Four percent of adults in the US are diagnosed with ADHD. Adults with ADHD experience many of the same symptoms as children, including problems with self-regulation, attention, and behavior. However, adult ADHD has unique characteristics and increasingly co-occurs with other conditions. Dr. Craig Surman explains how ADHD is diagnosed in adults, the challenges they face, and how other conditions can mimic ADHD. He points out that unlike for children with ADHD, there is less support for adults with ADHD.
Craig Surman, MD
Craig Surman, MD, is an associate professor of psychiatry at Harvard Medical School and scientific coordinator of the adult ADHD research program at Massachusetts General Hospital. He is the author of Fast Minds: How to Thrive if You Have ADHD (Or Think You Might) and editor of ADHD in Adults: A Practical Guide to Evaluation and Management. Dr. Surman has directed or facilitated over fifty studies on the impact of ADHD in adults. He is co-chair of CHADD’s professional advisory board.
Listeners will be able to:
- Discuss the diagnosis of ADHD in an adult.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You are listening to Pocket MD, training on ADHD in children and adults.
Dr. Eugene Arnold: I am Dr. Gene Arnold, professor emeritus of psychiatry and behavioral health at Ohio State University, and CHADD's resident expert. We have a podcast for you today on a timely topic, the occurrence of ADHD in adulthood. Dr. Craig Surman is here with us to elaborate on that. And Craig, before we begin, would you introduce yourself?
Dr. Craig Surman: Thank you for the welcome, Gene. I am Dr. Craig Surman. I am a scientific coordinator at the adult ADHD research program at Mass General Hospital and associate professor at Harvard Medical School, and very proud to be involved with Children and Adults with ADHD, which is sponsoring this podcast, as a co-chair of the professional advisory board.
Dr. Eugene Arnold: First, we should define ADHD. Exactly what is it?
Dr. Craig Surman: So, it’s a syndrome that is recognized by behavioral manifestations, and the typical challenges are those of self-control. And in the lifespan, it manifests in different ways, because as we age, we have different basic fundamental abilities in self-control, I think. But at the extremes, people have trouble with paying attention as they and others want them to and controlling their behavior as they and others want them to.
Dr. Eugene Arnold: Well, how common is this in adulthood?
Dr. Craig Surman: So, it depends how you define it. But by the diagnostic manual, the DSM definition, we think about 4% of the adult population in the US from sort of some of our best epidemiologic data. But world epidemiological data suggests anywhere between the 2% to up to 5% of the population can meet criteria. One of the challenges is identifying the difference between people with symptoms and people with actual full impairment because of those symptoms, which is what you need for a diagnosis.
Dr. Eugene Arnold: The important issue of impairment, because if without impairment, there’s no disorder. How does ADHD manifest differently in adulthood? Or is it different in any way?
Dr. Craig Surman: Because we try to find labels in mental health and in medicine to differentiate syndromes from each other, there’s sort of a core set of features, which are quite similar in children and adults, and it is about self-regulation, problems controlling attention and problems controlling behavior. So, that core remains true through children and adults; however, adults are more behaviorally in control than children, and so, it’s unlikely you're going to see as much physical activity and as much inappropriate behavior from an adult perspective. I'd like to say that I'd be more concerned if an adult is climbing on the chairs in my waiting room at the clinic, than if a child is. And that is just to show that this sort of a base level of self-control, which probably increases as we get older and into the older age, it may decrease again in ways that may be worth discussing.
But one of the other major challenges that we see is that as people get older, there’s two other major factors I think, and what we think about clinically and one is the co-occurrence of other conditions increases. So, by the 20s to 30s, a lot of our other mental health conditions have really sort of shown up if they are going to be present in a person's life, and then about 60% of adults with ADHD are going to have another condition. But also, the environments that people are in. There may be quite a difference between a child who is well-supported with parents and you know a herd of kids that are around them doing the same thing to help them be in control versus adults alone, running their own life. So, it may not be that people are impaired more as they are in the younger ages than in the older ages, it’s just more different manifestation, but the base ability to self-control probably improves. The consequences may be greater as we get older of not being able to do it well, and its dynamic in that people may have other conditions that evolve into their lives, but also the environments that they are operating in may be more or less conducive to them functioning well.
