Despite great strides in the identification, referral, diagnosis, and management of adult ADHD over the past two decades, much work remains to be done by mental health professionals to further improve the delivery of mental health services to most adults with ADHD. This course seeks to help ameliorate that situation by briefly reviewing the nature, diagnosis, comorbidity, and impairments associated with ADHD. It then provides both an overview of the evidence-based approaches currently available for the management of adult ADHD as well as myriad specific recommendations for the management of the various domains of impairment that are a consequence of adult ADHD.
This is an intermediate to advanced level course. After completing this course, mental health professionals will be able to:
The materials in this course are based largely on and adapted from the following books by Dr. Barkley: Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed., 2015, New York: Guilford Press), ADHD in Adults: What the Science Says (2008, Guilford Press), Taking Charge of Adult ADHD (2013, New York: Guilford Press), and When an Adult You Love Has ADHD: Professional Advice for Parents, Partners, and Siblings (2016, Washington, DC: Lifetools, American Psychological Association Press). But other sources were used as well, many of which can be found in the Resources and References sections at the end of this course.
The course contains the most accurate information available to the author at the time of writing. The scientific literature on ADHD grows daily, and new information may emerge that supersedes these course materials.
This course will equip clinicians to advise adults with ADHD and their loved ones on the most effective methods for managing the symptoms of ADHD and associated impairments in adults with ADHD.
Beginning in the 1990s, thanks to several large follow-up studies with adults, both the general public and many mental health professionals became aware that ADHD was not just a disorder of children but persisted into adulthood in at least 50%-65% of all cases diagnosed in childhood. Moreover, evidence began to accumulate that ADHD could be diagnosed in 3%-5% of the U.S. adult population. Many of these cases had never been diagnosed as such in childhood even though they likely had the condition. A major US population survey conducted in 2006 reported that 90% of those meeting diagnostic criteria for adult ADHD had never been diagnosed with it or received any treatment for it. And just 25% were receiving any treatment for any mental health condition. Yet the survey found these adults to be suffering impairment in several major life activities. Now, more than a decade later, the situation for adults with ADHD has and continues to improve, although the majority are likely still not receiving appropriate diagnostic and treatment services specifically for their ADHD. More mental health professionals are now well aware that adults can have ADHD, and many are seeking more information about its identification, diagnosis, and management. That is the purpose of this course: to assist in providing up-to-date continuing education training in how to recognize and treat ADHD in adults.
The history of ADHD is extensive for the childhood stage of the disorder. Far less information exists concerning the history of ADHD in adults, largely because throughout most of the past century ADHD was widely held to be a disorder strictly of childhood. While popular interest in the possibility that adults can have Attention Deficit Hyperactivity Disorder (ADHD) most likely originated with the bestseller Driven to Distraction, published in 1994 by psychiatrists Edward Hallowell and John Ratey, clinical and scientific papers acknowledging the existence of an adult version of this disorder date back at least 50 years, possibly even two centuries.
The first paper in the medical literature on disorders of attention that described a condition highly similar to ADHD is a short chapter in a German medical textbook by Melchior Adam Weikard in 1775. Weikard described symptoms of distractibility, poor persistence, impulsive actions, and inattention more generally in both adults and children. The next reference to adult ADHD was in the medical textbook by the Scottish physician, Dr. Alexander Crichton, in 1798. He discussed two attention deficits, one of which is very similar to adult ADHD while a second dealt with low levels of arousal, alertness, and energy that may be similar to the increasingly studied second attention disorder known now as sluggish cognitive tempo. Crichton espoused the view that inborn forms of inattention would diminish with age in some though not all cases. Noteworthy as well was that Crichton felt that problems with attention were associated with many other mental and physical disorders, and that there are different components involved in attention, making it multidimensional rather than unitary, as modern researchers now also believe.
We must skip 104 years ahead to find the next reference to attention disorders in the medical literature. In his series of three published lectures to the Royal College of Physicians, George Still (1902) described 43 children in his clinical practice having serious problems with sustained attention and in the moral control of their behavior. By the latter symptom, Still meant the regulation of behavior relative to the moral good of all. He viewed the latter construct as a conscious comparative process in which one evaluates both the present and likely future consequences of one’s actions for both one’s self and for others prior to choosing a course of action. Most of his cases were not just inattentive and lacking in forethought but also were quite overactive. He proposed that the immediate gratification of the self was the “keynote” quality of these and other attributes of the children. In addition, among all of them, passion (or heightened emotionality) was the most commonly observed attribute and the most noteworthy. Still noted further that a reduced sensitivity to punishment characterized many of these cases, for they would be punished, evenly physically, yet engage in the same infraction within a matter of hours. Still believed that the major “defect in moral control” so typical of these cases was relatively chronic. While it could arise from an acquired brain defect secondary to an acute brain disease, and might remit on recovery from the disease, in most cases it was chronic.
Here again we see reference to the possibility that ADHD may persist into adulthood, thereby logically opening the door to the possibility that adults can possess this same pattern of symptoms dating back to childhood.
The first papers on research studies involving adults having actual ADHD seem to date to the late 1960s. At that time, the disorder was known as Minimal Brain Damage or Dysfunction (MBD) and its likely existence in adults was supported by three sources. The first of these was the publication of several early follow-up studies demonstrating the persistence of symptoms of hyperactivity/MBD into adulthood in many cases. The second source was the publication of research showing that the parents of hyperactive children were likely to have been hyperactive themselves and to suffer in adulthood from sociopathy, hysteria, and alcoholism, not to mention the usual symptoms of inattention, lack of impulse control, and excess activity levels, all of which logically implies that ADHD could exist in adults. The third source directly supporting such a conclusion was the publication of studies on adult patient samples that were believed to have hyperactivity or MBD. Noteworthy for our purposes here was the finding that such adults had an early history of hyperactive-impulsive-inattentive behavior dating back to childhood and that was highly predictive of placement in an adult group characterized as impulsive-destructive, again implying a persistent course of this behavioral pattern from childhood to adulthood.
Adults in the studies were typified by marked difficulties concentrating, being emotionally labile, fearing their loss of impulse control, and showing marked irritability as well as anxiety and self-depreciation. Problems with poor motor skills and sluggish reaction or response timing were noteworthy. While EEG and neurological exams were normal for gross findings of hard neurological signs, all showed evidence of “soft” signs of “neuro-integrative disturbances” such as motor clumsiness, poor balance, confused laterality, and poor coordination. Psychological testing also revealed evidence of perceptual-motor problems and motor incoordination and timing.
Especially noteworthy was the large clinical study by Anneliese Pontius (1973) of more than 100 adult cases of MBD. She noted that many demonstrated hyperactive and impulsive behavior and that their disorder likely arose from frontal lobe and caudate dysfunction. Such dysfunction would lead to their “inability to construct plans of action ahead of the act, to sketch out a goal of action, to keep it in mind for some time (as an overriding idea) and to follow it through in actions under the constructive guidance of such planning” (p. 286). Moreover, if adult MBD arises from dysfunction in the frontal-caudate network, it should also be associated with an inability “to reprogram an ongoing activity and to shift within principles of action whenever necessary” (p. 286). She went on to show that indeed, adults with MBD demonstrated such deficits indicative of dysfunction in this brain network, making this the first paper to argue that adult ADHD was likely a disorder of the brain’s executive function networks – a conclusion supported decades later by neuro-imaging and neuropsychological research.
By the mid-1970s, researchers investigated the efficacy of stimulants with adults having MBD using double-blind, placebo-controlled methods to assess response to methylphenidate, pemoline (another stimulant), and the antidepressants imipramine and amitriptyline. About two thirds of cases showed a favorable response to either the stimulants or antidepressants. Yet, it would not be until the 1990s that both the lay public and the professional field of adult psychiatry would begin to seriously recognize the adult equivalent of childhood ADHD on a more widespread basis and to recommend stimulant or antidepressant treatment in these cases.
By the mid-1990s, Paul Wender set forth explicit criteria for the manner in which the diagnosis of ADHD in adults should be made, recognizing that nether the diagnostic criteria proposed for the syndrome of childhood hyperactivity in 1968 nor the later Attention Deficit Disorder in 1980 were developmentally appropriate for adult patients. Wender proposed an approach for diagnosis of ADHD in adults (Wender, 1995) that was subsequently used in a number of research projects, especially medication trials. Patients and an additional informant, preferably a parent, were to be interviewed to assess retrospectively the childhood diagnosis of ADHD. Evidence was also to be obtained for ongoing, continued impairment from hyperactive and inattentive symptoms. Seven symptoms were proposed to characterize the phenomenology of adult ADHD, namely, 1) inattentiveness; 2) hyperactivity; 3) mood lability; 4) irritability and hot temper; 5) impaired stress tolerance; 6) disorganization; and 7) impulsivity. Known as the “Utah criteria,” these diagnostic guidelines required a retrospective childhood diagnosis, ongoing difficulties with inattentiveness and hyperactivity, and at least two of the remaining five symptoms. A rating scale was also constructed to aid in the retrospective diagnosis of childhood ADHD. The Utah criteria have declined in use among investigators and clinicians in favor of using DSM-5 criteria that have been adjusted for use with adults.
A further watershed moment in the history of adults with ADHD was the development and FDA approval of the first medication for adult ADHD, the non-stimulant atomoxetine (Strattera®), by the Eli Lilly & Company. It was investigated in thousands of adults with ADHD in several randomized, placebo-controlled trials and found to be useful for its management. Later, stimulants (methylphenidate, mixed amphetamine salts) would eventually be studied more thoroughly for use with adults with ADHD and receive similar FDA approval for such. New delivery systems have also been subsequently developed that permit greater sustained therapeutic action across the day than did immediate release preparations. These include osmotic pumps (Concerta®), variable timed-release pellets (Focalin XR®, Metadate CD®, Ritalin LA®, Adderall XR®, et al.), and skin patches (Daytrana®), besides the earlier-available but clinically disappointing wax-matrix sustained release formulation of methylphenidate (Ritalin SR®).
More recently, a new non-abusable formulation of a mixed amphetamine compound (Vyvanse®) has received FDA approval for use with ADHD in which the pills must be dissolved and then absorbed through the gut before the amphetamine compound can be activated and available for therapeutic blood levels to become available and thus manage adult ADHD symptoms. As of this writing (late 2018), yet another delivery system has been FDA-approved, this one being a delayed onset version of both methylphenidate and amphetamine medications that can be taken at night and that reliably activates the next morning, about nine hours after ingestion (brand name awaiting assignment).
Psychological treatments for adults with ADHD, though numerous in clinical practice, have to date not received as much serious scientific scrutiny as medications. This remains a glaring deficiency in the clinical scientific literature on the disorder in adults, though it is improving of late. Cognitive behavioral therapies focusing specifically on adult ADHD symptoms have been developed by Safren and colleagues, then of the Harvard Medical School, independently by Ramsay and Rothstein at the University of Pennsylvania Medical School, and most recently by Solanto and colleagues then at Mount Sinai Medical Center in New York City. All focus to varying degrees on the executive function deficits associated with ADHD.<>
It appears from both childhood follow-up studies and, more directly, from studies of adult general population samples, that the prevalence of ADHD in adults in the United States is approximately 5%. The US Census Bureau (census.gov) estimates that in 2005, there were 295,507,134 people in the country, of which 221,868,077 were 18 years of age or older. Based on this figure and the 5% estimated prevalence for ADHD in adults, it seems likely that at least 11 million adults in the US probably have ADHD. This is a sizeable number, making it imperative that the mental health, medical, and educational professions, as well as employers, become more aware of the existence of this disorder and its treatments.
It also makes it essential that we understand as much about the expression of this disorder in adulthood – along with its comorbid psychiatric disorders and impairments in major life activities – if we are to be able to better understand the disorder and to be able to manage it and its consequences more effectively.
ADHD is recognized in the Diagnostic and Statistical Manual of Mental Disorders (5th edition, or DSM-5, 2013) as a neurodevelopmental condition that consists of developmental delays or deficiencies in at least two significantly related domains of neuropsychological abilities. These two dimensions are referred to as inattention and hyperactive-impulsive symptoms.
Readers should understand that despite the criticisms and limitations I will level at these criteria, at least as they pertain to the diagnosis of adults, they are the most empirically-based, rigorously tested, and logically coherent criteria of their time for the diagnosis of ADHD, especially in children.
The DSM-IV criteria specified a set of 18 symptoms divided into two lists; inattention and hyperactivity-impulsivity, on which were nine symptoms each. These symptoms have to occur often or frequently and been present for at least 6 months. In the more recent DSM-5 published in 2013, the same 18 symptoms will continue to be employed but they have been given clarifications in parentheses for use with adolescents and adults. The age of onset has now been adjusted upward to age 12 given that the earlier age seven had no scientific validity to it. By increasing the age of onset of the disorder, far more adults who otherwise meet all other criteria for the disorder except the age of onset of seven years old will now be eligible for the diagnosis; a good thing. The threshold for the diagnosis will remain at six symptoms on either list for children and will be reduced to five for adults. This too is an improvement, although most studies on this issue would suggest that four symptoms would be even better.
A further improvement is the explicit recommendation that symptoms reported by patients be corroborated through someone who knows the patient well. Also beneficial has been the removal of the subtyping scheme such that ADHD is now viewed as a single disorder in the population, which behavioral genetic studies of large populations clearly suggest. Clinicians can now specify which symptoms are more evident in the clinical presentation, such as Predominantly Inattentive Presentation. Still, some problems remain with the DSM criteria that were not addressed in DSM-5.
There is little evidence to suggest that ADHD symptoms currently identified in the DSM-5, designed as they were for use with children, best characterize adults with ADHD. My colleague and I (and others) have identified nine symptoms that were the most useful for identifying adults with ADHD, six of which were not in the DSM-5 but came from our evaluations of executive functioning. They are:
Has four of the first seven, or six of all nine of the following symptoms that have persisted for at least six months to a degree that is maladaptive and inconsistent with the subject’s developmental level:
Some of the above symptoms that cause impairment were present before ages 16-18. Some impairment from these symptoms is present in two or more settings (e.g., work, educational activities, home life, social functioning, community activities, etc.). And there must be clear evidence of clinically significant impairment in social, academic, domestic (cohabiting, financial, child-rearing, etc.), community, or occupational functioning.
Another problem with DSM-5 is that the greatest weight is given to inattention (nine symptoms), followed by hyperactivity (six symptoms), with the remaining three symptoms thought to reflect impulsiveness. Most of those impulsive items reflect principally verbal behavior. The words “impulsive” or “poorly inhibited” are not even mentioned in the symptom list despite being viewed currently as a core feature, if not THE core feature of this disorder. This has proven to be a glaring oversight because the symptom of “makes decisions impulsively” and others related to it (acts before thinking, has difficulty waiting for things, etc.) are among the most discerning symptoms for distinguishing ADHD from other psychiatric disorders as well as from the general non-disordered population. While DSM-5 tested additional symptoms of impulsivity, it was elected not to include them, perhaps due to concerns that it would increase the prevalence of the disorder.
Also problematic in DSM-5 is the requirement for the age of onset of symptoms to be by age 12. Unlike the assessment of children, the clinical evaluation of adults is highly dependent on patient self-reporting. However, adults have a limited recall of the exact time course and nature of symptoms within the developmental time frame associated with so precise a childhood onset and have a limited recall of the domains of childhood impairments related to those symptoms. Moreover, many adults who present for clinical care are unable to provide independent evidence of the disorder, either through retrospective parental report or records of academic functioning. Adults do not typically come to clinical evaluations with their parents in order to provide the customary evidence for judging symptom onset as is done in children.
Add to this the likelihood that ADHD may create a positive illusory bias in adults concerning their possible impairment – as it does in children with ADHD – that could possibly diminish self-awareness of symptoms and impairments. This gives a further reason to question the reliance upon adult patients for establishing the age of onset of their symptoms and associated impairments. I argue that the criterion should be abandoned or redefined to include the broader period of adolescence (ages 12 to 14). No evidence is available in the literature to our knowledge that suggests that onset of ADHD symptoms at or after age 12 results in a qualitatively or even quantitatively different disorder than cases of ADHD having the earlier recommended symptom onset. And my own research showed that age 16 would have been even more comprehensive.
A further limitation of the DSM-5 for use with adults is that it requires that some impairment from the symptoms is present in two or more settings (e.g., at school or work and at home). Problematic here, obviously, is that adults are involved in far more numerous and important adaptive settings or domains of major life activities than this criterion stipulates. Not only are the settings specified here too global to be of much good to the clinician evaluating domains of impairment (e.g., “home”), but they ignore many more domains of major life activities that are not only more specific but also comprise important domains of adult adaptive functioning. General functioning within the larger organized community (e.g., participation in government or formally organized community groups, cooperation with others living in the same neighborhood, abiding by laws, driving), financial management (e.g., banking, credit, contracts, debt repayment), parenting and child-rearing (e.g., protection, sustenance, financial and social support, appropriate education, discipline), marital functioning, and routine health maintenance activities are additional domains of major life activities in which symptoms may produce impairment that would not be evident in children. Current criteria fail to reflect these potential areas of impairment.
A further difficulty with DSM-5 is that controversy exists over the definition of impairment due to an enormous increase in requests for special accommodations in employment and high-stakes academic testing under the Americans with Disabilities Act (ADA). Further specification of the meaning of impairment in DSM-5 is necessary so as to avoid misunderstandings among clinicians and public agencies. Some clinicians assess impairment based on comparison of deficits relative to a person’s intellectual level, much as had been done in the earlier history of defining learning disabilities as being significant discrepancies between IQ and some specific area of academic achievement, such as reading. Others believe impairment is based on how well an individual functions relative to their specialized peer group, particularly if they are unusually intelligent or well-educated, such as fellow gifted individuals or peers in medical or law school.
Still others have argued that impairment should mean serious dysfunction in the performance of major life activities (e.g., family, marital, social, or occupational functioning) that are required of society in general. More to the point, this view holds that impairment should be defined as being relative to the norm or average person, as required by the ADA, and not relative to some narrow, highly specialized and accomplished subset of adults or to an estimate of one’s general cognitive ability, such as IQ. I prefer the latter view of defining impairment because of a number of factors: its consistency with scientific views on valid mental disorders (harmful dysfunctions that are failures or severe deficiencies in mental adaptations as noted by Jerome Wakefield ); its consistency with the ADA, with associated court rulings, and with the legislative intent behind the ADA (granting protections and accommodations to people functioning well below normal or average); and simple fairness or justice – individuals should not be viewed as disordered and granted special protections, accommodations, disability financial benefits, or other societal privileges when they are not below the average of the population at large. It is inherently unfair to grant advantages to those who are not actually subnormal. Also, this latter view of impairment respects the fact that one’s intelligence is not an indicator of functioning in all avenues of adult life nor are disparities between IQ and some other measure of adaptive functioning. The DSM-5 should have made the criteria for impairment clearer as to the domains it encompasses and the comparison group to be used for its determination.
Despite these continuing problems with the DSM-5 criteria for adults with ADHD, the changes that were made to DSM-IV are an improvement and make DSM-5 more sensitive to the detection of the disorder in adults than its predecessor DSMs. Even so, readers need to be alert to these limitations as they go about applying DSM-5 criteria to the diagnosis of ADHD in adults.
Other points to keep in mind in using DSM-5 are as follows:
The symptoms of ADHD are dimensional in that they reflect the extreme end of a continuum (most likely a bell-shaped distribution) of normal or typical human ability in these two areas. Therefore, adults with ADHD have a disorder that:
Many clinical researchers, myself included, conceptualize these symptoms as involving deficits in the following mental abilities, often referred to as executive functions (see Dr. Barkley’s course on Executive Functioning (EF), Executive Functioning and ADHD: Nature and Assessment):6
Goal-directed persistence and resistance to distraction (inattention)
What separates the attention problems seen in ADHD from those evident in other disorders such as depression is that those with ADHD have problems with sustaining attention to and persisting toward a goal, either self-imposed or assigned by others – in short, they suffer in their attention to the future. They are less able to persist at getting things done over time, in time, and on time that involve delayed or future events. Thus, they pay attention to what is happening now just fine but not to what they need to be doing to be ready for what is coming next or what they have been assigned to do. Even if they try to persist toward tasks or goals, they are more likely than others to react to distractions, which are events that are not relevant to the goal or task. Those distracting events are not just irrelevant things occurring around them, but also irrelevant ideas occurring in their mind. The problem here is not one of detecting those distractors as well as others do, but in failing to inhibit reacting to those distractors as well as others.
A large part of the adult’s inattentiveness in ADHD comes from the inability to hold in mind what goal they have chosen or been assigned, what steps are involved, the most efficient sequence for attaining that goal, and monitoring when it has been accomplished. This reflects a deficiency in working memory, which is remembering what to do. Memory for facts, knowledge, or information is not so much the problem as is remembering what is to be done and persisting at it until it is completed. Even if they try to hold in mind information that is to guide their behavior toward a goal or task, such as instructions or assignments clinicians give them, any distractions occurring around the adult with ADHD will disrupt and degrade this special type of memory. The mental chalkboard of working memory is wiped clean by the distraction and so the affected adult is now off doing something other than what they are supposed to be doing. And having reacted to a distraction, and so gone “off-task,” the adult with ADHD is far less likely to re-engage the original and now-uncompleted goal or task. In sum, the adult with ADHD is less likely than others to remember what they were supposed to be doing. Yes, adults with ADHD are forgetful. But it is a special type of forgetfulness – it is forgetting what they are supposed to be doing (forgetting the goal, specifically, and the future more generally).
