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Explore these common questions about ADHD:

Sarah was one of those kids who constantly lost her mittens or forgot where she left her backpack. Her bedroom was a disaster area; she put off cleaning just like she put off homework, which always felt so hard to begin, even when she fully understood the material.

Still, Sarah was smart and motivated, and managed to get good grades. And because she was well-behaved and a “lifelong perfectionist,” her parents and teachers never suspected anything might be wrong.

“I figured out how to cover up how much I was actually struggling,” recalls Sarah, whose last name has been omitted to protect her privacy.

It was only decades later, after years of falling behind on work responsibilities and apologizing for showing up late to events, that Sarah sought an explanation. Finally, at age 40, she was formally diagnosed with attention deficit hyperactivity disorder (ADHD).

Though we tend to associate ADHD with kids, Sarah’s story is more common than you might think.

ADHD diagnoses have been rising steadily for the past two decades, and in one population in particular: adults. ADHD diagnoses in this demographic have increased at more than four times the rate of diagnoses among children. Why?

It’s likely not because more adults are suddenly developing ADHD. While researchers are beginning to consider the possibility of adult-onset ADHD, historically an adult diagnosis has required that symptoms be present in childhood.

Yet ADHD symptoms are often missed or misdiagnosed during adolescence. This, coupled with an increased awareness of the disorder, helps explain why three in four adults with ADHD never received a diagnosis in childhood.

ADHD is a common, but also complicated, disorder. It’s easily missed, often dismissed, and frequently misunderstood. A variety of treatments exist, ranging from the well-researched to those backed only by anecdotal evidence (or little evidence at all).

Let’s set the record straight, first, with a brief refresher on what ADHD is and isn’t.

What Is ADHD?

ADHD is characterized by deficits in attention or impulse control, more commonly described as hyperactivity, or both. Individuals with inattentive-type ADHD tend to be easily distracted, make careless mistakes, struggle to stay organized, and are prone to losing or misplacing things.

Those with hyperactive-type ADHD struggle to sit still or wait their turn and tend to interrupt or talk too much. Some individuals do a bit of both, demonstrating what’s known as combined-type ADHD.

ADHD is characterized by deficits in attention or impulse control, more commonly described as hyperactivity, or both.

To be diagnosed with ADHD, symptoms must be present across a variety of contexts. A person who only interrupts at family gatherings or only gets distracted when their phone is nearby would not meet the disorder’s criteria. Nor would someone whose symptoms are better explained by another psychological condition, such as depression, anxiety, posttraumatic stress disorder (PTSD), or by a medical ailment such as poor vision or hearing.

Left untreated, ADHD can be debilitating. Work performance can suffer, relationship conflict can ensue, and the daily tasks of living — washing dishes, paying bills — can seem insurmountable. Yet with education, support, and interventions, adults with ADHD can lead healthy lives in which ADHD symptoms don’t have a significant effect on their daily activities.

Is ADHD Overdiagnosed, Underdiagnosed, or Misdiagnosed?

Answer: All of the above.

ADHD can look like many other issues, and many other issues can look like ADHD. Unless the diagnosing clinician does a full inventory of an individual’s history, lifestyle, and environment — and, ideally, incorporates some of the other assessment tools described below —  they’re at risk of misdiagnosing someone with ADHD when the issue is, in reality, something else entirely.

This is especially true when it comes to other mental health disorders. Compare the diagnostic criteria for ADHD with other common disorders and you’ll see many overlapping symptoms.

For instance, two of the six criteria for generalized anxiety disorder — restlessness and difficulty concentrating — mirror the criteria for ADHD, so what looks like ADHD might actually be anxiety (or vice versa). The chance for misdiagnosis is strong, especially among people who can’t accurately articulate their mental health struggles, such as kids.

“The rise of cellphones and shorter snippets of media are absolutely impacting our attention spans. Our brain gets tired when it’s constantly asked to change focus, which makes it hard to pay attention to the present.”

Physical impairments can also mimic ADHD symptoms. Poor hearing, for example, can manifest in difficulty paying attention, following instructions, or contributing to conversations appropriately. Various lifestyle factors may also simulate symptoms: Poor diet, elevated stress, and inadequate sleep can all impair our ability to focus.

We also live in a world designed for endless distraction, meaning all of us are vulnerable to attention impairments.

