Understanding Symptoms of Adult ADD Q&A

Interview with Dr. Lenard Adler

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Lenard Adler, MD, is director of the Adult ADHD Program at NYU School of Medicine and author of Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder. He is also the president of the American Professional Society of ADHD and Related Disorders (APSARD), an international professional organization that focuses exclusively on ADHD with the goal of improving the quality of care for patients with ADHD from childhood through adulthood.

I had the opportunity to talk with Dr. Adler about the different ways symptoms of ADHD can present and cause stress into adulthood and the importance of accurate diagnosis and treatment.

Q: Let’s start with some general information about ADHD.

Dr. Adler: ADHD is a neurobiological disorder. It is the second most common mental health disorder in adults after depressive disorders. ADHD has a very high prevalence rate, occurring in about 6% to 8% of kids and 4.4% of U.S. adults. About 60% of children with the disorder go on to be adults with the disorder, so it tends to run the lifespan. It's also a disorder that we think about 85% of the transmission is familial, so it tends to run in families. In fact, if there is a child in the family with ADHD there is a 30% to 40% chance that one of the two parents will have ADHD. And that is one of the things that commonly drives adults into the doctor’s office -– because they have a child that has been recently diagnosed and they realize they’ve had similar symptoms themselves in childhood and their spouse often nudges them and says, ‘Honey, you still have these things now but they are a little different.’

Q: How are the symptoms of ADHD different in adulthood?

Dr. Adler: Well, the symptoms are similar, but changed somewhat because adults are not just grown up children. The symptoms change in several ways. One is that the inattentive symptoms become a bit more prominent in adulthood and that is probably true somewhat more for women in general.

Females tend to carry a little bit higher load of the inattentive symptoms. In part that accounts for why more women present in adulthood as compared to girls, verses men to boys. Because if you are behaviorally disruptive in the classroom you’re more likely to be picked out and brought into the healthcare system as compared if you are inattentive and missing things and you may just be seen as underperforming. That is changing as we understand the inattentive symptoms better, but in general the gender distribution is a little different childhood to adulthood. It’s about 2 to 1 boys to girls in childhood, whereas it's a fairly even gender distribution 1 to 1 in adulthood.

So the symptoms change in several ways –- one is that the inattentive symptoms become more prominent. Secondly, the frank hyperactivity becomes much more felt rather than manifested –- the sense of needing to get in and out of your chair is felt. The adult doesn’t get out of the chair because they know it is very stigmatizing at a meeting if you are getting up and down.

They’ll also guard against some of the impulsivity because they know if you interrupt your boss at a meeting even if that happens occasionally, it’s probably not very good for your long term survival on the job. So what happens is they may guard against interrupting and ultimately get distracted from what is being said in the meeting. I can give you an example of a mid-level executive who I take care of who described (before treatment) losing track of what was going on in meetings. It was happening anyway, but especially when he felt he had something to say and was going to interrupt. He had to guard against interrupting so much that it distracted him and he further got lost in terms of what was being said.

Q: Why do symptoms present somewhat differently for adults?

Dr. Adler: The organizational load for adults is very different. Think about what the cognitive load is like for a young elementary school child –- they have a very structured day in terms of going to school, having a set amount of homework, staying in one classroom. Then think about what it’s like as they go through middle school where you start to use a planner, change classes and have to write down homework assignments to high school where you have much more homework and you are managing larger projects and AP classes. Then off to college where the parental support that’s often there to help organize is removed and into adulthood where you have the responsibilities of family, children and work and having to manage many, many more things with less structure. What happens is the symptoms tend to change and may be brought forward at these critical changes in one’s life, these watershed areas, when you move from elementary to middle and middle to high school and then to college and then into adulthood. So the individual with ADHD, as they have higher cognitive loads, may begin to have more organizational problems.

Q: Does the criteria to make the diagnosis change from children to adults?

Dr. Adler: No, the criteria to make the diagnosis are actually the same. There are four critical elements in making the diagnosis for both kids and adults. We talked about how the symptoms change in part in presenting into adulthood, but you have to have symptoms. You have to have 6 of 9 inattentive and/or 6 of 9 hyperactive/impulsive symptoms. That’s the first criteria. If you just had symptoms -– because we all have symptoms from time to time probably not the full spectrum of symptoms, but we all have some difficulty paying attention or we may feel restless if we haven’t slept well or if we have a major stressor in our life -- if we had no impairment, you wouldn’t make a diagnosis because we don’t just treat symptoms, we treat impairment. So, the second criteria is impairment. And you have to have impairment which can be relative in terms of underperformance in school or work, home, or social settings. The third criteria is the roots of the disorder have to lie in childhood. It’s a lifetime spectrum disorder. You don’t have to be fully symptomatic in childhood, but you have to have some significant symptoms. The last criteria, you have to be sure the symptoms are from ADHD and not something else.

