ADHD Across the Lifespan

More often than not, symptoms of ADHD will persist into adulthood. Obviously, the manifestation of ADHD symptoms differs across the lifespan. ADHD affects young children far differently than it does adults and the impact of symptoms, resulting impairment and methods of treatment vary by age and level of development. This section looks at ADHD at different stages of development: infants, toddlers and preschoolers; middle childhood; adolescence; and adulthood.

Infants, Toddlers and Preschoolers

Although about ten percent of infants appear to have difficult temperaments characterized by irritability, hyperarousal, overactivity and inability to be easily calmed, clinicians do not diagnose ADHD in infancy. However, the overactive, temperamental infant is at greater risk to become the hyperactive, difficult preschooler.

It is customary for preschool age children to be overactive and impulsive from time to time. Their attention is captured by things that interest them, but usually for short periods of time. They shift quickly from one activity to another. We expect preschoolers to be somewhat demanding, impulsive or self-centered and generally we don’t get too upset when they get frustrated and have occasional temper tantrums or crying spells. Hopefully, we anticipate their frustration, plan for their short attention span and vary their activities enough to sustain their interests.

At what point does activity exceed the bounds of normalcy and become hyperactivity? When is inattentiveness considered attention deficit? At what age should we expect immaturity to end and impulsivity to disappear? Unfortunately there are no objective answers to these questions. Healthcare professionals must be careful to differentiate normal preschooler hyperactivity and impulsiveness from the “over the top” behavior characteristic of preschoolers with ADHD. For example, some young children have language delays. They may exhibit hyperactivity and disruptive behavior out of frustration arising from their inability to communicate. Some young children may simply not be mature enough to handle the demands of preschool and the routines of their busy parents. They act out. Dr. Susan Campbell studied three-year-olds with a pattern of hyperactive, impulsive and related disruptive behavior. Nearly one half continue to experience behavioral problems by school age, and nearly one-third receive a diagnosis of ADHD.

Parents of ADHD preschoolers often describe themselves as exhausted by the child-rearing process. The typical methods of discipline such as time-out, positive reinforcement and punishment don’t work well. They may try to discipline their youngsters and teach appropriate behavior, but the child seems unable to learn. Parents are often left without an effective means of control. Teachers of ADHD preschoolers end up equally frustrated. Disruptive behavior, especially aggression toward other children, becomes a chief concern for the teacher. Parents of the more seriously involved kids are frequently asked to withdraw their child from the preschool only to end up in a desperate search for another school that will be able to handle their child’s problems. Such places are rare, and often the parent ends up relying on the good graces of another preschool director or teacher who is willing to give their child a second (or third) chance.

Fortunately, the majority of the preschool-age children described by their parents as inattentive and overactive will show improvement in these areas as they mature. However, for those children whose hyperactivity and conduct problems persist for at least one year, there is a much stronger likelihood that they will have continuing difficulty in these areas and may more likely receive a diagnosis of ADHD or oppositional defiant disorder (ODD) in the future.

Middle Childhood

Many children with ADHD will be identified by the time they are nine or ten years of age. If the child is primarily inattentive, but not necessarily hyperactive, he or she will leave a trail of unfinished tasks: uncovered toothpaste in the bathroom, clothes scattered about the floor of the bedroom, bed unmade, toys and books left wherever they were last used, games started and unfinished, tomorrow’s math homework paper mixed in with last month’s spelling, dresser drawers bulging from unfolded clothes and on and on.

If hyperactivity and impulsivity are also present, the picture at home becomes even more chaotic: toys scattered and broken, walls marked up, frequent family arguments over listening, meals disrupted by fighting, shopping trips marred by relentless demands, sibling conflicts and frayed nerves.

Patterns of academic frustration and failure, social rejection and criticism from parents and teachers build in elementary school to the point where other disorders associated with ADHD begin to appear. Approximately 60 percent of these children will develop oppositional disorder, characterized by defiant and non-compliant behavior. Frustrated by their lack of success, these children may become irritable and sullen. About half of this group of oppositional children will develop an even more serious behavior disorder in adolescence, namely conduct disorder (CD). Many ADHD children will suffer low self-esteem due to their inability to achieve the same levels of success as their peers. Still others will develop serious depression (Parker, 2002).

It is at this time that children are most likely to be referred for an assessment after which a diagnosis is given and treatment is started. Children with the hyperactive-impulsive or combined types of ADHD are much more likely to be referred by their teachers and parents for an evaluation. Because their disruptive behavior adds stress to their family and their classroom, parents and teachers become alarmed. The child with the inattentive type of ADHD may go unnoticed, but nevertheless may struggle with school work, may have trouble staying focused and organized and may not be able to keep up academically or socially.

After making a diagnosis, the physician may try different medications to see which are most effective. Strength of dosing and time of dosing will be modified based on the child’s individual response to the medications. The child’s parents become ADHD-educated about ADHD for the first time and learn about the benefits, and risks, of taking medication. This is often the time when parents take on a more formal role as their child’s advocate in school. Mothers and fathers help the teacher plan accommodations in the classroom, seek information from the teacher about their child’s progress and work closely with their child to ensure that the child is completing assigned work in an organized and responsible way.

