The diagnosis of ADHD in adults: clinical characteristics and evaluation

It is a neurodevelopmental disorder, and as such, it has been present since childhood. But what happens when you reach adulthood? What do the studies say? For diagnosis in adults, are the same criteria considered as in children? Could there be ADHD and another associated condition? Can an adult develop ADHD from one moment to the next? What do the studies say regarding neuropsychological evaluation in this population?

This article proposes to characterize ADHD in adults by answering these questions, as well as to provide some suggestions to carry out the diagnostic evaluation process.

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Description of the clinical picture

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder, and as such, it has been present since childhood. It is estimated that its prevalence in children is 3 to 5% of the world population. Between 30 and 60% of children diagnosed with ADHD persist with clinically relevant symptoms even into adulthood. According to the American Psychiatric Association (APA, 2013), it requires fewer symptoms in this population than in children. ADHD in the adult population is usually under/underdiagnosed. The clinical presentation can vary significantly in relation to the pediatric population.

Next, a description of the clinical picture will be made according to the European Consensus Declaration on the diagnosis and treatment of ADHD in adults (Kooij et al., 2018), along with some more characteristics resulting from findings in interdisciplinary studies.

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1. Lack of attention and hyperfocus

Patients with primarily inattention problems are often slow to think and formulate, due to distractions. They can formulate things in a tangential and long-winded way, getting lost in irrelevant details and having difficulty making decisions (Kooij et al., 2018).

Hyperfocus or hyperfocus is a state of heightened and focused attention that can be experienced by people with ADHD. During this state, people may find themselves completely immersed in a task or activity that they find interesting or stimulating, being able to ignore distractions and maintain their attention for long periods of time. Hyperfocus can be a form of compensation for the attention and concentration deficits experienced by adults with ADHD, but it can also be problematic if it becomes an obsession that interferes with other important areas of life.

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2. Hyperactivity

In adults, hyperactivity does not usually present itself in the same way as in children, such as through excessive movements. Hyperactivity in adults manifests itself as a constant feeling of restlessness or internal agitation. It can manifest itself through excessive talking, accelerated mental activity, inability to relax (Kooij et al., 2018).

3. Impulsivity

Impulsivity and associated interpersonal conflicts can have negative consequences on relationships with family, friends, colleagues, and employers. It can also seriously affect personal finances when impulsive spending leads to debt. Additionally, some people may engage in impulsive binge eating, such as overeating, as a way to cope with restlessness or to obtain immediate gratification. Often these behaviors involve taking risks, such as playing with fire, driving recklessly, having risky sex, or behaving in provocative ways that can lead to fights. These behaviors are related to “sensation seeking” behaviors, where people seek excitement through novel and exciting stimuli (Kooij et al., 2018).

4. Emotional dysregulation and rejection-sensitive dysphoria

The DSM-5 identifies emotional dysregulation as a characteristic feature of ADHD, which helps support the diagnosis. Emotional dysregulation in ADHD refers to a lack of ability to adequately regulate emotional states, such as irritability, frustration, and anger, as well as low frustration tolerance, temper outbursts, emotional impulsivity, and rapid changes in mood. the state of mind. Unlike symptoms seen in other disorders, such as depression or mania, the emotional symptoms of ADHD typically reflect exaggerated, short-lived changes in response to daily events, rapidly returning to baseline within a few hours. It is still unclear whether this type of emotional instability is different from that observed in other clinical conditions, such as borderline personality disorder or post-traumatic stress (Kooij et al., 2018).

Associated with emotional dysregulation in adults, the term “rejection-sensitive dysphoria” has become popular, which is coined by the author Dobson. Although to date there are no scientific studies associated with it, nor is it a term apparently accepted by the scientific community, it has become popular in the community of people with ADHD. It is characterized by intense changes in mood caused by: 1) rejection (whether real or perceived love, approval or respect), 2) jokes, 3) criticism (even if it is constructive), 4) persistent self-criticism or negative internal dialogue, caused by real or perceived failure (Dobson, 2023).

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Moods return to normal very quickly, so a person with ADHD may have multiple episodes of mood dysregulation in a single day (Dodson, 2023).

