Understanding Adult ADHD

What causes ADHD? One thing’s for certain. It is not a result of bad parenting, as some people think. We may disapprove of parents who can’t or won’t restrict Junior’s channel surfing, cell-phone use, texting, and multitasking, but that indulgent parental style has nothing to do with the condition. Parents may be responsible for another reason, however: ADHD is highly heritable. And there is suspicion that conditions in the womb can increase a child’s risk. Studies show that smoking during pregnancy increases the risk that a child will have ADHD, according to psychiatrist Tim Wilens of Massachusetts General Hospital, a specialist in treating adult ADHD. Scientists also suspect that exposure to certain environmental contaminants, such as pesticides, is a factor.

It is not clear why some children grow out of ADHD by adulthood and some do not. But there is no such thing as adult-onset ADHD: If you did not have it as a child, you do not develop it as an adult. Instead, adults with ADHD represent the 60 percent or so of children who did not grow out of it. That’s why a credible diagnosis of adult ADHD requires a paper trail—pediatric medical records, school records, recollections of the adult’s childhood friends and family—indicating that the person had the childhood form, even if it was not formally diagnosed at the time.

Adult ADHD is almost always ADD—that is, without the hyperactivity. Once you reach adulthood, hyperactivity symptoms tend to go away. There are other differences as well, says psychiatrist Jeffrey Newcorn of Mount Sinai. The adult form is characterized more by difficulties with executive functioning than by simple inattention. Executive function is basically the set of neurocognitive processes that let you organize your behavior across time to achieve your goals. These range from small goals like having dinner on the table on time to major ones, such as setting priorities at work and home. “It’s managing your time, organizing your schedule, running your life, meeting deadlines,” said Newcorn, adding, “Adults drift off to other things when they decide the first one is boring or uninteresting. They have a lot of files and programs open on their computer. They might be unable to have a conversation without changing the topic every 30 seconds.” And since deficits in executive function lower inhibition, “an adult with ADHD is more likely to say inappropriate things at meetings,” says Newcorn. “Colleagues sometimes interpret the behavior as a need for attention or a refusal to get with the program.”

And although the hyperactivity component is rare, it is not unheard of. “You do find some adults with ADHD who race around all the time and can’t relax,” says Newcorn. Some use drugs such as marijuana “to self-medicate, to relax,” saying, “it really helps me slow my thoughts.”

Although most people think of adult ADHD as impairing performance at work or school, it can also throw a wrench into relationships. “The ADHD spouse will tend to have lots of ideas but have a hard time following through,” says Robin, citing personal experience; that brilliant plan to redo the bedroom winds up with the room remaining a construction zone for months. “They also find it hard to move from the big picture to details,” she says, so let’s go away for the weekend never results in actual reservations at that quaint inn.

“We go from A to B to C to Z,” says Robin, “and the non-ADHD spouse has a hard time following.”

As with almost every mental illness, a combination of medication and psychological therapy can markedly reduce symptoms of ADHD in adults. Stimulants such as Ritalin (methylphenidate), which are also used to treat childhood ADHD, help many adults as well, says Wilens. So does Strattera (atomoxetine), which the FDA approved for adult ADHD in 2002. Still, “the evidence supporting the use of (drugs) for adults with ADHD remains less established” than it is for children, and most studies were short term, Wilens and colleagues concluded in a review article last October. “With medication, you typically see a clinically significant improvement in symptoms by six weeks, once you get the dose right,” says Wilens. But that falls short of a true cure. “You might not be as distracted, but you’re still distracted. You still have to monitor your environment to minimize distractions,” he says. Scientists believe the drugs work, to the extent they do, by targeting the neurochemical systems that seem to underlie ADHD: dopamine and norepinephrine. Both are in areas of the brain that imaging has shown to be affected in ADHD, the former in reward circuitry and the latter in attention circuitry.

Adults with ADHD also benefit from cognitive-behavioral therapy. They learn, for instance, to understand the environmental conditions that increase distraction and develop strategies to minimize them.

Even as adult ADHD gains recognition from health experts, it tends to have a bad reputation among the rest of us. To many, it’s a great excuse for why a co-worker didn’t finish his part of the group assignment on time or a trendy amateur diagnosis applied to people who refuse to buckle down and focus. It is, to skeptics, a set-up for a joke: “the man with adult ADHD was trying to daydream but his mind kept wandering.”

Those with a formal diagnosis are eligible under the Americans With Disabilities Act for “reasonable accommodations” at work. What does that mean? It can be as simple as allowing the ADHD worker to use headphones to listen to music—“sometimes an ADHD brain needs something to occupy part of it so other parts can focus,” says Robin. Someone with ADHD might focus better if she takes more frequent breaks, or checks in with a supervisor more frequently to make sure of staying on task. Which is not to say there is not abuse.

When baseball player Andres Torres began to speak publicly about his struggles with ADHD, there were snickers: Players with ADHD are allowed to take otherwise banned drugs—in this case, stimulants. Last season, of 111 drug exemptions the major leagues granted, 105 were for ADHD.

One was for Andres, an outfielder who struggled after signing with the Detroit Tigers in 1998, spending a decade in the minor leagues. He was diagnosed with ADHD in 2002 and began taking medication. As one sports writer put it, “Discerning a fastball from a changeup is difficult enough; imagine doing it with untethered focus, attention meandering.” On the medicine, his batting average soared, and he finally reached the major leagues in 2009. “Everything started clicking,” Andres told The New York Times. Having the disorder, he said, “is like being in your own world.”

To read comments from Ty Pennington, Andres Torres, and others with ADHD, visit saturdayeveningpost.com/adhd.

Sharon Begley’s last article for the Post, “The Cholesterol Conundrum,” appeared in the May/Jun issue.