ADHD in Adulthood: Lifespan Signs in a Woman Diagnosed at 36
Mary Smith is a 48-year-old Caucasian woman living in San Francisco, California. She is a single freelance journalist and an amateur athlete. Mary is the third of three daughters born to her middle-class parents.
At age 36, Mary was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). There is no known history of ADHD in her family, so any genetic etiology cannot be presumed, although experts agree there is probably a genetic component as well as environmental influences in ADHD. (National Institutes of Health, 2014) This examination of her development over her lifespan will explore whether there were risk factors for and evidence of ADHD prior to her diagnosis, and whether the symptoms she has experienced are necessarily ADHD or might be something else under a differential diagnosis. As Furman (2005) notes, ADHD is simply a collection of symptoms with no clear etiology, and it can be difficult to distinguish the symptoms from other underlying disorders, such as learning disabilities, mood disorders, environmental factors and other possible causes.
Mary is born three weeks premature and delivered breech at a San Francisco hospital. Her family often tells the story that, at a prenatal visit, Mary’s mother’s obstetrician said, “I see a foot!” but that Mrs. Smith insisted on retuning her library books before being admitted to the maternity ward. Mary was born later that day, feet-first, healthy but slightly underweight.
Mrs. Smith, like many women of the time, smoked cigarettes and drank moderately during her pregnancy. She also suffered from the genetic autoimmune condition, Hashimoto’s Thyroiditis.
Doctors and family members in the 1970s would not have been familiar with ADHD, since the Diagnostic and Statistical Manual of Mental Disorders was then in only its second edition, and the nearest condition to what we now know as ADHD was then called hyperkinetic impulse disorder. (Lange, Reichl, Lange, Tucha, & Tucha, 2010) They may also not have been aware that prenatal alcohol and tobacco use, premature birth, breech birth, low birth weight, and maternal thyroid disorders have all been found to increase the risk of ADHD. (Millichap, 2008)
Mary does not display any unusual behaviors in her first year of life. She has a stay-at-home mother who provided one-on-one attention, talked to her, read to her, and brought her along on her errands. Her father is an engaged parent who plays with and reads to her regularly. According to Erikson, this stability and connection is crucial for Mary’s successful movement through the first stage of development, in which she develops trust in her parents to provide for and protect her. (Psychology Charts, n.d.) She is a good-natured infant who hits typical milestones on the early side, crawling at 6 months of age, and walking and saying her first words at 11 months old. There is a strong connection between the acquisition of language and the development of other motor skills, such as walking. (Walle & Campos, 2014)
1–5 years old
Mary continues to be a bright, active, and curious child as she grows older. By 18 months old, she regularly plays hide-and-seek with her father when he comes home from work. This demonstrates that she has grasped the concept of object permanence, a key developmental milestone. (Piaget, 1954)
At two years old, Mary loves to sort through her toys and group them by color, a sign she has entered Piaget’s preoperational stage. By 3, she is also beginning to entertain herself with elaborate imaginary play. (Psychology Charts, n.d.)
Mary enters preschool at 4 years old and thrives in this environment, enjoying collaboration with her peers. She dresses herself in the morning and can sharpen her own pencil, showing independence and initiative as expected in Erickson’s third stage of development. (Psychology Charts, n.d.) At five years old she is on track developmentally in every cognitive, physical, and emotional aspect, and has a slightly more advanced vocabulary than average. She is very physically active and has begun showing interest in sports including gymnastics and soccer. Mary’s parents and kindergarten teacher note that she is strongly left-dominant in her handedness, which a 2017 study showed to be associated with almost three times greater probability of developing ADHD. (Simões, Carvalho, & Schmidt, 2017)
6–12 years old
Mary enters elementary school in the first grade at 6 years old. She is a bright student, follows directions, and plays well with her peers on the playground. She enjoys excelling in school, and is motivated by external praise, such as gold stars and good grade reports, which in turn bring her parental approval and attention. She is still in Kohlberg’s Pre-Conventional period of moral development, in which her perception of right and wrong is largely dictated by what produces the results she desires. Kohlberg called this stage “Self-Interest Orientation.” (Psychology Charts, n.d.)
