SPECIAL GUEST POST BY STEPHEN MALACH, MD

Nearly 30% of children diagnosed with ADHD have persistent symptoms into adulthood, according to an article recently published in the journal Pediatrics. The study focused on kids who were diagnosed with ADHD, which led me to ask myself: What about those children who go undiagnosed? And, how many of those children grow into adulthood with ADHD symptoms? 

Take Ben. He had been an excellent student but when he got to graduate school he started to really struggle, and began to experience panic attacksduring exams. What Ben hadn’t realized was that his superior intelligence along with his avoidance of subjects that he found difficult, such as math, had allowed his ADHD to go unnoticed--to him and others. But now he couldn’t avoid subjects or use his smarts to get through the material quicker than everyone else. During exams he became overwhelmed by the quantity of questions, the volumeof information he needed to focus on, and the time constraints. As a result he panicked. Ben’s story is not uncommon. People with undiagnosed ADHD can reach an “ADHD ceiling,” as they try to avoid jobs that require concentration or multitasking. They may become disorganized, procrastinate, or feel an inability to do their jobs to the highest capability. They can feel inadequate and develop low self-esteem. As a young woman named Allison once told me, “I feel as if I am an alien and I don’t belong. I can’t seem to understand things the way others do.” Kids and adults who struggle with ADHD often describe a sense of feelingdifferent. This can lead to low self-esteem, anxiety, and depression. They may self medicate these feelings with drugs or alcohol. The study describes this avalancheof consequences, finding that in the group of children whose ADHD persisted into adulthood, over half of them suffered from one or more additional psychiatric disorders on top of their ADHD. Other studies have suggested that people with ADHD have increased chances of being incarcerated. I remember a teacher of mine, a child psychiatrist, who would joke that use of Ritalin or Adderall lowered the chances of a child ending up in jail or becoming addicted to drugs. I guess he was right. 

Given the sometimes troubling consequences of ADHD, how can we figure out what is really going on? How do we know whether an individual suffers from anxiety or ADHD or both? Ben's case takes us to the heart of the “symptoms versus syndrome dilemma.” He was experiencing anxiety and panic, and such multiple diagnoses are common. But, anxiety and panic symptoms are not descriptions of an underlying disease process. Likewise, difficulties with attention and concentration are symptoms which occur in many common disorders including: ADHD, Generalized Anxiety Disorder, Major Depression, Bipolar Disorder, and Schizophrenia. Since we are still only beginning to understand exactly what happens in the brain when people have psychiatric diseases and as a result we have diagnoses based on a cluster of symptoms, we often can’t use x-rays or blood tests to find out what is causing someone’s anxiety, so we rely on symptoms. But they may not tell you very much about their deeper source, just like a cough cannot tell you whether you have a cold or pneumonia.  Which brings me to Alex, who was experiencing difficulty with attention and concentration,  having trouble completing tasks, and procrastination. Alex was sure he had ADHD. However, as it turned out intense anxiety was causing him to have difficulty paying attention and concentrating. Once his anxiety was alleviated, his ADHD like symptoms resolved. Had Alex been treated based on a sole symptom we would not have addressed his real problem. 

According to the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR), “The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity.”  In plain English: people with ADHD may be easily distracted, have trouble finishing tasks, and may repeatedly lose things. They may fidget, have trouble waiting their turn,talk excessively, or have difficulty playing or relaxing quietly. Plus, symptoms of ADHD must be present before the age of 7. You read that right: 7.

If an adult experiences symptoms of ADHD but cannot show or remember that they began before the age of seven, he/she is technically not able to carry a diagnosis of ADHD. Does this even matter? The correct diagnosis is important in certain legal and academic situations. In truth, though, whatever the name, struggles are still the same. So, bottom line: people who have difficulty maintaining attention and concentration should see a professional for an evaluation. Many find relief just by unburdening themselves of these “secret” symptoms. Whatever the diagnosis, treatment can help to alleviate the symptoms and the associated anxiety,depression, and substance abuse. That’s the good news. The more aware we are of how many adults struggle with ADHD, the more people will be able to seek treatment for what ails them. Remember, it’s not just for kids anymore. 

References: Barbaresi WJ, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. (2013).Mortality, ADHD, and Psychosocial Adversity in Adults With Childhood ADHD: AProspective Study. Pediatrics. Mar 4. DOI: 10.1542/peds.2012-2354http://pediatrics.aappublications.org/content/early/2013/02/26/peds.2012... American Psychiatric Association. (2000). Diagnostic and statistical manual ofmental disorders (4th ed., text rev.). Washington, DC 

Stephen Malach M.D., is a psychiatrist and psychoanalyst who practices inManhattan You can follow him on twitter @DrStephenMalach

Stephanie Newman, Ph.D., is the author of Mad Men on the Couch: Analyzing the Minds of the Men and Women of the Hit TV Show, which can be purchased fromBarnes & NobleIndie Bound, andAmazon

About the Author

Stephanie Newman, Ph.D.

Stephanie Newman, Ph.D., is a clinical psychologist and psychoanalyst, as well as the author of Mad Men on the Couch.

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