To the Editor: The article in the October 1997 issue by Drs. Lomas and Gartside (1) about the prevalence of symptoms of attention-deficit-hyperactivity disorder (ADHD) among homeless veterans cites several studies (2,3,4,5) that, like the study they describe, purport to demonstrate that ADHD persists into adulthood. Yet the shortcomings of both the cited studies and the authors' own study call the assumptions of ADHD in these populations into serious question.
The authors failed to adequately address questions of likely organic brain damage or dysfunction secondary to substance use. Relying on self-reports alone in screening for and assessing ADHD among those with highly probable substance use disorder seems quite inadequate. The finding that these ADHD veterans were 18 times more likely to suffer from an anxiety disorder than their non-ADHD counterparts suggests a confounding of the anxiety diathesis with the ADHD-like behavioral and cognitive correlates. It also suggests that the authors did not attempt to distinguish between these variables. Indeed, the entire matter of how other comorbid disorders were added to, or distinguished from, ADHD was not addressed.
The concepts of adult residual attention-deficit disorder or attention-deficit-hyperactivity disorder are undergoing repeated exploration, theorizing, and attempted validation. This thoughtful inquiry should not be abridged by superficial evaluations of homeless persons who abuse substances and who, through a variety of organic and environmental influences, appear to evidence symptoms of ADHD that have no definable continuity with a relatively well-defined childhood disorder. Adults with this constellation of symptoms merit closer scrutiny as to the likelihood of more typical adult disorders—anxiety, depression, or personality disorders—and better attention to their treatment needs.
Dr. Holmgren is medical director of Northwoods Guidance Center in North Branch, Wisconsin.