As Mary’s personality develops, she becomes more highly social and begins to play in organized community sports. She prefers team sports to individual sports and enjoys being considered sporty, athletic and a valuable soccer teammate. She also, however, develops a tendency toward injury. Running in to line-up for class at the end of recess in 2nd grade, she trips over a basketball and breaks her wrist. On a dare, she rides her bike down a steep driveway and crashes into the garage door, splitting her lip. She develops a reputation as a “klutz” for being injury prone. (DiScala, Lescohier, Barthel, & Li, 1998) All of these things suggest a pattern that an underlying attention and/or impulsivity issue could be at work. (Ohio State University Wexner Medical Center, 2017)
While Mary continues to be an outstanding student, she begins to exhibit difficulty with arithmetic beginning in the 4th grade. (Czamara, et al., 2013) She also has consistent reports from her teachers that she does not pay attention to detail in some of her lessons and has extremely messy penmanship. These difficulties might be dyscalculia or dysgraphia, two learning disabilities tied to executive functioning that are common in children with ADHD diagnoses. (Graham, Fishman, Reid, & Hebert, 2016)
At age 11, Mary is given an IQ test which measures her intelligence in the “gifted” range. Combined with her overall high level of achievement at school, her highly developed sense of humor and vocabulary, these measurements qualify her to be placed into a program for gifted and talented children at the local middle school. Mary, at this point, would likely meet some of the criteria for an ADHD diagnosis, but her intelligence and scholastic performance may be masking the symptoms. (Milioni, et al., 2017) Some experts on learning disabilities have characterized children who fit this seemingly contradictory set of facts to be “twice exceptional.” (Henderson, 2017)
13–18 Years Old
Mary enters adolescence in a state of flux; not only is her body changing, but she is in a new school where she knows few of her fellow students. She begins to show signs of social anxiety, difficulty making and keeping friends, and starts missing school more frequently. (Classi, Milton, Ward, Sarsour, & Johnston, 2012) She is sometimes overwhelmed by feelings of sadness or worry. She thinks she is perceived as awkward and “weird” by her peers. Her previous coping skills — using her intelligence and sense of humor to win people over — seem not to work as effectively as they had in elementary school.
Mary also begins to struggle more consistently with school, specifically with planning, organization, and time management when tasked with a larger academic project. (Langberg, et al., 2011) Her academic performance remains high, however, so her parents and teachers characterize her inattention as boredom, or laziness, but not something to be overly concerned about. A similar sign of disorganization can be found in her bedroom — the messy source of frequent conflicts with her mother, who wants the room kept tidy. Mary struggles with clutter and finding things in her chaotic space. (Blum, et al., 2008)
As Mary prepares to enter high school she is notably less socially confident. She isolates more and is less enthusiastic about sports than she had been in the previous several years. Hormonal changes might be accentuating underlying ADHD symptoms. (Quinn, 2005)
At age 14, she develops a bleeding duodenal ulcer, perhaps a sign of a worsening anxiety disorder. At 15 she experiments with self-harm, cutting patterns into her forearm with an Exacto knife. At 16, after a half-hearted suicide attempt, Mary is diagnosed with major depression, but is not put on medications. Depression and anxiety, as well as self-harm, are all common comorbid diagnoses in girls and young women with ADHD. (Hinshaw, 2002)
Mary completes high school near the top of her class. She has a steady boyfriend, and they move to a nearby city so she can attend University. She is living in the dormitory, her first place away from home. She has an extremely difficult time adjusting to the social demands of college, as well as the different academic environment. She becomes seriously depressed. After her first semester, although she passed all of her courses, she drops out of college and moves back home, feeling defeated. Dropout rates and difficulty adjusting are very common among college students with ADHD. (Modern Medicine Network, 2013)
19 Years Old — Present
Mary returns home and enrolls in the local community college, a condition of her living at home set by her parents. She takes a class in journalism and is hooked from the start and has clarity about her academic aspirations. Journalism allows her to pursue stories that interest her; her curiosity — an attribute that needs to be stimulated to keep her focused on a task — is well-served by the investigative nature of reporting. (Plaisance, 2014)
Mary transfers to a school with an excellent journalism program, and graduates in less than 4 years at the top of her class. She has a number of short romantic relationships but finds intimacy difficult and emotionally taxing. She finds herself either hyper-focused on the relationship, or avoidant.
Mary’s career takes off over the years following graduation. She starts of as a reporter at a small magazine, and then quickly gets a job at a national technology magazine. She feels consistently challenged and stimulated by her work, which helps to keep her mood up and her distractibility down.