“The rise of cellphones and shorter snippets of media are absolutely impacting our attention spans,” says integrative psychiatrist Henry Emmons, MD, who has extensive experience treating adults with ADHD. “Our brain gets tired when it’s constantly asked to change focus, which makes it hard to pay attention to the present.”

Are Some People More Likely to Go Undiagnosed Than Others?

Certain demographics are more likely to have their ADHD symptoms overlooked or misdiagnosed in childhood.

Most studies suggest a divergence in diagnoses between genders. Individuals identified as girls in these studies are more likely to exhibit symptoms of inattention, while hyperactivity is more common in participants identified as boys, though some studies point to hyperactivity symptoms being equally prevalent across genders, just less likely to be noticed among girls.

Inattention is far more subtle — think daydreaming or being easily distracted — and therefore much easier to go undetected (as was the case with Sarah). Hyperactivity manifests in visible and disruptive behaviors, and so tends to draw attention from parents and teachers.

Inattention is far more subtle — think daydreaming or being easily distracted — and therefore much easier to go undetected. Hyperactivity manifests in visible and disruptive behaviors, and so tends to draw attention from parents and teachers.

This helps explain why, in childhood, boys are diagnosed with ADHD four times more often than girls, according to some estimates, while the ratio is nearly equal among adults. It’s not that girls are necessarily less prone to develop ADHD; it’s just that their ADHD symptoms are more likely to fly under the radar.

Racial bias impacts diagnostic trends as well. ADHD has historically been less frequently diagnosed among young people of color, who are at a greater risk of being diagnosed with behavioral disorders such as oppositional defiant disorder or conduct disorder. Additionally, studies have shown that clinicians tend to be more responsive to a parent who suspects their child might have ADHD if that parent is white.

Socioeconomic status is another variable that can impact diagnosis. Many diagnostic tools — including computerized continuous performance tests — are expensive and difficult to access, explains clinical psychologist Marc Mooney, PhD, LP, who specializes in adult ADHD testing. He commonly sees six-month waitlists for adult ADHD testing and notes that without insurance, out-of-pocket exam costs can hit $2,000.

“Folks from a lower socioeconomic status often have less access to medical services, are less likely to have quality insurance, and simply have less time and resources,” adds interventional psychiatrist Brent Nelson, MD, who works with adults with ADHD at PrairieCare, noting that these issues are further magnified among immigrants and non-native English speakers.

What’s Behind the Rise in Adult ADHD Diagnoses?

The concept of ADHD only formally entered the psychological lexicon in 1968. It was described in that year’s edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the American Psychiatric Association’s official classification and diagnostic tool. That second edition of the DSM listed ADHD as “Hyperkinetic Reaction of Childhood,” a description that set the stage for several decades of the disorder being viewed as something only children experienced and would in most cases outgrow. It became known as ADHD in the third edition of the DSM, published in 1987.

But research increasingly demonstrated that symptoms could persist beyond childhood and often manifested in conjunction with other disorders, so the diagnostic criteria expanded.

The fifth edition of the DSM, published in 2013, noted for the first time that ADHD could be diagnosed if the onset of symptoms occurred after age 7, although it requires symptoms to be present by or before age 12. That edition of the DSM also allowed for more dual diagnoses — the possibility for clinicians to diagnose two concurrent disorders, such as ADHD and autism spectrum disorder.

Taken together, these changes now enable clinicians to cast a much wider net when diagnosing ADHD. And this has had an enormous impact on who can be diagnosed today as compared with even 10 years ago.

An individual with ADHD who grew up in the ’90s or early 2000s had a higher likelihood of being un- or misdiagnosed than a kid today. An individual who grew up in the ’70s or ’80s would have been even more likely to fly under the radar. And those who exited early childhood before 1968 could not have been diagnosed at all.

Alongside greater understanding in the mental health field has come greater advocacy in the world at large.

Both Mooney and Emmons attribute at least some of the rise in adult ADHD diagnoses to the fact that a generation of parents now recognize symptoms in their children that were missed or misdiagnosed in their own childhood.

In 1987, advocates founded the support group Children and Adults with Attention-Deficit/Hyperactivity Disorder. CHADD was needed because “[a]t that time, one could turn to very few places for support or information,” the group’s website notes. “Many people seriously misunderstood ADHD. Many clinicians and educators knew little about the disability, and individuals with ADHD were often mistakenly labeled ‘[as having] a behavior problem,’ ‘unmotivated,’ or ‘not intelligent enough.’ ”

Today, there is an official ADHD awareness month (October), magazines focused on individuals with ADHD (ADDitude), and books on everything from parenting boys with ADHD to the effects of ADHD on marriage.

