ADHD in Older Adults
written by George M. Kapalka, PhD, ABPP
ADHD is a disorder of which we have been aware ever since Hoffman, in the mid-1800's, described a case of "Fidgety Phil" whose distractibility and hyperactivity disrupted others around him and interfered with his education. In the last 150 years, this disorder was known by many different names - Morbid Defect in Moral Control; Post-Encephalic Behavior Disorder; Minimal Brain Damage, and Attention Deficit Disorder With or Without Hyperactivity - as our understanding of its etiology morphed through the years. Today, we know that individuals with ADHD exhibit differences in the size and function of key areas of the brain, particularly including the inhibitory centers in the frontal region. While environmental factors usually also play a role in the development of the symptoms, at the heart lies an inherited deficit in dopaminergic function that makes it more difficult for individuals with ADHD to control their impulses (to move, say things, or while making decisions) and filter out distractions. Consequently, individuals with ADHD present a mix of symptoms of hyperactivity and distractibility, although the specific profile of symptoms varies from one person to another - some individuals exhibit significant impulsivity and hyperactivity, while others primarily exhibit distractibility and disorganization.
Because genetic factors seem to be at play (several genes underlying ADHD have been identified), it is logical to expect that symptoms must be apparent early in childhood. Indeed, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) requires the presence of symptoms prior to age 7 in order to render the diagnosis. This, however, is complicated because of the varying nature of symptoms that individuals exhibit. Those with significant hyperactivity/impulsivity are likely to present management difficulties and parents usually become aware of these difficulties during early childhood. Even if treatment is not sought until later, most parents are able to recall whether or not the child, while little, exhibited a significant amount of these problems. Some children, however, only present problems with distractibility and disorganization, and these problems are easier to overlook during early childhood. Thus, when a teenager or adult first comes into treatment, it is sometimes difficult to determine how long these symptoms have been present.
Diagnosis of ADHD in adulthood is difficult to make for several other reasons as well. Developmentally, hyperactivity and impulsivity diminish with age, and tend to become much less pronounced by adulthood. While some adults with ADHD remain very impulsive, many others primarily exhibit symptoms of distractibility and disorganization. However, these symptoms may be secondary to many other disorders (like depression), or no disorder at all - perhaps the result of stress or problems adjusting to major life events (like divorce, loss of a job, etc.). While only a fraction of children with ADHD exhibit clinical depression, by some accounts, three quarters of adults with ADHD also exhibit a depressive disorder. Thus, when an adult is suspected of ADHD, depression is usually also evident, and it is difficult to determine whether the distractibility or disorganization is due to the depression or possible symptoms of ADHD.
How prevalent is ADHD among older adults? No reliable estimates currently exist, but it is safe to say that the prevalence of ADHD among adults is lower than it is among children. About 6 percent of school-age children exhibit symptoms of ADHD, and 40 to 50 percent of them "grow out" of this disorder by adulthood. This may be due to various factors, including growth of the brain (as the frontal portions increase to adult size, symptoms of ADHD significantly diminish), as well as the development of effective compensatory strategies. By the time adults age into their fifties and beyond, most have matured significantly and acquired life skills that help them cope with most situations. Thus, ADHD among older adults is probably less common than among children or younger adults.
Still, it certainly is possible for an older adult to have ADHD. Anyone who is currently in his or her fifties or beyond grew up during the 1960's or before, when recognition of ADHD was not prevalent and distractibility or hyperactivity often were written off as behavioral problems needing discipline. Similarly, the educational approach back then did not load the children and teens with as much academic content and home work as schools do today. While probably uncommon, it is not impossible for a person to avoid getting help over the years and exhibit symptoms of ADHD for decades until they become diagnosed in their fifties or later.
Understanding how issues of masculinity contribute to the diagnosis and treatment of ADHD is also important. ADHD is more common in males - estimates range from a three-fold to a ten-fold difference in prevalence. Because males are less likely to seek mental health treatment, and may be less receptive to some forms of psychotherapeutic interventions, it is more likely that males with ADHD may go untreated longer. Thus, it is possible that a male with ADHD was referred for treatment many times before, and perhaps was even occasionally seen by a medical or mental health professional, with limited follow-through, and that person would be likely to continue to exhibit symptoms into his fifties and beyond.
What symptoms would likely be present in an older adult with ADHD? We must start with recognition that, to have ADHD, symptoms must have started before age 7, although they may not have been diagnosed at the time. Today, that same person is not likely to exhibit much hyperactivity, although impulsivity in decision making (for example, impulsive buying) may still be present. However, it is most probable that an older adult with ADHD will primarily exhibit symptoms of distractibility and disorganization at home and in work-related areas. For example, the person may forget to pay bills, lose items easily, be careless while driving, forget appointments and tasks, etc. When these problems are significant enough to be diagnosable, secondary difficulties in relationships with peers and family members are likely to also be evident - marital discord, inconsistent relationships with other family members, few friends, etc.
What should an older adult do if he or she suspects that he or she may exhibit symptoms of ADHD? First and foremost, a careful diagnostic work-up will be needed. Initially, medical evaluation should be sought to rule out some of the medical problems that may result in similar symptoms. Usually, it will be necessary to check cardiac and thyroid function and rule out other medical problems that may contribute, like sleep disorders. If the person is cleared medically, psychodiagnostic work-up will then be needed. Because ADHD in adults is so commonly comorbid with other disorders, it will be necessary to rule these out before a diagnosis of ADHD is made. Similarly, neurological problems (like early symptoms of dementia) will also have to be ruled out.
If other causes of symptoms are ruled out, and developmental, personal and school/occupational history is consistent with ADHD, the diagnosis may be rendered in an older adult. Such an individual has the same choices of treatments available for younger adults. Medications may be helpful, and non-medical approaches such as individual counseling (to develop necessary compensatory strategies), marital or couples' counseling (to address relational issues), group counseling (to improve social adjustment) and coaching may be beneficial.
George M. Kapalka, PhD, ABPP, is the head of the Department of Psychological Counseling at Monmouth University, West Long Branch, NJ, 07764.
Dr. Kapalka email address is firstname.lastname@example.org
Also available by this author:
Kapalka, G. M. (2010). Counseling boys and men with ADHD. New York: Routledge. ISBN# 9780415993449.
Kapalka, G. M. (2007). Parenting your out of control child: An effective, easy-to-use program for teaching self-control. Oakland, CA: New Harbinger Publications. ISBN# 9781572244849. Translated into French, Portuguese, Russian and Korean.
Kapalka, G. M. (2009). Eight steps to classroom management success: A guide for teachers of challenging students. Thousand Oaks, CA: Corwin Press. ISBN# 9781412969444.
Kapalka, G. M. (2010). Nutritional and herbal therapies for children and adolescents: A handbook for mental health clinicians. San Diego, CA: Elsevier Science. ISBN# 9780123749277.