Adults with ADHD are not just impulsive (poorly inhibited) in their actions, which leads them to move around, touch things, and otherwise behave too much (the “Hyperactivity”). Their deficit in inhibition extends to their verbal behavior (talking excessively) and to their cognitive activities or thinking (impulsive decision-making). It also interferes with their self-motivation, meaning that they are more likely to opt for immediate rewards or gratification than others do. Put another way, they have a high time-preference and so steeply discount the value of a future or delayed event or consequence (reward or punishment) more than others do – they prefer to have small results now rather than larger results later. Finally, their impulsiveness is evident in their emotions. They display their emotional reactions more quickly and more often than do others of their age. And, if strong emotions have been provoked by some event, they will have a far more difficult time moderating or otherwise self-regulating that emotion. So adults with ADHD are less patient, more easily frustrated, quicker to become emotionally aroused, more excitable, sometimes sillier, yet also more likely to react with anger. And so the adult with ADHD is more likely to respond with aggression when provoked. They show emotions that are less mature and appropriate to the situation and less consistent with or supportive of their future welfare than others do.
Planning and Problem Solving
ADHD is associated with difficulties in generating multiple possible options for overcoming obstacles encountered when pursuing goals, or in contemplating multiple solutions posed by problems. A related deficit is in the ability to construct and execute the steps of a plan necessary to attain a goal. This difficulty is often evident in school or work settings in problems with mental arithmetic, providing verbal narratives to questions posed by others, and in rendering oral reports, written reports, and other tasks in which a complex, well-organized response is necessary.
A recurring theme here is that ADHD interferes with thoughts, actions, words, motivations, and emotions aimed at organizing behavior across time and preparing for the future instead of just reacting to the moment. To act impulsively, fail to persist, and be distractible is to be nearsighted toward the future – to be preoccupied by moments and so be blind to time. The aforementioned cognitive deficits will then disrupt the adult’s EF in daily life activities, as will be evident in problems with:
The vast majority of adults meeting diagnostic criteria for ADHD fall in the bottom 7% of the population in each of these major areas of EF in daily life. It is easy to see how such deficits would produce a myriad of difficulties with functioning in various major life activities that typically place a premium on these EF abilities. Those are the areas of daily functioning that adults with ADHD are most likely to describe as problematic for them. So clinicians should be listening carefully for complaints that fall into these areas when they initially evaluate an adult with ADHD or are working with them initially in a counseling or coaching circumstance.
In summary, it is important to understand the nature of adult ADHD and its need for treatment. For one reason, as noted above, a substantial percentage of adults in the U.S. have ADHD (one in every 20-25). For another, they will be increasingly presenting to outpatient clinical services for diagnosis and management of their disorder as public awareness of adult ADHD continues to increase. Moreover, they are likely to be suffering impairments in many domains of major life activities (see Consequences of Untreated ADHD, below) given the important role of EF in adult daily life.
Without identification and treatment, ADHD in adults will contribute to their experiencing increased harm or suffering to themselves as well as to society and may likely underlie the reason they are not benefiting much if at all from treatments aimed at the other disorders that may coexist with adult ADHD (substance use, marital problems, occupational difficulties, driving impairments, weight control and health maintenance, etc.). Unmanaged adult ADHD may also be costing society billions of dollars annually as a consequence of these unaddressed or under-addressed impairments and comorbidities.
For these reasons, this course will provide readers with information on the outcomes of unmanaged ADHD in adults as well as review the treatment options that can help to reduce or eliminate these impairments.
In order to capture all of the relevant information needed to adhere to the DSM-5 diagnostic criteria for adult ADHD as well as to the modifications to it discussed here, the assessment of a client for adult ADHD should incorporate the following procedures: an open-ended general interview; a structured interview of relevant DSM-5 disorders; rating scales of adult ADHD symptoms, executive functioning, and functional impairment; a review of archival records: corroboration of symptoms through someone who knows the patient well: psychological screening tests for IQ and learning disorders (achievement); and consideration of malingering.
These are listed below and discussed in more detail in the chapter on assessment of adults by J. Russell Ramsay, Ph.D. in the 2015 edition of my ADHD Handbook for Diagnosis and Treatment (Guilford Press).
As noted earlier, no precise age of onset of symptoms producing impairment should be required for a diagnosis of ADHD. The DSM-5 recommends age 12 but an upper boundary of ages 16-18 has been recommended by others based on extensive research on the issue. Typically, my colleagues and I require corroboration of ADHD symptoms and impairment from someone else who knows the person well – such as parents, siblings, or spouses/partners – as part of a clinical diagnosis of ADHD.
The clinician conducting the interview should exercise her or his judgment as to whether the patient’s reports on these matters could be considered to be realistic or have some veracity. As a consequence, a few individuals may be clinically diagnosed as having ADHD by the clinician despite their not meeting diagnostic criteria strictly by their own initial self-report. Others who meet criteria based solely on their self-report may not be granted the clinical diagnosis of ADHD. The latter may have other disorders that interfere with attention, such as anxiety disorders or depression, but do not have the cardinal features of ADHD (chronic ADHD symptoms from childhood). A moment’s reflection will show several reasons for why this necessarily has to be the case.
First, the self-reported ADHD-like symptoms may be clinically judged to be better accounted for by the presence of another diagnosis (such as dysthymia, depression, anxiety, substance abuse, marital problem, a situational stressor, etc.). This is a requirement of the DSM criteria for ADHD that may often go overlooked in research studies that select their ADHD group merely by rating scales or solely on self-reported information. This criterion can only be executed via clinical judgment and knowledge of differential diagnosis and cannot be incorporated into some mindless algorithm that relies exclusively on self-reporting.
Second, the symptoms that patients endorse and/or the associated impairments they allege may not rise to the level of being clinically significant in the clinician’s judgment. DSM criteria require that symptoms be both developmentally inappropriate and lead to impairment, which inherently involves clinical judgment. For example, a patient may endorse 14 of the 18 symptoms but the examples of the symptoms given were judged to be clinically trivial and the impact they had in producing clinically significant impairment is either minor or non-existent. Likewise, another patient may give evidence of having no real impairment other than an internal perception that he was somehow not working up to his potential or not being as successful or effective as he thought he should be. In other words, there is no other historical corroborative evidence in these reports that the behavior of which they complain is actually a symptom (abnormal) or that the impairment claimed is so interfering with their functioning that it resulted in being well below the average-person standard discussed above. For example, in the second patient’s case, despite his reported symptoms he had suffered no problems in school, had received no prior psychological treatment, had received no accommodations for a disorder at school or at work, was happily married, demonstrated no occupational impairment, or failed to manifest convincing social or daily adaptive impairment that in the clinician’s judgment was significant and a consequence of ADHD. In some cases, these are what one might call “ADHD wannabes” who are self-diagnosed before coming into the clinic, typically based on reading a popular trade book on ADHD in adults or hearing media accounts of the disorder and believing themselves to have it. In short, to be eligible for the diagnosis of ADHD, patients have to have a sufficient number of DSM symptoms that in the clinician’s judgment produce clinically significant real-world functional impairment in major life activities.
Third, for the clinician to render an ADHD diagnosis, he or she needs to see fairly compelling evidence of an onset of symptoms sometime during childhood or adolescence, a chronic (unremitting) and pervasive pattern of ADHD symptoms, and impairment that could be reasonably attributed to ADHD. The clinician should not simply record mere self-reported symptom counts or statements of impairment, relying solely on a judgment-free algorithm. It is clear that some patients do not have a good perspective on what constitutes impairment. For example, a patient may have denied having any significant impairment, yet a closer look at her history and school, driving, and other archival records may show substantial struggles in school achievement and deportment, in adverse driving outcomes, in conduct in the community (delinquency), in her job performance or social relationships, or in just managing daily major responsibilities. However, she might have simply chalked it up to "I just hated school" or her job, or her friend or partner, etc., rather than viewing it as stemming from any sort of disorder.
Finally, there has to be convincing evidence that the symptoms actually developed and produced impairment sometime during childhood or adolescence. Consistent with the criticisms raised above about the DSM criteria for ADHD, when many patients are asked about onset, they have a hard time specifying an exact age. They use phrases such as "as long as I can remember,” "always," "forever," etc. Others give evidence of a very poor memory of their childhood and cannot remember when they first noticed problems, yet they may have given the clinician other information that helped attach an age to the onset of symptoms producing impairment (such as getting suspended or held back in first grade). In addition, some might say their impairment began in high school, yet during the interview or from inspecting school records it becomes clear that the impairment had begun much earlier. Our research in fact showed that, on average, patient reports of age of onset were 4-5 years later than was the actual onset as recorded in longitudinal studies following them from childhood to adulthood. And we found that parent reports were no more accurate concerning retrospective recall of age of onset of their child’s symptoms when judged at the child’s adult follow-up. Hence, differences could exist in self-reported perceptions of onset (and even parents’ reported age of onset) versus a clinician’s determination of onset based on the totality of information received during the assessment.
All of these issues should be kept in mind when making the diagnosis of ADHD. The DSM-5 should be viewed as providing only rough guidelines for making this diagnosis in adults, and requires sound clinical judgment to implement the guidelines properly in adult cases. Interview and rating scale forms that the clinician may find helpful in conducting this evaluation can be found in my rating scales of adult ADHD and Executive Functioning more generally (See Resources). Moreover, impairment can be assessed using my new impairment rating scale which for now remains the only normed rating scale of adult impairment.
Unmanaged ADHD can lead to numerous adverse consequences in many areas of adult daily life. Here are briefly described the various domains that can be negatively impacted by adult ADHD. More detail on these impairments can be found in others of my courses on adult ADHD. These are the domains for which clinicians are going to have to provide treatment. After all, treatment should not be targeted only at symptom reduction but at decreasing impairments in major life activities. Such advice occurs later in this course. For an even more detailed look at these various domains of impairment, see my textbook, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed., 2015). Not all adults with ADHD experience impaired functioning in all of these areas, but such an adult is more likely to have difficulties in these domains than would a typical adult. Yet with clinical help and proper treatment, much improvement can usually be made in these domains for the adult with ADHD.
Clinicians will see that ADHD has a pervasive negative effect in someone’s life if it is not properly treated. While such a diagnosis can initially prove discouraging to the adult patient with ADHD, the fact is that ADHD in adults is among the most treatment-responsive psychological disorders currently known. This brief review is to show that adult ADHD is a serious condition if not properly treated, and to help clinicians motivate clients to take it seriously and get treatment.
Before discussing some specific impairments with which adult ADHD is associated in various major life activities, it may be helpful to distinguish among the terms “symptom,” “disorder,” “impairment,” and “disability,” as used here. As I have written elsewhere, I consider symptoms to be the cognitive and behavioral expressions of a possible disorder shown by an individual. A psychological or psychiatric disorder exists when such symptoms reach such an abnormal or statistically aberrant degree of frequency or severity as to result in impairment in one or more major life activities. Disorders begin where impairment begins.
Impairment to me refers to the degree of functional ineffectiveness an individual is experiencing in a major life activity where such ineffectiveness has reached a degree where serious harm or adverse consequences are occurring to the individual as a result. That is, the ineffective functioning has reached such a degree that the environment is “kicking back,” or generating adverse consequences. So, symptoms are the expressions of a disorder while impairment is the consequence of those expressions.
A disability is a domain- and setting-specific term used by government and regulatory bodies to refer to the degree of impairment (functional ineffectiveness) an individual may be having in one or more major life activities that warrants either protection from discrimination, as under the Americans with Disabilities Act; or an entitlement to societal support, as under disability insurance, workman’s compensation, or the Social Security Administration. A disability is typically judged as existing against the standard of a normal or typical person, which is to say that the individual must be functioning significantly below the typical adult in the general population, and not just relative to their general cognitive ability or a highly specialized peer group (i.e., law students). While professionals often use the term impairment and disability to mean the same thing, government and regulatory bodies have their own definitions of a disability that must be met in order to gain access to certain protections and entitlements.
Returning to the discussion of impairments associated with adult ADHD, below are two diagrams showing many of the domains of impairment that can occur or have already occurred to a far greater extent in adults with ADHD than in the typical adult population. The first deals with domains impaired during childhood and the second with those likely occurring in adulthood. Space does not permit delving into each in much detail, but below are summaries of at least what is known about the risks that arise in most of them.
Consequences at School
Undoubtedly, the domain of education is the one most likely to be adversely affected in the histories of adults having ADHD and it is affected more severely than might happen in other domains. This is especially so in childhood and adolescence because of the requirement to be in school during these years. But adult ADHD can also have an adverse impact during young adulthood if the adult with ADHD went beyond high school for any additional education. And ADHD can cause problems in her current life if she is participating in any adult continuing-education programs, such as additional college or technical training or work-related training. All of this makes perfect sense when clinicians consider the problems ADHD produces in inhibiting behavior, paying attention, remembering instructions, resisting distractions, sitting still, and being quiet. It is even more obvious when clinicians consider the executive deficits discussed above – poor time management, self-organization, problem solving, emotional self-control, self-restraint, and self-motivation. All of these mental abilities are essential for functioning effectively in school or in any other educational setting as an adult.
People with ADHD are more likely to have been held back in a grade (25%-50%), placed in special education (50%-80%), suspended for inappropriate conduct (20%-60%), expelled (10%-15%), or to have quit (10%-35%) before completing high school. They are therefore less likely to attend college. And, if they do attend, they are less likely to complete that program (5%-10% vs. 35%-41% of adults). They have more days of unexcused absences from school, a lower class ranking in high school, a lower grade point average in high school, and, if they attended college, more grades of D and F than adults in a general community sample. Individuals with ADHD therefore often have less education than do others their age. Obviously, those with high levels of intelligence are better able to achieve more years of education and some may even complete advanced graduate degrees. Yet overall, the educational system can prove to be a very difficult situation for adults who had ADHD when they were growing up.
There are well-known downstream negative effects on one’s life if a person does not get a good education. The amount of money a person is likely to earn both annually and across their lifetime is directly related to how much education they received. And the amount of education a person receives is likely to determine the types of occupations they will be able to pursue. Not graduating from high school, for instance, results in not getting access to many work opportunities and types of occupations. This results in a far more restricted range of work opportunities for such a person than for someone completing high school or someone who gets at least some college. So even after people with ADHD eventually leave school, there may be lasting detrimental effects on their adult lives from their educational difficulties.
Consequences at Work
The domain of current functioning most impaired in adults with ADHD is that of work or occupational functioning. Again, this makes perfect sense given the symptoms of the disorder and the deficits in self-control and EF discussed earlier. If an adult is poorly inhibited, easily distracted, unable to sustain their attention as long as others, forgetful, and generally demonstrates less self-control or self-discipline than others because of their ADHD, work life can prove to be quite a struggle. Of course, all this depends on the kind of work an adult chooses to do. Some jobs are more ADHD-friendly than others. For instance, an adult with ADHD might find being a salesperson or physical education teacher to be better suited to their ADHD-related symptoms and so will be less impaired by those symptoms in such jobs. But he (this course will alternate between using he/him and she/her) would find it difficult to deal with his symptoms if he worked at a desk job dealing mainly with paperwork or in which he had to manage a lot of time-sensitive logistics, such as an event planner, builder, or factory plant manager. Yet even when an adult with ADHD finds an occupation in which he is less affected by his ADHD, he may still have trouble with the organization and time management aspects of even these ADHD-friendly occupations. As they enter the workforce, teens and adults with ADHD have more problems in performing their work as well as others. They start working at a younger age than others, which may sound like a good thing for them, but this is probably due to their being less likely to pursue further education after high school or to even graduate from high school. It also means they do not have the skills necessary to move up in entry-level jobs, such as fast-food worker, restaurant busboy or waitress, lawn-care worker, farm field-hand, or construction worker. More adults with ADHD change jobs out of boredom than do other adults. My own research has found that adults with ADHD were two to three times more likely to be dismissed from a job due to poor conduct and were fired from a greater percentage of the jobs they had held since leaving high school than were other adults. More than half of adults with ADHD have been fired from a job at least once and have quit jobs impulsively, with no other job to go to when they quit. Perhaps this explains why a substantial number of adults with ADHD may go for several months or longer being unemployed.
Concerning behavior at work, adults with ADHD show more oppositional behavior such as being hot-tempered, argumentative, or defiant. More than half the adults with ADHD who participated in the study noted above had significant problems getting along with others. They were also less punctual for work, appeared to manage time less efficiently, were more forgetful and disorganized, and so required more supervision than did other workers. Clearly this results in an adult with ADHD receiving lower ratings of her work performance from supervisors than do others without ADHD. All this inevitably leads to an adult with ADHD having a greater likelihood of having formal disciplinary actions taken against her by her employers than would typical adults.
These difficulties as well as a propensity for being more easily bored by work than others may explain why an adult with ADHD spends significantly less time in any given job than do others. As a result, she winds up having held more jobs in her checkered work history than do other adults. All of these problems can lead to lower earnings, less opportunity for workplace advancement, and overall lower-status jobs than adults without ADHD who persist far longer at the jobs they take.
Adults with ADHD also have more accidents at work, suffer more injuries, make more claims for worker’s compensation, and take more unexcused absences from work. They also may use more of their sick leave and spend more of their time at work not being especially productive than do adults in the general working population. They are also more likely to file for disability claims or Social Security Disability Insurance. And if they drive a vehicle for a living or do so often simply as part of their work, they show a greater risk for vehicular crashes. Just as was found with schooling, the workplace setting is likely to pose significant challenges to adults with ADHD more so than other adults, even those with other psychological disorders.
Antisocial Behavior and Its Consequences
Children with ADHD are routinely found in follow-up studies to be more likely to engage in antisocial activities, to be arrested, and to be jailed as they grow up than are non-ADHD children. A substantially greater proportion of adults with ADHD have engaged in shoplifting, stealing without confronting a victim, breaking and entering, assaults with fists, carrying an illegal weapon, being arrested, and being sent to jail than is the case in typical adults. In addition, more adults with ADHD have sold drugs illegally in comparison to community control groups. The most common forms of antisocial activity for the adults with ADHD were shoplifting (53%) followed by assaulting someone with their fists (35%), and selling illegal drugs (21%). While much of this risk for antisocial behavior was mediated by the presence of a childhood history of Conduct Disorder (CD) (established retrospectively), even the non-CD subset of those having ADHD still committed more antisocial activity than the control groups.
Consequences in Money Management
Adults with this disorder have a hard time managing their money, paying their bills, and handling credit. Impulsive people like those with adult ADHD find it hard to defer gratification, think about and plan for the future, or follow through on promises and commitments. And so they do not do very well handling their finances. Adults with ADHD are more likely to use their money unwisely, make purchases without thinking, and too often use their credit cards on impulse, resulting in overspending their budgets or income. They are also less organized and more forgetful when it comes to paying bills on time. These money problems may even have led the adult with ADHD to return to live in their parents’ home because he simply cannot make it financially on his own; at least not yet.
Because adults with ADHD are less likely to save money and more likely to buy things on impulse or to go on shopping sprees, their credit card balances are higher than those of typical people of their age and they often exceed their credit limits more than adults without ADHD. Many adults with ADHD have trouble sticking to a budget, if they have made one at all. As a consequence, they are more likely to have had their utilities turned off because of late or non-payment of their accounts. Missing loan payments, such as for car loans, is also more common in adults with ADHD than in other adults, which may explain why they are more likely to have their cars repossessed. It should be obvious from this why adults with ADHD have a poorer credit rating than typical adults.
When people have difficulty with handling money, they often borrow it from friends, family, or even coworkers. In our research, we found that adults with ADHD were more likely to borrow from relatives and friends than did other adults, thereby placing a greater burden on others to help them with their financial problems than is the case in adults who do not have the disorder. Trouble handling money, then, may be yet another reason clients with adult ADHD are in need of treatment and counseling on financial management.
Consequences in Friendships
The symptoms of ADHD and its underlying problems with self-regulation are likely to create numerous social difficulties for adults with ADHD. The list of 18 symptoms listed earlier reads like a scroll of impaired social behavior – lack of persistence, high distractibility, poorly inhibited behavior, impulsive decision-making, excessive talking, frequent interruptions, intrusions on ongoing activities of others, difficulties following instructions, blurting out of responses in conversations, and inability to engage in leisure activities quietly. Not surprisingly, adults with ADHD often report significant impairment in their social relationships.
Studies of children with ADHD found that at least 50% had no close friends by the time they reached second or third grade. If the children also had trouble with anger and defiance, this number rises to 70%. As a result, children growing up with ADHD are far less likely to have been invited to play at the homes of other children, to be included in sleepovers with friends, to be asked to birthday parties, or even out on dates as they became teenagers. For those who are hyperactive and impulsive, their talkative and generally outgoing and easily excitable nature may make them fun to have at a party, or in a short-term relationship. But it can be stressful and overbearing over the longer term. Such social problems are likely to continue into adulthood in many cases. So clinicians may hear that the adult with ADHD might have memories of childhood that are filled with social problems.
