In most adults who end up being diagnosed with ADHD, the moment isn’t a surprise. It’s a recognition – that over the past few decades, they’ve been through a lot and now it is finally named.
Adult ADHD is not a condition that some people don’t outgrow. A neurodevelopmental condition affecting the regulation of attention, executive functioning, impulse control and emotional responsiveness – and which for many people continues into adulthood. A study released recently estimated that 6% of adults in the U.S. have an ADHD diagnosis, with approximately half of these receiving the diagnosis as adults.
What they talk about, almost always, is a long trek to the diagnosis, misattributions, wrong treatments, and a feeling that they somehow weren’t doing it right, and it didn’t work out – when everyone else seemed to just get along fine. This is for everyone who is still on that path who wants to change it.
What Is ADHD in Adults – And Why Is It So Often Missed?
Persistent patterns of inattention or hyperactivity-impulsivity that interfere with functioning or development in at least two settings, such as at home, at school or at work, define attention-deficit/hyperactivity disorder (ADHD).
It’s often not diagnosed in adults because it’s traditionally thought of as a childhood disorder, marked mainly by hyperactivity that’s visible. Adult ADHD does not typically manifest itself as a child who can’t sit still. It looks like an attorney who performs brilliantly under deadline pressure but cannot file paperwork on time. It appears that it is a parent who lives in a highly disorganized manner, is very loving, but unable to organize, due to neurological issues, not because of effort or intent.
Many adults acquire mechanisms of coping and develop adaptive responses that can make their symptoms hard to identify in a typical clinical interview, placing even highly trained clinicians at risk of misdiagnosis. Now, add to that the fact that ADHD symptoms are particularly likely to be overlooked in girls and women during childhood, and you can see why so many adults reach their 30s, 40s, or 50s without a diagnosis that fits.
Adult ADHD Symptoms: What to Actually Look For
There are important differences between symptoms of adult ADHD and childhood ADHD. If hyperactivity does occur, it is more likely to be in the form of internal restlessness than physical restlessness. There are three main groups of symptoms:
Inattentive Symptoms
- Ongoing problems with maintaining attention especially on repetitive or administrative tasks
- Failure to remember or forget what one is supposed to remember due to conscious attempt
- Starting lots of projects, finishing very few – switching tasks without finishing them
- Forgetting conversations, instructions or appointments; working memory failures
- Persistent problems with organization at work, money, daily activities, etc
Hyperactive and Impulsive Symptoms
- Mental noise – a feeling of internal restlessness that mostly never calms down
- Impatience, interrupts, or does not finish thoughts before speaking or acting
- Lack of attention to consequences – financial, career, or relational decisions made without thinking through consequences.
- Unable to focus on low-level, quiet activities for extended time periods
Executive Dysfunction – The Hidden Core of Adult ADHD
In addition to classic symptom categories, executive dysfunction is also a frequent and often most severe symptom of adult ADHD. Executive functioning is the brain’s ability to plan, initiate, prioritize and regulate – and when it’s compromised, so is every aspect of adult life.
Task paralysis is a common phenomenon among adults who suffer from ADHD in which they may feel unable to start a significant task even though they know it is important, late, and will have a significant impact. They talk about how they have a problem with time – time blindness – and it means that they are always late and always miss opportunities. They explain emotional dysregulation – quicker and stronger emotional responses that come before the capacity to think through the situation.
These are not characteristics of personalities. They are symptoms – and they are clinically addressable.
Co-Occurring Conditions: Why ADHD Rarely Travels Alone
It is one of the most crucial things to keep in mind about adult ADHD is that it often shows up along with other psychiatric diagnoses – which is a major reason why it takes a lifetime to be misdiagnosed or underdiagnosed for so long.
Adults often have both ADHD and anxiety. The anxiety is often a result of years of poorly managed ADHD – the constant stress of trying to catch up, the fear of a missed deadline, the pressure from others to do something they really want to do but feel they just can’t stop. Anxiety can be treated on its own, but that only brings partial and temporary relief until the underlying ADHD causes the anxiety to return.
Depression and ADHD are alike. Individuals who have been operating at a deficit for years, when they are actually neurologically impaired, have been deemed unreliable, scattered, or underperforming and are prone to depression, often as a secondary effect of that deficit.
Similar symptoms can be caused by stress, sleep disorders, anxiety, depression, or other physical conditions or illnesses. This is why a comprehensive psychiatric assessment (which looks at all factors contributing to the condition, not just the most obvious symptoms) is a key first step in effective adult ADHD treatment.
How ADHD Is Diagnosed in Adults
Attention deficit/hyperactivity disorder can only be diagnosed by a healthcare provider, typically a psychologist or psychiatrist. They will ask what symptoms you have at the moment and whether you have any issues growing up.
There are several essential elements to a comprehensive evaluation of an adult with ADHD:
Developmental and life history. Diagnosis is made if the symptoms have been ongoing for an extended period of time, and are clear for at least six months. ADHD does not begin at adulthood, but is diagnosed at that time. Accurate history taking takes clinical skills – not a quick screener.
Functional impairment assessment. Symptoms are not enough, the evaluation should clarify how symptoms impact functioning across the various life domains: work, relationships, money, and how the patient experiences themselves internally.
Differential diagnosis. Anxiety, depression, sleep disorders, thyroid disorders, trauma responses – all of these produce similar symptoms and careful clinical differentiation is the key to making an accurate diagnosis. Many people have positive tests but do not have full diagnostic criteria and others underestimate symptoms.