In her personal life, things are not as smooth. She has a series of unstable and emotionally explosive relationships. She experiences periodic outbursts of anger far out of proportion to the events which precipitated them. Her relationships and her physical health are complicated by ongoing symptoms of anxiety and depression. Her doctors consider diagnoses of bipolar disorder and borderline personality disorder, but she doesn’t meet enough criteria for either. However, the overlap in symptoms for bipolar and ADHD is significant, and Mary’s mood instability, impulsivity, and racing thoughts could have suggested it as a differential diagnosis. (Dodson, 2015) Her emotional dysregulation and impulsivity could look like Borderline Personality Disorder. (Matthies & Philipsen, 2014)
She is even referred to an audiologist when a relationship breaks up because she “doesn’t listen” and sometimes forgets previous conversations or remembers them differently than her partner. She is found to have a mild auditory processing disorder, something that can be associated with ADHD. (Riccio, Hynd, Morris, Hall, & Molt, 1994)
At the age of 36, Mary is frustrated with her difficulties with her memory and concentration and how these struggles are affecting her relationships as well as her career. Her mother was diagnosed with Alzheimer’s, and she becomes concerned that her memory issues might be early-onset dementia. Her psychiatrist runs a battery of neuropsychological tests over several days. The results led the doctor to diagnose Mary with ADHD, as well as possible early signs of Parkinson’s Disease.
Soon after this diagnosis, Mary begins taking Adderall to help with her symptoms. While she experiences some improvement with her symptoms, she continues to struggle with memory and concentration, as well as increasing symptoms of anxiety and depression. Her physician runs a series of blood tests and discovers that Mary, like her mother, suffers from Hashimoto’s Thyroiditis, an autoimmune condition that causes memory and concentration issues (“brain fog”), anxiety and depression. Notably, these are all things that can also be attributed to ADHD. (Hartwell-Walker, n.d.)
At 47, Mary began experiencing the symptoms of perimenopause. These symptoms, too, can look a great deal like ADHD. In women with ADHD, hormonal changes associated with menopause can make symptoms even worse. After a series of job losses and deaths in the family, Mary’s stress level was at an all-time high, and her memory and concentration hit an all-time low. She became convinced, again, that she had early-onset dementia. A psychiatrist determined that it was simply a combination of stress, depression, anxiety, hypothyroidism, and perimenopause. It can be difficult to determine where one begins and another ends. (Wasserstein, 2005)
Mary continues to experience career disruptions as a result of her memory, organization, time management issues.
Our subject Mary Smith was not diagnosed with attention deficit hyperactivity disorder until she was well into adulthood. Upon reflection, many of the signs and risk factors were present from the earliest stages and persisted throughout her childhood and into adulthood. But as Furman (2005) notes, there is reason to question whether ADHD is a distinct illness, or simply a collection of symptoms that can be ascribed to other psychological, neurological, biological, or environmental factors.
In Mary’s case, the fact her mother consumed alcohol during pregnancy may or may not be related to her ADHD symptoms, or those symptoms may in fact be more related to Fetal Alcohol Syndrome. (Peadon & Elliott, 2010) Her self-harm and suicidality in adolescence could be a result of major depressive disorder, anxiety, bipolar disorder, or indicative of borderline personality disorder. (Matthies & Philipsen, 2014) Her memory and concentration issues in adulthood might be ascribed to her autoimmune thyroid disease, or the onset of menopause, or both.
In the end, Mary’s physicians worked together to find a balance of antidepressant and antianxiety medication, thyroid hormones, estrogen replacement, and psychostimulants to address all of the possible contributors to her symptoms. She participates in cognitive behavioral therapy, attends a dialectical behavioral therapy program, and practices meditation and yoga as interventions. (Zylowski, et al., 2008)
Blum, K., Chen, A. L.-C., Braverman, E. R., Comings, D. E., Chen, T. J., Arcuri, V., . . . Palomo, T. (2008, October). Attention-deficit-hyperactivity disorder and reward deficiency syndrome. Neuropsychiatric Disease and Treatment, 4(5), 893–918.
Classi, P., Milton, D., Ward, S., Sarsour, K., & Johnston, J. (2012, October 4). Social and emotional difficulties in children with ADHD and the impact on school attendance and healthcare utilization. Child and Adolescent Psychiatry and Mental Health, 6, 33.
Czamara, D., Tiesler, C. M., Kohlböck, G., Berdel, D., Hoffmann, B., Bauer, C.-P., . . . Heinrich, J. (2013, May 27). Children with ADHD Symptoms Have a Higher Risk for Reading, Spelling and Math Difficulties in the GINIplus and LISAplus Cohort Studies. PLoS One, 8(5), e63859.
DiScala, C., Lescohier, I., Barthel, M., & Li, a. G. (1998, December). Injuries to Children With Attention Deficit Hyperactivity Disorder. Pediatrics, 102(6), 1415–1421.
Dodson, W. (2015, feb 27). 6 Factors That Differentiate ADHD from Bipolar Disorder. BP Magazine.
Furman, L. (2005, December). What is attention-deficit hyperactivity disorder (ADHD)? Journal of Child Neurology, 20(12), 994–1002.