Also at this time, comorbid problems such as a learning disability, anxiety disorder, depression or oppositional disorder appear as the child may struggle in school and in social surroundings. The child and the parent may visit a psychologist, social worker or counselor to manage behavior and emotions. Parents may provide more structure at home by implementing behavioral treatments. The child may be taught self-control strategies.

Children with ADHD in these middle childhood years are at risk for academic failure. They are more likely to repeat a grade, be placed in special education, and receive academic tutoring. Close communication between parents, healthcare professionals and teachers is essential to make certain that treatments are addressing the child’s needs appropriately and effectively.

Adolescence

As many as 80 percent of children diagnosed with ADHD in middle childhood will continue to have symptoms of overactivity, inattention and impulsivity through adolescence. Longitudinal studies following groups of children with ADHD into their adolescent years consistently find that teens with ADHD have higher rates of disruptive and non-disruptive problems including anxiety, depression, oppositional behavior and school failure. Rate of substance abuse is also higher, but this is only found in those teens who have CD (more severe defiance associated with running away, truancy, lying, stealing, etc).

School problems can intensify in middle and high school. Greater demands are placed on students in secondary schools. They have more teachers to cope with, more work to be responsible for, more activities to organize and they tend to be less closely supervised by teachers and parents. The ADHD adolescent starts middle school with several teachers each of whom probably has two hundred or more students to teach. It is easy to get lost in the shuffle.

Raising an adolescent with ADHD is challenging to parents and other family members. There is likely to be more conflict between the ADHD teenager and his/her parent. This is much more prevalent, however, when the adolescent with ADHD has additional problems related to substance abuse, delinquency or learning difficulties or when there is other stress or adversity in the family.

Adolescents with ADHD present a significant challenge for the doctors and counselors that treat them. As the demands of school, social life and responsibilities in general increase in adolescence and the number of comorbid diagnoses increase (conduct disorder, anxiety, depression, learning problems) healthcare professionals are faced with a mountain of problems that may be difficult for the teen, the doctor or the parent to manage. Teenagers are often unwilling to accept responsibility for their behavior. They may be reluctant to accept medical treatments. They may refuse to take the ADHD medication they willingly took during childhood and may be adverse to accepting other treatments as well (seeing a counselor, getting extra academic help, etc.).

Adulthood

Within the past 15 years, the persistence of ADHD into adulthood has been increasingly recognized. Unfortunately, there are relatively few studies of adults with ADHD. Many of these studies have focused on issues related to the identification of the disorder, the presence of other psychiatric disorders in adults with ADHD and the use of medication treatments. There seem to be more questions than answers.

Dr. Sam Goldstein explains that the picture of ADHD in adulthood can be very variable. He divides adults with histories of ADHD into three categories: (1) those who seem to function fairly normally as adults although they have had childhood ADHD; (2) those who continue to have significant problems with ADHD as well as life difficulty involving work, interpersonal relations, self-esteem, anxiety and emotional lability; and (3) those who develop serious psychiatric and anti-social problems and are quite dysfunctional. The sections that follow contain outcome information about academic and occupational functioning, social skills, and family functioning in adults with ADHD.

Academic and Occupatonal Attainment

Adults with childhood histories of ADHD and/or a diagnosis of ADHD made in adulthood, on average, have more difficulty achieving in school and in their employment. They are less likely to go on to higher education and are more likely to be employed in skilled labor positions and to change jobs more often. Adults with ADHD may do better in occupations that are fast-paced and involve risk-taking and an outgoing style of communication. These job characteristics seem to match the characteristics found in many adults with ADHD.

Social Skills

A few studies have looked at how adults with ADHD function in social interactions. Symptoms such as inattention and impulsivity are likely to contribute to social difficulties. Adults with ADHD are often described as having difficulty with the give and take of conversation. They may ramble on, unaware of cues given off by the person they are talking with that they should alter the style of their communication. Drs. Gabrielle Weiss and Lilly Hechtman (1993) found that young adults in the ADHD group they studied were significantly worse at social skills in job interviews and other situations which required assertiveness and oral communication. Dr. Michele Novotni, in her book, What Does Everybody Else Know That I Don’t?, gives many illustrations of how ADHD symptoms can impact on adult social interaction and offers strategies for improvement.

Family Functioning

Due to the high heritability of ADHD, adults with ADHD who become parents are more likely to have children who also have ADHD. As a result, these parents have a double challenge. They must manage their own ADHD symptoms and they must help their child with manage theirs. ADHD can interfere with a parent’s patience and ability to use effective parenting strategies. Children with ADHD have a greater need for a parent who has a clear and consistent parenting style, established routines and structure in the home. Parents may have to implement different behavioral treatment programs requiring consistent delivery of rewards and consequences. They may have to be good time managers to keep their ADHD child on track so they have time for schoolwork, household responsibilities and recreation. Often treatment of ADHD symptoms in a parent leads to improvements in parenting skills. Unfortunately, ADHD may have a negative impact on marital stability as higher rates of separation and divorce have been found in adults with ADHD. Moms with ADD: A Self-Help Manual by Christine Adamec and Voices from Fatherhood: Fathers, Sons and ADHD by Patrick Kilcarr and Patricia Quinn offer many tips for parents, particularly if you suffer from ADHD as an adult

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