ADHD commonly does co-occur with other mental health conditions including substance use disorders 20% of the time, depressive disorders probably also somewhere around 20% to 25% of the time, bipolar disorder 10% to 15% of the time, anxiety disorders. So what you want to be sure is that the symptoms that are presenting are from ADHD and not something else and the way the clinician does that is by taking a lifelong history and looking when the symptoms started and what else was going on.

Q: What if these conditions are co-occurring with the ADHD?

Dr. Adler: It is important for patients and clinicians to understand that they can co-occur because very commonly it’s not only looking for the co-occurring condition with ADHD, it’s also the reverse. Many patients with the other disorder who present for treatment for the other disorder have ADHD and the ADHD has been missed. Adult ADHD is vastly under recognized and undertreated. According to the National Co-morbidity Survey, the largest epidemiologic community based survey that is done for mental health disorders, only about 10% of the individuals with ADHD were diagnosed and treated for their condition. We just published findings from a large survey of primary care physicians who treat patients with mental health disorders. When surveyed about their understanding of ADHD, their comfort level in treating it, and what level of training they had, it was very clear that they were about twice as comfortable treating depression and anxiety as they were ADHD and they had received very little training in ADHD. So there is a huge knowledge gap here that needs to be addressed.

Q: And that is where APSARD comes in…

Dr. Adler: That’s the part where APSARD comes in because part of our mission is outreach and education. APSARD is a society of professionals involved in the treatment and evaluation of ADHD. Part of the mission in outreach and education is improving the rate at which individuals who have ADHD are diagnosed and treated. We hope to do this by involving the broad spectrum of professionals involved in the treatment of ADHD, including psychiatrists, child psychiatrists, psychologists, social workers, neurologists, primary care physicians, nurse practioners, coaches and educators. Our intent is to provide the latest and up to date information about ADHD through our website, APSARD.org.

The impairments in ADHD are very real. Adults with ADHD, again who are mostly untreated at this point, have higher rates of divorce and separation, are twice as likely to use substances we think in part because they are self-medicating, are twice as likely to smoke cigarettes and are much less likely to quit smoking. They also underperform on the job, change jobs more frequently and have lower earning values. And there are also other impairments. Dr. Russell Barkley has written extensively on the driving impairments associated with untreated ADHD in terms of higher accident rates, more severe accidents, more speeding tickets. If you think about driving, it’s a very attention demanding task. This all highlights the need for treatment.

Q: What percentage of adults with ADHD does receive treatment?

Dr. Adler: Right now we think it is anywhere from 10 to 25%. The 10% figure comes from the National Co-morbidity Survey and the 25% comes from the prescription data base survey done by Medco where they found that 1% of individuals in their entire data base were being treated with ADHD. So, not matter how you look at it there is vast undertreatment.

Q: Is that because of a lack of education about adult ADHD or not recognizing the symptoms?

Dr. Adler: Well, I think it’s from several factors. ADHD used to be conceived of as a childhood disorder. This was a disorder that children had that somehow they were magically supposed to grow out of as they went into adolescence. Now, looking back that may not make the most sense because ADHD is a neurobiological disorder. Until the mid 1970s the concept of treating adults with ADHD with the medicines we use for kids to treat ADHD didn’t even exist. Then Paul Wender, MD, who was at the University of Utah had a group of adults who presented with ADHD-like symptoms and had been diagnosed with ADHD in childhood. He gave them stimulant medication and their symptoms improved. Until 1987 we could not even make a full active diagnosis of ADHD in adults in our diagnostic manual. So in part the knowledge gap exists because of the way the disorder was conceptualized. There has been a lot of research going forward since then, but obviously there is a lag because ADHD in kids has been described since 1900 by George Still, MD, who was a pediatrician who wrote about clinical presentation of kids who would look like ADHD kids today.

Q: If an adult is concerned they may have ADHD, where do they start?

Dr. Adler: There is a screening test for ADHD, called ASRS or Adult Self Report Scale screener, which we developed with the World Health Organization. If individuals are worried whether they may have ADHD, this is a great place to start. The ASRS is 6 questions designed to identify individuals at risk. If you have at least 4 of these 6 significantly, you may be at risk for ADHD. So that means if you screen positive, you really need to talk with your doctor and see if this is an issue.


Lenard Adler, MD. Phone interview. June 26, 2009.

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