Attention Magazine Fall 2017

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PART TWO

FOR DECADES IT WAS ASSUMED THAT THE DISORDER CURRENTLY KNOWN AS ADHD always started in early childhood and always was outgrown sometime during adolescence. We now know that ADHD sometimes doesn’t show up until adolescence or beyond. We also know that for most, ADHD continues to cause impairments and sometimes gets worse during adolescence and adulthood.

However, it is also true that for many, ADHD gradually improves. This article describes some of the ways in which those improvements may occur spontaneously or as a result of interventions and/or good fortune.

Brain development may be delayed but then catch up.

Delays in brain development characteristic of ADHD sometimes improve. Philip Shaw and colleagues (2007) found that the usual pattern of cortical proliferation followed by pruning to develop more efficient circuits tended to be delayed by approximately 3-5 years in persons with ADHD. Several of the imaging studies described in that earlier section of this chapter reported on participants who were found to have ADHD in childhood but no longer met criteria for ADHD when they were evaluated in adulthood. It is not unusual for children who manifest ADHD symptoms of hyperactivity and/or impulsivity to outgrow those symptoms during early adolescence, but for 70%-80% of those with ADHD symptoms in childhood, impairments of executive functions related to attention tend to persist into adulthood. This means that for 20%-30% of children with ADHD, ongoing, although belated, brain development eventually improves functioning.

The answer to the question of how long ADHD impairments persist past childhood depends on how persistence is defined. Joseph Biederman and colleagues (2010c) found that adults who were treated for ADHD diagnosed in childhood tended to fall into one of three categories: 1) full syndrome persistence (fully met the entire official diagnostic criteria for ADHD), 2) symptomatic persistence (had more than half of the official diagnostic criteria for ADHD), and 3) functional impairment (did not meet official diagnostic criteria but were continuing to take medication for ADHD).

Using these categories, a follow-up study of boys diagnosed with ADHD found that when they reached their early 20s, 35% of them still met full diagnostic criteria, 22% had symptomatic persistence, 6% were in the functional impairment group, and 22% no longer fit any of the three categories for continuing to have ADHD impairments (Biederman et al. 2010c). Another study assessing girls diagnosed with ADHD found that 33% continued to meet full diagnostic criteria, 29% met the partial symptoms criteria, and 33% were no longer impaired by ADHD (Biederman et al. 2010b, 2012).

Part One, “How ADHD Sometimes Gets Worse,” appeared in the Summer 2017 issue of Attention.

Supportive relationships with particular family members, teachers, mentors, or friends provide guidance and encouragement.

Just as adversities within the family or community may complicate and impair the development of children, adolescents, or adults with ADHD, an ongoing relationship with a particular parent, grandparent, older sibling, or other family member may provide emotional support and stabilizing guidance for someone with ADHD. In some situations, it may be not a family member but a particular teacher, coach, neighbor, therapist, or perhaps even a peer who becomes a close friend, confidant, and advisor to help the growing person with ADHD feel recognized, appreciated, and encouraged to deal with frustrations, avoid potential trouble spots, and develop his or her personal strengths. It is difficult to overestimate the value and benefits that such a relationship can provide at critical points in the life and development of an individual with ADHD.

After completion of basic schooling, some individuals find success in work that better fits their interests and skills.

Usually, the most difficult times for persons with ADHD are their years from middle school through the first few years after high school. Those are the years when students are faced with the widest range of tasks to do and the least opportunity to escape from the tasks that they struggle with or find to be boring. As they progress in their education, some who are fortunate may discover areas of study in which they have strong interest and abilities. They may then be able to progress to more specialized study in those areas, which may eventually lead them to a career for which they are particularly suited.

Some students who are especially strong in quantitative thinking and data analysis but struggle with reading or writing papers may move into studies in accounting, finance, or computer science, where they can develop their specialized strengths without pressure to continue with intensive work with words. Likewise, some who struggle with math while having strengths in verbal communication may meet the minimum requirements for study of math while developing their skills in other areas that depend more on use of oral or written language. Others may specialize in technical, mechanical, artistic, or scientific domains that do not require work in areas for which they are less competent.

In some work settings, one can delegate to others tasks that are problematic for oneself. For example, a tradesman who is skilled in doing construction or plumbing or electrical work but struggles to keep up with billing and office tasks may develop his business sufficiently to hire a part-time or full-time secretary or office manager who can respond to phone inquiries, schedule appointments, and manage billing and bookkeeping tasks, leaving the tradesman to devote himself fully to the work he does best. A business executive may fulfill major responsibilities for planning and managing diverse operations of his business organization and demonstrate excellent leadership skills, while depending heavily on the support of an administrative assistant who helps to organize his incoming communications, plan his schedule, and manage daily operations.

Some individuals develop a relationship with a partner in which each can complement the strengths of and help compensate for the weaknesses of the other.