Dr. Eugene Arnold: You mentioned that the consequences may be greater in adulthood because the expectations, of course, of adults are greater. Deviation from that is more egregious. So, exactly what kind of impairments; how would ADHD symptoms impair adult functioning?
Dr. Craig Surman: We by definition require impairment in two of three major life roles. So, from that lens, we’re thinking about self-care, sort of social involvement, which could be domestic or with friendships, etc., or work or school. And those are kind of lumped together, performance at tasks that the outside world expects. And so, you want to look for impairment in two of those three areas, self, social, and work or school. I think often what presents in a story of ADHD is underperformance relative to potential either as perceived by the individual or by others. And so, you get a story of a lot of effort with less return. So, people may be on top of one area of their life, and no one necessarily knows that they’re struggling, but gosh, it’s taken a lot of work to pull that off. Late nights at the office mean less time at home to help out your partner or even to form a family. Sort of, you know, challenges controlling your impulsive comments socially: I mean, it’s going to take longer to find that partner who actually tolerates the first impression and gets to know you deeper, right? So, people will have a harder time.
Dr. Eugene Arnold: And the fact that there is a higher divorce rate with ADHD.
Dr. Craig Surman: Right, there is a higher divorce rate. And I think that we do not know how that compares to other conditions, but it’s just one example of where people struggle. I tend to think, though, that it’s often a relative challenge that a person has that is exacerbated. I mean, it’s classic. You will see it with kids who, say, have a learning disability like dyslexia, and also have ADHD that, oh boy, is learning by reading even harder than if they didn’t have ADHD. If someone has relative social skill challenges, is quirky socially, or it takes a while to get to know, they may end up having more problems that their comments are impulsive and their pattern of follow through is less reliable, which is what you see with the consequences of attention and its impact on memory. So, the manifestation often is unique to the individual because of whatever is hard for that individual. It’s like, I think, an invisible headwind the person has to fight against which may be exhausting and tiring or mean that they don’t perform as well.
Dr. Eugene Arnold: So, they have to work harder at the ordinary challenges of young adulthood than people without ADHD.
Dr. Craig Surman: Well, through the lifespan, really, the way that I see it. And fortunately, you can really help people.
Dr. Eugene Arnold: How would you diagnose an adult with ADHD? How would that be different from diagnosing a child with ADHD?
Dr. Craig Surman: The biggest difference is the informant and the kind of conversation you can have. You are talking with an individual who’s aware of their own personal story and is going to operationalize from what you guys talk about. So, the frame of reference to the conversation from my perspective should be what’s going to be workable with that person. So, what do they notice that’s impairing, right? You could have a spouse there that’s concerned, just like you have a parent that’s concerned about a child. But unless the individual themselves is concerned about it, you’re not going to have as much sort of purchase on trying to make a change in their life. So, that is sort of like a medical answer to your question, but the informant of the information really matters. It can be much harder to get a third-party perspective. There isn’t a teacher often that you can ask. It’s pretty rare that it’s going to be comfortable without consequences asking an employer. So, that’s a big difference.
The other difference is how much water there is under the bridge in that person's life and how they think about themselves and see themselves, which is a huge opportunity for psychoeducation because a core question is, if for your entire life, ever since you were little, you've had pervasive challenges with self-control. And if the answer is, "Oh my gosh, yes, that explains a lot," that's going to be a few conversations I think hopefully, ones that the person may have with you as a clinician, or you could direct them to a source like CHADD so they can sort of explore those things. And then the individuals can make decisions themselves about what they are going to do. Are they going to take medication for this? Are they going to change their job? Are they going to educate people around them? Are they going to figure out new strategies and new environments that they can thrive better in? So, there's a big agency difference when you're working with an adult versus a child.
Dr. Eugene Arnold: Would it be fair to say that most adults with ADHD have more insight than children? It’s typical for young children, for example, to say, you know, "I don't have any problems. It's just the teachers, the parents, it's the other kids, but there's nothing wrong with me." And does that change? And can you expect more insight with the adults?
