it impossible to memorize any music or stay with a composition long enough to learn it. After one week of taking the medication, my piano teacher remarked on my improvement. I can now practice for hours without difficulty. I am now able to attend meetings without fidgeting or drumming a pencil.
A review of my childhood history fits the AD/HD criteria:
1. Hyperactivity
2. Inability to pay attention
3. Difficulty in school
4. Difficulty reading
5. Poor social skills
6. Always trying to please people
I learned many coping skills to overcome some of these difficulties and became a successful entrepreneur in the process, but this did not improve my low self-esteem or calm the frequent feeling that something was wrong. While I was unaware of some of my social skill problems, I did know I frequently interrupted people in conversations and I was easily distracted.
Among the coping skills I developed at work were starting multiple tasks and delegating them to someone else for completion. I would monitor the progress, but did not have to finish the tasks myself. Being the owner and president of the company, I was able to work on a project for a short time (usually 15 minutes), then do something else and return to the task later. This continual change and a fast-paced environment fit very well with my AD/HD characteristics. When I was doing schoolwork, I learned to rotate three subjects every 15 minutes to accomplish what needed to be done.
I would have been spared much grief and self-criticism had I known the cause of my difficulties and been given medication early on. I would have been a better parent, without my angry outbursts.
Dr. Lynn Weiss in her book Attention Deficit Disorder In Adults (1997) discussed a case in her chapter "The Hidden Disorder" where she failed to recognize the disorder in a forty-two-year-old man. She said (pg. 20), "He had me stumped. I was becoming increasingly tense around him, and not just out of wounded professional pride. Physically, there was nothing smooth about him. He was restless during our meetings. He continually jiggled his foot and shifted his weight in his chair. His eyes darted around the room. His mind jumped, with no continuity, from one topic to another. He was bright, educated, and seemly well socialized, but had very low self-esteem."
She said, "Finally, though it went against my professional training and everything I had been taught, I tentatively diagnosed him as an adult suffering from AD/HD" (Weiss, 1997). This was the beginning of her work with AD/HD in adults.
A review of professional literature and research has turned up virtually no discussions of AD/HD in older adults. It makes no sense to think that the disorder goes away as people become older. We can assume that approximately the same portion of the older adult population has the symptoms as younger adults.
Unless the client is aware of the nature of the disorder, he or she will not know what information is important for the clinician to have during an assessment, nor is technical
information readily available to the general public. Presently, few clinicians skilled in treating AD/HD have any expertise in geriatrics, and vice versa. Until clinicians have been educated to accept AD/HD as a disorder in older adults, under-diagnosis and misinformed treatment will continue.
Anyone 50 years or older, who has children or grandchildren who have been diagnosed with AD/HD, should examine their own symptoms and those of their parents. Research has shown that the disorder runs in families and is thought to be primarily a genetic disorder. AD/HD is difficult to diagnose in anyone, but much more so in older adults.
Questions to ask an adult to help establish whether they have AD/HD symptoms are:
1. Do you seem not to listen when spoken to directly?
2. Do people often have to repeat what they say to you?
3. Is it difficult for you to finish tasks, even when you know how to perform them?
4. Is it difficult for you to plan and organize your work assignments?
5. Is it difficult for you to wait in line?
6. Is it difficult for you to sit still?
7. Was yours a difficult birth?
(Khouzam, 1997)
Core symptoms found in adults with AD/HD are inattention, hyperactivity and impulsivity. Older adults may show diminished hyperactivity, but stilI remain somewhat inattentive and/or impulsive. Also, the signs of AD/HD may be absent in some situations, where the person is in very strict control or the requirements of the situation are very familiar and exacting. The symptoms usually worsen where sustained attention or mental effort is required and in groups or work environments (Khouzam, 1997).