Graham, S., Fishman, E. J., Reid, R., & Hebert, M. (2016, May 17). Writing Characteristics of Students with Attention Deficit Hyperactive Disorder: A Meta‐Analysis. Learning Disabilities Research & Practice, 31(2), 75–89.
Hartwell-Walker, M. (n.d.). It May Not Be ADHD. Retrieved June 2018, from PsychCentral: https://psychcentral.com/lib/it-may-not-be-adhd/
Henderson, L. (2017). Strategies for Twice Exceptional Children Who are Gifted and ADHD. CHADD Conference (pp. 1–6). Atlanta: CHADD: The National Resource on ADHD.
Hinshaw, S. P. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices. Journal of Consulting and Clinical Psychology, 70(5), 1086–1098.
Langberg, J. M., Epstein, J. N., Girio, E. L., Becker, S. P., Vaughn, A. J., & Altaye, M. (2011, June 1). Materials Organization, Planning, and Homework Completion in Middle School Students with ADHD: Impact on Academic Performance. School Mental Health, 3(2), 93–101.
Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010, December). The history of attention deficit hyperactivity disorder. ADHD Attention Deficit and Hyperactivity Disorders, 2(4), 241–255.
Matthies, S. D., & Philipsen, A. (2014, April 10). Common ground in Attention Deficit Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD)–review of recent findings. Borderline Personality Disorder and Emotional Dysregulation, 1(3), 1–3.
Milioni, A., Chaim, T., Cavallet, M., de Oliveira, N., Annes, M., Dos Santos, B., . . . Cunha, P. (2017, April). High IQ May “Mask” the Diagnosis of ADHD by Compensating for Deficits in Executive Functions in Treatment-Naïve Adults With ADHD. Journal of Attention Disorders, 21(6), 455–464.
Millichap, J. (2008). Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics, 121(2), 358–365.
Modern Medicine Network. (2013, August 1). Ensuring college success for students with ADHD . Retrieved from Contemporary Pediatrics: http://www.contemporarypediatrics.com/modern-medicine-feature-articles/ensuring-college-success-students-adhd
National Institutes of Health. (2014, Spring). Causes of ADHD. NIH MedLine Plus, 9(1), pp. 15–16.
Ohio State University Wexner Medical Center. (2017, May 11). Athletes with ADHD more likely to choose team sports, could increase injury risk, study finds. Retrieved June 2018, from Science Daily: https://www.sciencedaily.com/releases/2017/05/170511135755.htm
Peadon, E., & Elliott, E. J. (2010, September 7). Distinguishing between attention-deficit hyperactivity and fetal alcohol spectrum disorders in children: clinical guidelines. Neuropsychiatric Disease and Treatment, 6, 509–515.
Piaget, J. (1954). The construction of reality in the child. New York: Basic Books.
Plaisance, P. (2014, December 10). Why Is Curiosity Critical in Good Journalism? Just Ask! Retrieved from Psychology Today: https://www.psychologytoday.com/intl/blog/virtue-in-the-media-world/201412/why-is-curiosity-critical-in-good-journalism-just-ask
Psychology Charts. (n.d.). Erikson’s Stages of Development Chart. Retrieved June 2018, from Psychology Charts: http://www.psychologycharts.com/erikson-stages-of-development-chart.html
Psychology Charts. (n.d.). Kohlberg’s Stages of Moral Development. Retrieved June 2018, from Psychology Charts: http://www.psychologycharts.com/kohlberg-stages-of-moral-development.html
Psychology Charts. (n.d.). Piaget’s Stages of Cognitive Development. Retrieved June 2018, from Psychology Charts: http://www.psychologycharts.com/piaget-stages-of-cognitive-development.html
Quinn, P. (2005, May). Treating adolescent girls and women with ADHD: gender-specific issues. Journal of Clinical Psychology, 61(5), 579–587.
Riccio, C., Hynd, G. W., M. C., Hall, J., & Molt, L. (1994, July-August). Comorbidity of Central Auditory Processing Disorder and Attention-Deficit Hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 33(6), 849–857.
Simões, E., Carvalho, A., & Schmidt, S. (2017, June). What does handedness reveal about ADHD? An analysis based on CPT performance. Research in Developmental Disabilities, 65, 46–56.
Walle, E., & Campos, J. (2014). Infant language development is related to the acquisition of walking. Developmental Psychology, 50(2), 336–348.
Wasserstein, J. (2005, February 18). Diagnositc Issues with Adolescents and Adults with ADHD. Journal of Clinical Psychology, 61(5), 535–547.
Zylowski, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S., . . . Smalley, S. L. (2008, May 1). Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders, 11(6), 737–746.