Table 1 Examples of symptoms related to ADHD

Inattention – Easily distracted by sounds, movements
– Trouble resuming tasks after a distraction
– Lack of concentration during conversations, meetings, conferences, etc.
– Difficulty starting and completing tasks, procrastination
– Forgetfulness, misplacement or loss of items, delay in deadlines
– Difficulties with focus and comprehension when reading
– Dreamer, “gets lost” in thought
– Disorganization
– Running out of steam, poor attention monitoring
– Requires more time than average to complete tasks Hyperactivity
– Restlessness (inner)
– Difficulty relaxing
– Go and come
– Talk too much and too loudly
– Restlessness, rocking or tapping
– Not being able to endure office work due to restlessness.
– Knocking things down due to excess mobility
– Be able to sit still, but this comes with muscle tension
– Sleep without rest
Impulsiveness – Act without thinking
– Saying things without thinking or that are inappropriate for the environment, uninhibited.
– Start projects but not finish them
– Making promises but then overcommitting, “impulsive compliance”
– Difficulty waiting your turn: related to feelings of irritability
– Interrupt others
– Impatience and difficulty waiting for your turn
– Spend too much
– Exit jobs
– Start relationships quickly
– Not being able to postpone gratification
– Sensation-seeking and risk-taking behaviors
– Binge emotional dysregulation
– Mood lability
– Low tolerance to frustration
– Emotional impulsivity
– Irritability
– Outbursts of anger
– Increase in symptoms in premenstrual stages Adapted from Kooij et al. (2018)

Table 2 Examples of each of the common ADHD symptom domains

Inattention – Easily distracted by sounds, movements
– Trouble resuming tasks after a distraction
– Lack of concentration during conversations, meetings, conferences, etc.
– Difficulty starting and completing tasks, procrastination
– Forgetfulness, misplacement or loss of items, delay in deadlines
– Difficulties with focus and comprehension when reading
– Dreamer, “gets lost” in thought
– Disorganization
– Running out of steam, poor attention monitoring
– Requires more time than average to complete tasks Hyperactivity-Impulsivity – Frequent changes and restlessness
– Tapping fingers or pen, moving foot, playing with objects
– Discomfort with sedentary and limiting tasks
– Mental restlessness, juggling several ideas but not carrying out any of them
– Start projects but not finish them
– Saying things without thinking or that are inappropriate for the environment, uninhibited.
– Making promises and then overcommitting, “impulsive compliance”
– Impulsive spending, substance use
– Difficulties managing discomfort, boredom.
– Problems with “turning off the brain” Obtained from Barkley (2015)

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5. Excessive mind wandering

A common feature of ADHD in adults is excessive mind wandering, also known as mental restlessness. In the DSM-5, it is described as the appearance of unrelated thoughts. Although mind wandering is common, some types can be disruptive as they interrupt the performance of a task. Adults with ADHD often describe finding themselves distracted by multiple unrelated thoughts, constantly jumping from one topic to another. Although mind wandering is also a characteristic of other mental health disorders, such as depression or obsessive disorders, in ADHD it is characterized by distraction and without repetitive or abnormal patterns in its content. Research has found that excessive mind wandering is strongly related to ADHD symptoms and is a stronger predictor of ADHD-related impairments than ADHD inattention and hyperactivity-impulsivity symptoms (Kooij et al., 2018). ).

6. Behavioral self-regulation (deficit in executive functions)

ADHD has been described as a disorder of executive functions, including skills such as inhibition and working memory. These problems include difficulties organizing, prioritizing and initiating work, focusing, sustaining and shifting attention to tasks, regulating alertness, maintaining effort and processing speed, managing frustration and regulating emotions, using memory work and access memory, and monitor and self-regulate behavior. Although these clinical descriptions are accurate in terms of the difficulties experienced by adults with ADHD, behavioral measures do not correlate well with cognitive or neuropsychological tests of executive functions. A distinction needs to be made between behavioral EF deficits (as measured by rating scales) and results of neurocognitive tests of EF, such as working memory and inhibition. The scores in…