Dr. Craig Surman: It's interesting. I think that what I have learned from working with so many people in a specialty clinic is that personality and how people protect themselves against what’s hard in life really manifests differently in different people. And you will get people who are externalized and say, "I don't know what they're talking about." And you will get people who are like, "Wow, I'm really like that?" And they really take it in. And I think that’s true sort of across the lifespan. But what people are able to care about really matters, it’s very different, I think. And I think of it more, Gene, in terms of what audience a person is performing for. It’s not answering your question directly, but I find it very useful in my work. Whose opinion do you care about, right? Is it your peers in the playground or is it what your parents say? And you can get a kid who is very adult-oriented and is like, "I'm really performing for my teachers." And that’s very different than a kid performing for trying to make best friends as they go to middle school, and they are shifting around at the lunch table. So, there’s no one size fits all about this, but I come down on what is workable. What can I mutually observe with this person and measure over time that we’re going to be able to talk about and track? Because if a spouse, as often happens, is seeing something different and cares about something different, unless they're coming every time, we're not going to measure that.
Dr. Eugene Arnold: You have alluded to the fact that that there is a kind of a transition of symptom presentation from childhood to adulthood, starting out with more hyperactivity and impulsiveness in young children, and then that’s waning to some extent, but the inattentive and disorganizational issues coming more to the fore for adults.
Dr. Craig Surman: Absolutely.
Dr. Eugene Arnold: Did that make any difference on the DSM criteria for adult diagnosis?
Dr. Craig Surman: This is an excellent point. So, the newest version of the DSM, DSM-5, recognizes that there’s more self-control with age, and you need less symptoms. So, for example, for children, you need six of nine inattentive or six of nine impulsive hyperactive to be positive for inattentive or impulsive hyperactive ADHD. If you have both, then you have combined type. But with adults, the threshold's a little lower, such that if you have five of either, then you end up being positive for adult ADHD. And the other big difference is that retrospectively an individual should have manifested symptoms since before age 12. And so that sort of holds true across the lifespan now, the way the DSM thinks about ADHD, but it’s a big burden of proof. None of us have a time machine to go back and see what a person was actually like in childhood. And the mood a person's in alone can shade what stories they bring into your clinic and office. So, there is a lot of subjectivity to this. And before, there was sort of a higher bar that meant that people probably wouldn’t have been identified as ADHD by the book if people are actually going by the full criteria.
I want to comment that there’s always a space in the DSM for unspecified diagnoses, and a lot of our clients end up in that space where it’s like, okay, do you have four symptoms, or is it five and a half? And if I saw you in a different week, what would it be? And so, if you are really being technical, a lot of people end up in this unspecified category. And I think the feeling among experts typically is if they have impairment, they’ve got it.
Dr. Eugene Arnold: Yeah. I think in fact, Dr. Maggie Sibley has published some data suggesting that four symptoms might be a more accurate cutoff for adults. Do you have any opinion about that?
Dr. Craig Surman: My opinion is what’s the impairment that you actually can make an impact on? You don't know unless you try. So, if someone is impaired and there’s no other explanation, and it’s because of three symptoms, I am not going to quibble. I am going to try to treat them.
Dr. Eugene Arnold: Adults have a different sex ratio than children. Usually we expect like three to one males to females in childhood. But most of the studies of adults with ADHD presented a much more balanced sex ratio. Can you comment on possible reasons for that?
Dr. Craig Surman: So, this is an emerging area of research that’s very interesting, and there’s a thought that there may be gender-based differences in how ADHD manifests between women and men. I think what we can say with confidence from a research perspective is that the typically the comorbid diagnoses that a specialist could identify in a mental health clinic or in a neuroclinic are different in males and in females. There’s thought that there’s more externalizing behavior among boys than among girls, and the thought has been that means they stick out more in a classroom. There may be more complaints or more concerns. There’s a stereotype I think of a shy, inattentive girl who doesn’t get noticed because they are socially compliant and very held by the expectations of their social environment, versus a boy—and this is a sexist perspective, I think, on boys and girls, but I will just perpetrate the stereotype to some degree because in some ways that holds true for what’s historically been done in terms of diagnosis and the lens things have been seen through, in that boys may get more social credit for example. And this is sort of storytelling, not factual stuff, because of class-clown behavior, externalizing behavior.