The penchant of children and adults with ADHD to have more problems with emotional self-control guarantees by itself more mercurial, conflict-ridden, and distressing relationships with others than is the case for typical people. Research shows that children and adults with ADHD have significant problems with anger and hostility. Those problems, not surprisingly, make them more likely to be rejected by others. This negative effect on others does not take weeks or years to develop, but can occur within minutes or a few hours of a child or adult with ADHD entering a new peer group.
Adults with ADHD often complain of significant problems with both initiating and maintaining social relationships. They may have unstable personal relationships, break off those relationships over trivial matters, or have difficulty with those social skills needed for maintaining friendships. This may result in their having fewer close friends, and some have even become social isolates or recluses by middle age. This is, in part, a consequence of a life-long course of social difficulties and in part an attempt to avoid any further such hazards. Their relationships are often described as being frequently punctuated with conflicts with those they considered to be friends or social acquaintances. One reason for this is that adults with ADHD can have trouble negotiating and resolving the everyday conflicts with others that anyone is likely to encounter. Those unresolved conflicts might add up over time, causing the friendship to end. The greater propensity to show strong emotions during social interactions with others is often one cause of this among many, though not all, adults with ADHD. The adult with ADHD is also more likely to be loud, boisterous, silly, or clownish more than others.
A further difficulty likely to contribute to the social and friendship problems of the adult with ADHD is the adverse effect the disorder has in diminishing her self-awareness or her self-monitoring of her ongoing behavior. Adult patients have often said that they simply did not realize just how poorly they were coming across to others during various social encounters. It is not surprising that such lack of awareness leads to social problems with close friends or acquaintances. Moreover, the difficulties adults with ADHD might have taking turns during conversations or social encounters, and their unguarded comments or insensitivity to the social etiquette appropriate to the moment, likewise cause harm in their social relations. These difficulties can arise because an adult with ADHD often does not realize these social violations until it is too late. The social cost has been exacted and others are likely to steer clear of further interactions with him.
Adults with ADHD are often described as being self-centered, demanding, intrusive, or insensitive to the feelings or needs of others. She is more likely to be unappreciative of assistance from others. And she can be socially “sticky,” not knowing when to end the interaction and move on or let the other person do so. It is therefore not just the impulsiveness or inattentiveness of ADHD that tarnishes social encounters with others. It is also the poor emotional self-control, the more limited self-monitoring of social behavior, and the impaired ability to participate in the necessary give-and-take that makes for a successful social encounter.
Thus, one of the major reasons adults with ADHD can be so demoralized at times about their situation in life is not just their checkered educational histories or periodic failures in school or in the workplace. It also can arise in many cases from this detrimental impact of their behavior on building supportive and lasting social relationships with others. No wonder adults with ADHD often have feelings of low self-worth.
Consequences in Dating, Marriage, or Cohabiting
One of the most important domains of adult life is in the relationships we have with people with whom we become intimate, such as in dating, marriage, or living with a partner. Because of the closeness and frequency of interactions in such relationships, not to mention the shared responsibilities they often involve, one should not be surprised that they can be negatively impacted by ADHD when it exists in one member of that relationship. Divorce rates are nearly three times higher among adults with ADHD by the time they are in their mid-40s. Adults with ADHD (especially women) may be less likely to be married than others of the same age who do not have ADHD because of their interpersonal difficulties. By mid to late life (60-94 years of age), adults with ADHD may also have fewer family members involved in their social network and so may experience emotional loneliness. Even if they stay married, adults with ADHD are four to five times more likely to report having fair- to poor-quality relationships than do typical adults. As many as 58% of adults with ADHD have maladjusted marriages and low levels of marital satisfaction compared to 25% of typical adults.
The chart below shows some of the specific problem behaviors that occur in couples in which one has adult ADHD.
Problems Reported by Couples Where One Person Has ADHD
These were identified as trouble spots by Drs. Robin and Payson in a survey conducted with couples in which one of the adults had ADHD:
One factor that may contribute to their relationship troubles and reduced satisfaction is that adults with ADHD report being markedly more likely than others to have engaged in extramarital affairs. Another is that adults with ADHD are often more emotionally impulsive and are especially quick to react to others with impatience, frustration, and anger. Such behavior can obviously generate more hostility in close relationships. Even young adults with ADHD who are in intimate relationships have been observed to engage in more negativity and less positivity during situations of conflict than do typical young couples. Perhaps as a consequence, adults with ADHD may be almost twice as likely to engage in violence in intimate relationships .
Certainly, we all recognize that financial problems that occur within a marriage or intimate relationship can be a major source of distress. As discussed above, ADHD in an adult greatly increases the likelihood he will have such financial difficulties. These financial problems can be yet another reason for the greater marital conflict, poor marriage quality, and higher divorce rates evident in adults with ADHD.
Recently, Pera and Robin (2015)wrote about the types of problems encountered in couples where one has adult ADHD. They include:
Studies conducted with college students in the U.S. and China found that increased levels of ADHD symptoms were associated with increased fear of intimacy in intimate relationships, lower expectations for intimacy in their relationships, and lower relationship self-confidence. Yet the researchers had not found any greater levels of sexual anxiety in young adults with high ADHD symptoms.
If the adult with ADHD is in an intimate relationship, the other partner may experience resentment or anger, or feel over-burdened. They report that it can feel as if they are raising another child, given the amount of extra time, effort, and resources they may have to invest in repairing the consequences caused by the ADHD in their partner. In some cases they may even have suffered emotional or physical abuse stemming indirectly from the disorder, given that adults with ADHD have been shown to manifest more violence toward their intimate partners.
Consequences in Parenting
ADHD in a parent can make them less attentive to their children, less rewarding of their children, more inconsistent in using discipline, and more likely to respond with impulsive comments, directives, commands, or reprimands. In general, they can be more hostile toward their children than typical parents are. While this is not always the case for every parent having ADHD, on average they are more likely than other parents to manifest these difficulties. Parents with ADHD also seem to be less adept at problem-solving as it applies to dealing with child behavior problems. The home life that such parents arrange for their children has also been noted to be less organized, more chaotic, and to have routines that are less structured and inconsistent than occurs in typical families. Thus, parents with high levels of ADHD symptoms or a full diagnosis of the disorder clearly struggle with maintaining a consistent, calm, and organized approach to managing children.
Given that the children of adults with ADHD are also more likely to be ADHD as well as oppositional, the ADHD in both parent and child can greatly magnify the problems in family functioning. The impaired parental behavior created by adult ADHD can obviously result in higher levels of stress in the family lives of adults with ADHD. This is worsened when the child also has ADHD. It is also likely that the above parenting problems in an adult with ADHD will contribute to a greater occurrence of child misbehavior, such as defiance, arguing, tantrums, and neglect of typical home chores and schoolwork assigned to that child. Again, if that child also has ADHD, the odds are even greater that these other difficulties with defiance and chores and schoolwork will arise.
As noted above, parents with ADHD are less likely to monitor their children’s activities than do parents who do not have ADHD. Inadequate parental monitoring of their children is one of several factors that can increase the risk of accidental injuries in those children. This may help to explain, in part, why children with ADHD have higher rates of such injuries of all types than do typical children. Not only are children with ADHD more impulsive and risk-taking, their parent with ADHD may be less attentive to their activities, may be monitoring them less often, and thus may be less able to detect and prevent risk-taking behavior that can lead to accidents.
One might think that such parenting problems would be a very good reason for the parent with ADHD to get additional professional help with child management, such as is commonly done in standard parent-training programs for parents of defiant children. But if that parent’s ADHD is not being treated, it can interfere with their success in such a training program. This is yet a further reason why adult ADHD needs to be identified, diagnosed, and treated – it has a detrimental effect on the family ecology, child rearing, and response to child management training.
Parental ADHD can also be yet another factor that could potentially damage a person’s marital harmony besides those issues mentioned above under Consequences in Marriage. It can do so by contributing to a greater degree of stress that one or both parents may be experiencing in raising their children. Adults with ADHD who have children are substantially more stressed in their roles as parents than are other adults. This stress stems partly from the parent’s own symptoms of inattention, distractibility, and poor impulse-control. It is also related to their difficulties with controlling their emotions and to the other EF difficulties discussed earlier (time management, organization, etc.). But it can also arise from the fact that adults with ADHD are eight times more likely to have children with ADHD than typical adults because of the strong genetic contribution to this disorder. Research suggests that 30%-54% of children of adults with ADHD will also have ADHD, thus creating an even more ADHD-filled family environment. Also, the children of adults with ADHD may be more oppositional and defiant even if they do not have ADHD. Children who argue, defy, throw tantrums and otherwise refuse to obey can place a great deal of stress on even typical parents. But such behavior in a child can overwhelm adults who have ADHD and emotion-regulation problems of their own. Having a child with ADHD, regardless of whether or not one parent has the disorder, can significantly increase the risk that those parents will divorce. Should one parent also have ADHD, those odds are further increased, unsurprisingly.
Risky Sexual Behavior
ADHD is not associated with any higher incidence of sexual disorders, thankfully. But my own research with Dr. Mariellen Fischer and other colleagues in Milwaukee found some other problems with sexual behavior. We found a pattern of early initiation of sexual intercourse during adolescence (one year earlier on average) and an overall riskier pattern to their sexual activity as teens or young adults (more partners, less use of contraception). This riskier pattern of conduct led to a nearly 10 times greater risk for having been involved in a teen pregnancy, either as the father or the mother (38% for the ADHD group vs. 4% for the control group). We also found a four times greater risk for having had any sexually transmitted diseases (STDs) in the ADHD than in the control group (17% vs. 4%) by age 20. These patterns of sexual risk-taking and even early parenthood continued into the young adult years in the group with ADHD. Young adults with ADHD become parents far earlier than do others, sometimes as teenagers when they are not prepared to be parents to a baby. Kate Flory, Ph.D. and her colleagues found similar risks in their own follow-up study in Pittsburgh, further confirming this increased problem with risky sexual behavior. For this reason, teens and young adults with ADHD seem more likely to place their children up for adoption or have the children be raised by their own parents (the baby’s grandparents) than might other teens or young adults.
There is a small but growing amount of scientific evidence that children and adults with ADHD are prone to certain health problems more than others. For several decades we have known that adults with ADHD voice more complaints about bodily symptoms, such as headaches, stomachaches, and vague bodily concerns that may have little if any medical origins. These are known as “psychosomatic” or “somatoform” symptoms.
More adults with ADHD have sleeping problems (40%), than do those with the disorder. These are not the result of taking stimulant medication for their ADHD, although sometimes those drugs can result in more insomnia than usual. Even off-medication, adults with ADHD report more insomnia or trouble getting to sleep, more restlessness while sleeping, and more waking during the night. Those adults also have a greater chance of having restless leg syndrome, a condition in which they feel that their legs have to be moving for them to be comfortable. An adult with ADHD also may have less efficient sleep, more breathing problems during sleep, and report being more tired the next day. That inefficient sleep and greater tiredness can make his problems with attention worse, as clinicians can imagine. Treating his ADHD symptoms with medication during the daytime can sometimes help reduce these sleeping problems. Some research suggests that taking melatonin at bedtime (delivered under the tongue) may help induce sleep earlier than usual. Otherwise, the sleeping problems may need to be directly treated with other medical and psychosocial interventions. Some adults with ADHD find it helpful to create a “going to sleep” routine in which they disengage from technology, social media, and other more exciting activities, especially those that involve focusing for extended periods on a lighted computer, smartphone, or iPad screen. Also, this can include taking a shower at night before bedtime rather than in the morning, reading, or having light conversation with a partner before falling asleep, and then turning on a sound generator that plays soft music without lyrics or even a “white noise” machine so there is some background stimulation.
Excess Weight, Obesity, and Eating Disorders
Another problem for adults with ADHD is an increased risk for being overweight or having obesity. Adults with ADHD, or those children who grew up with it, are twice as likely to be obese (have a body mass index over 30) than typical adults. Likewise, adults who are obese are six to eight times more likely to have adult ADHD. This relationship of ADHD to obesity arises as a result of the poor impulse control specifically, and poor self-regulation (executive functioning) more generally linked to ADHD. If clinicians couple that with situations where junk food is readily available, it is no surprise that the adult with ADHD tends to consume more such food than others. But it is also the case that adults with ADHD do not exercise as often, pay less attention to maintaining a healthy lifestyle, smoke more tobacco and marijuana, drink more alcohol, and are more likely to interact with electronic media such as TV, Internet videogames, etc. Teenage girls and women with ADHD may be three to six times more prone to binge eating or even the more extreme disorder of bulimia. This is especially so if they also have co-existing anxiety or depression. All of these factors may contribute to the risk of being overweight that can be associated with adult ADHD. Some research now shows that treating ADHD with medication in such obese individuals is likely not only to improve their ADHD but also to result in reduced weight (a well-known side effect of ADHD stimulant medications).
By adulthood, children growing up with ADHD may have significantly lower HDL cholesterol (high density lipids or “good” cholesterol) than do typical adults. This gives adults with ADHD a poorer HDL-to-Total cholesterol ratio, both of which are risk factors for future cardiovascular or coronary heart disease (CHD). Future risk of CHD has been repeatedly linked to several health and lifestyle characteristics, with the most frequent being: smoking, high blood pressure, elevated serum cholesterol (and specifically HDL:LDL and HDL:Total ratios), excess body mass index, diabetes, and infrequency of exercise. In the study noted above, it was found that the risk of developing CHD was 26% higher for the next five-year period and 33% greater for the next 10-year period of life if current lifestyles were to continue for our ADHD group. And this was at the young adult age of 27, on average. The point here is that growing up with ADHD that persists into adulthood is associated with an increasing risk for CHD in future years, even if at a small magnitude of risk at young adulthood. It was also found that adults with ADHD that had persisted since childhood had a 40% greater risk for current and future atherosclerosis of the coronary vessels. Once again, if clinicians think or already know that the adult with ADHD may show such a high risk profile for CHD, that is but one more reason to encourage her to get treatment for her ADHD (and CHD risk) if she has not done so already.
Adults with ADHD are predisposed to difficulties with substance use, dependence, and abuse, regardless of their sex. Those adults are more likely to smoke cigarettes and marijuana than other adults and to smoke more of these substances than do adults without ADHD who routinely use them. Once they begin smoking, adults with ADHD may increase their use more rapidly than others who experiment with tobacco. One reason for the greater use of tobacco may be that it serves to partially treat ADHD symptoms. Nicotine, the addictive compound in tobacco, is a stimulant that has been shown to improve symptoms of ADHD. So this might be an instance where some adults with ADHD are self-medicating, that is, self-treating their disorder with nicotine. Even where that is not the case, the poor impulse control associated with ADHD would make an adult more likely to use and less likely to be able to quit using tobacco or other potentially addictive drugs.
Caffeine is also considered a stimulant. Not surprisingly, research finds that young adults with ADHD consumed more caffeinated drinks per week than did young adults in the control groups. Again, this might be an effort at self-medication – trying to treat the ADHD symptoms by increased use of readily available stimulants. But caffeine is not especially effective at doing so because it increases the wrong neurotransmitter in the brain (epinephrine) and in the wrong regions (brain stem) than those involved in adult ADHD. So clinicians should not encourage the adult with ADHD to just drink more coffee or other caffeine-containing beverages to try to manage their symptoms.
Alcohol is another substance that adults with ADHD seem to use more often than typical adults, even though in this case it does not treat their symptoms. But it may give them a temporary sense of wellbeing, help reduce their focus on their problems, and even reduce any anxiety they may be experiencing over those problems. Perhaps this is why some of them drink more alcohol than is typical. Alcohol is known to temporarily constrict or reduce awareness of or concerns about time, such as the past and future. For that reason, it may help reduce concerns about ongoing problems and conflicts. Interestingly, some of the genes that seem to be linked to ADHD are also known to convey an increased risk for substance use disorders such as nicotine abuse and alcoholism, providing yet another explanation for the increased consumption of these substances.
For more than 40 years, scientists have known that children with ADHD are considerably more likely to experience injuries due to accidents of all types than are children growing up without ADHD. Interviews with parents of these children find that:
Other studies have found that children with ADHD are more likely to be involved in either pedestrian-auto or bicyclist-auto accidents while they are out playing in their neighborhoods than are other children. Also, when someone with ADHD has an accident as a child, the accidents are more serious ones and the injuries they suffer are likely to be more severe and long-lasting than is the case for children who do not have ADHD. Recent research suggests that treatment with stimulant medication can reduce these risks of accidental injuries.
Beyond these childhood risks, adults with ADHD continue to be at a higher risk for experiencing accidental injuries at home and at work. Because of these greater risks of accidental injuries and other such injuries, ADHD can be considered a life-threatening disorder. It is therefore not surprising to learn that children with ADHD (and other disruptive behavior problems) were more than twice as likely to die before the age of 46 than children without the disorder (2.8% vs. 1.3%). Recently, adults with ADHD have been found to be 1.8 times more likely to die during any four-year period relative to typical adults, and these deaths are three times more likely to have resulted from accidents. Across adulthood, those with ADHD are nearly five times more likely to die compared to typical individuals, often as a consequence of accidents or suicide. Given all of the health risks noted above, and especially the risk for accidental injury, if left untreated across adulthood, ADHD may well shorten a person’s life expectancy by as much as 13 years.
One area of adult life that poses serious risks for someone with ADHD is driving a motor vehicle. After all, since inattention is the most common cause of accidents while driving, ADHD (being a disorder of attention) would be highly likely to cause far more accidents than would be the case for a typical adult.
Many studies have focused on ADHD and driving risks. They find that adults with ADHD:
Such poor driving habits can easily lead to various adverse consequences in the driving histories of adults with ADHD. Among these is a three to five times greater frequency of receiving traffic citations, especially for speeding, as well as for illegal parking. The latter problem arises from their impatience – they do not want to take the time it may require in a crowded traffic area to search for a parking space. So they just park anywhere they like, impulsively. Given their impaired driving behavior, adults with ADHD are more likely to experience these adverse consequences:
Fortunately, the driving-performance problems of teens and adults with ADHD can be improved with medications. Hopefully, this may serve to reduce their risks for these adverse and even life-threatening driving outcomes.
Excessive Internet Use and Addiction
Research is only beginning to explore the relationship between ADHD and excess use of technology such as computers, smartphones, etc. for playing games and using social media. What little has been done so far suggests that young adults with ADHD are two to three times more likely to use the Internet excessively, especially for gaming, and to even develop an Internet addiction. Internet or gaming addiction involves such symptoms as an excessive preoccupation with the Internet or videogame, uncontrolled impulses to use it, usage more than intended, tolerance, withdrawal, impairment of control, excessive time and effort spent, and impairment in decision-making ability concerning the use of the Internet or videogames. The more severe are someone’s ADHD symptoms, the more likely they are to develop an Internet or gaming addiction. This risk is also increased if the adult with ADHD uses marijuana, alcohol, or tobacco. The risk is further heightened if they have co-existing social phobia and/or depression with their ADHD. Treating ADHD with medication might reduce excessive Internet or game use in young adults with the disorder.
While not necessarily a consequence of ADHD, there is compelling evidence that having a diagnosis of ADHD increases the liability for certain other psychiatric disorders. More than 80% of our ADHD groups had at least one other disorder, more than 50% had two other disorders, and more than a third had at least three other disorders, these levels being markedly higher than in our control groups in both studies. As in the prior literature on children and adults with ADHD, we found a markedly elevated risk for Oppositional Defiant Disorder (ODD), and to a lesser extent for Conduct Disorder (CD), in our clinic-referred ADHD group and in our hyperactive children as adults. Current ADHD was especially associated with a childhood history of ODD.
The internalizing disorders of major depressive disorder, dysthymia, and anxiety disorders are more likely to occur in ADHD cases referred to clinics than are seen in a community control group. But MDD and anxiety disorders are also significantly elevated in non-ADHD clinical control cases seen at the same ADHD clinic and thus may not be as specifically linked to ADHD as to general outpatient psychopathology. Even so, both epidemiological studies in children and adults find some association between ADHD and depression that make it unlikely that our findings of a limited association are purely due to referral bias. Nevertheless, the relationships that do exist are not as strong when comparisons to other clinical samples are used than when comparisons to community samples are studied. Our Milwaukee Study did not find an elevated risk for MDD specifically in those with persistent ADHD into adulthood, but did find an elevated risk for depressive personality disorder and for mood disorders more generally, both of which suggest some link between ADHD and the level of depressive symptoms, even if not with full syndrome MDD. Neither study found any elevated risk for OCD, bipolar disorder, or schizophrenic spectrum disorders.
Adults with ADHD have a greater risk for alcohol use disorders and also showed a greater risk for cannabis use disorders compared to community controls. Alcohol use disorders and risk for any drug use disorder may be specifically linked to ADHD, though the level and type of drug use disorders probably have more to do with comorbid CD and antisocial personality disorder as well as local access to specific drugs than to ADHD, per se.
Concerning the risk of suicidal ideation and attempts, ADHD may only slightly increase the risk for both ideation (25% vs. 15-16%) and attempts (6% vs. 2-4%) prior to 18 years of age. After age 18, however, ADHD in adults is linked to elevated rates of suicidal thinking (27-29% vs. 6% in controls). And it has been repeatedly linked to a greater risk of suicide attempts relative to a community control group (8% vs. 1%). The greater risks of ideation were largely mediated by the presence of MDD and, to a lesser extent dysthymia, but were not especially related to the presence of comorbid CD. The greater risk for attempts is directly linked to the impulsivity dimension of ADHD.
