ADDult ADD CRITERIA

Ed Note: Part of Friday's GRADDA conference presentation I'll share with you is Dr. Hallowell's suggested criteria for diagnosis of ADD in adults.

The current DSM 3 and the upcoming revision DSM 4 criteria is applicable to children only. There is no similar criteria for adults that have gone through a professional and clinical review to be used as official guidelines. Note that these criteria are based on extensive clinical experience but have not yet been statistically validated by field trials.

One thing to remember while reviewing this information is that it is not as simple as whether or not the patient has or doesn't have these; it is also a matter of intensity and duration. Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age. Further, Dr. Ned requires that a patient have at least 15 of the 20. The criteria are followed by other considerations which must be included and found in the overall assessment. I've included some anecdotes used as illustrations.

1) A sense of underachievement, of not meeting one's goals (regardless of how much one has actually accomplished).

We put this symptom first because it is the most common reason an adult seeks help. "I just can't get my act together!" is the frequent refrain. The person may be highly accomplished by objective standards, or may be floundering, stuck with a sense of being lost in a maze, unable to capitalize on innate potential.

2) Difficulty getting organized.

A major problem for most adults with ADD. Without the structure of school, without parents around to get things organized for him or her, the adult may stagger under the organizational demands of everyday life. The supposed "little things may mount up to create huge obstacles. For the want of a proverbial nail -- a missed appointment, a lost check, a forgotten deadline -- their kingdom may be lost.

3) Chronic procrastination or trouble getting started.

Adults with ADD associate so much anxiety with beginning a task, due to their fears that they won't do it right, that they put it off, and off, which, of course, only adds to the anxiety around the task.

4) Many projects going simultaneously; trouble with follow-through.

A Corollary of #3. As one task is put off, another is taken up. By the end of the day, or week, or year, countless projects have been undertaken, while few have found completion.

5) Tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark.

Like the child with ADD in the classroom, the adult with ADD gets carried away in enthusiasm. An idea comes and it must be spoken, tact or guile yielding to child-like exuberance.

6) An ongoing search for high stimulation.

The adult with ADD is always on the lookout for something novel, something engaging, something in the outside world that can catch up with the whirlwind that's rushing inside.

7) A tendency to be easily bored.

A corollary of #6. Boredom surrounds the adult with ADD like a sink-hole, ever ready to drain off energy and leave the individual hungry for more stimulation. This can easily be misinterpreted as a lack of interest; actually it is a relative inability to sustain interest over time. As much as the person cares, his battery pack runs low quickly.

(Dr. Ned noted that a common reaction to boredom is to create something, even if it's only inside your mind, to break the boredom . . even if that something isn't actually present.)

8) Easy distractibility, trouble focusing attention, tendency to tune out or drift away in the middle of a page or a conversation, often coupled with an ability to hyperfocus at times.

The hallmark symptom of ADD. The "tuning out" is quite involuntary. It happens when the person isn't looking, so to speak, and the next thing you know, he or she isn't there. The often extraordinary ability to hyperfocus is also usually present, emphasizing the fact that this is a syndrome not of attention deficit but of attention inconsistency.

9) Often creative, intuitive, highly intelligent.

Not a symptom, but a trait deserving of mention. Adults with ADD often have unusually creative minds. In the midst of their disorganization and distractibility, they show flashes of brilliance. Capturing this "special something" is one of the goals of treatment.

10) Trouble in going through established channels, following proper procedure.

Contrary to what one night think, this is not due to some unresolved problem with authority figures. Rather, it is a manifestation of boredom and frustration: boredom with routine ways of doing things and excitement around novel approaches, and frustration with being unable to do things the way they're supposed to be done.

11) Impatient; low tolerance for frustration.

Frustration of any sort reminds the adult with ADD of all the failures in the past. "Oh no," he thinks, "here we go again." So he gets angry or withdraws. The impatience has to do with the need for stimulation and can lead others to think of the individual as immature or insatiable.

12) Impulsive, either verbally or in action, as in impulsive spending of money, changing plans, enacting new schemes or career plans, and the like.

This is one of the more dangerous of the adult symptoms, or, depending on the impulse, one of the more advantageous.

(Dr. Ned told of a woman who had such trouble with overusing her credit cards that she put them in a tupperward dish, filled it with water, then put it in her freezer. The technique worked because after all the work required to chip them loose (she didn't have a microwave oven) or let them melt, the impulse to spend was past.)

13) Tendency to worry needlessly, endlessly; tendency to scan the horizon looking for something to worry about alternative with inattention to or disregard for actual dangers.

Worry becomes what attention turns into when it isn't focused on some task.

(Some people literally scan the horizon in search of something to worry about and if there are no major issues, they'll look for minor issues . . anything to come up with something to focus their worry on.)

14) Sense of impending doom, insecurity, alternating with high risk-taking.

This symptom is related to both the tendency to worry needlessly and the tendency to be impulsive.

15) Mood swings, depression, especially when disengaged from a person or a project.

Adults with ADD, more than children, are given to unstable moods. Much of this is due to their experience of frustration and/or failure, while some of it is due to the biology of the disorder.

16) Restlessness

One usually does not see, in an adult, the full-blown hyperactivity one may see in a child. Instead, one sees what looks like "nervous energy"; pacing, drumming of fingers, shifting position while sitting, leaving a table or room frequently, feeling edgy while at rest.

17) Tendency toward addictive behavior.

The addiction may be to a substance such as alcohol or cocaine, or to an activity, such as gambling, or shopping, or eating, or overwork.

18) Chronic problems with self-esteem.

These are the direct and unhappy result of years of conditioning: years of being told one is a klutz, a spaceshot, an underachiever, lazy, weird, different, out of it, and the like. Years of frustration, failure, or of just not getting it right do lead to problems with self-esteem. What is impressive is how resilient most adults are, despite all the setbacks.

19) Inaccurate self-observation.

People with ADD are poor self-observers. They do not accurately gauge the impact they have on other people. This can often lead to big misunderstandings and deeply hurt feelings.

20) Family history of ADD or manic- depressive illness or depression or substance abuse or other disorders of impulse control or mood.

Since ADD is genetically transmitted and related to the other conditions mentioned, it is not uncommon (but not necessary) to find such a family history.

Childhood History of ADD - It may not have been formally diagnosed, but in reviewing the history the signs and symptoms were there.

Dr. Hallowell emphasized the importance of this requirement by saying, "There is no such thing as adult-initiated ADD!"

Situation not explained by other medical or psychiatric condition. - It cannot be stressed too firmly how important it is NOT to diagnose oneself. From the information and examples presented here it is hoped your suspicion may be raised, but an evaluation by a physician to rule out other conditions is essential!

Ned opened the floor to question following this portion of his presentation.

Q) Why are there no affirmed criteria for diagnosis of ADD in adults?

A) Until recently, it was thought that ADD went away during childhood. That belief is waning now but we still don't have an adult list under consideration. In fact, it wasn't until 1979 that the first scientifically screened paper about ADD was published and even today there are some who don't believe it exists. In those early days the condition was called Minimal Brain Disfunction.