Adults With ADHD Present Symptoms Differently Than Children, Requiring Unique Assessment

For adults with attention-deficit/hyperactivity disorder (ADHD), the overall theme with hyperactivity and impulsivity is going to be restlessness, explained Elizabeth Breeden, PharmD, CPP, during her presentation at the APhA 2023 Annual Meeting & Exposition. Even though adults with ADHD may not be running or climbing on things when it's inappropriate like children with ADHD might, adults with ADHD may still feel uncomfortable sitting still for a long time.

“ADHD is characterized as a pattern of inattention and or hyperactivity or impulsivity,” Breeden said during the presentation. “The criteria are that there is going to be a persistent pattern of symptoms, and it does have to interfere with functioning or development for the patient.”

Breeden noted that the term attention-deficit disorder (ADD) was used more in the past, but it has been phased out. Now, ADHD is more commonly used as the overarching diagnosis, with 3 different subtypes: predominantly inattentive, predominantly hyperactive/impulsive, and combined presentation.

Breeden explained further that when looking at the diagnosis criteria for ADHD in the DSM-5, there is going to be a difference in the presentation of symptoms in a child versus in an older adolescent or adult. For older adolescents and adults, they need to have 5 or more symptoms of either the inattention type of ADHD or the hyperactivity/impulsivity type; for children, they would need to have 6 or more symptoms, according to Breeden.

With the predominantly inattentive type, which would mean that you have at least 5 or more symptoms of inattention for adults or 6 or more for children. For the predominantly hyperactive/impulsive type, this would again require 5 symptoms for adults or 6 for children. However, in the combined presentation, adults with ADHD would need to have 5 symptoms of inattention and at least 5 symptoms of hyperactivity and impulsivity.

“That does not mean we have 3 of one and 2 of another,” Breeden said. “We have to have 5 from both categories to get that combined presentation.”

Within the diagnosis subtype, there is also categorization based on intensity of symptoms, with the categories being mild, moderate, or severe. Among these categories, mild would mean that patients hit those 5 symptoms per category, but there is not as much impairment to their lives. On the other hand, for patients with severe symptoms, they probably have more symptoms than the diagnosis criteria require, and these symptoms will likely be heavily impacting their quality of life.

“Another thing is that these symptoms do have to be present prior to age 12. So even if you do have an adult who's presenting for diagnosis for the first time in their late 40s or 50s, we still need to look back at those childhood symptoms and make sure that they were present before age 12,” Breeden said.

Another criterion is that adults with ADHD must have symptoms present in at least 2 or more settings. For children, those 2 settings are likely school and home; however, for adults, those settings will likely be in their work setting and then also in their home or social life.

“So it can't be that we're just struggling at work or struggling when we're at school. It has to be across the board in multiple settings,” Breeden said. “Then the last thing is that it does have to reduce their quality of life. So, if the symptoms are bothersome to them and interfering with their day-to-day functioning, that would qualify.”

The first symptom of hyperactivity/impulsivity in adults with ADHD is fidgeting, tapping their hands or feet, or squirming in their seat, which can be a similar presentation for both children and adults, according to Breeden. Further, the second symptom of this ADHD type is going to be often leaving their seat in situations when remaining seated is expected.

“For adults [with ADHD], that can be leaving their spot in their workplace. So if they have a designated work area, and they may be getting up pretty frequently, or if they're in long meetings or at a restaurant for a long period of time, they might not feel comfortable staying in that seat for an extended time period,” Breeden said.

The next symptom in the DSM-5 is running or climbing in situations where it's inappropriate to do so. However, Breeden noted this needs to be interpreted differently in adults, since most adults are going to know to not climb on chairs during professional meetings or other times when it would be socially inappropriate to do so. Instead of acting on these urges, they may just feel internalized restlessness for this symptom. For this reason, adults with ADHD may not be able to play or engage in leisure activities quietly.

“When we think about children who have to engage in quiet time at school or at home, that can be really difficult for them,” Breeden said. “For adults, think about relaxation—they may have trouble being quiet, relaxing, reading—activities where they have to be quiet, and it can be really difficult for them.”

The next symptom on the list for adults with ADHD is being unable to sit still or being uncomfortable staying still for an extended timeframe, Breeden explained. Notably, this symptom ties into a lot of hyperactivity/impulsivity type symptoms, as adults with ADHD are often just uncomfortable having to be still, according to Breeden.

The next symptom is talking excessively and more frequently than their peers. Similarly, another symptom is the tendency to blurt things out before someone is finished speaking.