Increased awareness of ADHD has likely contributed to the increased rate of diagnosis — especially when that awareness hits close to home. Both Mooney and Emmons attribute at least some of the rise in adult ADHD diagnoses to the fact that a generation of parents now recognize symptoms in their children that were missed or misdiagnosed in their own childhood.

“Remember, ADHD has a large genetic component,” explains Emmons. “So, it’s common to see patterns across generations.” 

How Is ADHD Diagnosed?

Proper assessment of adult ADHD entails gathering information from a variety of sources.

Mooney starts with a comprehensive diagnostic interview to learn more about a patient’s family history, medical history, and current lifestyle. This allows him to rule out external variables, such as life changes or stressors, as well as other mental or physical disorders that might better explain attention issues.

Because symptoms must have been present prior to age 12, Mooney uses the Conners’ Adult ADHD Diagnostic Interview for DSM-IV. The CAADID is a structured interview designed to elicit recollections of childhood symptoms; there’s also the option of having parents provide information. Evidence of attention deficits in childhood is key to an accurate diagnosis, but Mooney concedes that he’s often working with less-than-perfect information.

“It’s difficult for most people to recall anything before age 12,” he notes. “Ideally, we would get information from a parent to fill in the blanks, but that’s not always an option.”

A more objective solution is provided by assessments like the Test of Variables of Attention (TOVA). Mooney relies on these and similar computerized tests to measure a client’s focus, consistency, impulsivity, and speed of response to visual or auditory stimuli.

Finally, Mooney assesses how symptoms impact current functioning: How well is the patient performing at work? Have they faced any disciplinary issues? How are things going at home and in their relationships?

How Do Symptoms of ADHD Show Up in Adults Compared With Kids?

ADHD is a neurological disorder, which means it does not resolve with age. An individual with ADHD will not “outgrow” their symptoms; rather, those symptoms will manifest in different ways and in different contexts.

“In adults, I keep an eye out for warning signs like struggling to hold a job or constantly procrastinating,” says Emmons. People with ADHD often wait until the last minute to complete tasks, he adds, because the rush of stress can be stimulating.

Nelson looks for difficulty keeping up with household chores, bills, and schedules. He notes that adults with ADHD often have partners frustrated by their inability to follow through with these responsibilities.

“More often, adults with ADHD will swing back and forth between being hyperfocused — losing themselves in an activity for hours at a time — and being unable to focus at all.”

Indeed, the impact of ADHD on relationships is another area in which adults and children differ. We tend to extend kids some slack when it comes to social skills, but adults who struggle to sustain attention in conversations or fail to follow through with commitments may not elicit such patience. Friends or partners may view such symptoms as signs of irresponsibility or disinterest.

Still, all brains mature with age and certain symptoms tend to wane as executive functioning improves. Impulse control, in particular, may improve as individuals with ADHD enter adulthood.

“Adults are less likely than kids to be hyperactive, since most of us simply get better at sitting still with age,” says Nelson. “More often, adults with ADHD will swing back and forth between being hyperfocused — losing themselves in an activity for hours at a time — and being unable to focus at all.”

For ADHD Treatment, Is Medication Effective — or Even Safe?

There are a wide range of ADHD medications in both the stimulant and nonstimulant class. By increasing dopamine levels in the brain, stimulants allow neurotransmitters to function more effectively; this improves executive functioning tasks like impulse control, working memory, and selective attention, all of which tend to be challenging for an ADHD brain. Stimulants are fast-acting, so you’ll know quickly whether they’re helpful. Nonstimulants take a little longer to become fully effective — often between two and six weeks — but you can usually tell fairly rapidly whether the medication is a good fit.

Finding the right medication fit while navigating potential side effects can be a daunting task. Stimulant medications can bring on increased anxiety, poor sleep, and appetite suppression, as well as prompt generally mild increases in heart rate and blood pressure, which some experts worry could raise the risk of serious issues such as heart attacks and strokes for some people.

Nonstimulant medications may be more appropriate for those with a history of stimulant addiction or a contraindicated condition such as hypertension.

To shepherd his patients through this process, Nelson generally starts with a low dose to ensure they can tolerate the medication, then adjusts the dose as needed. He describes the process as a “fact-finding mission,” during which he and his patients assess benefits against side effects until they find the right fit.