Clinicians can now see that adult ADHD can have a wide array of negative effects on various major areas of adult life when untreated – school, work, money management, friendships, dating and marriage or cohabiting, risky sexual activity, parenting, and health and medical problems. The economic impact of these problems is substantial for the individual with the disorder, for their families, and for their community. The social and emotional consequences that flow from a life fraught with these adverse outcomes for those with adult ADHD are also just as serious, substantial, numerous, and no doubt troubling. That all of these negative outcomes would arise in conjunction with ADHD is easily understood in view of the symptoms of ADHD and the attendant problems with self-control. What is clear here is that ADHD in adults has substantial and varied adverse impacts on numerous major life activities. In view of all of the health and medical risks discussed above, ADHD is not just a mental health problem, it is also a public health problem.
As discouraging as these various risks may seem, they may also serve to motivate adults with ADHD to get and stay in treatment for their ADHD, if they have not already done so, in order to try to reduce these risks. Clinicians will find numerous recommendations in the second half of this course for how best to help the adult with ADHD in dealing with many of the domains of life discussed here. Adult ADHD is a highly treatable disorder; it is more treatable than most other psychiatric disorders. The problems we face are not lack of effective treatments, but a lack of awareness about this condition, the fact that adults with it often do not get referred and diagnosed, and that those adults may not get access to appropriate care.
Many adults have one or more of the various reactions associated with grieving when diagnosed with ADHD, as noted below. By recognizing these reactions and understanding their origin (e.g., grieving their diagnosis), clinicians can help the adult with ADHD negotiate these initial reactions and hopefully come to a state of acceptance of their disorder. For without such acceptance, cooperation with subsequent treatments is likely to be suboptimal, if they engage in treatment at all.
Fortunately, most adults with ADHD are open to accepting their disorder and move on to learning about ADHD following their diagnosis. This is largely owing to the fact that they initiated the request for the evaluation to begin with and so had some openness to hearing about the nature of their problems, symptoms, and impairments. These adults may experience a sense of profound relief at finally knowing what they have and how it accounts for their life-long struggles. They can reframe their past from being one in which the problems were due to being stupid, lazy, or unwilling to improve. In place of self-recrimination, they now know that ADHD is largely a result of a neurological disorder of the brain’s executive system.
There is also relief in knowing that the likely reason for many of the problems these adults with ADHD experienced in school, work, and/or social relationships was a subtle neurobiological deficit in the brain over which they had little control. As Dr. Kevin Murphy explains it:
“Their problems were not the result of deliberate misbehavior, low intelligence, or lack of effort. These misguided and damaging perceptions should be recast in a more positive and hopeful light, so patients can begin to rebuild their self-confidence and believe that successful treatment is possible. As a consequence, patients will ideally be in a better position to break out of the shackles of feeling stuck, demoralized, and chronically frustrated.”31
Upon receiving the diagnosis, some adults with ADHD experience temporary demoralization or dysthymia. That is because, after all, it is a chronic disorder that has no quick cure such as an antibiotic that may treat a transient infection. No advice, therapy, or drug to date gets rid of ADHD permanently, even if it can be managed quite effectively. Clinicians can therefore understand why the diagnosis might be at first disheartening to the client. As Dr. Kevin Murphy has written:
“Most adults with ADHD have suffered years of feeling demoralized, discouraged, and ineffective because of a long-standing history of frustrations and failures in school, work, family, social, and daily adaptive domains. Many report a chronic and deep-seated sense of underachievement and intense frustration over squandered opportunities, and are at a loss to explain why they cannot seem to translate their obvious assets into more positive outcomes. Furthermore, many report having heard consistent complaints about themselves from parents, teachers, spouses/partners, friends, or employers. Such complaints focused on their behavioral, academic, interpersonal, or productivity shortcomings. The cumulative effect of such a history can sometimes lead to feelings of intense frustration and demoralization, and to a sense of anticipating failure as the predictable outcome of their efforts. Sadly, some appear so wedded to this belief system that they eventually give up believing life could be different for them. Many are completely unaware that their condition is a highly treatable one.”
What other reactions might clinicians see in the adult with ADHD immediate following a professional diagnosis of ADHD?
Many adults, upon learning of the diagnosis, may react with anger and frustration for various reasons, as noted above. Not the least of these is the long delay to finally receiving the appropriate diagnosis for their problems, especially if they have sought help previously only to be told they had a different disorder or no disorder at all. Anger can also arise from learning that their condition is quite treatable and thus many of the harms that have befallen them earlier in life might have been avoided had a knowledgeable clinician diagnosed and managed their ADHD properly.
Sadness or Loss
Other patients, upon their diagnosis, show a mixture of both sadness and anger because of previous adverse events they have experienced that likely stemmed from their disorder. The sadness comes from recognizing that some of these adversities cannot be repaired. These irreparable harms might include lost relationships or marriages, visitations with or custody of their children after an acrimonious separation or divorce, lost education and related opportunities, lost jobs and other employment opportunities, previous drug abuse and its consequences, and even previous arrests, jail time, or related harms caused to victims of their previously impulsive and even anti-social activities.
And then there are the many social relationships such as friendships that fell victim to the individual’s inappropriate ADHD behavior. Those relationships may be difficult or impossible to re-establish or reclaim. The list here could be nearly endless, but the point is that many adults come to realize that even now that they have the proper diagnosis and a treatment plan, little can be done about some of the past irreparable harms that have occurred because of their previously undiagnosed ADHD.
A Grief Reaction
All of the above are actually part of human grieving. So it is understandable that adults with ADHD may show a grief reaction when they first receive a diagnosis of ADHD. They are grieving what has been lost and may not be recovered. Yes, there is some relief in knowing what the core problem is and what can be done about it. But there is also a profound sense of loss as to adversities and harms that have befallen them in the past that didn’t have to be that way if only they had been diagnosed and treated earlier. This sense of loss for what might have been may be so strong a grief reaction that it requires counseling sessions with a clinician in order to assist them in understanding, venting, and resolving these reactions.
Also, the grief reaction that an adult diagnosed with ADHD may experience may cause him, out of desperation, to try any quack remedy he may have heard about on the Internet or from other sources. He may start to think with his grief and not with his brain. That means he may look for promises of quick cures rather than the evidence-based treatments that do not make such promises but are more likely to be effective in the longer-term.
Clinicians can help adults with ADHD negotiate and resolve many of these reactions by simply being a sensitive listener to those reactions. Acknowledge that one understands how she can feel that way, thus legitimizing the feelings. Sympathize with the unfairness of it all – that it had to take this long to get the right diagnosis and treatment – then encourage her to move past such grief responses to a healthy acceptance of the disorder. Hopefully, after the catharsis and exorcising of past regrets comes an acceptance of her condition. With that acceptance or ownership of the disorder, she can adopt a more forward-looking perspective of hopefulness, based on the knowledge that ADHD is highly treatment-responsive and that one’s future does not have to look like one’s past.
Over years of working with adults with ADHD, we have learned that this next step is a crucial one – it is all about the attitude adults with ADHD adopt toward this diagnosis. Unless they develop an attitude of “owning” their disorder, accepting the diagnosis for what it means, and then becoming educated about the condition, they are not likely to accept treatment for it. Even if they are offered treatments, they may not be likely to cooperate fully with the treatment plan.
In that sense, ADHD is like diabetes. It is a condition whose symptoms can be managed quite effectively on a day-to-day basis, yet the underlying cause of those symptoms cannot be easily corrected or cured, if at all. The goal of treatment then is essentially the reduction of any possible harm that might come to adults with ADHD if their disorder is not managed well. It is to reduce the risks he may experience for various adverse consequences that are likely to occur if the disorder isn’t treated. Those harms can include all the areas of impairment discussed in earlier sections (i.e., work, education, family life, driving, etc.).
From this point of view, ADHD must be managed on a daily basis if those secondary consequences are to be prevented or at least reduced. That means treatment can go on for years, just as it does for diabetics. Yet, like people with diabetes, adults with ADHD can lead a relatively normal and fulfilling life when their disorder is well managed. Fully engaging in this sort of ongoing or continuous treatment, at least as needed, requires that a person first accept that they have a chronic condition. They must first adjust their attitude toward themselves and incorporate the diagnosis into how they personally view themselves and what that means for getting help for it.
The adult with ADHD will need to own it, then learn about it, and lastly deal with it. Absent such acceptance, it is unlikely that anything further can be done to help her manage her disorder. Following acceptance, she must then learn as much as she can about this condition and hopefully that will lead her to be able to manage her disorder as best she can. These are things that no one else can do for her. The adult with ADHD must reframe her view of herself and her life if she wishes to actually take charge and manage, if not master, her ADHD.
The extent to which ADHD may disable an adult is directly related to the environments they place themselves into and what changes they make in their surroundings (accommodations). It is also related to the kind of people they choose to be surrounded by and how well (or poorly) those people contribute to the adult’s impairments, either by worsening or improving them. The degree of the impairment the adult with ADHD experiences is also related to the resources he may have available and how well he uses them.
Understand that while disorders belong to people, handicaps belong to situations. Change the situation well enough and a person can reduce or eliminate the degree to which he will be handicapped or disabled within a disorder. However, that willingness to modify settings so that one is less handicapped by their disorder first requires that the person accept that he has a disorder. The adult with ADHD has to own it!
Some clinicians have worked with adults with ADHD who could acknowledge the disorder at some detached intellectual level. They could even sit through counseling sessions nodding their head in recognition of what was being said. But in their head, in their personal life, in that inner sanctum of their mind where we hold our self-image, they didn’t “get it.” These adults had not really owned the disorder at all. They paid lip service to the diagnosis but privately denied that this disorder is really a part of their self-image. So the adult with ADHD might adopt some intellectual understanding of the information about ADHD but not take on the entire package of the disorder or even accept that it is a disorder.
When adults with ADHD accept their disorder and truly come to own the diagnosis, it is not demoralizing at all – in fact, it can actually be liberating. They come to understand that they are not dumb or stupid as many had come to believe. The cloak of demoralization and moral self-criticism is lifted, making them free to better understand the struggles of the past. They also no longer have to play mind games with themselves or others in which they deny, excuse, defend, distort, massage, or in other ways avoid accepting the disorder, what it is, and what it means for their life.
It is important to recognize here that owning the disorder does not mean using it to make excuses for one’s inappropriate behavior. A diagnosis of ADHD does not mean one is allowed to engage in violations of social etiquette, or even laws, and claim not to be responsible – “it was my ADHD that did it!” Nor does it mean committing various criminal acts or becoming drug dependent or a drug abuser and then claiming it could not be helped – “it was my ADHD that did it.” The diagnosis of ADHD provides an explanation but not an excuse. It can help clinicians and the adult with ADHD understand why she may be having difficulties behaving in a less-than-optimal or frankly inappropriate way. But it does not excuse such behavior, especially from its consequences.
The diagnosis is a means to motivate one to come to understand their ADHD and to accept the diagnosis for what it represents in one’s life. It does not provide carte blanche to behave in any unacceptable way one wishes while excusing the conduct and its consequences. Clinicians must understand that to have adult ADHD is not to be a victim whose circumstances are to be dealt with by eliminating all accountability for one’s actions or to excuse one from doing anything about the problem. The result of such an approach could be disastrous.
After adults with ADHD adjust to their initial reactions to the diagnosis, and then come to own the diagnosis as part of their identity, the next step in helping them build a treatment program is to help them learn as much as they reasonably can about ADHD, the condition, and its management. Clinicians can suggest books and videos to help the adult with ADHD improve his knowledge. Some of these are listed in the Resources section at the end of this course. Encourage the adult with ADHD to read widely, watch videos (I have many available on YouTube), listen to (and even talk with) other experts, ask questions, visit the most informative websites (also listed in the Resources section), follow up on what interests them, and pull together as much information about ADHD as she has time to do.
As the author David Lindsey once wrote, “truth is an assembled thing!” It comes from no one book, source, expert, guru, video, or website. The more widely clinicians pursue information, the more likely clinicians and the adult with ADHD are to be able to distinguish the knowledge that is most reliable and trustworthy from that which is fashionable, flimsy, baseless, or outright false or misleading. There is much reliable science-based knowledge about adult ADHD. Yet there is also much nonsense, misinformation, and blatant propaganda that one needs to filter out as unreliable, unrepresentative, and even intentionally misleading.
Be skeptical. Especially, beware of the Internet. It can be both a blessing and a curse in finding information about any disorder. If one enters ADHD into a browser, you will get millions of “hits.” Yet only about 10-20 websites offer truly accurate, science-based information. Many of these are listed in the Resources section. Look for what seems to be the consensus of the clinical and scientific experts who specialize in the disorder. If the adult with ADHD really wants to read the science behind any specific topic related to ADHD, then do not have them use a general browser like Google, FireFox, or Safari. Use Google Scholar – a browser that searches just the scientific journals and textbooks for what is known on that topic.
The following therapies have a sufficient body of evidence supporting their effectiveness in the scientific literature so as to consider them for routine use in the management of adult ADHD. That said, all treatments, including psychosocial ones, are associated with adverse events. These may arise from the mere fact of human diversity, unusual patient characteristics or comorbid disorders which may be exacerbated by these therapies, from incompetence or misapplication by therapists, or from misunderstanding and misapplication by clients. For an excellent discussion of these issues, see the articles on the side effects of these therapies in the March 2018 issue of The ADHD Report (Guilford Press, www.Guilford.com).
An important step involved in treating an adult with ADHD after she has been properly evaluated and diagnosed is to make sure she is well educated about the disorder, its true nature, causes, risks, and both the general management principles reviewed earlier as well as the treatments set forth below. Adults with ADHD can’t fully benefit from or participate in treatment of their disorder if they are not fully aware of the broad knowledge that exists about it. Counseling them about ADHD serves that important purpose. Self-education through trade books, the Internet, and other sources is fine, but many adults with ADHD often choose to also receive one or a few sessions of general counseling with a mental health professional knowledgeable about the disorder. This can help them get more fully educated about it and have their specific questions about their own unique case answered. Accessing a knowledgeable and trusted professional can usually provide reliable information about the disorder quickly, without the need to sort through the myriad information, points of view, and even propaganda about the disorder available through other sources such as the Internet.
Apart from conveying such information, short-term counseling with a professional can often help to address some of the phases of grieving or adjustment to the diagnosis discussed earlier that may have arisen since the adult with ADHD received his initial evaluation. Some of those reactions can be serious enough to warrant working through them with a competent professional instead of struggling with them on one’s own.
Along with the need to maintain a realistic picture of adult ADHD, there remains the equally, if not more important, attitude of instilling hope that things can be improved. Absent such hope, there is little likelihood that the adult with ADHD is going to undertake the various treatment programs and coping strategies that are necessary to successfully manage this disorder and its associated impairments. He must come to feel that getting treatment has a high likelihood of improving the quality of his life, which it does. He also needs to know that people close to him sincerely believe that he can benefit from treatment. And he needs to know that supportive others may even opt to be his partners in that treatment process, if possible, to help him to be more likely to engage in it and benefit from it. Counseling can inspire hope while also tailoring general information on the disorder to the client’s specific case.
Although such counseling sessions are generally offered as a short term course, additional sessions may be needed periodically as new problems or impairments arise, new issues come to the fore, or symptoms break through from being effectively managed. All of these situations may require readjustment of the treatment components, such as medications, to deal with them. Such counseling may also serve as a central hub for the other components of the treatment package needed to manage an adult’s ADHD. For instance, the therapist can help in:
Professionals and even adult ADHD coaches can also assist the adult with ADHD in applying the general strategies for coping with ADHD from the perspective set forth earlier of adult ADHD as a disorder of EF. (Also see later sections of this course.) Further advice on how best to cope with working memory problems and forgetfulness, poor impulse control, organization and problem-solving, emotional self-control, as well as time management may all be provided by this counselor. Or the counselor can arrange for a consultation with someone more expert in cognitive behavioral therapy that focuses on the executive deficits associated with adult ADHD.
Help the adult with ADHD identify not just problematic behavior and impairments and what to do about them, but also the positive qualities and assets she or he may have. Those assets can be brought to bear to either help deal with problems or help offset the adverse consequences or demoralization one may experience from them. Skilled therapists can help offset or counterbalance any negative self-perceptions, promote greater self-acceptance, and reinforce strengths, talents, and other qualities as needed for adults with ADHD. And certainly, if there are comorbid psychological disorders co-existing with the ADHD, these may require their own separate psychological or medical treatments that can be provided by or arranged through the general counselor/therapist.
One of the best scientifically investigated non-medical treatments for adults with ADHD to date is Cognitive Behavioral Therapy (CBT), a widely used therapy modality for various disorders including anxiety, depression, post-traumatic stress disorder, substance-use disorders, and personality disorders among others. This method of therapy has now been specifically adapted for adult ADHD and targets the adult’s deficits in executive functioning, among other ADHD-related symptoms. Traditional CBT helps a patient identify inappropriate or maladaptive thoughts and associated negative emotional reactions, environmental triggers for such unreasonable or irrational thoughts and emotions, and ineffective behavior that may flow from or exist in conjunction with them, and then suggests various ways to correct them. These suggestions typically focus on helping patients modify or avoid problematic settings. It also helps them learn to refocus their attention to less emotionally provocative aspects of the setting. And it especially teaches them to rephrase and reframe inappropriate thoughts and conclusions to more rational and constructive ones. Some CBT methods also teach adults to self-soothe and otherwise cope with negative emotions, construct more appropriate coping strategies, and reduce or prevent inappropriate actions. Therapy can also teach an adult how to substitute more constructive behaviors that may flow from the problem situation and from the patient’s thoughts about and reactions to it.
For adults with ADHD, CBT goes even further than this traditional paradigm. It strives to identify problematic behavior and thoughts and to substitute more specific coping strategies for the express problems these adults have with self-restraint, time management, self-organization, problem-solving, emotional self-control, and self-motivation, among others.
Professional manuals on these methods for therapists are now available at major booksellers, such as those written by Mary Solanto, Ph.D., Steve Safren, Ph.D., and J. Russell Ramsay, Ph.D. The next three diagrams summarize the basic essential features of these treatments.
Trade books for adults with ADHD also provide advice on these strategies, such as those by Ari Tuckman, Ph.D., Craig Surman, M.D., Tom Brown, Ph.D., Lenard Adler, M.D., Edward Hallowell, M.D., and myself. (See Resources at the end of this course.)
It is important to appreciate that these therapies are not an alternative to or replacement for the ADHD medications discussed later in this course. Most adults with ADHD benefit most from these therapies if they are also taking their ADHD medications while they participate in CBT. The medications are usually more effective than CBT alone, but using CBT with medication can further improve the treatment response of the typical adult with ADHD.
Knouse (2015) has critically reviewed these and other forms of CBT for adults with ADHD for their evidence base and effectiveness and also has a meta-analysis of all of the studies (2017). She concluded, as she had done in an earlier qualitative review in 2010, that the results of research support the effectiveness of the forms of CBT adapted for adult ADHD in augmenting the effects of ADHD medications and in reducing symptoms, EF deficits, and impairments, whether in comparison to no-treatment wait-list control groups or to more active therapies, such as psychotherapy or meditation. These conclusions were echoed in another review of this literature in 2012 by Mongia and Hechtman, who likewise concluded that CBT for ADHD significantly improved functioning, particularly when combined with medication, and augmented the effects of the ADHD medications. A more recent, large study comparing medicated adults with ADHD receiving treatment as usual with those on medication who also received CBT for adult ADHD, documented significant effects on ADHD as well as some improvement in comorbid disorders over a more extended follow-up period.
Another approach to helping adults with ADHD is Coaching; the adaptation of the life-coaching therapy modality to the specific needs of adults with ADHD. One general approach to Coaching is shown in the figure below for illustrative purposes.
Coaching typically involves providing an ongoing professional relationship that focuses on the adult with ADHD taking action toward the realization of their vision, goals, or desires. It uses a process of inquiry and personal discovery to build ADHD clients’ levels of awareness and responsibility, to help them develop new skills, and provides them with structure, support, and feedback. Like the general counseling or therapy discussed above, Coaching is a supportive, pragmatic, educational, and collaborative process. But it differs from traditional general counseling in that a coach is in much more frequent contact with an adult with ADHD, often several times each week. This is typically accomplished using means of communication other than face-to-face sessions, such as telephone calls, emails, text messages, and other social media. Contact is usually accomplished using daily or less-frequent 10- to 15-minute telephone conversations. These calls serve to identify goals, and strategies to meet those goals, as well as providing compassionate, constructive, and otherwise supportive advice to the ADHD client. Coaches can also provide the structure, accountability, and at times gentle confrontation that may be needed to address the Executive Functioning deficits noted above, typically by giving many of the same suggestions given earlier about dealing with EF deficits. Murphy and colleagues (2009) described several cases in which Coaching was used to assist clients with adult ADHD.
A small amount of research has been done to date on this therapy. It suggests some promise as a standalone modality or as an adjunct to the ADHD medications discussed in the next section. However, the studies to date are few in number, of a small sample size, are less rigorous in methodology than is desirable, and many concentrated on college students. Thus, while initial results are promising, more research of a more rigorous nature with clinic-referred adults with ADHD is needed to properly evaluate the utility of this therapy. Professional associations now exist to provide training and guidance to professionals who wish to practice Coaching with adults with ADHD.
