Persistence of ADHD: The Life Transition Model

International experts in attention-deficit/hyperactivity disorder (ADHD) have collaborated to present a developmental lifespan perspective.¹ Often, children with ADHD are identified and diagnosed because of disruptive, hyperactive, and impulsive behaviors before 10 years of age. However, those children who are not disruptive but are suffering with inattention, daydreaming, distractibility, and procrastination may go unrecognized, especially if their academic capabilities don’t seem compromised. So, when will they become identified, if ever?

In addition to the requisite threshold symptom count, impairment is a critical factor in the diagnostic assessment of ADHD. However, high intelligence, a low student-to-teacher ratio in the classroom, a structured and supportive home environment, and tutor support are some factors that may reduce or mask the symptomatic impairment that may have arisen were such factors absent. Therefore, the impairment requisite for the ADHD diagnosis might not be evident with such supports.

So, when does ADHD cause impairment, if not in childhood or adolescence? Assuming a developmental perspective,¹ my colleagues and I posit that each development phase from childhood through adulthood is fraught with unique and increasing responsibilities that may create impairment due to ADHD. For example, a child moving from middle school to high school has a greater academic burden. With denser lectures and longer hours of homework, the symptoms of ADHD become more impairing. At this point, a teacher or parent, or even the child, may notice a decline and seek help.

As an adolescent, the student’s social peer relationships may introduce the temptations of sex, drugs, and rock and roll. Impulsive, risky behavior leading to motor vehicle accidents, unplanned pregnancy, substance and alcohol abuse, or arrests should raise clear red flags for ADHD evaluation.

The student then progresses to college and is required to organize and manage a class schedule without parental oversight. Attending classes regularly, completing assignments on time, budgeting time for studying, and controlling the impulse to “blow off school” will tax the person with ADHD. Grade decline or failure may indicate that the person’s ability to compensate has been exceeded by the demands of the environment. The individual may present to student health services with symptoms of anxiety and/or depression; this is also an opportunity for an ADHD evaluation.

Upon getting the first job, the responsibility to follow directions and complete tasks in a timely manner becomes imperative to maintaining employment. The ability to control emotional annoyances and outbursts is essential to working cooperatively with coworkers. Poor performance may lead to a visit to the personnel office. Let’s hope the human resources staff knows what ADHD looks like.

With the happiness of getting married comes the added responsibility of coordinating a respectful and cooperative relationship with another person. The ability to be consistent and dependable is important in a partnership of reciprocity. An unequal division of responsibilities will eventually lead to a fracturing in the relationship, which accounts for a 2-fold higher divorce rate for adults with ADHD than for the general population.² The couple may find themselves sitting in a marital therapist’s office, where ADHD could be detected.

The next phase is the addition of children. The need to be organized becomes essential with the added activities of childrearing. If the individual with ADHD can’t equally contribute to the household, the impairments quickly become a source of conflict and accusation. Now comes a visit to the family therapist and another opportunity to diagnose the ADHD.

A job promotion is another phase of added responsibility. The job will now add extra burdens to the adult with ADHD, on top of all of the previously mentioned responsibilities of adult life. Unsatisfactory performance leads to job probation/suspension or termination. Adults with ADHD often have more jobs than others over a lifetime because of poor performance.²

Our publication¹ reviews in more detail the burdens that arise at each of these development phases from childhood through adulthood. The answer to the question “When does someone with ADHD get diagnosed?” is “Whenever the ability of the person with ADHD to compensate is overcome by the demands of the environment, and resultant impairments become evident to the person or to those around him or her.” The clinician who asks the patient “Why are you here now?” should focus on impairment and whether it developed after major life transitions.

Financial disclosure:Dr Goodman has received research grants from Shire and McNeil; has received honoraria from WebMD, Medscape, Temple University, American Professional Society of ADHD and Related Disorders, and Neuroscience Education Institute; is a consultant for Shire, McNeil, Ingenix, Thomson Reuters, Guidepoint Global, Otsuka, Med-IQ, Novartis, Avacat, Major League Baseball, American Physician Institute for Advanced Professional Studies, and HealthEquity; and has received royalties from MBL Communications.

References

1. Turgay A, Goodman DW, Asherson P, et al. Lifespan persistence of ADHD: the Life Transition Model and its application. J Clin Psychiatry. 2012;73(2):192–201. Full Text

2. Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. J Clin Psychiatry. 2006;67(4):524–540. Full Text​