“When we think about children or people in the academic setting, they're blurting out answers before their teacher can end the question,” Breeden said. “For adults, this can look like they're completing people's sentences or they're kind of coming into conversation before the other person is done speaking, and sometimes they can't wait their turn in line for conversation.”

The next symptom of hyperactivity/impulsivity is difficulty waiting in line or waiting their turn. For children, this may look like difficulty standing in line to go from classroom to classroom, according to Breeden. However, for adults, this may occur when they’re waiting in line for a restaurant or waiting at a customer service area.

Lastly, another symptom of this type of ADHD is interrupting or intruding on others, which can tie back to the prior symptom of blurting out answers before questions are completed. In children, interrupting or intruding on others may look like interrupting conversations or play activities. For example, they may be interrupting other children’s games or maybe taking their toys without getting permission first. For adults, this symptom can look like taking over someone else's work.

“Maybe there's a project that they weren't involved in, but they decided that they wanted to work on it, so they kind of take over,” Breeden said.

There are 9 symptoms for the inattention subtype type of ADHD, the first of which is failing to give close attention to detail. For children, this can be that they're not paying attention to a lot of things, or they're missing details during instruction from a parent or teacher, Breeden explained. However, for adults, this may look like they're overlooking things, they are doing inaccurate work, or they're overlooking a lot of small details.

The next symptom is difficulty sustaining attention and tasks or play activities. Again, in children, this may look like their parents trying to get them to do something, but they are just feeling really distracted and are unable to sustain their attention on that task. For adults, this could look like not being able to sustain attention at meetings or work, or other activities that would require they are involved and focused for long periods of time.

“This can include like reading or going over reports as well, when we're thinking about adults in the work setting,” Breeden said. “Next, we have that they do not seem to listen when spoken to directly. I think we can all picture a child who you are talking to, and you're saying something directly to them and their eyes are just going all over the place, and they're not listening to you. For adults, this can feel like they're just not listening, maybe they're having some thoughts in their minds that are distracting them. There's nothing really present that you can see, but they're just not listening to you, or you feel like they're distracted.”

Next, another symptom is not following through on instructions. In children, this may look like telling them to do something, either in the classroom or at home, such as getting a toy or a piece of clothing before school, and they just don't do it. For adults, they may feel that they are starting things at work and then they're easily sidetracked. They may be starting a task but then they don't follow through on it.

Next is difficulty organizing tasks and activities. For kids, this can be difficulty keeping all of their school materials together, keeping all their toys in the same place, and feeling just a little chaotic. For adults, that can be having difficulty with sequential tasks. So they can't do things in the order that they're supposed to be done and they can have messy or disorganized work. Another hallmark of this for adults would be having poor time management.

Next, a symptom can be that adults with ADHD may dislike or avoid engaging in tasks that require sustained mental effort. For children, this may be not wanting to do their homework: They know that this task is going to require them to be present and focused for a long period of time.

So instead, they just don't want to do it or they avoid it until the last possible moment. For adults, this can be if they have lengthy reports to make, if they know they have to read over a long document or do a lot of paperwork, they may push that off to the side because they know it's going to take a lot of time for them to sit down and really focus on it.

Next, we have the symptom of often losing things necessary for tasks or activities. For children, this may be a specific pencil or item for classroom activities that they forget or lose. For adults, this can be that they're misplacing things like their keys or wallet, or they are constantly losing their glasses. This could also appear as being to keep up with bills or appointments.

Next, there is the symptom of being easily distracted by extraneous stimuli. For children, when there's a lot of things going on, their eyes may be darting to a lot of those other things, even though they’re trying to focus on the person speaking to them. For adults, the extraneous stimuli may just be their own thoughts distracting them from focusing on the task at hand.

Lastly, for the inattention subtype, there is forgetfulness around daily activities.

“Again, this kind of goes back to keeping up with their appointments, returning phone calls, keeping up with their bills, all of those things could be a sign of inattention for adults,” Breeden said. “When we think of a child with ADHD, they're very hyper, bouncing off the walls, running around a lot, and they can't sit still. So this is the image that I think a lot of us get in our head when we think about children with ADHD. It is not as common in adults, but it can still be present and bothersome to them, [although] they might just hide it a little bit better and have it more internalized.”

Reference

Breeden A. Stimulating the Discussion on Adult ADHD. Presented at: APhA 2023 Annual Meeting & Exposition in Phoenix, AZ; March 25, 2023.