![[Separator]](../../images/lines/bluline1.gif)
Jay J. Jones
Fresno, California
Contrary to a commonly held notion, ADHD symptoms and problems are not outgrown, and do not disappear in adolescence. Problems related to ADHD generally span the entire lifetime (Gardner, 1971; Gittelman, et al. 1985; Nichamin & Windell, 1984; Lambert, et al. 1987; Mannuzza, et al. 1988; Roberts, 1982; Wender, 1987; Wallander, 1988; Wender & Garfinkel, 1989; Wood, Rheimerr, Wender, & Johnson, 1976).
There has been--and is still--considerable mythology connected to these notions. Many parents and professionals think that since blatantly "hyperactive" symptoms often disappear by adolescence, that the ADHD syndrome is mainly a childhood problem. One reason for this broadbased misunderstanding is that observable symptoms often turn into unobservable or less critical features of ADHD. The following paragraphs will highlight some of the diverse, and most troubling of the ADHD features that are present during the span of human development.
Symptoms of ADHD are seen as early as infancy. When mothers respond to developmental history questions, they often suggest that their ADHD children had striking differences as compared to their Non-ADHD children (Barkley, 1981). Early manifestations can include problems with eating and sleeping, activity level, colic, irritability, irregularity in feeding patterns, allergies to milk and other substances, and sleep pattern irregularities (Wender, 1987).
Although the most common age of diagnosis is at about 9 years old, it is common to see symptoms in the pre-school ages (Garfinkel & Wender, 1989), and even as early as infancy (Barkley, 1989).
ADHD symptoms become apparent during the early school years. This is generally attributable to increased demands in academic, social, and behavioral areas. Particularly problematic is the ADHD child's difficulties with rules, regulations and restrictions (Coker & Thyer, 1990) or what Barkley refers to as "rule governed behavior" (Barkley, 1981).
During these years, especially the ages 7 thru 11, increasing concern develops over a variety of other symptoms. Many ADHD children begin to show signs of depression and low self esteem. In part this can be attributed to the problems they are having with school performance and peer relations. Teachers and parents often attribute problematic behaviors to "willful disobedience" rather than understanding them as features of the ADHD syndrome. In addition, ADHD children may be experiencing few successes, a fact that also contributes to self-esteem problem.
Acting out may begin to surface at this age, partly due to the child's frustration, and due to the impulsivity. Children at this age may be observed to lie and brag as a way of trying to gain acceptance and get attention. Cheating in games or on academic assignments maybe present. School avoidance and truancy may begin at this age, although the latter more commonly surfaces during adolescence. The first contact with school or law enforcement authorities may begin at this age, but is generally more prominent in adolescence (Wender, 1987).
Unfortunately, it is at this age that tendencies toward CD features may begin. This often presents as increased conflict with teachers, fighting and stealing (Gittelman, et al. 1985). Many ADHD children are beginning to demonstrate excessive verbal and physical aggression at this age. The physical aggressiveness is of particular concern. Both clinical and research studies suggest that manifestations of aggression mixed with ADHD at this age increase the likelihood of adolescent and adult antisociality and conduct disorder. In fact, it appears that the more severe the level of aggression in childhood, the worse the overall prognosis into adolescent and adult years (Barkley, 1981). It is also during the late childhood years that symptoms of Oppositional Defiant Disorder may appear.
Undoubtedly one of the most misunderstood concepts is the notion that ADHD features disappear by adolescence. To the contrary, the features of inattention, impulsivity, and hyperactivity often continue well into adolescence and adulthood (Gittelman, et al. 1985; Gueuremont, et al. 1990; Lambert, et al. 1987; Manuzza, et al. 1988; Nichamin & Windell, 1984; Roberts, 1982; Wallander, 1988; Wender, 1987; Wender & Garfinkel, 1989; Wood, et al. 1976). One study (Gittelman, et al. 1985) revealed that at least one-third of children diagnosed as ADHD continued to experience the full equivalent of the syndrome into adulthood (Gittelman, et al. 1985). Most ADHD children retain disturbing symptoms into adolescence and adulthood, even then they do not experience enough symptoms to fully meed the diagnostic criterion (Mannuzza, et al. 1988). As mentioned earlier, adolescents often evidence aggressive and other CD disorders, especially if they have had aggressive symptoms as children (Roberts, 1990). Thus it is predictive that aggressive ADHD children may well develop various antisocial features in later years.
