Diagnosing an adult with attention-deficit/hyperactivity disorder (ADHD) requires at least five symptoms of inattention and/or hyperactivity and impulsivity, per the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). An adult with the neurodevelopmental disorder may constantly feel restless or overwhelmed, always leaving something undone. They may continuously shift focus or change jobs frequently. They may struggle with procrastination or have difficulty with relationships.
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According to the DSM-5, symptoms of ADHD:
- Are present in two or more settings
- Interfere with everyday functioning
- Are not caused by another mental disorder
- Were evident before age 12
It’s that last point that has some clinicians and researchers raising questions. What if an adult has indications of ADHD, but didn’t as a child? Could adult and childhood ADHD be two distinct conditions?
A Brazil study recently published in JAMA Psychiatry suggests they are. The population-based longitudinal study found that only 17 percent of children with ADHD still had the disorder as young adults. And only 13 percent of young adults who met DSM-5 criteria for ADHD (except age at onset) had the disorder as children.
A U.K. study, published concurrently with the Brazil study, reported similar findings. Out of 247 children with ADHD, only 54 (22 percent) still had the disorder as young adults. And out of 166 young adults who met DSM-5 criteria for ADHD, only 54 (33 percent) had the disorder as children.
Does this hint that adults can grow into ADHD just like children can grow out of it? Michael Manos, PhD, founding Director of Cleveland Clinic’s ADHD Center for Evaluation and Treatment, doesn’t think so.
How social scaffolding affects ADHD
“It’s not that someone can outgrow or grow into ADHD,” says Dr. Manos. “It’s whether or not the symptoms — which were probably always there — are impairing. Adaptability, the means to manage or even leverage ADHD symptoms, is what changes throughout life.”
That explains how a child with ADHD may not present with ADHD as an adult, and vice versa. Dr. Manos attributes this to “social scaffolding” — the life situations and relationships in which a person operates.
- A child performs well in school and thrives in a regular routine managed by his parents. When he leaves home and enters college, his performance declines. He isn’t able to self-manage and doesn’t function well with an irregular schedule. ADHD symptoms are unmasked because now he has to self-direct more concertedly rather than have schedules and demands dictated for him.
- A child with ADHD grows up and begins an enjoyable career in a structured workplace. She marries a highly organized spouse who willingly manages the household and family finances. Her symptoms of ADHD may no longer be impairing — or even evident — in adulthood because details are handled for her.
- An adult is a successful sales representative, exhilarated by constant travel and personal interaction. When promoted to a management position, a job that requires meticulous organization and more sedentary office work, symptoms of ADHD become intrusive, inhibiting his well-being.
When social scaffolding changes, so does presentation of ADHD symptoms.
“Despite recent studies, it is premature to designate adult and childhood ADHD as different syndromes,” says Dr. Manos. “For adults newly diagnosed with ADHD, it’s more likely that their symptoms in childhood were subthreshold.”
ADHD is most likely the same disorder no matter your age, he says, although it may manifest differently.
Differences in adult ADHD
While DSM-5 criteria clinically define adult ADHD, symptoms in adults may not present accordingly. Say an adult shows only three ADHD symptoms instead of the requisite five. But, say those three are severely impairing. Might he or she still have ADHD?
Maybe, says Dr. Manos, pointing to genetic studies that indicate ADHD is highly variable.
“It’s more important to help a patient adapt to their circumstances and manage their symptoms,” he says, “not name the condition.”
Treating ADHD or ADHD-like symptoms is the same in children and adults. A combination of medication and behavioral intervention is the top-line treatment, although not everyone requires it, says Dr. Manos.
“How treatment is administered will differ,” he adds. “If behavior modification is needed for a child with ADHD, parents and teachers are usually the primary change agents. For adults, the change agent might be a spouse, therapist or even themselves.”
Tips for diagnosing and treating adults
In light of these differences, Dr. Manos advises three things when caring for adults.
- Monitor cases of subthreshold ADHD. If patients do not meet all DSM-5 criteria, they may still require treatment. Adults can be severely impaired by a smaller number of symptoms.
- Understand that ADHD symptoms may not have been evident in childhood. Symptoms may have been masked by social scaffolding. Adults diagnosed with ADHD usually report childhood symptoms in hindsight, says Dr. Manos, whether or not symptoms were impairing at the time.
- Consider stimulants an effective treatment. Research shows that 80 to 90 percent of adults with ADHD respond favorably to stimulants, with no or few nonintrusive side effects.
“A standard office visit is probably insufficient time for physicians to confirm ADHD symptoms, evaluate impairment, rule out other causes and identify comorbidities,” says Dr. Manos. “Behavioral health professionals, including our team at Cleveland Clinic’s ADHD Center, can perform a comprehensive evaluation.”
In addition to conducting thorough interviews and using various rating scales, ADHD professionals will collect input from multiple observers, such as a spouse and co-workers.
“Adaptability is our job,” says Dr. Manos. “We help patients find ways to manage their symptoms so they can have productive lives, make meaningful contributions and maintain healthy relationships.”