For adults specifically, there are many reasons someone may not be diagnosed with ADHD until adulthood. Your teachers or parents might not have noticed the disorder in your child or you might have a mild case of ADHD that could be controlled well until you get to the pressures and demands of adulthood, particularly at work. These are all valid reasons, none of which turn the diagnosis of a later age into any less valid – or life-changing.
ADHD Treatment Options for Adults
Treatment for ADHD may involve medication, mostly stimulant medication, therapy and/or other behavioral treatments, or a combination of these. The best method for any family and individual will vary. Effective treatment plans will include close monitoring, follow-ups, and making changes, if needed, along the way.
Medication Management
Adopted correctly and under the right supervision, ADHD medication can be the most directly effective treatment that many adults ever have received. There is good clinical evidence that stimulant medications (amphetamine and methylphenidate based) and non-stimulant alternatives work well in adults. The key word is monitored – medication management requires skillful selection, dose individualization, and follow-up to make sure that the medication is working as it would for the patient as circumstances change.
Behavioral and Organizational Strategies
Medication treats the underlying brain changes in ADHD. Behavioral strategies are a way of dealing with symptoms that has been learned over the course of many years of symptom management without assistance. Structure, external accountability systems, time management tools tailored to the way the ADHD brain processes time and methods that are specifically designed for task initiation and working memory are beneficial for adults with ADHD.
Treatment for Co-Occurring Conditions
Anxiety and depression are common with ADHD in adults, leaving the treatment of these disorders often intertwined. A psychiatrist who addresses the ADHD problem within the context of the whole clinical picture and not only the ADHD problem, generates more meaningful results while treating than a psychiatrist that treats only the visible part of the problem, namely the ADHD problem.
When to Seek an Evaluation
If you feel you experience the symptoms and have the experiences that have been detailed throughout this article, and you are unable to see a way to sustain your performance, think of a formal psychiatric evaluation as the next step.
A diagnosis of adult ADHD is not the end of the world. It explains why some parts of function have been more challenging than they should be – and how it can be addressed in real, measurable ways through treatment.
Dr. John C. Shershow, M.D. is a Board-Certified Psychiatrist with over 30 years of experience in the assessment and treatment of adult ADHD in New York and New Jersey. He sees new patients for telehealth services throughout New Jersey and in-person services in Manhattan.
Schedule Your Adult ADHD Evaluation Today
Frequently Asked Questions — Understanding ADHD in Adults
Q: Can you develop ADHD as an adult, or does it always start in childhood?
ADHD is a neurodevelopmental disorder that starts in childhood, even though some ADHD symptoms are present before the age of 12, according to the current diagnostic criteria. Many adults are just discovering symptoms that they have always had. Diagnosis often occurs in adulthood, and is common and clinically valid, as symptoms of ADHD are often masked by high intelligence, structured environments, and robust compensation strategies. But a late diagnosis is not a less real diagnosis, it is a delayed diagnosis.
Q: What is the difference between adult ADHD inattentive type and combined type?
According to the DSM-5, there are three presentations of ADHD in adults: predominantly hyperactive-impulsive, predominantly inattentive (also known as ADD in adults), and combined. Inattentive ADHD – the most missed presentation in adults – does not manifest itself externally as hyperactivity, but rather as a subjective feeling of difficulty in focusing, working memory problems, executive dysfunction, and paralysis of tasks. Combined type involves both attention difficulties and hyperactivity/restlessness and impulsivity. The choice of presentation is important because it directly affects the choice of treatment and which symptoms should be targeted.
Q: How is adult ADHD different from anxiety – and can you have both?
Because of the shared symptoms of anxiety and ADHD, which include difficulty concentrating, restlessness, and trouble completing tasks, the two conditions are often mistaken one for the other or one for the other. The crucial difference is the underlying mechanism; for anxious attention difficulties, it is worry or rumination, while for ADHD it is a lack of an attentional regulatory process regardless of emotion. It can be common for both to be present at the same time – in fact, for some adults, the anxiety may be a byproduct of longstanding ADHD. Only a psychiatrist can make an accurate clinical diagnosis and treat them and the underlying problem.
Q: Does adult ADHD always require medication?
Treatment for adults with ADHD does not always include medication – it’s just one part of an intensive, personalized treatment plan. Many adults find that the right medication and supervision can make a tremendous difference in functioning, a benefit for which behavioral strategy alone has failed. Some adults choose to start with non-medication methods and for others a combination of medication and behavioural support is best. Treatment planning should always involve a discussion between the patient and psychiatrist, taking into account the whole clinical picture and the patient’s goals and preferences.
Q: How long does it take to get an adult ADHD diagnosis?
The duration of the process will be different depending on the provider and its timeline. The experienced adult ADHD psychiatrist will be able to make a clear diagnosis in a single comprehensive psychiatric evaluation that includes developmental history, current impairment, and differential diagnosis in one appointment. These neuropsychological testing procedures take several weeks to months. Take care with 10 minute visits that result in a diagnosis without history or impairment review and without differential diagnosis – speed doesn’t equal accuracy.
Q: What should I do if I recognize these ADHD symptoms in myself?
The best place to start is by booking a formal evaluation with a Board Certified Psychiatrist who specializes in adult ADHD – that is not through an on-line quiz and that is not by waiting to see if it gets better on its own without a clinical evaluation. Take all previous psychiatric and medication records and a history of how your symptoms have impacted your functioning throughout your life to your evaluation. The evaluation process is meant to give exactly the information and yield clinical conclusions that are specific, accurate, and useful enough to work around in the development of a meaningful treatment plan.