A particularly alarming phenomenon exists in the relationship of ADHD and adolescent substance abuse. There is evidence that ADHD in childhood, especially with CD, predisposes toward substance abuse disorder in adolescence (Gittelman, et al. 1985). One obvious implication of this finding is that children who fit this early symptom picture should be identified for substance abuse education and counseling in late childhood and early adolescence (Mannuzza, et al. 1988).
A most disabling adolescent characteristics is the feature of low self esteem. Even when the other problematic features of ADHD do disappear (or the adolescent learns to compensate for them) the self esteem problems associated with under achievement, poor peer relations, and negative adult relationships continue to have a great negative effect (Lambert, et al. 1987).
Substance abuse and antisocial behavior is prominent in adults ADHD's. Gittelman, et al. (1985) found a significant excess of antisocial personality disorders in adult ADHD's. This finding was consistent even when the adult did not continue to have other ADHD symptoms (Mannuzza, et al. 1988).
It has been noted that some dysfunctionality disappears in adulthood. This is probably because adults have a greater variety of activities from which to choose to make a living, consequently there are broader areas for success available. Nonetheless, adult ADHD's are still more impulsive, inattentive, and restless (adult equivalent to hyperactivity) than their peers (Barkley, 1989). They have a higher rate of personality disorder (Gittelman, et al. 1985) and experience a higher degree of other emotional and psychiatric disorders than normal adults (Mannuzza, et al. 1988).
Again, in adulthood, a pattern of substance abuse is present in many ADHD's. This is especially true for those adults who have a history of CD as children (Gittelman, et al. 1985). Optimistically, in those cases of ADHD where the symptoms impulsivity, inattention, and restlessness / hyperactivity do not continue past adolescence, the likelihood of demonstrating adult substance abuse disorder is no greater than that of non-ADHD peers (Gittelman, et al. 1985). According to this source, the full symptom picture persists in at least one-third of the diagnosed cases. Wender (1987) estimates that more than one-half of those with ADHD have symptoms disappear in adulthood, perhaps one-half continue to have symptoms into adulthood.
The problems related to inattentiveness do continue for many ADHD's past adolescence into adulthood. Goldstein (1987) reports that at least one sub-group of ADHD's had problems with inattention past adolescence and well into adulthood. Wender (1987) underscores that, of all the symptoms that persist into adulthood, inattentiveness is the one most frequently found. Mannuzza, et al.(1988) found that 20% of ADHD's had moderate to extreme problems with inattention, compared to 5% of controls.
Problems associated with personality disorder appear with greater frequency in adult ADHD's. In one follow-up study, Gittelman, et al. (1985) found significant excesses of personality disorder in ADHD's as compared to controls. As mentioned earlier, ADHD is often seen in combination with substance use disorder. Gittelman, et al. (1985) report a greater frequency of illegal earnings (selling drugs or stolen goods) and a higher use of weapons in ADHD adults as compared to controls.
Emotional and psychiatric problems not directly connected to the ADHD "syndrome" affect more ADHD adults than normals. Gittelman, et al. (1985) report that in one research study comparing ADHDs and a group of controls, 52% of the ADHDs had a diagnosable DSM III episode at some time during and beyond adolesce. This compared to only 32% of the controls. Many people are significantly affected by emotional and psychological problems, yet are not severely enough disturbed to meet all DSM III criterion. When considering this, the magnitude of significant emotional problems would be considerably greater than statistics may reflect (Mannuzza, et al. 1988).
Last Modified: Tuesday, November 11, 1997 8:40:54 PM
Steven J. Foust, peregrin@enteract.com