Attention-deficit/hyperactivity disorder (ADHD) was once thought to be a condition that only affects children, but awareness has grown that it often persists into adulthood. For many who are diagnosed as adults, it can make sense of difficulties they’ve long experienced.  

“For me personally, I thought I was dumb. In high school, I just thought, ‘well, Honor Society is just not for me,’” said Tamara Rosier, who spoke at a recent National Academies webinar on ADHD in adults.  

“For many people, getting a diagnosis can be a turning point in their life,” said Rosier. In her work, she often hears from individuals who have spent much of their lives feeling ‘less than’ and also ‘too much,’ she said. “After diagnosis, this can be such a powerful moment, because it shifts the narrative.”  

Rosier founded and directs the ADHD Center of West Michigan, where she and her staff of coaches and therapists help people with ADHD learn strategies and develop new skills to live effectively with the neurodevelopmental disorder. “Diagnosis is not a label — you’re not labeling someone — but it is an explanation,” she stressed.  

Awareness of adult ADHD has risen because of the internet and social media, said psychiatrist David Goodman of the Johns Hopkins University School of Medicine, noting that #ADHD is among the most popular health-related hashtags on TikTok.  

But along with that popularity has come a lot of misinformation, he added. In a recent study, for example, psychiatrists and psychiatric residents evaluated the accuracy of 100 of the most popular TikTok videos on ADHD. Roughly one out of every two videos was determined to be misleading.  

“We hope that … people begin to identify the source of the information first, before they look at the information offered,” Goodman said.

The basics of adult ADHD

ADHD is a brain-based disorder characterized in children, adolescents, and adults by symptoms such as having difficulty sustaining attention, poor time management, tardiness, frequent forgetfulness, disorganization, interrupting in conversations, and being easily distractible, Goodman explained.  

To be diagnosed with ADHD, according to the latest version of the Diagnostic and Statistical Manual of Mental Disorders, an adult needs to have five or more symptoms of inattention and/or hyperactivity and impulsivity, said Goodman. Also, the symptoms start in childhood, persist throughout one’s life, and cause significant impairments in several areas of one’s life.  

While some people may not be diagnosed until adulthood, symptoms don’t just appear for the first time in adulthood, Goodman said. “[Diagnosis] is predicated on … symptoms as a child or early adolescent into adulthood,” he said. “You don’t develop ADHD at 25, 37, or 48.”  

Seventy-five percent of ADHD’s cause is genetic, he added. “There are environmental effects that influence ADHD, but it is largely genetic and runs in families.”   Neuroscientist Amy Arnsten of the Yale School of Medicine described the ways ADHD operates in the brain. “Much of the research suggests that ADHD involves slowed or altered development of the prefrontal cortex, which we need for the executive functions and top-down control of our attention and actions,” she said.

Why diagnosis is complex

Diagnosing adult ADHD is complicated, in part because many conditions — not just ADHD — can affect the prefrontal cortex and the abilities it controls, Arnsten explained.  

“The prefrontal cortex is like the ‘Goldilocks’ of our brain,” she said. “It has to have everything just right, and especially it has to have just the right neurochemical environment. And so things like stress, fatigue, inflammation, and hormonal imbalances from menopause or premenstrual dysphoric disorder — all of these can cause neurochemical changes in the prefrontal cortex where it doesn’t work properly.”  

Other mental and behavioral disorders — such as depression, bipolar disorder, and substance abuse — can also affect the prefrontal cortex and cause symptoms similar to those of ADHD, she added. Non-psychiatric conditions such as connective tissue disorders and polycystic ovarian syndrome can cause cognitive symptoms as well, said Goodman.  

“You have to have a clever diagnostician — someone who really knows the field — who can really determine why you’re having these symptoms, and make sure you get the treatment that will help,” said Arnsten.  

Another hurdle to diagnosis has been that until recently, clinicians have not been educated to look for or recognize ADHD in adults, said Goodman. “Adult psychiatry abdicated ADHD to child psychiatry, and we’re all coming around now to understanding this is the second-most prevalent psychiatric disorder in adults.”  

As a result of greater public awareness driven by media, he said, clinicians have had to get up to speed in terms of learning about adult ADHD and how to diagnose it.  

Finding a knowledgeable professional and going through the diagnostic process — navigating the paperwork, cost, and insurance matters — can itself be a hurdle for those with ADHD, said Rosier, remarking that one highly qualified doctor she knows has a 50-page intake form.  

“The whole thing is incredibly arduous, and for those of us who lack a regulated prefrontal cortex, it seems excessive,” said Rosier. Still, working with a qualified practitioner to get an accurate diagnosis is important, she stressed. “We really want to make sure it’s ADHD and not other things.”  

Rosier urged people who suspect they might have ADHD to keep track of what they’re experiencing. “Start documenting your own symptoms,” she said. “Ask someone you trust — a spouse, parent, partner — to also observe your symptoms, and then bring that information to someone who you want to have the discussion with … If you can say, ‘This is what I’m experiencing,’ it will help your practitioner help you better.”

Medication and ‘the dignity of choosing’

Asked about the risks and benefits of using medications to treat ADHD, Goodman said it is first important to consider the risks if the condition goes untreated.  

Untreated ADHD can have long-term consequences for people’s lives, he said. Young people face a higher likelihood of academic underachievement, dropping out of high school, and not finishing college. In late adolescence and early adulthood, they are more likely to get arrested. Adults with ADHD are twice as likely to get divorced, he said.  

“I don’t want to paint a horror story,” Goodman said, noting that some people with untreated ADHD do find successful paths forward. But it’s important to note that for some people, not treating ADHD can have consequences that are dramatic and traumatic, he said.  

ADHD is often treated with short-, medium-, and long-acting stimulant medications, which can start working very quickly, said Goodman.  

“These medications work to optimize the neurochemical environment so that your prefrontal cortex works better,” explained Arnsten. “Oftentimes what they’re doing is increasing the availability of neurotransmitters called dopamine and norepinephrine; some also affect serotonin … It’s mimicking how your prefrontal [cortex] acts when it’s feeling rested and safe and interested in something.”  

Risks and side effects of stimulants tend to be decreased appetite and upset stomach, said Goodman; blood pressure and pulse also need to be monitored to see if they increase. And all of the stimulant medications have the potential to be abused and addictive.  

For those who can’t tolerate stimulants, there are also nonstimulant medications for ADHD, though they don’t work quite as well or as quickly, said Goodman. Arnsten described guanfacine, a nonstimulant medication that her lab at Yale developed, which can protect and strengthen connections within the prefrontal cortex; it can be used alone or combined with stimulants, she said.  

Treatment includes more than medication, multiple speakers noted. “It’s ‘skills with pills,’ so we need to teach people organizational techniques,” said Goodman. Therapy and ADHD coaching can help as well, said Rosier.   The decision about whether to take medication ultimately belongs to the patient, Goodman said. “If you take medication and it improves your symptoms and the quality of your functioning during the day, then you decide whether or not you want to stay on the medication,” he said. “This is a choice [about] quality of life.”  

Goodman described some of the changes he’s seen in patients after starting treatment — an older woman who went back to law school, young people who completed college rather than dropping out, a patient who doubled their business in three years. “If you get diagnosed with ADHD and you get appropriately treated, this is transformational,” he said.  

Rosier applauded Goodman’s emphasis on “giving us the dignity of choosing.” She continued, “To any psychiatrists who are listening: This is the goal. Give your patients the choice, but also give them the glimmer of hope: ‘You know that potential you’ve been chasing? I’ve got some answers that could help you.’”

Related Resources

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