More information on this treatment approach can be found on the Internet. ADHD Coaches can be located through several websites, including totallyadd.com/coaching-directory-search/. Be aware that there is no licensing at the state or national level, nor is there currently any credentialing or certification for adult ADHD Coaching that has been widely adopted by the field. But that is changing for the better as professionals in the Coaching community develop a consensus on what training is essential in order for one to become an ADHD Coach. For now, understand that Coaches can vary markedly in their educational background and depth of training about ADHD and mental health services. Clinicians are cautioned to investigate the quality and education of any Coaches the adult with ADHD may be considering employing, just as clinicians would do with any other unlicensed services.
ADHD medications are the most effective treatments currently available for managing ADHD in adults. Period. No other approach to managing ADHD in adults results in as much control of the symptoms and executive deficits, as much improvement in the adverse impact of ADHD on major life activities, for as many people and in such an economical way as medication management of ADHD. So if an adult with ADHD opts not to use medication to master her ADHD for whatever reason, understand that she has just declined the most effective treatment currently available to deal with the disorder. It is a choice that is equivalent to a Type 1 diabetic choosing not to use insulin while trying to make a go of it in dealing with their diabetes strictly through diet, more exercise, and better hygiene. Maybe that will work, but it is much less likely to do so than would medication. And it will result in far less control of the disorder than using medication to manage it.
In my experience and that of many of my expert colleagues, adults with ADHD who choose not to try medication following their diagnosis typically return within three to six months asking to go on it. That is because most come to realize that all of the other options they’ve tried are not addressing their problems very well. I am not saying here that some adults with ADHD cannot manage their disorder without medication. Some can. This is likely the case for those adults with marginal or mild symptoms of ADHD, who have no other psychological disorders, who are otherwise healthy, maintain good nutrition, avoid abusing nicotine, alcohol, and other drugs, exercise regularly, and who have made a number of lifestyle modifications to permit them to function satisfactorily despite their ADHD symptoms. These adults may be able to get by without medication. I applaud them for doing so. But understand, these people are not representative of the majority of adults with the disorder.
While I recommend using medication, it should not be advocated as the only treatment approach. There are many other methods that clinicians can use to assist clients in mastering their ADHD, such as those discussed above. But for the majority of adults with ADHD, especially those with moderate to severe symptoms, medication management should be the core component around which to build the other treatments – just as in managing diabetes. Those other treatment methods will be designed to address what the medications are unable to change or improve sufficiently so as to reduce the client’s ADHD-related impairment in any particular area of their life. But those treatments can rarely do it alone without being combined with ADHD medications.
In addition to the practical fact that medications work and work well for most people with ADHD, there is another reason they are so important for managing the disorder. Research over the past decade has shown that the medications actually help to either correct or compensate for the underlying neurological problems that are likely contributing to the ADHD in the first place. Indeed, in children who remain on the medications for several years, brain regions may develop more similarly to those of their peers without ADHD.
These medications control symptoms only temporarily. That control lasts only as long as the medicines are in the blood stream, and hence in the brain of the adult with ADHD, but they do work. We now know that ADHD medications can normalize the behavior of 50%-65% of those with ADHD. And they result in substantial improvements, if not normalization, in another 20%-30% of people with the disorder. In other words, less than 10% of people with ADHD will not have a positive response to at least one or more of the ADHD medications currently available in the U.S.
When the medicines work, they can result in substantial improvements in the symptoms of ADHD. Those improvements are, on average, two to three times greater than those seen with any other psychiatric medications used to treat other psychiatric disorders, such as anti-depressants and anti-anxiety medications. And that improvement in ADHD symptoms is likely to lead to significant improvements in the downstream impairments in major life domains that are due to those symptoms.
There are two basic categories of ADHD medicines that are approved by the FDA for use with adults – stimulants and non-stimulants. Both have to be taken daily. As noted above, they all control the symptoms of ADHD only as long as the adult with ADHD takes the medications. They produce no enduring positive effects on the client’s ADHD once clinicians stop prescribing them. Ceasing the use of medication often results in a return of the ADHD symptoms back to their pre-treatment levels.
Both types of ADHD medications typically work by increasing the amount of two (or more) chemicals in the brain known as neurotransmitters. Those chemicals are involved in permitting nerve cells to communicate with each other so the brain can function effectively. More specifically, these drugs increase just how much of these chemicals are residing outside of the nerve cells. That can increase the activity of adjacent nerve cells. The two neurotransmitters are dopamine and norepinephrine. By causing nerve cells to express more of these neurochemicals, or by keeping the nerve cells from pulling these chemicals back into the cell once they have been released, the drugs increase the communication that occurs between nerve cells in regions of the brain that are related to directly causing ADHD. In short, increasing these brain chemicals in these regions lets that brain area function better and sometimes normally.
For a detailed discussion of FDA-approved medications for use with adult ADHD in the U.S., readers should consult the chapter by Dr. Jefferson Prince and colleagues at Massachusetts General Hospital in my professional handbook on ADHD (see Resources).
There are two basic types of stimulants currently marketed in the U.S. – methylphenidate (MPH) and amphetamine (AMP). These stimulants act in the brain to mainly increase the amount of dopamine available for use outside the nerve cells. Yet they can, to a smaller extent, increase the amount of norepinephrine outside the nerve cells as well. AMP does this mainly by increasing the amount of dopamine that is expressed from the nerve cell when it is activated. To a lesser extent, it may also block the transport system by which the dopamine is normally re-absorbed back into that nerve cell after being released. That can result in more dopamine being left outside the cell to continue to function. MPH mainly acts by preventing the re-absorption of dopamine. That is why it is known as a transport or re-uptake blocker.
Both AMP and MPH have the potential to be abused because they increase dopamine in regions of the brain known as reward centers. Stimulating those centers can lead to an increased likelihood of addiction to drugs that do so. But ADHD medications are very unlikely to do this when taken by mouth and swallowed, as prescribed. They certainly can do so when they are sniffed through the nose as a powder or injected into a blood vein in a solution, such as when mixed with water. Because of this potential for drug abuse, the Drug Enforcement Administration in the U.S. has classified the stimulants as Schedule II controlled substances along with other potentially addictive drugs. This classification places limits on how much of the drug can be produced annually, how the drug is to be prescribed, how it is to be stored in pharmacies, and how it is to be dispensed and otherwise monitored in the U.S.
There are up to seven different methods by which these two drugs are delivered into the body. The five most common methods are described in the Appendix to this course. A liquid form of both of the stimulants is also available for children or adults who do not wish to swallow tablets or capsules and, more recently, a chewable form of AMP has come on the market that dissolves on the tongue without a need for water. The various methods also differ in how long they maintain the level of the drug in the body, and so in the brain. There are hundreds of studies on the safety and effectiveness of these stimulants and delivery systems.
Non-stimulants – Atomoxetine (ATX)
In 2003, the FDA approved the first non-stimulant drug for the management of child, teen, and adult ADHD; the first new drug for ADHD in more than 25 years. That drug is atomoxetine (ATX), under the brand name Strattera®. This was the most-studied ADHD drug before receiving FDA approval that has ever been brought to market. Randomized and double-blinded studies were done involving more than 6,000 patients worldwide to thoroughly study the effectiveness, side effects, and safety of this medication. Now, like the stimulants above, millions of people worldwide take this medication for management of their ADHD.
ATX differs from stimulants in that it does not affect the brain centers that are likely to be related to drug addiction or abuse. It increases the amount of norepinephrine in the brain by blocking the re-uptake of this chemical once it is released from a nerve cell. And it does so in some parts of the brain where stimulants may not be acting. For instance, this drug does not activate the brain’s reward center and so does not lead to a risk for addiction. And that is also why it is not classified as a controlled substance in the U.S. Research shows that the drug has a very low potential for abuse. The different means by which it acts in the brain can result in a different profile of potential side effects (adverse reactions) and possibly somewhat different benefits from this drug than is seen with the stimulants.
ATX is nearly as effective for managing ADHD symptoms as are the stimulants, but not quite. The same percentage of patients appears to positively respond to both of these classes of drugs (stimulants and non-stimulants), averaging about 75% of people responding. However, some studies suggest that while 50% of people respond positively to both types of medications, 25% respond better to a stimulant than to ATX. But the remaining 25% respond better to ATX than to one of the stimulants. In other words, some people are unique responders who do better on one type of ADHD drug than on another. Some studies suggest that ATX may not produce quite as much improvement in ADHD symptoms as do the stimulants. But for some adults, the degree of improvement is sufficient to effectively manage their disorder while not necessarily producing the same types of side effects that one might get with a stimulant.
The issue that physicians face in daily practice with ADHD patients is therefore not which drug works better, but which drug is best suited to which individual patient, given their unique profile of characteristics. Having many different drugs, just like having many different delivery systems, lets physicians better tailor their treatment to the uniqueness of each patient. The adult with ADHD can expect, however, that ATX will take longer to adjust to in order to find the right dosage than is the case with a stimulant. That is because it takes longer for the body to adjust to the side effects of drugs such as ATX. And that is why physicians like to leave patients on a particular dosage a bit longer than they might with a stimulant before adjusting the dosage upward.
Two other medicines are sometimes used to treat adult ADHD, but they should be considered “last choice” medicines to be used only if the other ADHD medicines are not proving satisfactory. Both originated as drugs used to treat high blood pressure, called anti-hypertensive drugs. One is clonidine, and works as an alpha-adrenergic enhancer. Some nerve cells in the brain have little portholes on them called alpha-2 receptors. These drugs seem to act to reduce or close off these portholes, which results in stronger or more effective nerve signals in those cells. At low doses, this drug appears to stimulate inhibitory systems in the brain. The FDA approved an extended-release version of clonidine, clonidine ER (Kapvay®), in 2010 as a treatment for ADHD in children ages 6-17. But as noted above, physicians can use it “off-label” outside of this age range, such as for adults with ADHD. It can be used alone or combined with stimulants. The drug is not as effective, in my opinion, as the other ADHD medicines discussed above. So it is sometimes used to treat ADHD when it co-exists with another disorder such as conduct or antisocial problems, or irritability and anger. It can also treat tic disorders and sleep disturbances, and may reduce anxiety. Regular clonidine is fast-acting, but the extended-release version approved for ADHD can last much longer.
Another anti-hypertensive drug used for ADHD management is guanfacine. In 2009, the FDA approved an extended-release version, guanfacine ER (Intuniv®) for the treatment of ADHD in people who are 6-17 years old. Again, physicians can use it with adults off-label if they think it essential to do so. The drug can be given alone or in combination with either of the stimulant medicines discussed above. There may be some advantages of guanfacine over clonidine. These include less sedation, a longer duration of action, and less risk of cardiovascular problems. Its benefit may be in helping to treat coexisting disorders with ADHD, such as anger and aggression, and in reducing highly impulsive or hyperactive behavior.
Clinicians and adults with ADHD should be aware that there is very little research on using these two anti-hypertensive drugs to treat ADHD in adults. That is why they were FDA-approved mainly for children, on which more research was available. Because of the lack of research, these drugs are considered last-choice options for managing adult ADHD. The other ADHD medicines above should be tried first.
Another non-stimulant, bupropion, is sometimes used for treating adults with ADHD but it is not FDA-approved for doing so. The drug is sold under the brand name Wellbutrin® here in the U.S. While it also increases norepinephrine in the brain by a mechanism similar to that of ATX, it also affects other brain chemicals. That can be an advantage if a physician is trying to treat ADHD and another disorder that responds to bupropion at the same time, such as anxiety or mild depression. But it can also produce unwanted side effects as well. It also may not work as well as the stimulants if all one is trying to change are ADHD symptoms. It has not been studied as extensively as ATX and so its value in managing ADHD is less well established. Even so, some physicians can still use this drug for treating ADHD if they choose to do so, known as “off-label” use. More often, the drug is used to manage a co-existing anxiety disorder or mild depression in patients who also have ADHD.
Other non-stimulants have also been used off-label to treat adult ADHD, such as anti-depressants, anti-anxiety drugs, and even some mood stabilizers or anti-psychotic drugs. None of these are especially effective for managing ADHD or have as extensive a research background as the FDA-approved medicines discussed here. Often they are being used to manage another co-existing disorder and may even be combined with the ADHD drugs discussed here. The anti-narcoleptic drug, modafinil (Provigil®), has shown some promising results as a treatment for ADHD symptoms in children. Yet even then, the results have not always been replicated in other studies. There is also no research as of this writing on using this drug with adults with ADHD. The drug increases wakefulness and arousal and sometimes has been used to treat sleep apnea (disrupted breathing while asleep). But the drug has not received FDA approval for ADHD as of this writing.
What to Expect from Medication Treatment
Most adults with ADHD experience a significant improvement in their symptoms from these medications once a therapeutic dosage has been found for them. A minority of patients reported such remarkable improvements that they had become functionally normal. If so, patients may be joyful or near tears over just how well they are able to function now that they have been treated. For some people, the medication is the only treatment they may require to address their ADHD-related concerns.
Most people report that their symptoms are improved substantially due to medication. They are: (1) more productive at work, (2) more attentive while engaged in various tasks, (3) less impulsive and more thoughtful about what they are doing, (4) less scattered or distractible in their ability to focus on tasks and complete them, (5) less forgetful, (6) better able to organize their thoughts, (7) better able to carry on conversations with others, (8) able to compose written projects such as business letters or reports faster and more coherently, (9) more persistent in following through on promises to others or on activities, and (10) better emotionally controlled or stable.
Not infrequently, adults with ADHD often say that they finally know what it is like to feel or behave like a “normal” person or at least nearly so. Just don’t expect that all of the client’s symptoms or concerns will be miraculously solved. Troubles at work, in relationships, in school, or elsewhere can arise from other sources besides ADHD. Consequently, treating the ADHD does not always eliminate these other problems or unresolved issues. As noted earlier, most people with ADHD have at least one other disorder and many have two other disorders. Those other disorders are not likely to be spontaneously cured by effectively treating their ADHD. Other treatments will be needed to address those disorders.
The dosages needed to treat ADHD vary substantially across people, with some requiring very small doses, equal to those used with children. Others need substantially higher doses well above the average. Expect the client’s physician to try a range of dosages. The doctor will start with a low dose and then increase it every week until a good response is obtained or the adult with ADHD reports such annoying side effects that going to an even higher dosage is no longer an option. The adult with ADHD has a 75% chance of responding to whatever ADHD drug is tried first. But he needs to be patient (not a strong suit of most adults with ADHD), as it can sometimes take two to three weeks or even one to two months to find the best dosage for his needs. The adult with ADHD has a 10%-25% chance of not responding to the first drug tried, and a 3%-10% chance of not being able to tolerate the drug at all. Be sure that the physician is getting information from others who know the adult with ADHD well, such as yourself or anyone he may be living with at the time. Sometimes these drugs can be improving his ADHD symptoms but the he seems less aware of that change than do those around him.
If the first drug tried does not work or does not work as well as the adult with ADHD and the doctor would like, don’t worry. There are several other options that may well be the right ones for her. The adult with ADHD should keep trying other ADHD medicines and delivery systems if she didn’t respond to the first one tried. These drugs are among the safest and best-tested in all of psychiatry. Therefore, it pays for the adult with ADHD and her prescribing doctor to experiment with different drugs, dosages, and delivery systems so as to find what is right for her. A physician should only go off-label and use a non-FDA-approved drug for the client’s ADHD if she has not shown a positive response to any of the ADHD medications or if there is a very good reason not to start her on an ADHD drug first.
While routine physical exercise is recommended for all adults, increasing research suggests that it may be especially beneficial for people with ADHD. It seems to temporarily reduce the symptoms and/or help the adult to better cope with their symptoms. It can also help to address their propensity toward obesity, noted earlier. Some studies with children with ADHD even suggest that just allowing some movement or fidgeting while working can help those with ADHD to concentrate better and improve their performance of mental work. There is no reason to think this would not work as well for adults with ADHD, but good quality research specifically with adults with ADHD is lacking. So the adult with ADHD might wish to think about how to incorporate some repetitive movement into the work they have to do and even develop a routine aerobic exercise program. This small motor activity while working or studying can be something as simple as keeping a rubber ball or tennis ball in the non-dominant hand and squeezing it frequently.
Understand of course that large muscle and aerobic exercise comes with its own risks, particularly for injuries. But done properly, moderately, and carefully, routine physical exercise may well prove to reduce symptoms, improve self-regulation, and help with weight management for adults with ADHD given that it provides such benefits in studies of general-population adults. No one particular form of sport or exercise has shown itself to be superior to others. Therefore, the adult with ADHD should be encouraged to identify a method of exercise that interests him, for which he may have some aptitude, and which he is most likely to incorporate routinely and easily into his daily schedule. He can then consider incorporating small motor activity into work/study periods as needed to help address ADHD symptoms in those settings.
There is no research yet on the effectiveness of couples counseling for those couples in which one has ADHD. But it is often a necessary therapy for adults with ADHD and their cohabiting partners given the findings discussed earlier about the social impairments often seen with ADHD. Low marital satisfaction, impulsive emotional reactions, difficulties managing home responsibilities and finances, driving problems, excess tobacco, alcohol, and drug use, greater health problems, risky sexual practices and a propensity for casual sex (one-night stands), and even a propensity for reactive aggression in intimate relationships are among the many problems couples may face when one member has adult ADHD. Helping couples address these problems through marital/couples counseling will be essential for a substantial number of adults with ADHD.
Fortunately, a few trade books exist to provide some preliminary guidance to such couples about these problems and possible ways to address them. One excellent book is by Gina Pera, Is It You, Me, or Adult ADHD. Another is by Melissa Orlov, The couple’s guide to thriving with ADHD. And a newer textbook for clinicians has been published recently on couples’ difficulties and possible counseling methods for adults with ADHD (by Ms. Pera and Arthur Robin, Ph.D.; see Resources). So this remains an area in serious need of greater empirical research on treatment methods that may be most effective in dealing with the markedly higher rates of marital dissatisfaction, conflict, and even intimate partner aggression linked to adult ADHD.
When young adults are first starting to think about a career, those with ADHD would likely benefit from being advised to seek out a thorough vocational assessment first. There is almost no research on the issue of optimal occupational specialties for adults with ADHD. But given what little is known, identifying an area of vocational specialization for which a young adult has an aptitude would seem to help with identifying those that will be most intrinsically interesting to that young adult. Ideally, this evaluation should be done by a professional who is knowledgeable about adult ADHD, although that is quite uncommon. More likely, clinicians specializing in adult ADHD will need to combine their expertise on the disorder with that of a professional in vocational assessment and counseling in order to incorporate the specific knowledge of the problems inherent in ADHD with the results of the vocational assessment. From such an evaluation, one can suggest appropriate ADHD-friendly educational options and career paths.
Research suggests that such occupations include frequent movement, changes in the nature of the work (or novelty), assignments that require multi-tasking, busy and fast-paced work, hands-on or physically demanding tasks, intrinsically interesting projects, and more frequent feedback about performance than may occur in other, more sedentary, repetitive, and isolated work. Even if such a counselor is not well aware of ADHD in adults, she can collaborate with those professionals more traditionally trained in the disorder. The latter include such professionals as clinical psychologists, psychiatrists, and clinical social workers who can help adapt the results of the vocational assessment to the particular symptoms and characteristics of the adult with ADHD.
Although numerous “apps” have been developed to assist teens and adults with ADHD in addressing the various problems they have with Executive Functioning in daily life (time management, self-organization, etc.), no research is currently available on their effectiveness. Off-loading the cognitive demands of tasks in which the adult with ADHD may have some deficiency (e.g., scheduling, working memory) onto either low-tech means (calendars, day-planners, paper lists, etc.) or high-tech devices (computers, tablets, smartphones) does make some sense as a method of compensating for these EF deficits. Dr. Kevin Murphy recommends that adults with ADHD be aware of the tools technology may offer to assist them in coping with their executive deficits. As he notes:
“A variety of tools and devices can help greatly in communication, writing, spelling, keeping track of time, and the like. Word processors and programs with spell-check and grammar-check options can aid in writing and spelling more quickly, legibly, and effectively. Smartphones, tablets, and PDAs offer a wide range of components including an electronic address book, a planner/calendar, “to do” list, and notepad. Smartphones and text messaging make communication easier, more spontaneous, and faster. Many software programs are available to assist with personal finances and taxes. Websites devoted to organizational skills, time management, and just about any other relevant topic are immediately available on the Internet. Electronic banking offers online bill paying, including setting up automatic payments at regular intervals to protect against delinquent payments and late fees. Books on tape and voice-activated word-processing programs can assist in learning and writing. “Smart pens” can greatly assist students in note taking and recording classroom lectures. These sorts of devices and interventions should be used whenever appropriate, but will require time, practice, and persistence to master.”
One treatment approach for adult ADHD that is becoming more popular but which does not yet have a sufficient evidence base in the scientific literature to definitively determine its effectiveness is mindfulness meditation. It is often recommended in the mainstream media as a self-help approach to coping with stress, anxiety, depression, and other emotional difficulties. It has also been recommended for coping with psychological problems that may be associated with chronic health problems or even life-threatening disorders such as cancer.