In adulthood, some individuals with ADHD are able to develop and maintain a relationship with a partner in a work situation or in family life who is able and willing to take care of some aspects of life that the person with ADHD finds more difficult. At the same time, the partner benefits from the contributions of the person with ADHD. For example, some businesses thrive with a leadership team in which one member manages production of a product or service while the other member manages marketing and sales of the product or service. In some marriages, one partner may take primary responsibility for managing the household and family finances, while the other takes a lesser share of those responsibilities and contributes primarily to supporting the family by generating income.

Some individuals who have ADHD complicated by another disorder may recover from that other disorder and thus be better able to manage their ADHD.

One example of such recovery is the individual who has struggled with excessive drinking or excessive use of marijuana or other drugs, perhaps during late teens and early adulthood, and then is able to recover from that addiction and maintain abstinence or adequate control over their excessive substance use. Research indicates that a majority of addicts quit using illegal drugs by age 30 (Heyman 2013).

For those seriously addicted to drugs or alcohol, such recovery is not easy to gain or maintain, but many do manage to put their excessive drinking or drug use behind them as they enter their twenties or thirties. This might occur after a stint in a rehabilitation program or sustained participation in a 12-step program or other treatment program, but often it occurs without professional assistance (Heyman 2013). Usually, the first few years of recovery are the most difficult as the individual struggles to cope with a variety of emotional problems that may have been the initial precipitants of the excessive substance use. In some cases, recovery is helped substantially by the individual’s finding productive work, which provides satisfaction and financial rewards that give the person in recovery motivation to continue to sustain their recovery.

Another factor that helps some persons who have substance use disorders, persistent depression, or excessive anxiety is finding someone with whom they are able to develop a close friendship or perhaps even a life partnership. Finding and sustaining a mutually beneficial relationship with someone can be a strong factor in helping individuals make important changes in their previous maladaptive lifestyle.

Some individuals develop compensatory strategies that allow them to deal with some of their ADHD-related impairments.

Some persons with ADHD eventually find ways to develop habits or routines that prevent their ADHD symptoms from disrupting their lives. Such compensatory strategies can be as simple as consistently placing one’s keys in a particular place beside the door immediately on entering the house or utilizing reminders on one’s cell phone for help in remembering to take pills on schedule each day. Other strategies may include maintaining an electronic or day-timer calendar for keeping track of all appointments and/or utilizing a ”To Do” list with each item assigned a 1, 2, or 3 priority value and a set time for reviewing and revising that list once or twice each day to monitor progress and keep the task list and appointment schedule within manageable bounds.

Another strategy some persons with ADHD find helpful is to employ an ADHD “coach” who has been trained to help those with ADHD identify areas of difficulty in their daily functioning and then to provide assistance with developing better coping strategies to manage specific problems. The coach should also provide frequent phone or face-to-face accountability monitoring and support for the stated goals.

Some individuals are fortunate enough to receive adequate assessment and effective treatment for their ADHD with or without co-occurring disorders.

An important factor that can help most persons with ADHD is finding and working with an adequately trained medical or mental health professional who can provide adequate assessment and treatment for ADHD symptoms and any co-occurring disorders. Many professionals claim that they can provide such services, but it is not always easy to locate an adequately trained professional who is accessible both in terms of getting an appointment within reasonable travel distance and affordability of the necessary services. Some medical insurance plans provide adequate coverage for such assessments and treatments; others do not. However, even when cost is not a problem, finding the right clinician and getting needed appointments can be quite difficult.

Even when a competent clinician is available, there is still a need to clearly to assess the ADHD impairments, to tailor an effective plan for treatment, and to sustain that treatment relationship for adequate monitoring and adjustments of the treatment process.

 

REFERENCES

(In order of appearance in text)

Shaw P, Eckstrand K, Sharp W, et al: Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences USA 104(49):19649–19654, 2007.

Biederman J, Petty CR, Evans M, et al: How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD. Psychiatry Research 177, 299-304, 2010c.

Biederman J, Spencer TJ, Monuteaux MC, et al: A naturalistic 10-year prospective study of height and weight in children with attention deficit hyperactivity disorder grown up: sex and treatment effects. Journal of Pediatrics 157(4):635–640, 640.e1, 2010b.

Heyman GM: Addiction and choice: theory and new data. Frontiers in Psychiatry 4:31, 2013.

 

Excerpted with permission from Outside the Box: Rethinking ADD/ADHD in Children and Adults by Thomas E. Brown, American Psychiatric Association Publishing, © 2017.

Thomas E. Brown, PhD, is a clinical psychologist who specializes in assessment and treatment of high-IQ children, adolescents, and adults with ADHD and related problems. After serving on the clinical faculty of Yale Medical School for 20 years, Dr. Brown relocated to Los Angeles, where he has joined the faculty at the Keck School of Medicine of the University of Southern California. His new Clinic for Attention and Related Disorders will open in Manhattan Beach in June 2017. His book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults (Yale University Press, 2005), has been published in seven language. He is also the author of Smart but Stuck: Emotions in Teens and Adult with ADHD (Jossey-Bass/Wiley, 2014), and A New Understanding of ADHD in Children and Adults: Executive Function Impairments (Routledge, 2013).