Older adults present some special problems in reaching an accurate diagnosis because of life cycle issues. These include:
1. Physical losses
2. Retirement
3. Depression from aging issues
4. Memory loss
5. Lack of focus because of too much leisure time
These issues can cause some AD/HD-like symptoms. Because clinicians expect older adults to suffer from these life cycle events and to present symptoms such as anxiety, depression and personality disorders, they attribute the symptoms to aging issues rather than consider the possibility of AD/HD. For example, one of the criteria for diagnosing memory loss in older adults, the complaint of forgetting the location of objects, is a common problem for individuals with AD/HD at any age. Other indicators of AD/HD, which may be confused with aging issues, may be disorganization, difficulty traveling to new locations and problems performing complex I tasks. Uncovering AD/HD in older adults requires a long-term, across the life span view of symptoms, rather than assessment of current behavior alone.
As part of the assessment process, a family and school history is important; however this is often impossible to collect or verify for adults since many have lost parents and relatives who could have provided information. Personal histories and talking to the client's spouse and children is helpful. If the older adult's children or grandchildren have AD/HD or have the common symptoms, this also can help in the assessment.
Personal history should include personal feelings about oneself, one's actions and one's relationships. A physical life span history along with current medical status is helpful. Childhood history and sleeping patterns are an important part of the assessment. Educational, job and career histories will provide more valuable data for a complete analysis. AD/HD does not begin in later life. Its presence affects individuals throughout their lives.
This information, with completed checklists and assessment tools, will provide the clinician with the data needed to complete the diagnosis. While the clinician is conducting the assessment, careful observation and notes with regard to physical and attentional behavior such as fidgeting, finger drumming or foot moving will be helpful in making a proper diagnosis.
History of medications and substance use must be part of the assessment process since many individuals with AD/HD self-medicate. Because this is also a common problem with aging adults, careful analysis is needed to distinguish AD/HD from aging issues.
Treatment for adults is similar to that provided for children in some ways, but quite different in others. The first step in treatment of AD/HD for adults is education. This involves reading, attending lectures, talking to experts and others that have AD/HD.
The benefits of medication should be explored. Although core symptoms can often be reduced with medication, counseling is needed to help with social skills. Many of the habits developed in response to AD/HD do not disappear with medication, but most clients do respond to counseling in addition to medication. "As in childhood AD/HD, the combination of medication and psychotherapy results in a better outcome than the use of either modality alone" (Khouzam, 1997). If there are any coexisting conditions, the treatment plan should address these as well.
Counseling can help clients in structuring techniques, reminders, and organizational techniques. Group counseling is very helpful for adults, having a coach such as a spouse or a friend is useful for clients with AD/HD. Cognitive therapy teaches techniques for managing stress and reducing conflicts, as well as building self-esteem. Using behavior modification and positive re-framing can substantially reduce symptoms.
Persons with AD/HD are often aware of their inadequacies. They grieve over losses of opportunity and feel angry out of frustration. Often individuals with AD/HD experience flooding: they absorb instantly all that is in the environment, and the absorption is so fast, intense and pervasive that it "floods" the person (Weiss, 1997). They are confused as to why people are angry with them when they are trying to please them and are unaware of their poor social skills. It is common for individuals with AD/HD to have low self-esteem and rigidity.
It is not too late for someone in their 50s or older to find relief from the negative effects of this condition.
Those of us who have received help find a whole new wonderful world. We can now appreciate beauty everywhere, hear and see things we never experienced before, and we can enjoy our partners and our friends. Given the rewards of helpful treatment, families with younger members who have AD/HD may find it among their older members and introduce them to these benefits too.
References
Biederman, Joseph, A 55 Year Old Man with AttentionDeficit/Hyperactivity Disorder, JAMA, The Journal of the American Medical Association, September 23,1988, V2 P 1086 (1)
Khouzam, Hanri R., Attention Deficit Hyperactivity Disorder in Adults: Guidelines for Evaluation and Treatment, August 1997, Consultant, V37 nB p2159 (6)
Weiss, Lynn, (1997), Attention Deficit Disorder in Adults, Taylor publishing Company, Dallas, Texas