So, we do see higher rates of sort of oppositional or a conduct disorder even diagnoses among males and females, but it’s really unknown how much of that is a social phenomenon as opposed to a core biological phenomenon. There’s always this nature versus nurture question. There’s been thought even, fast forward into adulthood, that women may be more comfortable or motivated in different ways to seek help. They may be oriented towards doing something, again a sexist perspective, for their children. We don’t have data on whether there's different motivations bringing people to care. And that’s why we see different, more equal rates. So, this is a very important emerging area of research. And especially when it comes to treatment interventions, we have concerns for women that are quite different than for men. There’s a real lack of research on pregnancy and breastfeeding and what’s the impact and how do women navigate the dual and triple and quadruple roles that they may hold in their lives. And men have lots of roles, too, but the stress levels are different for women when they are trying to run a family and work than for men in many cases. So, it’s not that the core underlying ADHD should be diagnosed differently, but the distress and the particulars of the story are going to be different in a way that may be genderized at times.
Dr. Eugene Arnold: Some people, I think, have speculated also that women may be more likely to seek help and be diagnosed than men, who may tend more to deny their problems.
Dr. Craig Surman: Right. So, there are these ideas about why. I think there’s been at least in some segments of society a real normalization of seeking treatment for performance issues in terms of cognition you get local cultural differences for. And I really like to find out whether people's peers are comfortable with the concept of ADHD. How alone is somebody when they are coming in with this? Because often there is a story of why someone is there. That’s not just about them. It’s about how they see ADHD, who else had it, did their child have it, there's a parent-teacher conference that hit a little bit too close to home, and oh my gosh, maybe my problems at work are similar to what my kid is going through now, as I am sitting in this parent-teacher conference and hearing this and this diagnosis?
But when people are comfortable with the label, comfortable with mental health, comfortable with treatment, that’s I think a much bigger factor about whether they come to someone like us. And so, people are often going to other sources well before they are coming to your clinic. So, you want to know that. What have you Googled? Have you found good resources like CHADD? Good information about ADHD? Or are you just basically going off of what your buddy said helped him get through his last all-nighter?
Dr. Eugene Arnold: Yeah. There has been an evolution of thinking about the age issue in ADHD. Originally, it was thought to be just a childhood disorder and then came the realization that it can persist into adulthood as a chronic neurodevelopmental disorder. And then more recently there was a publication suggesting that there can be new onset of ADHD in adulthood, which was then counteracted by another publication by Maggie Sibley again, who’s done a lot of work in this area, showing that very few adults with new onset. There can be adolescent apparent onset, because the problems are brought out by the challenges of middle school and high school for, particularly, very high IQ individuals who were able to survive through elementary school by dent of their superior intelligence, underperforming but still performing at a normal level, but then the problem comes out in adolescence. But for adult onset, it appears that, according to Sibley's data, the only people who would first be diagnosed as adults were those who had very close to kind of sub-threshold symptoms, very close to diagnosis in childhood, and then have additional complexities like substance abuse and depression, anxiety, and so forth. Would you comment on those issues?
Dr. Craig Surman: We really lack data about to what extent people can have a neurodegenerative sort of challenge that manifests looking like ADHD versus neurodevelopmental, but I’m phrasing it this way because I think it’s very important that we hold some framework around our neuropsychiatric disorders. And it’s quite different I believe, the way I think about it, that if something has been present ever since childhood, it is a different manifestation of it versus no evidence of it. And now there’s something new. So, I really hesitate to think that we should call that ADHD at all, frankly, just from a nosological perspective. I certainly have had a number of clients who say, "Yeah, only in the last couple of years have I struggled," but when you get into it, there's almost always a story to be told, whether it's the cause or not is the question about, why now? And it’s something about new challenges, new comorbid diagnosis that’s come up. So, this is an area of great interest to us. And it is very important to understand whether these people need a different kind of support or they should get the usual kinds of treatments.
Dr. Eugene Arnold: What would be the differential diagnosis of ADHD in adulthood?