The next figure summarizes the mindfulness meditation approach developed by Susan Smalley and colleagues at the UCLA Medical School. It is certainly representative of similar approaches used by others.
A somewhat different approach that has received more attention recently is the mindfulness meditation method developed by Lydia Zylowska and colleagues (see Resources). In an initial feasibility study, Zylowski and colleagues enrolled 24 adults and eight teens with ADHD in an eight-week mindfulness meditation program and found significant pre- to post-treatment improvements in ADHD symptoms, anxiety, and depression. Satisfaction with the program was good. Yet, this is merely a quasi-experimental design lacking in the more rigorous methods (placebo or alternative treatment comparison group, blinded assessments, appropriate same size, etc.) needed to fully evaluate the effectiveness of this approach. Another pilot study of this same approach likewise demonstrated effectiveness for ADHD and related EF deficits, among other outcome measures, and had the added advantage of at least a wait-list comparison group.
And so while initial clinical reports suggest some promise for this approach to treating adult ADHD, those reports and other studies were typically not rigorously done sufficiently to definitively evaluate the effectiveness of this therapy for ADHD. That leaves the results to date open to considerable debate and even doubt. Until that type of research is done, mindfulness meditation is not recommended as a first-line treatment for adult ADHD as would be ADHD medications and Cognitive Behavioral Therapy (CBT). Dr. Mary Solanto and her student Ayman Househam from NYU Medical School, recently reviewed the research to date on this treatment, concluding that the evidence, while quite promising, has not yet proven its effectiveness for adult ADHD. But they believe that there is reason to pursue additional, more rigorous research. More information on this treatment can be found on the Internet. Additional information on this approach is contained in the book by Zylowska and Seifel, The Mindfulness Prescription for Adult ADHD (see Resources).
Despite the existence of much promise in the available, yet limited, evidence base for the above non-medication treatments for adult ADHD, such interventions do not have anywhere near the amount of evidence for their effectiveness as do ADHD medications, suggesting that much more research is needed before these treatments can be viewed with the same degree of confidence as can medications.
Before reviewing the specific strategies that can be used in particular domains of major life activities for adult ADHD, here are some common-sense suggestions that can help manage the symptoms and impairments from the disorder based on what is known about it as a disorder of EF and self-regulation.
The problems those with ADHD experience in major life activities have more to do with not using what they know than with not knowing what to do. Adult ADHD is therefore a disorder of performance – a problem of not doing what one knows to do. Like patients with injuries to the frontal lobes, adults with ADHD find that what they know does not guide what they do (performance). Thus, the individual with ADHD may know how to act but may not act that way when placed in social settings where such action would be beneficial for them in the long term! The timing and timeliness of behavior is being disrupted in ADHD, not the basic knowledge or skills.
From this vantage point, treatments for ADHD will be most helpful when they assist with helping the adult do what he or she knows is best to do at the point of performance, where it would be best to do it. That “point” is the place in the natural environment where they are having problems. Addressing ADHD requires helping that person to show what they know at those crucial places – at those points of performance. A related idea to this is that the further away in space and time a treatment is from this point, the less effective it is likely to be in assisting with the management of ADHD at that point in the natural environment. Not only is assistance at the “point of performance” going to prove critical to treatment success, so is assistance with the time, timing, and timeliness of behavior in those with ADHD.
This will not be achieved just by training a person with ADHD in what to do. It must come from arranging the particular problem setting in such a way as to assist her to actually do it. Nor will there necessarily be any lasting value or maintenance of treatment benefits from providing that kind of assistance if it is summarily removed within a short period of time. The value of such treatments at the point of performance lies not only in providing assistance by helping the adult with ADHD show what she knows; it also rests in maintaining the scaffolding at that point of performance so that the improved behavior can be sustained over time in that natural setting. Yes, there is the possibility that with sufficient repetition and success the individual can even reduce or remove some or all of this “scaffolding” or accommodations due to habit formation. But that takes time and repeated practice within that setting so as to make an effortful behavior more automatic.
Given the above considerations, adults with ADHD should likely reject most treatment recommendations that do not involve helping them with these sorts of active interventions at the points of performance in their daily life where they are having major problems due to ADHD. These are treatments such as talk- or insight-oriented therapy, psychoanalysis, weekly group therapy focusing on complaining or general self-disclosure of feelings, etc. Those treatments are just not going to do it for the executive deficits that ADHD has created.
Adults normally regulate much of their behavior by using mental information (held in their working memory) that guides what they are doing. This working memory capacity is less effective in those with ADHD.
The accommodation then is: Don’t rely so heavily on mental information. Instead, make that information physical in some way in that situation – “externalize” it. Clinicians and the adult with ADHD can do that by placing the information in some physical form in front of them to remind them of what needs to be done. For instance, if the client’s boss or someone else has given her a set of instructions to get something done over the next few days, have her stop trying to carry this around in her head so she can remember it over that period of time. That can’t work if she has ADHD. Instead, have her always carry a small journal and pen and instantly write down the task, any steps given to her to get it done, and the deadline for when it’s due. Then make sure she keeps this journal in front of her where the work is to be done over the next few days to help remind her of the project to be done. The journal can serve as an external type of working memory.
Clinicians can even help the adult with ADHD translate this written plan into smaller steps and insert them into her day planner as goals for each hour of that day and even over the next few days before the work is due. The technique here is not what is important – the principle behind it is! Make important information, plans, goals, and deadlines external (in a physical form) around the adult with ADHD (within their sensory fields) in problem situations if clinicians hope to improve their chances of getting things done. In tech-speak, off-load the information that must be held in mind to some other, more physical medium that exists in that situation or workspace.
This is one of the most important ideas clinicians and the adult with ADHD can learn about adult ADHD from viewing it as a disorder of EF. It not only gives clinicians both a deeper understanding of its nature but a richer understanding of how to help. Difficulty with organizing behavior across time, known as time management, is one of the ultimate mental deficiencies created by ADHD. ADHD is to time what nearsightedness is to vision. The disorder creates nearsightedness toward the future. The individual’s behavior is being governed by events close at hand and not by events in the more distant future. Things that are within “the now” and the immediate situation control him far more than thoughts about “the later.” The adult with ADHD is not able to think as well about long-term future events related to that situation. He simply doesn’t stop to think before he acts. Instead he acts on impulse and pays a heavy price for doing so. This helps us to understand why adults with ADHD make the decisions they do, shortsighted as those decisions often seem to be. If one is not able to consider future consequences, then much of that person’s behavior will be aimed at maximizing the immediate rewards. It will also be aimed at escaping from immediate hardships without concern for the later negative consequences of those actions.
How can clinicians help?
Make time physical. That is, make time more visible in situations where time matters. The adult with ADHD can do this with kitchen timers, clocks, computers that give periodic reminders about deadlines, day-planners or week-at-a-glance desk calendars that show the days broken down into hourly units, cell-phone timing devices, smartphones with deadline reminders, etc. The ways to do this are countless, but it’s the principle that is important here. The more external or physical one can make the passage of time in front of her and structure that time with periodic physical reminders, the more likely she is to better manage her time.
Reduce or eliminate the problematic timing elements of a task when feasible. For instance, rather than have the adult with ADHD take on a task that has large time gaps in it such as one that can be done over days or weeks of time, reduce or eliminate those gaps whenever possible. Instead of his accepting a project that must be done over the next month as is, encourage him to break it down into much smaller steps and try to do a step a day toward that eventual goal. That way, each step does not seem so overwhelming as does the entire project. Breaking big projects into small steps makes it much easier to get motivated to do a smaller chunk of work. When those small tasks are done every day, then when the deadline arrives the work will have been done.
Viewing adult ADHD as an EF disorder also implies that it greatly reduces a person’s ability to create internal motivation; what we generally call self-motivation, drive, persistence, or stick-to-it-iveness. The adult with ADHD can’t self-motivate like other adults are able to. She cannot do as well at getting herself “pumped up” or activated to start projects or to sustain her motivation for the activities that need to be done over time toward deadlines and goals as well as others.
How to help:
As noted earlier, ADHD prevents an adult from thinking as well as others both before and while she is behaving – she is less capable of using mental information to contemplate what she needs to be doing and to guide her along so she does it. The solution to this problem is not to nag those with ADHD to simply try harder or to remember what they are supposed to be working on. It is instead to take charge of that immediate context and fill it with physical cues to help them remember what to do and to stay on task. The external environment has a stronger pull or influence over the behavior of someone with adult ADHD, and that environment is often filled with irrelevant and distracting events.
Encourage the adult with ADHD to get rid of those distractions in the places where they typically work. Replace them with cues, reminders, cards, lists, signs, sticky notes, day planners, or whatever devices will keep his mind focused on the task and goals at hand.
Adults normally possess sets of internal rules for what to do or how to act in particular situations, such as at work, in school, while driving, or even when in social gatherings. Adults activate these mental rules at those crucial times to guide them more effectively through that situation. Adults with ADHD are far less likely to activate these rules. Even if they do, the rules or instructions they recall don’t control their behavior very well. Remember, ADHD makes mental forms of information very weak as a means of controlling one’s own behavior.
What can clinicians do to help?
As noted earlier, the approach taken to the management of ADHD must be the same as that taken in the management of other chronic medical disorders or for other chronic developmental disabilities. Diabetes is a good example of just such a medical disorder to help clinicians and the adult with ADHD grasp this point. At the time of diagnosis, all involved realize that no cure exists for diabetes. Still, multiple means of treatment do exist that can provide symptomatic relief and thus reduce the deleterious effects of the condition. Such steps may include taking daily doses of medication and changing settings, tasks, and lifestyles. Immediately following diagnosis, the clinician educates the patient and family on the nature of the chronic disorder, and then designs and implements a daily treatment package for the condition. This package must be maintained over long periods so as to sustain the symptomatic relief that the treatments initially achieve. Ideally, the treatment package, so maintained, will reduce or eliminate the secondary consequences of leaving the condition unmanaged.
However, each patient is different and so is each instance of the chronic condition being treated. As a result, symptom breakthroughs and crises are likely to occur periodically over the course of treatment that may demand re-intervention or the implementation of modified or entirely new treatment packages. Changes to the environment that may assist those with the disorder are not viewed as somehow correcting earlier faulty learning or leading to permanent improvements that can permit the treatments to be withdrawn. Instead, the more appropriate view of psychological treatment is one of designing an artificial social environment that serves to help the adult with ADHD better cope with and compensate for her disorder.
Throughout all this, the goal of the adult with ADHD, their family members, and their treating professionals is to try to achieve an improvement in the quality of life and success for the individual, though life with ADHD may never be totally normal.
The following specific strategies are common-sense recommendations given the risks for adverse outcomes noted earlier in this course and the fact that they have been found to be useful clinical recommendations in professional settings by many specialists in adult ADHD. Granted, research on their effectiveness still needs to be done, but in the meantime, the following strategies may serve to benefit adults with ADHD in dealing with problems caused by their symptoms and EF deficits in these specific domains of major life activities.
As discussed in earlier sections above, the vast majority of adults with ADHD experience problems in their educational history. They are likely to still do so if they are pursuing adult education classes or workplace educational programs. If the adult with ADHD is a young adult who is in college or technical training, then she will likely require certain accommodations to help her succeed. Adults with ADHD are entitled to reasonable adjustments or accommodations in their educational activities as well as in the workplace, as provided under the Americans with Disabilities Act (ADA), depending on the severity of their disorder, extent of impairment (disability), and the reasonableness of the requested accommodations. Clinicians may want to become familiar with the requirements for documenting a diagnosis of ADHD under the ADA, especially its most recent reauthorization, as this will have to be provided to the college or employer if the adult with ADHD wishes to take advantage of these reasonable accommodations. Several books that can explain the protections afforded against discrimination under this act can be found below in the Resources section. Those books also explain the documentation needed to access such protections and accommodations, and the sorts of reasonable adjustments to the school or workplace setting that may be required to assist the adult with ADHD.
Besides taking medication, a variety of strategies exist that may prove useful in the school or workplace environment to help compensate for ADHD and associated EF deficits. This assumes, of course, that these strategies are feasible to implement in those settings.
Find a “coach” or “mentor” to whom the adult with ADHD can ask to be held accountable several times each day for the work that needs to get done that day. This can be a teacher, professor, roommate, classmate, more senior student, or someone in the special student services office. At work, it can be a co-worker, friend, or supportive supervisor. The adult with ADHD can also hire a formal ADHD Coach, as discussed above. If possible, the adult with ADHD should meet with this person for five minutes two to three times each weekday. Use the first meeting, usually in the morning, to review her “to do” list or goals for that day. Then she should meet with that person again at mid-day (lunchtime, perhaps) and again late in the day to show the mentor what items on that list have been accomplished. One sure-fire way to help the adult with ADHD stay focused and on-task in pursuing goals and work is to have her be accountable to someone else she has agreed to involve, and meet with that person frequently.
Identify the ADHD specialist if the adult with ADHD is in a college setting (usually they are in a student special or disability services office) or the disability specialist in human resources in the workplace. This is usually the person to whom the adult with ADHD must declare that he has ADHD and to whom the documentation (prior evaluations) that proves it should be provided. That specialist will then explain to him the types of curriculum adjustments and other accommodations typically provided to students with ADHD in that college, or workplace adjustments, to see which ones he may need. They will also work with the teachers (or supervisors, if at work) to see that he gets those accommodations. And they can often link him up with psychologists, counselors, and physicians (usually psychiatrists) that work at the student counseling center or that have contracts with the employer for providing employee mental health services should he require therapy or medication.
Encourage the adult with ADHD to use a daily assignment calendar and a journal. The calendar is for setting goals for that day and tracking appointments. Typically, it shows the entire week at a glance broken down into one-hour segments. This can be very useful not only for tracking appointments, but also for entering in the time one plans to use to handle a project or smaller steps of a more complex, longer-term project. The journal is simply a book with blank pages into which they can write any promises, deadlines, assignments from others, etc. Later, some of these can be transferred into the calendar. These two books are what she will review with the “coach” during the meetings discussed above. She should keep both in a visible spot in the workspace so she can see them often and be reminded to stay focused on goals and appointments for that day. Writing everything down can help compensate for a poor working memory. The adult with ADHD can use a journal for anything of the slightest importance that should be written there to make up for his working memory deficits. Yes, one can use computers, tablets, or smartphones to take such notes – and this may be preferable if she has trouble with handwriting (see the next strategy). But generally, low-tech paper journals and calendars are better, as they are always visible and available for writing. The relevant apps on smartphones or iPads disappear from view when the device is closed, and thus become out of sight, out of mind, and of little help. Clinicians should suggest that the adult with ADHD review this journal several times a day to make sure she is doing the things recorded there.
Use word processing on a computer rather than handwriting lengthy assignments. People with ADHD often have motor coordination or other handwriting problems that make them slower to write and have less legible handwriting. Whenever possible, the adult with ADHD should use a laptop computer or other means to type his work. In college, the adult with ADHD may also use the word processor for easier note-taking. He can also record some of the assignments this way. Computers with cameras can also be used to create an audio CD or media file as an alternative to a written report if he has a history of significant writing problems. The special student services counselor mentioned above may be able to get him this type of curriculum adjustment if he requires it. Or, many recent-generation computers, smartphones, and tables have voice recognition software built into them that allows the adult with ADHD to dictate assignment answers or lengthier reports that are then automatically transcribed into print. Those passages can then be further edited before being printed out on paper as his report.
Digitally record important lectures or meetings, or use a smart pen digital recorder (such as can be found at livescribe.com). Or, if handwriting is not a problem, use continuous note-taking to boost concentration in classes or meetings. As one way to stay awake, alert, and focused is to be doing something active, he should keep the hand moving continuously and take notes even if he doesn’t really need to write down the information.
Get any extra-curriculum materials teachers may have available or that have been reserved at the library especially for these classes. These may be videos that supplement what is being taught in class, additional notes or articles that further explain the topics that are being covered in class, etc. In the workplace, the adult with ADHD should check to see if there is a library or information center that contains resources for further learning on the job.
Get the adult with ADHD a notebook organizing system at the local bookstore or office supply store to help him get and stay organized. Having separate colored folders for each school class or project at work can be very helpful. This is where he keeps completed assignments to ensure that assignments can be easily found and so turned in on time. It is not unusual for adults with ADHD in college settings or at work to do assignments and then misplace their work. Then they are not able to find the work on the date that it is due in their classes or to their supervisors. Since many people now store their work on computers in digital files, encourage the adult with ADHD (or assist them directly) to better organize these files for easier access, relocating them when needed, and backing them up to cloud storage facilities for safe keeping such as with DropBox, iCloud, etc.
Suggest that adults with ADHD schedule harder classes/meetings/work during their “peak performance” time slot each day. For most people, this may be the mid-morning or early afternoon, but people vary in the time each day they are most alert. From prior experience, the adult with ADHD should know when these peak hours of alertness and concentration are likely to occur each day. Some research shows that adults with ADHD have an altered circadian rhythm and possibly an altered sleep cycle, and so find afternoons or even evening hours to be their best time to focus and concentrate. This is a few hours later than adults in the general population are likely to report as their peak performance time. In any case, encourage the adult with ADHD to identify her daily cycle of arousal and alertness and use that knowledge to better schedule those tasks that require more concentration and effort into that time slot.
The adult with ADHD should alternate required or harder courses with elective or fun classes during the day or across the weekly schedule of classes. Don’t let him stack all the hard classes into a single day or during the first few days of the week, as this can over-tax him. It can also make him too tired to do well in these classes, lose interest or motivation part way through them, and ruin his attitude toward school in general. So suggest that he intermingle the hard stuff with classes or activities he finds more interesting or entertaining. That way he is never faced with too many classes or projects that are boring or demand lots of effort being too close together. Clinicians can suggest that adults with ADHD do this at work as well by arranging the work each day so that they alternate difficult/demanding tasks with easy/interesting tasks.
Should the adult with ADHD request extra time on timed tests in college or at work? Many young adults with ADHD in college settings believe or have heard from others that this may be a useful accommodation to request. But what little research there is on the subject is not that clear cut. Everyone, disabled or not, seems to benefit from some extra time to take timed tests. But that does not mean it will necessarily help compensate for ADHD or solve other problems with taking these tests, such as test anxiety.
More recent opinion suggests that the adult with ADHD might be better off using a method called “time off the clock.” This involves using a stopwatch to take these timed tests. The adult will not get any more “face time” with the test using the stopwatch than do other students. But what she will be allowed to do is to stop the watch anytime, as often as she likes, to take a short break of a minute or two. Use this time to stand up, stretch, walk about the room or into the hallway, get a drink of water, use the bathroom, then return to the test and restart the stopwatch. When she has used up the test time on the stopwatch, then the test is done.
Yes, this will result in taking more time than others to complete the test, but that is not the point. The strategy that one is using here is the important thing. That strategy is breaking up the test into smaller work quotas and having frequent breaks to briefly refresh her mental focus and concentration. If she is required to periodically take timed examinations as part of her work, she should try to get this type of accommodation on the tests by using the human resources department that is responsible for implementing ADA accommodations in that work setting. Whether or not a “time off the clock” approach is allowed, encourage the adult with ADHD to request test settings that are free of distractions or offer greatly reduced chances of being distracted.
Encourage the adult with ADHD to exercise before exams, boring classes, extended meetings at work, or protracted work periods. As discussed above, routine aerobic exercise improves a person’s ability to concentrate for up to 45-60 minutes more than usual should they have ADHD. Adults with ADHD should learn to build in brief exercise breaks throughout the day but use them especially before they have to do something that is difficult to concentrate on or pay attention to during that day. Although adults with ADHD are also encouraged to routinely engage in more extensive workouts regularly throughout a typical week, that is not what is being suggested here. Here we are encouraging much briefer exercise periods – just two to five minutes of exercise may be enough to help the adult with ADHD concentrate better if it is done just before he enters a boring or demanding class or exam. If the class, meeting, or work project is long enough that he is being given beverage or restroom breaks, suggest that he use those breaks to do a quick aerobic exercise. This can be helpful even if it is just faster-than-normal walking outside the building, in the hallway adjacent to the work area, or walking up and down stairs in a nearby stairwell.
While in settings where staying seated is required, suggest that the adult with ADHD engage in small motor activities. This was discussed earlier.
Wear a tactile cueing device to frequently prompt self-awareness and focus on goals or the work at hand. For a small amount, one can buy “The MotivAider” on the Internet (check the website: addwarehouse.com). This is a small plastic box about the size of a cell phone that contains a vibrator inside and a digital clock. The clock can be set for any intervals one may wish, or one may choose the random setting. When the interval expires, the device vibrates (or will do so at unpredictable intervals if they chose the random option). This tactile cue can serve to remind the adult with ADHD to stay alert and focused on what she is doing.
If the adult with ADHD has lots of reading to do for school or work, encourage him to learn to use the SQ4R method for improving his reading comprehension, if that is a problem for him. The chart below shows how it works.
Improved Reading Comprehension - The SQ4R System
Survey the material to be read – just leaf through it quickly to get some idea of how much is to be read, how it is broken up, etc.
Draft some Questions that need to be answered from what is to be read. Often these are at the end of the chapter to be read or have been provided by the teacher or workplace supervisor.