The impact can be profound, especially when medication is started early in a patient’s life. Individuals often experience improvements in work or school functioning, reductions in impulsivity and delinquent behavior, and an overall boost to their self-image.

Mooney compares stimulant medication with prescription glasses: Both improve focus by correcting a physiological impairment, but just as glasses don’t give you x-ray vision, medication won’t give you mental superpowers.

As with any treatment, however, it’s wise to temper expectations. Mooney compares stimulant medication with prescription glasses: Both improve focus by correcting a physiological impairment, but just as glasses don’t give you x-ray vision, medication won’t give you mental superpowers.

“Symptoms may only improve 10 to 15 percent,” he says. “But this alone can be huge.”

There can be other issues with medications, too. Some people grow accustomed to the drugs and find that they lose efficacy over time; patients then sometimes have to switch it up.

When medication works, it can become a lifetime strategy for some people. But others may be able to lower the dosage or discontinue it entirely in favor of other strategies. When weaning off medication, tapering down rather than quitting cold turkey is the safest method.

Can Diet, Supplements, or Exercise Improve ADHD Symptoms?

For some adults with ADHD, lifestyle changes can prompt significant improvements.

Because our brain is fueled by the foods we eat, researchers have explored whether diet can cause — or even improve and possibly resolve — neurological disorders like ADHD. Studies have indeed linked the typical American diet — laden with processed foods, saturated fats, and sugars — with ADHD, even when controlling for other factors.

While it’s unlikely that any one vitamin, nutrient, or dietary regimen can effectively replace ADHD medication, diet should absolutely be considered part of one’s treatment arsenal. Here are some of the most promising dietary interventions.

• Vitamin D is one of several vitamins and minerals that have shown potential for reducing ADHD symptoms. Believed to be neuroprotective, vitamin D may be key to mitigating cognitive impairments associated with ADHD. Supplementation appears to reduce symptoms in children as an adjunctive therapy to the common ADHD medicine methylphenidate, although only among those who were below baseline vitamin D levels. (For more on vitamin D, see “Vitamin D: What You Need to Know.”)

• Omega-3 and omega-6 fatty acids are known brain boosters that can improve ADHD symptoms, including inattention, impulsivity, and hyperactivity. Fish, nuts, and seeds provide omega-3s, whereas omega-6 fats are prominent in vegetable oils. (For more on omega fatty acids, see “The Omega Balance.”)

• Iron and zinc regulate neurotransmitter metabolism, and low levels of one or both elements have been associated with ADHD. Adding these elements into one’s diet seems to help: Iron and zinc supplementation have been correlated with mild reductions in some ADHD symptoms.

• Plant-focused diets can offer numerous benefits. Exposure to heavy metals like mercury and lead in utero or during childhood is a well-known risk factor for ADHD; a plant-heavy diet may alleviate the metals’ lingering effects. The most effective detoxifiers include tomatoes, onions, berries, grapes, and spirulina, a type of algae.

Eating more vegetables can also boost overall health, including by supporting mitochondrial function and energy, reducing inflammation, providing essential nutrients and fiber, and supporting your microbiome. (For ways to get more veggies in your diet, see “How to Eat More Veggies.”)

• Ketogenic diets limit carbs and proteins in favor of high-fat foods, and a significant body of research suggests that such diets may offer relief for a host of psychiatric disorders, including depression, anxiety, and ADHD. Hyperactivity symptoms could see the greatest improvement: Keto diets have been shown to help regulate blood-glucose levels, which, when disrupted, can impair self-control.

• High-protein, low-carb diets may reduce neuroinflammation, Emmons says, and numerous studies have linked ADHD with inflammation, though the direct connection remains unclear. He recommends combining this diet with vigorous exercise, which can mimic what stimulant medications do by promoting the release of the neurotransmitters and hormones noradrenaline and dopamine.

Eliminating common food allergens like dairy and gluten can yield a positive overall effect. While it’s not known whether allergic reactions cause ADHD, several studies have demonstrated that an oligoantigenic diet, or “few foods” diet, can mitigate symptoms. However, maintaining such a diet requires diligence. Though you may reintroduce certain foods at some point, you may need to subsist on highly focused meals (think rice, meat, and some vegetables) for some time.

• Other supplements, like magnesium and ashwagandha, are known for their calming properties and are sometimes part of Emmons’s recommendation. L-theanine, an amino acid that has been shown to improve sleep and reduce acute stress reactions, can also be beneficial. (For more on L-theanine, see “What Are the Benefits of L-Theanine?“)

“For many people, it’s a combination of medication, natural therapies, and lifestyle changes that does the trick,” says Emmons. “Finding that combination can be a process that takes time and requires fine-tuning.”

