Adults and Attention Deficit Problems

For the past ten years or more, I have worked with children and adolescents who have presented for counseling with symptoms of ADHD. Recently, though, most of the people who see my listed specialty in ADHD and have called seeking counseling have been adults, who have concerns about how this condition may be interfering with their lives now.

As a couple of points of quick clarification, I am a therapist, not a physician, so I cannot prescribe medication for ADHD. Most of the kids I worked with were getting medication from a pediatrician or family physician, or else they had seen (or I referred them to) a psychiatrist for medication evaluation. I am not qualified to say whether I think someone would benefit from medication or not. That’s why I prefer to refer people to a psychiatrist for a medication evaluation, especially if they have other health issues or may be on medication for some other condition already.

Second, people often express confusion over the difference between ADD and ADHD. Mental health clinicians follow the American Psychiatric Association DSM-IV guidelines, which refer to one disorder (Attention deficit-hyperactivity disorder), which can have three subtypes: Primarily inattentive, primarily hyperactive-impulsive, or combined type. It is categorized as a disorder that usually arises in childhood, and in fact one of the diagnostic criteria is that some symptoms need to have been present during childhood.

 Most children who meet the criteria for ADHD come to the attention of clinicians due to school problems; although the criteria also require that some problems need to be evident in another setting, such as at home. Most children with this diagnosis tend to outgrow most of the symptoms by late adolescence. This makes sense because ADHD can be thought of as the lack of an age-appropriate ability to focus attention and/or restrain behavioral impulses. All young children lack these abilities to some extent, which is why it is not really appropriate to give the diagnosis to a child younger than kindergarten age.

Some adults mature out of the hyperactive-impulsive symptoms, but retain some of the inattentiveness, disorganization, and difficulty planning and carrying out tasks. These are often the people who seek counseling later.

Interestingly, some researchers have found a genetic marker that’s strongly associated with ADHD; and even more interestingly, a disproportionate number of these individuals are in, or have been in, the military services. There’s a bit of a confounding variable here, because kids with ADHD often do less well in school and are less likely to go on to college (making the military a more likely career choice). But these researchers also raised the intriguing possibility that this genetic trait may have conferred a survival advantage at some point in human history, and that this advantage may also translate into being well-suited to be a soldier. Taking in all stimuli, and not screening out the “irrelevant” stimuli, may actually serve as a survival mechanism for someone who is doing the work of a soldier in harm’s way.

 When I’m working with an adult who has concerns about ADHD, I always stress a few important points as we start to work together:

  •  The functional impairment experienced by adults with ADHD usually involves occupational functioning, but may include relationship problems due to poor self-management, money management, time management, and/or impulse control.
  • The treatment of choice for ADHD in children and adolescents is usually medication (Stimulants or newer ADHD-specific medications) that are intended to improve symptoms of inattentiveness and/or impulsivity. The primary focus of this symptom improvement is often school performance, and the goal is successful educational preparation for adult life. Parenting and behavior management are often a secondary treatment goal.
  • Adults with ADHD may or may not benefit from medication, but often suffer from the complication of having adapted over a period of years to their style of processing information, and sometimes suffer consequences from years of living with behavior patterns and relationship styles influenced by their ADHD. Substance abuse may be another issue that is well-recognized as a complication of ADHD. Spouses and children may have adapted to these patterns as well.
  • For adults, treatment goals for any identified attention deficit disorder must take into account the current functioning of the patient as well as realistic expectations for functional improvement and quality of life. Reduction or elimination of symptoms may or may not be part of this goal. Successful adaptation to life should be the primary goal.
  • Whether or not an evaluation for medication is recommended, counseling goals need to include coaching for self-management, relationship improvement, time management, organizational skills, and impulse control. Referrals for substance abuse treatment may also need to be considered, and often take precedence over other treatment goals.
  • Often, adults who have been living with symptoms of ADHD for a number of years also have interfering ideas and beliefs about themselves, their abilities, authority figures, tasks, and obligations. These interfering ideas may cause as much difficulty as the actual ADHD symptoms, if not more. We can often work on identifying what those beliefs  may be, and start to help change them.
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