Now use the 4Rs: Read just one paragraph, Recite out loud in a soft voice or whisper what was important in that material, wRite that material down in your notebook, then Review it.
Do this for each paragraph. This not only makes the ADHD adult review what was read four times per paragraph (read, recite, write, review) but it gives frequent mental breaks at the end of each paragraph. That can happen as she or he shifts their concentration from reading, to reciting, to writing, to reviewing across the assignment. As the adult with ADHD gets good at this, she or he can read longer passages, such as two paragraphs at a time or even an entire page before engaging in the recite, write, and review steps. This is a great strategy for people with working memory problems.
Try some peer/co-worker tutoring.
This is where the adult with ADHD and a fellow student agree to study together and alternate teaching each other the material. One of them is the instructor, the other the student. Then they reverse these roles with each tutoring session. Having to teach someone new material is a sure-fire way to learn and retain such information compared to just routine independent study. The same method can be applied at work with a co-worker when new material needs to be absorbed.
Suggest that the adult with ADHD work as a team with more organized people.
Working around or with others who do not have ADHD can serve to keep her better focused on the work that is to be done. It also makes her more publicly accountable for doing that work than if she goes solo and does the work in isolation.
Find a “fall-back” college classmate or co-worker.
The adult with ADHD will use this person in any instance where he is outside of school classes or away from work and finds that he has forgotten an assignment or other important information. Suggest that he swap contact information with this other person and do the same for him. That way both people can get the lost or missing assignments or information quickly when either one finds they have this problem.
Attend after-class (or after-work) help sessions whenever they are given.
Many teachers in college or instructors in workplace educational settings are willing to set aside extra time to help people who need more instructor assistance in learning a topic. If that is available at the college or worksite of the adult with ADHD, then recommend that she use it to the hilt. Even if she doesn’t really need the assistance, the extra review will help with forgetfulness. It will also show her to be a motivated student or employee and so make a better impression with instructors.
The adult with ADHD should schedule faculty or supervisor review meetings often – every three to six weeks (not at the end of grading periods or only at workplace performance review meetings).
Remember that the more often the adult with ADHD is held accountable for his work, the better he will do. So, in addition to using the “coaching” suggestion above each day, suggest that he schedule more frequent and informal reviews with the people actually responsible for grading or evaluating his work at school or on their job. This lets him get more frequent feedback more quickly on just how well he is doing.
Gently prompt the adult with ADHD to watch, limit, or eliminate the caffeine, nicotine, alcohol, or marijuana use.
Adults with ADHD are more prone than others to use these substances and become dependent on them. And they sometimes try to self-medicate their own disorder using readily available caffeine-containing beverages or tobacco products. Yes, caffeine and nicotine are stimulants and they can help people be more alert, though nowhere nearly as well as the ADHD medications do. But caffeine especially works on the wrong brain neurochemicals for people with ADHD and it can, in moderate or high doses, be counter-productive. That is because it makes the adult with ADHD less focused, more jumpy and jittery, more nervous, and more likely to frequently need to urinate. She is better off using a prescription ADHD drug than trying to use substances containing caffeine or over-the-counter pills that contain caffeine. And, while nicotine may benefit ADHD symptoms to some degree, it is a highly addictive drug with which to self-medicate. Doing so is only going to increase the risk of addiction to this chemical, not to mention increase the risk for pulmonary and heart disease and cancer. Again, using a prescription ADHD drug instead does not carry such risks and is far more effective.
The Internet can become a big source of wasted time and an incredible distraction from work or home tasks, even for typical people. But for adults with ADHD who already have significant problems with self-control, having Internet access readily available at home or work can pose far worse problems. Research shows that teens and adults with ADHD spend far more time on the Internet, whether surfing various websites or gaming, than do typical people of the same age. They are also far more likely to have problems disengaging from the Internet or gaming when the situation demands that they shift to other more important things which need to get done. And 15%-20% of young adults with ADHD can be said to be Internet-addicted, showing all the typical signs of dependence or addiction often used to diagnose more common alcohol and drug addictions. There are a few things that clinicians can advise the adult with ADHD to do at work or at home if the Internet is proving to be a serious and prolonged source of distraction for them and interfering with other more important demands. If the adult with ADHD is not sure just how much time is being wasted on the Internet, recommend a software program such as RescueTime be installed on that computer. It will track each Internet page that was opened, how long was spent on that website, and even send clinicians or the adult with ADHD a report broken down by categories including the websites he is browsing the most. What else can clinicians do to help alleviate this symptom?
At home, place the computer and Internet access in a space set aside for working, such as a home office.
Don’t just leave computers, iPads, and other Internet-enabled devices in bedrooms, family rooms, and kitchens where they will tend to easily capture the ADHD adult’s attention during times when he should be busy doing more important tasks or projects. Advise the adult with ADHD to have a room for computers and only use these rooms when computer work is to be done, while otherwise keeping the computer out of sight (and so out of mind) when tasks are being done that don’t require the use of computers or the Internet. When in the workspace, have him keep the door closed and wear headphones or use a “white noise” machine if necessary to cut down on distractions that might divert him from his work.
Better yet, set up two different computers – one for work only and the other for play.
The adult with ADHD can use a desktop or laptop computer for her work. This computer is only to have programs on it critical to the type of work that she needs to do. This device is to have just one browser and also one of the programs below that can be set for limiting Internet access or access to certain play-related websites. Keep the work email program closed until certain times of the day set aside for doing work emails. And keep the instant messaging program closed as well. If she must instant message someone, open the program for just that short query and close it when she has gotten the reply. Don’t leave this program in the active mode while working. Software for gaming, social media, or other such time-wasters is not to be installed on this computer. Instead, she can use a tablet or even another laptop as her “play” machine. On this computer is to be installed all the entertainment and social media software she wishes to use, but is to have no work-related programs or work email. By setting up two different systems, it becomes easier when using the work device to not be distracted by the availability of play, gaming, or other social media programs or personal email accounts. Advise her to never play on her “work computer” and never work on her “play computer.”
Install Internet time-management software on the home and workplace computers.
There are now several software programs that can be added on to Internet browsers that can be programmed to restrict Internet access or block access to websites that are for sheer entertainment and to which the adult with ADHD is likely to go that can interfere with work. These programs include StayFocused and ChromeNanny for Google Chrome, WasteNoTime for Chrome and Safari, and Leech Block for Firefox. They can be set to allow fixed times and durations for accessing certain websites, after which the sites will be blocked. They can be programmed to limit access to certain times during work or business hours and for specified durations. Some of these add-on programs can also be set up so that they cannot be disabled and so that any changes the adult tries to make to alter the settings don’t take effect until the next day, both of which can serve to block impulsive use of the Internet for entertainment or distraction when other work needs to be done. Note that some of these programs only work on a specific browser so they won’t prevent the adult with ADHD from getting out on the Internet using another browser.
If the adult with ADHD has a Mac computer, programs including Self-Control and Anti-Social can be set up to manage Internet or website access or even block it on any browsers on that computer. So can the program Focal Filter. On a Mac computer, the program Time Out can be installed and programmed to give gentle reminders to take a break at specified intervals while an individual is on the Internet. The program Freedom, can be used on both Mac and PC computers to shut down Internet access on that computer for specified time periods. Of course, adults with ADHD can also use the Parental Controls setting to give control of their website access to another caring adult, such as a partner, coworker, or friend who can serve in the parental role by blocking or unblocking Internet or website access. If the problem is Internet access from a cell phone, look at programs such as Tasker and Do Not Disturb as possible ways to limit or block Internet access to keep the adult with ADHD from using it to waste time.
Of course, all of these tactics can be overcome with “work arounds” if an adult with ADHD tries hard enough to circumvent them. But the goal is to put enough initial obstacles in the way of access or lengthy Internet use to cause the adult with ADHD to have second thoughts about this impulsive desire to get on the Internet, and hence will restrain himself from doing so.
Adults with ADHD need to pay more attention to the health and lifestyle risks likely to come with their disorder than do most adults. Those risks were discussed in an earlier section. Many health habits and lifestyle activities that adults with ADHD are prone to are likely to put them at greater risk for coronary heart disease and cancer, among other medical and dental problems (more dental cavities, possibly more oral infections). Add to this their greater risk for accidental injuries and one has a recipe for a life filled with preventable misfortunes. So the adult with ADHD is going to need more assistance from medical and health professionals who are expert in the management of these health risks and lifestyle problem areas, such as smoking cessation programs, dietary management, exercise regimens, etc.
Don’t let the adult’s ADHD shorten her life expectancy because of its association with these risk factors. This means not only helping the adult with ADHD to get her ADHD under control as much as possible, but she may also need encouragement to pay attention to the lifestyle, nutrition, and other choices that may leave her at greater risk of a shortened life. Here are some reminders to pass along to the adult with ADHD to help get her started.
Develop regular weekly exercise patterns (three-plus times per week) for increased attention, better health, stress management, etc.
As clinicians have already heard, regular routine physical exercise done three to four times per week, even for just 20-30 minutes each time, is good for health. But for adults who have ADHD, it also seems to be of particular benefit to further controlling ADHD symptoms or compensating for them. It can also help fend off the risk for obesity that comes with this disorder. So whether it’s running, biking, weight-training, dance-classes, using one’s favorite gym equipment (treadmills, elliptical trainers, stair-climbers, etc.) or some mixture of various types of exercise, the client, more than most people, needs to be doing routine physical exercise.
Encourage the adult with ADHD to make an appointment for a routine physical exam with a doctor if he has not had one in a while or never did get one as an adult.
This is a status check to see what problems or issues are developing and to try to head them off early with better preventive medical care. If he doesn’t have insurance or the money needed to do so, maybe a parent, sibling, or relative would cover this cost. If that is not possible, check with the local county or city hospital about getting such a physical exam through them at the county or state’s expense under such programs as Medicare or Medicaid if the adult with ADHD falls below the poverty line in income. Call the local department of social services to see if they can direct the adult with ADHD to free care clinics. Other things that clinicians and the adult with ADHD may wish to discuss with the physician:
Facilitate a consult with a local dentist for the adult with ADHD to catch any developing dental problems or diseases she may have.
If left unchecked, these could cause her to lose some or all of her teeth, require a partial or full set of dentures, lead to more extensive dental or gum surgery, or possibly even abscessed teeth. The latter has the potential to be lethal if that infection happens to enter the blood stream and attack the heart.
Strongly encourage the adult with ADHD, if appropriate, to go on medication to treat their ADHD.
Often times, the medical and dental risks we have identified in our research on adults with ADHD stems from their unmanaged ADHD and the disorganizing effects it has on their lives. Getting the client’s ADHD under control with medication can allow him to engage in these other medical, dental, and health-related activities with a greater chance of success. One side effect of those medicines is that they can often result in weight loss. For an adult who is already overweight, this is not actually a side effect but a side benefit of taking these medications for managing ADHD.
Driving is a serious and potentially life-threatening area of impairment for adults with ADHD. If the adult’s ADHD is of a moderate to severe degree, clinicians are strongly urged to have her use an ADHD medication whenever operating a motor vehicle or heavy equipment. Other things clinicians can have her do to improve this domain include the following:
Make sure the medication covers as much of the waking day as possible. What is important here is greater attention to the timing of when the adult with ADHD takes her medication relative to when she is most likely to be driving. That is because clinicians want to insure that the adult with ADHD has adequate levels of medication in the blood stream at those hours, such as morning and evening commuting, late night driving for work or social occasions, etc. It is possible that earlier doses, even of extended release medicines, may have worn off to the degree that she is no longer adequately treated with medicine at these peak drive times.
If the adult with ADHD is not taking medication or refuses to and she has children, suggest that the spouse or partner who does not have ADHD drive the children to their various activities. The same applies when she is out with a partner, spouse, family member, or other adult with ADHD in the same vehicle and the adult with ADHD is not medicated.
Strongly advise the adult with ADHD with that absolutely NO alcohol should be consumed when she plans to operate a motor vehicle. Research shows that alcohol has a differentially greater detrimental effect on driving in an adult with ADHD than a typical adult, even at low doses. So advise the adult with ADHD to avoid alcohol use if she plans to be driving.
At least one in four adults with ADHD are likely to have a problem with excessive use, dependence, or abuse of one or more substances. As discussed earlier, the most common substances an adult with ADHD may over-use or abuse are nicotine, alcohol, and marijuana; sometimes all three. A lesser percentage of ADHD adults are likely to be using or abusing “hard” drugs, such as cocaine, heroin, methamphetamine, etc., or illegally using prescription drugs. Sometimes the client’s excessive drug use or abuse is admitted by him as part of the initial evaluation. Other times it can be inferred from the other difficulties the he may be experiencing, as well as from the reports of significant others about him. Some signs of drug abuse are typically associated with abrupt changes in patient mood, behavior, or physical appearance for which there is no obvious explanation. For instance:
If the adult with ADHD is showing excessive drowsiness, slurred speech, glassy eyes, slowed reaction time, poor motor coordination and imbalance, or even depression, clinicians might suspect he is abusing alcohol. Another possible category of abusable drugs showing such signs is prescription sedatives, such as Valium, Librium, and Seconal.
In contrast, is the adult with ADHD excessively alert? Does he have narrowed pupils, show more energy than usual, or seem “high” or manic? Or does he seem more restless, nervous, or fidgety than usual? Does he show excessive talking with pressured speech (words rush out like a fountain), have disjointed thinking, or even seem to be paranoid or hallucinating? Then consider that he may be abusing a stimulant. These include cocaine or “crack,” “speed” or methamphetamine, as well as prescription stimulants like the kind used to treat adult ADHD. Those drugs can be abused by crushing the tablets and snorting them nasally, mixing them with water and injecting them, or even by taking prescription medication in doses far larger than prescribed.
Are clinicians seeing signs of mild euphoria in the adult with ADHD, an excessively laid back or unconcerned attitude, or is he overly relaxed? Does he show racing or paranoid thoughts? Does he report odd perceptual distortions (vivid colors, acute hearing of soft sounds, etc.)? Do clinicians see him engaging in unusual smiling as if everything seems mildly ironic or funny? Then he may be abusing marijuana, hash, or THC (the main abusable ingredient in both), or heroin, morphine, or codeine.
Other signs that an adult with ADHD may be abusing drugs is an abrupt change in his daily life functioning. This can include unexpected and unexplained changes in his finances, where money family members thought he had is now gone. Or maybe money he had in his wallet is missing. Has he asked to borrow money from family or friends for vague expenses or ones that don’t make much sense? Have those people reported finding bills they thought were paid that really were not, utilities threatened to be turned off, or that he is suddenly over-extended on his credit cards (especially if from taking cash advances)? Look as well for changes in his work life, such as being repeatedly late for work when he previously was not (perhaps due to oversleeping), or a sudden loss of motivation to work. Or he complains he is getting calls from employers about being absent or for inappropriate things that have happened at work, or maybe even being fired. A sudden change from his normal driving patterns, increased negative consequences of driving (speeding tickets, etc.), or using his car at inappropriate times such as very late at night to meet “friends” unknown to his family or partner. Sudden declines in educational performance can also be evidence of this. Because adults with ADHD may have trouble in these domains anyway, even without abusing substances, clinicians should look for sudden changes from the usual level of functioning as a potential sign of drug use or abuse.
If the adult with ADHD has such problems with excessive drug use or even abuse, he will find it harder than others abusing these drugs to quit using or abusing them. That is because ADHD creates a problem with self-control. It requires substantial self-control to detox from a substance on which someone is dependent or to which one is addicted. So even if the adult with ADHD is interested in discontinuing his abuse of a substance, it can prove quite difficult. That means he is going to need all of the support he can possibly get from others who care about him, such as you. And it also means that he may need to have his ADHD treated to help boost his self-control.
If the adult with ADHD isn’t sure that he has a drug-use problem, an initial step to consider is to help him with monitoring how often he is consuming that substance. Just keeping a calendar in which he can record the frequency of use of the substance each week can help him answer the issue of whether the frequency is too great. This will be apparent if his use of alcohol is occurring far more than is typical for most adults. Also check to see if it is being done in an uncontrolled fashion across various settings and times of day. Is he binge-drinking or binge-consuming that substance? Check to see if his behavior or daily functioning is being adversely affected, or if others have commented to him about his excess substance use. Watch to see if he is dependent on use of the substance to get through stressful situations.
Encourage cohabiting partners to help remove the substance from the home without provoking serious problems with withdrawal. If he is an alcoholic, daily user of tobacco, or of marijuana, or is clearly addicted to harder drugs, then clinicians may not be able to encourage a partner or friend to eliminate the substances from his living space so easily. He may need some medical assistance to help treat his withdrawal symptoms.
Encourage the adult with ADHD to get professional assistance with his substance use problem.
If the problem is with nicotine, then clinicians or the client’s primary care physicians may be knowledgeable about area programs for quitting smoking. Those programs can provide nicotine alternatives to help while the he steps down from using tobacco or goes “cold turkey” from using tobacco. Sometimes other drugs may be needed to treat the symptoms associated with withdrawal from nicotine.
If the adult with ADHD has an alcohol use problem, then clinicians or the client’s primary care doctors may know the regional resources for treating alcoholics, such as Alcoholics Anonymous, or other forms of group and individual therapy. Again, the adult with ADHD may need certain medications to help him quit (such as Antabuse) or to help him cope with his symptoms of withdrawal. Sometimes the alcoholism is sufficiently severe to warrant a short-term (one- to two-month) stay in a residential treatment center for alcoholism or other drug use disorders. If that is the case, be sure the center understands that the he also has a dual diagnosis of adult ADHD. Also make sure that the staff is knowledgeable about treating that disorder in the context of a drug-use disorder. The presence of both disorders usually complicates the otherwise routine treatment plan for drug abuse to some degree.
If the adult with ADHD has a problem with marijuana use or abuse, then the same sorts of steps above may also help clinicians identify resources for this type of drug problem. While there are not as many resources for dealing with this type of dependency or abuse as there are for alcoholism, should clinicians be unaware of such programs they may find them by following the same advice given above: speak with a primary care doctor, call the state psychological and psychiatric associations, call university medical school psychiatry departments or university clinical psychology programs, check with county mental health centers, and use the Internet to search for resources.
If the adult with ADHD is dependent on or addicted to other, harder drugs than these, then inpatient hospitalization may be needed to help acutely treat his problem. This hospitalization can be followed by a short-term stay in a residential facility that focuses on treating this type of drug use. Most individuals who are using substances excessively, or who are abusing them, often have more than one psychiatric disorder besides the drug-use problem. Many have several, including their adult ADHD. Disorders such as anxiety, depression, bipolar disorder, personality disorders, etc. often coexist with drug-use disorders. Therefore, don’t be surprised if the adult with ADHD winds up being treated for these additional disorders alongside his treatment for his drug use, and in addition to treatment for his adult ADHD.
This course was intended to convey basic information on the variety of evidence-based and promising approaches to the management of adult ADHD. To do so, it also reviewed basic information about the nature of the disorder and its risks for impairment of patients’ life-course that are relevant to such treatment. Besides reviewing the types of medical and non-medical treatments often used to treat adult ADHD, this course provided some general recommendations for compensating for the Executive Functioning deficits associated with adult ADHD. And it provided numerous specific recommendations to consider for the adult with ADHD on how to deal with problems in various specific domains of major life activities, such as work, education, and driving.
In closing, remember that while adult ADHD is a serious disorder, it is also one that is highly treatable using a variety of science-based interventions that can reduce its symptoms and greatly improve daily functioning. Adult ADHD does not have to prevent one from pursuing one’s dreams and becoming a successful, happy, well-adjusted adult, provided the disorder is properly diagnosed and treated. And that success also depends in no small degree on the support that adults with ADHD receive not just from loved ones but from their treating professionals as well.
The Five Stimulant Delivery Systems
Five of the six different delivery systems are the 5 Ps – Pills, Pumps, Pellets, Patches, and Pro-drug. The sixth is a delayed release formulation. The various brand names of ADHD medicines clinicians will hear about are either one form or another of MPH or AMP and involve one of these delivery systems:
Pills These are the original versions of these medicines that have been available for many decades. The first versions of AMP were discovered in the 1930s while the first version of MPH was discovered in the 1950s. In pill form, these medications are absorbed quickly, usually within 15-20 minutes after being taken by mouth and swallowed. They usually reach their peak level in the blood (and so in the brain) in 60-90 minutes, and may last three to five hours in controlling the symptoms of ADHD in most people. That was their problem. If clinicians wanted to control the symptoms of ADHD across the waking day of say 14-16 hours for most adults, clinicians had to give these medications two to four times per day or more often. The inconvenience that posed for people having to take these drugs is obvious, not to mention the fact that many had to remember to take these drugs so often that they frequently forgot to do so. These and other problems with these immediate-release pills led pharmaceutical companies to explore better ways to get the medicines into the body and keep them active there longer. The brand names clinicians are likely to hear about for these pills are Ritalin® (MPH, a mixture of d-MPH and l-MPH), Focalin® (just d-MPH), Dexedrine® (d-AMP), Benzedrine® (l-AMP), and Adderall® (a mixture of the d- and l-AMP forms or salts).