(For more on natural supplements to boost mental health, see “8 Key Supplements to Boost Your Mental Health — Naturally.”)

Alongside evidence-based interventions, anecdotal advice abounds — though there may be limited or no research to support such advice — including the following:

  • Cannabidiol (CBD) has emerged as a popular treatment for numerous mental and physical conditions, and some individuals with ADHD preach its benefits. Yet few if any studies back up this claim, and for his part, Emmons considers the chemical a mixed bag. “CBD can help mitigate anxiety and insomnia,” he explains, “but it’s not necessarily effective in promoting focus.”
  • Caffeine is an old stimulating standby, but how effective is it truly? “I think of coffee as a poor substitute for stimulants,” says Emmons. “The initial effect is similar, but caffeine is short-acting and can disrupt sleep and cause agitation.”

(For more on nutrition and ADHD, see “Connecting ADHD and Nutrition” and “A Guide to ADHD Nutrition: Foods to Eat and Foods to Avoid.”)

Can You Make Your Life More ADHD-Friendly?

We all perform executive functions, like time management, goal setting, and impulse control, more effectively when we’re well rested and relaxed. So, Nelson encourages his patients to incorporate good sleep hygiene, meditation, and other practices that help mitigate stress into their daily lives.

Nelson also teaches his patients to make their day as ADHD-friendly as possible by breaking tasks into bite-sized chunks and limiting excess stimulation, which can include anything from desk clutter to phone notifications.

Nelson also teaches his patients to make their day as ADHD-friendly as possible by breaking tasks into bite-sized chunks and limiting excess stimulation, which can include anything from desk clutter to phone notifications.

“I see ADHD as a signal-to-noise problem,” he explains. “If there’s too much mental noise, individuals expend a ton of energy just trying to function.”

Thankfully, there’s no shortage of resources for adults seeking ADHD-oriented organization, focus, and time-management techniques. Tips range from the practical — opt for a small desk to limit clutter; buy colorful versions of easy-to-lose items — to the personal: In an article for ADDitude, ADHD advocate Ben Glenn recommends enlisting a trusted friend to help prioritize goals and intentions.

When possible, Nelson encourages adults with ADHD to pursue types of work that “fit their brains.” Jobs that hit the stimulation sweet spot might include those involving children, such as teaching; those requiring moderate physical activity; and those in which periods of pressure are counterbalanced by periods of calm (think firefighters or EMTs).

Are There Other Alternatives to Medication?

There’s some evidence that ADHD brains can be trained to build better neural habits.

Neurofeedback is a form of electroencephalographic (EEG) biofeedback that transforms brain functioning into real-time auditory and visual cues, enabling participants to track and ultimately control their underlying neural activity.

Because it teaches the brain to self-regulate, neurofeedback seems to be a good fit for individuals struggling with the poor impulse control and other executive-functioning concerns characteristic of ADHD; several studies have supported its efficacy in improving attention, at least among children. However, other studies have contradicted these findings, and the treatment is not accessible or cost-effective for many.

More accessible are the range of brain-training apps and games such as CogniFit, Elevate, and Lumosity. Designed to hone deficits in memory, processing, and focus, these apps are free of side effects and accessible to anyone with a smartphone. Evidence for their efficacy remains slim, however. The only FDA-approved, clinically proven gaming treatment is EndeavorRx, which is available by prescription only and designed for kids rather than adults.

Amid these tech-forward treatments, one of the oldest forms of mental stimulation seems to hold substantial promise. A growing body of research suggests music can help ADHD brains effectively hone and direct attention. Studies suggest that classical music in particular can both improve a person’s mood and offer ADHD brains a just-right amount of arousal.

Though the evidence remains anecdotal, some individuals with ADHD recommend binaural beats and 8D music. Binaural beats incorporate two distinct frequencies played in each ear, which trick the brain into creating a third frequency. 8D music uses audio effects to make it seem as though sounds are coming from different directions. Both are believed to promote calm and focus. (For more on music and ADHD, see “Can Music Help People With ADHD Focus Better?”)

Alexandra
Alexandra Smith, MA, LPCC

Alexandra Smith, MA, LPCC, is a licensed professional clinical counselor in Minneapolis and an Experience Life contributing editor.

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