Why is ADHD often undiagnosed in adults?
About 4 per cent of adults in the United States have enough symptoms to qualify for ADHD, but only an estimated 1 in 10 of them is diagnosed and treated. For comparison, roughly 9 per cent of children in the United States have been diagnosed with the condition, and three-quarters have received medication or behavioural therapy for it.
One reason for the lack of diagnoses in adults is that when people think of ADHD, they often imagine a boy who can’t sit still and is disruptive in class, said Dr Deepti Anbarasan, a clinical associate professor of psychiatry at the New York University Grossman School of Medicine. But those stereotypical hyperactive symptoms are present in just 5 per cent of adult cases, she said.
Instead, symptoms such as forgetfulness, trouble focusing, organisation problems and procrastination — what experts call inattentive ADHD (as opposed to hyperactive ADHD) — are more common in adults. “With adults, it’s oftentimes not necessarily hyperactivity or impulsivity, it’s more executive functioning issues,” Anbarasan said. “It’s more subtle.”
ADHD may also be misdiagnosed as another psychiatric condition. For example, it is common for people with ADHD to have problems with emotion regulation; people can be quick to anger or have dramatic mood swings. Excessive worry and anxiety can also occur, sometimes because of the ADHD symptoms themselves. As a result, many adults may have been diagnosed with depression or anxiety when the root problem is actually ADHD.
How do you diagnose adult ADHD?
There are three main questions a psychiatrist will go over with you to help determine whether you have normal inattention or forgetfulness or ADHD: How many symptoms do you have? Have you had them since childhood? And do they affect two or more parts of your life?
The last two are particularly helpful in determining whether someone will be diagnosed, said Craig Surman, a psychiatrist who runs the Adult ADHD Research Program at Massachusetts General Hospital. Once those have been established, he said, “you really winnow out a number of people.”
A person must have five out of nine symptoms listed in the official psychiatry diagnostic manual to qualify for inattentive ADHD. These symptoms loosely fall into three categories: problems with productivity or performance (procrastinating at work or failing to finish chores); memory (frequently losing your phone or keys or forgetting to pick up milk on your way home); and organization of objects and time (having a cluttered house or always running late).
These symptoms must negatively affect two or more parts of life, such as work, home and relationships. If your house is a mess, but you’re successful at work and your personal life is rich and fulfilling, you probably wouldn’t qualify for a diagnosis.
The symptoms also must have been present since before you were 12 years old. In the eyes of most clinicians, ADHD is a neurodevelopmental disorder, meaning it started when the child (and their brain) was young. This can be the most difficult to determine because people might have received assistance or compensated for their symptoms without realising it. For example, a parent may have provided them with daily reminders to finish homework that helped get them through school.
“They’ve had the disorder probably for most of their lives, but they’ve learned how to cope with it in various ways,” Anbarasan said. “They’ll be people who write everything down or they follow a structure very well and they put a lot of time and effort into organizing themselves.” Many people don’t recognize something is wrong until the demands and responsibilities of adulthood add up and the systems they’ve been using begin to fail.
This can be especially true for women. Boys are roughly twice as likely to be diagnosed with ADHD in childhood as girls are because, even at young ages, girls’ symptoms tend to be more inattentive than hyperactive in nature. As a result, girls with ADHD might struggle a bit in school or be seen as quiet daydreamers, but evade diagnosis because they aren’t noticeably disruptive in class or at home.
If you are seriously concerned about your attention but didn’t have ADHD symptoms in childhood, your problems could be caused by another medical or psychological issue — recent traumatic or stressful events, changes in sleep or substance use behaviours, other psychiatric conditions, or even the early onset of a neurodegenerative disorder — that you might mistake for ADHD.
“There’s at least a dozen psychiatric conditions and cognitive conditions that can mimic ADHD, as well as a substantial list of medical conditions,” Nigg said. “When somebody thinks they have ADHD, I would recommend a full work-up.”
What options are available if you are diagnosed?
The good news is that ADHD is fairly easy to treat. Stimulant medications such as Ritalin or Adderall are effective at helping people harness their attention. Another class of drugs, called alpha-2 agonists, were originally developed to treat high blood pressure but are also sometimes prescribed for ADHD. These medications can help people focus without many of the unpleasant side effects of stimulants, such as trouble sleeping or decreased appetite.
Non-pharmaceutical treatments, such as behavioural coaching and therapy, can also be useful. These techniques help people understand how ADHD affects their daily lives and gives them strategies to cope.
Because stimulant medications can be abused, the question of when and how to treat people with ADHD can be a tricky one for clinicians. “I see part of the diagnosis as, ‘Are they unhealthy because of it?’ And that’s different than, ‘Are they unproductive because of it?’” Surman said. If someone meets the diagnostic criteria, but the symptoms don’t cause them much distress and they’re generally functioning well day-to-day, Surman said he tends to recommend strategies like coaching and behavioural therapy over medication.
Regardless of your recommended treatment plan, it’s important to take ADHD seriously. Untreated, people with the condition have a higher risk of early death, both from accidents and suicide. They are also more likely to have problems with their finances, legal issues, substance use, unsafe sexual behaviour and unsafe driving. But with effective treatment, those risks are dramatically reduced.
This article originally appeared in The New York Times.
Written by: Dana G. Smith
Photographs by: Pierre Buttin
©2022 THE NEW YORK TIMES