The Pump Then came the invention of an ingenious water-pump system for delivering these drugs into the body and keeping them in the blood stream longer. The brand name for this system is Concerta® and it contains MPH. It is a capsule-appearing container with a small laser-drilled hole on one of its long ends. Inside there are two chambers. One chamber contains a paste-like sludge of MPH, and the other chamber is empty. There is also powdered MPH coating the outside of the capsule. Now here is the neat part: when adults with ADHD swallow the capsule, the powder goes right to work just as it would in the pill form of MPH described above (i.e., Ritalin). That covers the short time it takes for the capsule to start up its ingenious pumping system. It absorbs water from your stomach (and later your intestines) through the wall of the pump in a continuous, even flow into its empty chamber. As that chamber fills up, it presses against the other chamber that contains the MPH paste. That pressure then squeezes the MPH paste out of the hole in the capsule. It is designed to do that continuously for 8-12 hours or more. The end result is that many people, especially children, only need to take one capsule a day, and not the usual two to three (or more) they would have to take using the regular pills discussed above. The capsules come in various size doses of course so that physicians can adjust the dose to better suit the individual needs and responses of their ADHD patients. One problem though is that some older children and teens, and especially adults, may need a longer course of medication each day than what this provides. To deal with that issue, some physicians use the pills of MPH or AMP toward the end of the day. They do this to get an extra three to five hours of treatment with medication after the Concerta® may be losing its beneficial control of ADHD symptoms. Even so, clinicians just have to love the human ingenuity that led to the development of this delivery system.
The Pellets At around the same time as the water-pump method was being invented, chemical (pharmacological) engineers were modifying a method that uses time-release pellets to create a way to keep medicines in the body and blood stream longer than the pills. This method had been used for years with some cold medicines, like the old Contac brand. But the system had to be modified in various ways for use with MPH and AMP. Now we have time-release pellets for both of these stimulants. Little beads of the drug are coated in such a way that some dissolve immediately after being swallowed, others dissolve one, two, three, or more hours later. This means that the drug can be more gradually activated and absorbed into the blood stream across 8-12 hours for most people. Here is another ingenious delivery system. It has the added advantage that if someone simply cannot or does not want to swallow the capsule that contains these pellets, they can open the capsule (pull it apart) and sprinkle it on a teaspoon of applesauce, yogurt, or other food and swallow it that way. It does not change the way the drug will work in the body, typically. Clinicians may have heard of these delivery systems by the brand names of Ritalin LA® (MPH), Focalin XR® (d-MPH), Medadate CD® (MPH), and Adderall XR® (AMP) here in the U.S. Again, there are different sizes (doses) of these capsules to permit a physician to adjust the dose for each individual to their optimum level. Like the water-pump method above, these time-release pellet systems sometimes have to be supplemented late in the day with a regular or immediate-release pill version of the same drug. That permits even longer symptom control if necessary. Some research exists that shows that this pellet system gives a little better control of ADHD symptoms in the morning than afternoon hours. In contrast, the pump system above provides a bit better control in the afternoon than morning hours. Both delivery systems provide good control of ADHD symptoms across the day but not at exactly the same hours of the day. This can be an issue sometimes in deciding which delivery system may be better for someone depending on when during the day they need the greatest control of their ADHD symptoms.
The Patch The next invention of a delivery system for the stimulants was approved by the FDA just a few years after the two above (pump and pellet). It is a patch with an adhesive coating that is applied directly to the skin, such as on the back of one’s shoulder or on the buttocks. The patch contains MPH. When applied to the skin, the MPH is absorbed through the skin and gets into the blood stream by that means. So long as patients wear the patch, MPH is being delivered into the body for as many hours during the day as one wants. Because the stimulants can cause insomnia or trouble falling asleep, the patch needs to be removed several hours before bedtime to permit the drug left in the body to be broken down and removed without adversely affecting the onset of sleep. This delivery system used to go by the brand name Daytrana® (MPH), but the patent on the device is up for sale and may be purchased by another company and renamed in the future. Here is another clever invention for getting the stimulants into the blood stream and keeping them there for a sufficient time to control the symptoms of ADHD across most of the waking day. It has the advantages of not needing to be swallowed and of delivering the medicine into the blood stream as long as patients are wearing the patch that day. Of course, the disadvantage is that patients have to remember to take the patch off well before they want to go to sleep. Another problem is that 15%-20% of people experience a skin rash at the site of the patch and may need to stop using the patch for this reason. As with the drugs above, the patch comes in different doses to better adjust the amount of the drug to each individual.
The Pro-Drug In 2008, another delivery system received FDA approval for use with adults with ADHD, and that system goes by the brand name of Vyvanse® (a form of AMP). Here is yet a further example of human inventiveness. One of the problems with the immediate release pills as well as with the pellet systems discussed above is that they have the potential to be abused. That is usually done by crushing and inhaling the powder from the pills or the crushed beads from the pellet systems. That powder can also be mixed with water and injected into a blood vein. Whether snorted through the nose or injected into a vein, the stimulants get into the blood very quickly and so into the brain very rapidly. It is this rapid invasion of the brain by the drug and nearly as rapid decrease of activity in certain brain regions that creates the “rush” or euphoria that people can experience with stimulants delivered in this fashion. This effect does not occur from oral ingestion of the drug. This problem led a small biotech company near Albany, NY to invent a method in which the AMP (d-amphetamine) is locked up so that it cannot be activated unless it is in the human stomach or intestines. They achieved this by bonding a lysine compound to the d-AMP. This bonding of an active drug to another compound alters its typical pattern of activation and is called a pro-drug by the FDA. In this form, the AMP is inactive and will remain so until it is swallowed. Then, a certain chemical that naturally occurs in the stomach and intestine splits the lysine from the d-AMP, allowing the d-AMP to go to work and be absorbed into the blood stream. The drug is designed in such a way that the d-AMP lasts 10-14 hours, typically. This delivery system greatly reduces the abuse potential of this version of AMP while providing for the desired longer time course of action from a single dose.
The Delayed Onset Formulations As of this writing (Fall 2018), the FDA approved a new medication delivery system that can be taken at bedtime and that will reliably activate the next morning, typically nine hours later. This system has been developed for delivery of both methylphenidate and amphetamines. Once activated, the system maintains therapeutic blood levels of these medications across the day and into evening hours.
Dr. Barkley’s personal website containing fact sheets on ADHD, his speaking schedule, and information about his various books and newsletter. ADHDLectures.com contains 10 hours of lectures for parents and 25 hours for professionals addressing various topics related to ADHD and its management, all of which can be viewed for free.
ADD Warehouse: addwarehouse.com
Lists a variety of books, videos, and other products related to ADHD for sale.
American Academy of Child & Adolescent Psychiatry: aacap.org
Official website which also contains a separate directory of fact sheets on childhood and adolescent mental disorders.
American Academy of Pediatrics: aap.org
Official website on which one can find some factual information about ADHD and other developmental disorders.
ADDA Organization (Attention Deficit Disorders Association): add.org
This organization advocates for those with ADHD and has, over time, come to focus more on adults with the disorder.
A non-profit organization dedicated to providing information on ADHD. The website claims to host hundreds of service providers and its Information Site has a carefully curated assortment of articles, guides and helpful tips for ADHD, not to mention countless hours of recorded broadcasts and seminars.
Three websites that provide information on the ADHD coaching approach to treatment several of which contain lists of coaching professionals by region.
A website created by journalist, Gina Pera, who also specializes in providing information on ADHD for adults, especially for couples in which one partner has adult ADHD.
CHADD Organization (Children and Adults with ADHD): chadd.org
The U.S. national non-profit organization dedicated to advocating for children and adults with ADHD and their families. Contains fact sheets on ADHD, a directory of state and local CHADD chapters, and information on its annual conferences.
Sponsored by Everyday Health Media, this page of this website has information on the symptoms and treatments for ADHD. The website does accept advertisements for products in the ADHD marketplace.
Bills itself as a trusted non-profit guide to information on mental health and well-being created to the memory of Morgan Segal whose suicide may have been prevented by having better, factual information on mental health disorders and their treatment. The website notes that it collaborates with the Harvard Medical School concerning information posted to the site.
National Institute of Mental Health: help4adhd.org
Co-created with the CHADD organization (see above) this website sponsored by the U.S. federal government offers informative and useful fact sheets about many aspects of ADHD in children and adults.
This website was co-created by two Canadians, one a comedian with adult ADHD and the other a video producer with adult ADHD, who became well-known for their independently produced program, ADHD and Loving It, that aired on many PBS and CBC stations several years ago. It provides a positive, light hearted, and sometimes humorous approach to understanding ADHD in adults.
This is a for-profit website providing information on many medical and mental health disorders including ADHD.
Books and Videos on Adult ADHD
The list below is not intended to be comprehensive or exhaustive but provides those books that Dr. Barkley believes offer useful and evidence-based information on adult ADHD.
Adler, L. (2006). Scattered Minds: Hope and help for adults with attention deficit hyperactivity disorders. New York: G. Putnam & Sons.
Bailey, E. & Haupt, D. (2010). The complete idiot’s guide to adult ADHD. New York: Alpha Books (Penguin Group).
Banaschewski, T., Coghill, D. & Zuddas, A. (2018)_(Eds.), Oxford Textbook of Attention Deficit Hyperactivity Disorder (pp. 94-102). London: Oxford University Press.
Barkley, R. A. (2001). ADHD in adults [DVD]. New York: Guilford Press.
Barkley, R. A. (2013). Taking Charge of Adult ADHD. New York: Guilford Press.
Barkley, R. A. (2015). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2016). When an Adult you Love Has ADHD: Professional Advice for Parents, Partners, and Siblings. Washington, DC: LifeTools, American Psychological Association.
Barkley, R. A., Murphy, K. R., and Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford.
Bramer, J. S. (1996). Succeeding in college with attention deficit hyperactivity disorders: Issues and strategies for students, counselors, and educators. Plantation, FL. Specialty Press, Inc. 300 Northwest 70th Avenue, Suite 102, Plantation, FL.
Brown, T. E. (2013). A new understanding of ADHD in children and adults: Executive function impairments. New York: Routledge.
Brown, T. E. (2014). Smart But Stuck: Emotions in Teens and Adults with ADHD. Hoboken, NJ: Jossey-Bass.
CHADD (2001). The CHADD Information and Resource Guide to AD/HD. Landover, MD: CHADD (301-306-7070; chadd.org)
Gordon, M. & Keiser, S. (2000). Accommodations in higher education under the Americans with Disabilities Act: A no-nonsense guide for clinicians, educators, administrators, and lawyers. New York: Guilford Press.
Gordon, M., Lewandowski, L. J., & Lovett, B. J. (2014). The assessment and management of ADHD in educational and workplace settings in the context of ADA accommodations. In R. A. Barkley (Ed.), Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Goldstein, S. & Teeter Ellison, A. (2002). Clinician’s Guide to Adult ADHD. New York: Academic Press.
Gordon, M., & McClure, D. (2008). The down and dirty guide to adult ADHD (2nd ed.). DeWitt, NY: GSI Publications.
Hallowell, E. M., & Ratey, J. J. (1994). Driven to distraction. New York: Pantheon.
Hallowell, E. M. & Ratey, J. J. (2005). Delivered from distraction: Getting the most out of life with attention deficit disorder. New York: Ballentine Books.
Jacobs, C., Wendel, I. & Cerulli, T. (2010). The everything health guide to adult ADD/ADHD: Expert advice to find the right diagnosis, evaluation and treatment. Fairfield, OH: Adams Media.
Joffe, V. & Iachan, M. (2006). A day in the life of an adult with ADHD. Miami, FL: Vera Joffe, Ph.D.
Kessler, Z. & Quinn, P. O. (2013). ADHD according to Zoe: The real deal on relationships, finding your focus, and finding your keys. Oakland, CA: New Harbinger Press.
Kohlberg, J. & Nadeau, K. (2002). ADHD-friendly ways to organize your life. New York: Routledge.
Levrini, A. & Prevatt, F. (2012). Succeeding with adult ADHD: Daily strategies to help clinicians achieve your goals and manage your life. Washington, DC: American Psychological Association.
Lovett, B. J., & Lewandowski, L. J. (2014). Testing accommodations for students with disabilities: Research-based practice. Washington, DC: American Psychological Association
Matlin, T. & Solden, S. (2014). The queen of distraction: How women with ADHD can conquer chaos, find focus, and get more done. Oakland, CA: New Harbinger Publications.
Nadeau, K. (1994). Survival guide for college students with ADD or LD. Washington, D: Magination Press. Call the ADD Warehouse at 800-233-9273 to order.
Nadeau, K. G., & Quinn, P. (2002). Understanding women with AD/HD. Silver Spring, MD: Advantage.
Orlov, M. (2010). The ADHD effect on marriage: Understand and rebuild your relationship in six steps. Plantation, FL: Specialty Press.
Orlov, M. & Kohlenberger, N. (2014). The couple’s guide to thriving with ADHD. Plantation, FL: Specialty Press.
Pera, G. (2008). Is it you, me, or adult ADHD? San Francisco, CA: 1201 Alarm Press.
Pera, G.A. & Robin, A.L. (2015). ADHD-focused couple therapy: A clinical guide. New York: Routledge.
Puryear, D. A. (2012). Your life can be better, using strategies for adult ADD/ADHD. Minneapolis, MN: Mill City Press
Ramsay, J. R., & Rothstein, A. L. (2014). Cognitive-behavioral therapy for adult ADHD: An integrative psychosocial and medical approach (2nd ed.). New York: Taylor & Francis.
Ramsay, J. R., & Rothstein, A. L. (2014). The adult ADHD tool kit: Using CBT to facilitate coping inside and out. New York: Routledge.
Ratey, N.A. (2002). Life coaching for adult ADHD. In S. Goldstein & A. Teeter Ellison, (Eds), Clinician's guide to adult ADHD: Assessment and intervention. San Diego: Academic Press.
Ratey, N. A. (2008). The disorganized mind: Coaching your ADHD brain to take control of your time, tasks, and talents. New York: St. Martin’s Griffin.
Safren, S. A., Otto, M., Sprich, S., Winett, C., Wilens, T., & Biederman, J. (2005). "Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms." Behavior Research and Therapy, 43, 831-842.
Safren, S., Perlman, C., Sprich, S., & Otto, M. W. (2005). Therapist guide to the mastery of your adult ADHD: a cognitive behavioral treatment program. New York: Oxford University Press.
Sarkis, S. M. (2008). Making the grade with ADD: A students guide to succeeding in college with attention deficit disorder. Oakland, CA: New Harbinger Publications.
Sarkis, S. M. (2011). 10 simple solutions to adult ADD: How to overcome chronic distraction and accomplish your goals. Oakland, CA: New Harbinger Publications.
Sarkis, S. M. & Klein, K. (2009). ADD and your money: A guide to personal finance for adults with attention deficit disorder. Oakland, CA: New Harbinger Publications.
Sarkis, S. & Quinn, P. O. (2011). Adult ADD: A guide for the newly diagnosed. Oakland, CA: New Harbinger Publications.
Solden, S. (2012). Women with attention deficit disorder: Embrace your differences and transform your life (2nd ed). Nevada City, CA: Underwood Books.
Solanto, M. V. (2013). Cognitive behavioral therapy for adult ADHD: Targeting executive dysfunction. New York: Guilford Press.
Surman, C. (2012). ADHD in adults: A practice guide to evaluation and management. Totowa, NJ: Humana Press.
Surman, C., Bilkey, T., & Weintraub, K. (2014). Fast minds: How to thrive if clinicians have ADHD (or think clinicians might). New York, NY: Berkley Trade (Penguin Group).
Thurlow, M. L., Elliott, J. L., & Ysseldyke, J. E. (2003). Testing students with disabilities: Practical strategies for complying with district and state requirements. Corwin Press.
Tuckman, A. (2007). Integrative Treatment for Adult ADHD: A Practical, Easy-to-Use Guide for Clinicians. Oakland, CA: New Harbinger Publications, Inc.
Tuckman, A. (2009). More attention, less deficit: Success strategies for adults with ADHD. Plantation, FL: Specialty Press.
Tuckman, A. (2012). Understand your brain, get more done: The ADHD executive functions workbook. Plantation, FL: Specialty Press.
Wasserstein, J., Wolf, L., & Lefever, F. (2001). Adult attention deficit disorder: Brain mechanisms and life outcomes. In the Annals of the New York Academy of Sciences, Volume 931. New York: New York Academy of Sciences.
Weiss, M., Hechtman, L., & Weiss, G. (1999). ADHD in adulthood: A guide to current theory, diagnosis, and treatment. Baltimore, MD: Johns Hopkins Press
Young, J. (2007). ADHD Grown Up: A guide to adolescent and adult ADHD. New York: W. H. Norton.
Zylowska, L. & Siefel, D. (2012). The mindfulness prescription for adult ADHD: An 8-step program for strengthening attention, managing emotions, and achieving your goals. Westville, South Africa: Trumpeter Publishers
American Psychiatric Association (2013). Diagnostic and Statistical Manual for Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.
Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Ramsay, J. R. (2015). Assessment of Adult ADHD. In Barkley, R. A. (Ed.). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2015). Etiologies. In R. A. Barkley (Ed. ). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2015). Executive functioning and self-regulation as an extended phenotype: Implications of the theory for ADHD and its treatment. In Barkley, R. A. (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed., pp. 405-434). New York: Guilford Press.
Barkley, R. A. (2015). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2015). Educational, occupational, social, and financial impairments in adults with ADHD. In Barkley, R. A. (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2015). Health problems and related impairments in children and adults with ADHD. In R. A. Barkley (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Barkley, R. A. (2012). Executive Functions: What They Are, How They Work, and Why They Evolved. New York: Guilford Press.
Barkley, R. A. (2012). Barkley Functional Impairment Scale. New York: Guilford Press.
Barkley, R. A. (2011). Barkley Deficits in Executive Functioning Scale. New York: Guilford Press.
Barkley, R. A. et al. (2008). ADHD in adults: What the science says. New York: Guilford Press.
Barkley, R. A. & Fischer, M. (2018). Hyperactive child syndrome and estimated life expectancy at young adult follow-up: The role of adult ADHD and other potential predictors. Submitted for review for publication.
Barkley, R. A., Fisher, M., Smallish, L., & Fletcher, K. (2006). Young adult follow-up of hyperactive children: Adaptive functioning in major life activities. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 192-202.
Barkley, R. A. & Murphy, K. R. (2010). Deficient emotional self-regulation in adults with ADHD: The relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities. Journal of ADHD and Related Disorders, 1(4), 5-28.
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford Press.
Buitelaar, J. N. J., Posthumus, J. A., & Buitelaar, J. K. (2015). ADHD in childhood and/or adulthood as a risk factor for domestic violence or intimate partner violence: a systematic review. Journal of Attention Disorders. ePub ahead of print, doi: 10.1177/1087054715587099.
Chronis-Tuscano, A. et al. (2016). Parent ADHD and evidence-based treatment for their children: Review and directions for future research. Journal of Abnormal Child Psychology. Epub ahead of print.
Dalsgaard, S. et al. (2015). Effects of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study. Lancet, 385, 2190-2196.
Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. (2015). Mortality in children, adolescents and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet, 385, 2190-2196.
De Crescenzo, F et al. (2017). Pharmacological and non-pharmacological treatment of adults with ADHD: a meta-review. Evidence Based Mental Health. Epub online ahead of print.
Fedewa, A. et al. (2011). Stability balls and students with attention and hyperactivity concerns: Implications for on-task and in-seat behavior. Journal of occupational Therapy, 65, 393-399.
Field, S. et al. (2013). Asssessing the impact of ADHD Coaching services on university students learning skills, self-rgulation, and well-being. Journal of Post-secondary Education, 26, 67-81.
Flory, K., Molina, B. S., Pelham, W. E., Jr., Gnagy, E., & Smith, B. (2006). Childhood ADHD predicts risky sexual behavior in young adulthood. Journal of Clinical Child and Adolescent Psychology, 35, 571-577.
Frodl, F. T. & Skokauskas (2012). Meta-analysis of structural MRI studies in children and adults with attention deficit hyperactivity disorder indicates treatment effects. Acta Psychiatrica Scandinavica, 125, 114-126.
Gonzalez, R. A., Kallis, C., & Coid, J. W. (2013). Adult attention deficit hyperactivity disorder and violence in the population of England: Does comorbidity matter? PlosOne, 8, e75575, 1-10.
Househam, A. & Solanto, M. (2016). Mindfulness as an intervention for ADHD. The ADHD Report, 23(2), 1-5.
Hoza, B. & Smith, A. L. (2015). Is aerobic physical activity a viable management strategy for ADHD? The ADHD Report, 23(2), 1-5.
Johnston, C. & Chronis-Tuscano, A. (2015). Families and ADHD. . In R. A. Barkley (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
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Knouse, L. E. (2015). Cognitive behavioral therapies for adult ADHD. In R. A. Barkley (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
Knouse, L. E. & Safren, S. A. (2010). Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder. Psychiatric Clinics of North America, 33, 497-509.
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McQuade, J. & Hoza, B. (2015). Peer relationships in children with ADHD.In Barkley, R. A. (Ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.
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See Mike Elgan’s article on this method at the website https://www.computerworld.com/article/2507281/web-apps/elgan--how-to-overcome-internet-distraction-disorder.html
My thanks to David Cravens, Application Developer at Palmetto Health IT, for sharing some of these suggestions with me.
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