Dr. Craig Surman: It’s very broad. It doesn’t take much for the brain to have what I think of as a mild encephalopathy, which is sort of the framework medically of thinking about ADHD. Our frontal lobes are pretty sensitive to hypoxia or to inflammatory states or the consequences of infection. Anyone who has attended someone with delirium understands that systemic illness can sort of create an inattentive picture. We have two majors, if you want to think about it this way, sort of attentional circuits in the brain. And one of them is fundamentally responsible, sort of for consciousness and being alert and awake and aware. When we’re talking about ADHD, it’s not that sort of awareness circuit, if you will, it’s more of a milder sort of what is the aware and awake brain attending to. And so, it’s a more fragile system. And I think there’s sort of a list of usual suspects that I think about in my clinic, but it’s usually the things I can interact with, I can do something about. I try to be pragmatic. So, if I’m screening for sleep disorders, I may be able to help someone with a sleep disorder. Sleep apnea could be treated. Someone who is a brittle diabetic, where their insulin sensitivity is terrible and they have never been treated, they may have some consequences for cognition.
Overall, systemic health and conditions involving systemic health can affect the brain. Especially over time there is a wear-and-tear effect. Does that tend to look like ADHD? In the moment, yes, but the big differentiator in the differential diagnosis is usually, has it been present ever since childhood? And often the answer is no for these things that we can intervene on. And there are very few exceptions when it comes to that. There’s a long list of possibly etiologic causes of ADHD-like syndromes. And you kind of will never know if someone had lead poisoning or if the level of encephalopathy in childhood somehow changed critical neural developmental features; if their environment, we think is maybe about 30%, very hard to estimate how brains develop in their capacities. And so, is there something extreme about the environment that meant this person never developed certain circuitry. The brain is plastic, we think, and there’s sort of critical periods for development. But the sort of identification of the why is different than the sort of a differential that you can sort of work with. And I think that’s what you can treat, and the usual list of suspects, the sleep disorders, systemic illness, and anything else that's long-standing traits, which would be compromising to brain function. It’s quite easy when someone is coming in depressed or in generalized anxiety. But in a mental health clinic, you don’t want to underestimate the power of a preoccupied mind, sort of someone where they are worried and nervous. And so, you ask them what they’re having trouble paying attention to, where their mind is going. And if they are saying what have, could have, should have, thinking about the past and worrying as opposed to what I'm going to have for lunch, or oh, maybe I forgot to do something, I have to do that later, random kinds of things, that's steering you in a direction that maybe there's something else here to treat. So, there are these sorts of shadow syndrome kind of situations you often end up in where it’s like, yes, there is an ADHD theme, but then there is something else as well.
And the other question that helps me understand, besides has been there since childhood, about whether I should focus on that instead is, is it a full syndrome? Is this someone in the throes of a substance use disorder? Are they in the throes of major depression? Is this a full-blown other condition? Because you’ll get a lot of traits of this, traits of that, mild learning disability, mild social skill problems, but you really want to think, does the full syndrome present in a way that explains it better than ADHD?
Dr. Eugene Arnold: You mentioned an interesting point of different problems contributing a little bit and adding up to a big problem.
Dr. Craig Surman: Absolutely.
Dr. Eugene Arnold: Are there any final things you would like to say?
Dr. Craig Surman: Well, I think the biggest gift a clinician can give a patient is self-understanding. And I am really proud to be a part of CHADD, which is a wonderful resource for people to learn more about ADHD. As clinicians, I think it’s very important to hold up the standard of the diagnosis. ADHD is thrown around in a colloquial sort of sense now, and it’s wonderful that people know more about it. But there are criteria for ADHD. You can educate yourself and educate your clients about it. And it’s important to help people who have had these longstanding challenges understand that it’s a dynamic condition that interacts with context, with the environment, and that goes both good and bad. It means there will be times when people need more support and less support. And with self-knowledge of where people have functioned well, they can make choices about who their teammates are, what treatments they decide to do, how they track their symptoms, what job changes they make, what new relationships they form, that might help them thrive better in the long term. So, I really appreciate interest in what we are saying today and would steer you back to the CHADD website.
Dr. Eugene Arnold: Thank you, Dr. Surman.
Dr. Craig Surman: It’s a pleasure, Dr. Arnold, to speak with you today.
Announcer: Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.
- CHADD NRC Staff. Diagnosis of ADHD in Adults.
- Young, Joel L & David W. Goodman. (2016). Adult Attention-Deficit/Hyperactivity Disorder Diagnosis, Management, and Treatment in the DSM-5 Era, The Primary Care Companion for CNS Disorders, 18(6) doi:10.4088/PCC.16r02000
- Katzman, Martin A. et al. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry, 17(1):302. doi: 10.1186/s12888-017-1463-3.
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