Treating the Difficult and Persistent Condition of Severe ADHD in Adults

Adults with Severe ADHD

One of the most common psychiatric disorders diagnosed in childhood, attention deficit hyperactivity disorder (ADHD) was typically believed to improve as children reached adolescence and to virtually disappear in adulthood. While symptoms of ADHD do diminish in some individuals, the disorder continues to significantly impair the daily functioning and behavior in adults. Symptoms of inattentiveness, hyperactivity, and impulsivity can range from mild to severe. Many adults, however, are now thought to experience severe functional, behavioral, and psychosocial impairments throughout their lifetimes.

Adults with even severe forms of this disorder tend to be under-diagnosed and under-treated due to several factors. The symptoms of ADHD can become more subtle, shifting from hyperactivity and impulsivity in childhood to inattention, restlessness, and impairments in executive function in adults. Another factor occurs when comorbid disorders may be diagnosed as the one and only disorder in patients. Additionally, stigma still exists in seeking help for psychiatric disorders.

Severe ADHD symptoms can be compared to “typical” ADHD with tendencies to become easily distracted by external stimuli, in starting or stopping activities or behavior when requested, and in sustaining attention on tasks or other activities. Individuals also have difficulties planning and organizing tasks and activities. With severe ADHD, these more intense symptoms impair every area of daily life. Adults with these severe symptoms have great impairments maintaining relationships, finding and keeping employment, and managing emotions.

The more severe an individual’s ADHD symptoms are, the more likely they are to be underachievers and have high rates of absenteeism at work if they are employed. Adults with more severe forms of the disorder are more prone to driving accidents and other potentially harmful accidents, such as animal bites or burns. These people display more behaviors associated with unhealthy lifestyles, with smoking, drinking, using other drugs, participating in risky sexual activity, and experiencing the effects of chronic sleep problems. Individuals with severe ADHD have significantly higher rates of arrests, convictions, and incarcerations, too.

Parents with severe symptoms have more difficulties in relationships with their children, who have a genetic predisposition to this disorder. Due to inattention problems at work, employees often cannot compete for promotions, even with coworkers with similar cognitive abilities, and therefore may have limited financial resources. Severe ADHD can additionally lead to loneliness and social isolation, and can result in increased levels of anxiety and depression.

Treatments for Severe ADHD

A multimodal approach is necessary in treating the intensity of the symptoms of severe ADHD and any coexisting conditions (anxiety and depression). The multimodal approach includes psycho-education about the disorder or disorders, pharmacotherapy for ADHD and other disorders, cognitive-behavioral therapy (CBT), coaching, and family therapy. Psycho-education and family therapy should include any relatives and others in close relationships with the individual.

Psycho-education is an important first step in helping the patient understand his disorder or disorders. Providing information can bring reassurance and comfort to isolated patients and give insight into past difficulties and ongoing challenges. Including family members can deflate feelings of guilt and shame and can help begin to restore relationships. Patients should be informed of support groups, which can offer more reassurance and understanding with the sharing of experiences.

Pharmacotherapy is often not used alone to treat such severe and complicated symptoms of ADHD. While treatment such as CBT better promotes lasting changes in behavior and functioning, medication can help improve core symptoms. Stimulants are the first choice in medication, improving symptoms and behaviors associated with the disorder. Low self-esteem, mood swings, outbursts of anger, and cognitive and social abilities also improve with stimulants. Non-stimulant medication is used to treat ADHD as well. Antidepressants and anti-anxiety medications may be prescribed if these other disorders cause persistent and severe enough symptoms to interfere with treatments for ADHD.

CBT and coaching work to identify and accept the impairments of the disorder. These therapies teach individuals to deal with work difficulties by showing them how to manage time, initiate and complete tasks, and remain organized. With CBT and coaching, patients learn to recognize the emotions related to ADHD and develop strategies to cope with them and to use in relationships. Difficulties in relationships with spouses and children should be addressed in marital and family therapy, recognizing specific problems experienced in daily life and identifying problem-solving solutions.

Treatments for severe ADHD should remain ongoing as the disorder is a lifelong condition and can have numerous consequences in underachievement, financial challenges, and difficulties in familial and social relationships. Continuing treatment assists adults with pervasive impairments in coping with the many emotions, negative beliefs, and the high levels of frustration associated with ADHD.

References

Kooij, Sandra JJ. et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. <em>BMC Psychiatry.</em> BioMed Central, 2010.

Rosenfield, Bradley M., Ramsay, J. Russell, and Rostain, Anthony L. Extreme Makeover: The Case of a Young Adult Man with Severe ADHD. Clinical Case Studies. University of Pennsylvania School of Medicine, 2008.