When he was attending law school at Wake Forest University in the 1980s, E. Clarke Dummit couldn't study in the library. It was just too quiet.
"I got in the habit of hanging out at a Krispy Kreme doughnut shop and drinking coffee while I studied my law books," he says. "I needed constant noise around me and a stimulant to focus."
Another decade would pass before Dummit saw a psychologist and was diagnosed with attention-deficit hyperactivity disorder. The diagnosis came as a revelation, and it helped him to fit together some of the jigsaw pieces of his life.
"It was fascinating. I've always had learning disabilities and had to work my way around them," says Dummit, now a 50-year-old criminal defense attorney with his own firm in Winston-Salem, N.C. "I have focus when I really need to for a short period, but then my brain has to relax for a certain amount of time."
Dummit and other adults with ADHD also have to battle a stereotype that ADHD is a childhood mental disorder that doesn't affect adults. Most research on ADHD has focused on children, and the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists symptoms for ADHD that apply mainly to children, such as losing toys or climbing on things. But a growing body of research is examining the effects of ADHD on adults and documenting that the disorder can have lifelong consequences.
ADHD can cause serious disruptions for adults in their careers, personal relationships and higher education, says J. Russell Ramsay, PhD, an associate professor of psychology and co-director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania School of Medicine. "Society in general values good self-regulation, being able to follow through on things, being reliable, completing tasks on deadline. These skills are important at school and work, and they are equated with good character," Ramsay says. "An individual going through life with ADHD often ends up saying, ‘I must not be good enough. I must be lazy. I must be stupid.' These negative beliefs get reactivated and strengthened and may lead people to start giving up or limiting themselves."
Several studies have shown that more than half of children with ADHD will continue to have full symptoms as adults, while some level of impairment may affect up to 80 percent or 90 percent, says Ramsay, who has researched ADHD for more than a decade. "Many adults aren't growing out of ADHD. They're actually just growing out of the childhood definition of ADHD, such as running around and climbing on things," he says. "Adult ADHD research has been hampered because the current symptoms were designed for childhood and adolescence."
Diagnosing adult ADHD
Many middle-aged and elderly adults grew up at a time when children with ADHD were just considered to be hyperactive or poor learners. ADHD first appeared in DSM-II in 1968, when it was called "hyperkinetic reaction of childhood (or adolescence)." The symptoms included "overactivity, restlessness, distractibility and short attention span, especially in young children."
When Dummit was growing up in the 1960s in Columbia, Tenn., he had trouble focusing in school so his parents took him to Nashville for an evaluation at the Peabody College of Education and Human Development, now part of Vanderbilt University. "No one diagnosed me with ADHD," Dummit says with a laugh. "They said my father was being overbearing and too demanding. My dad said, ‘You're damn right,' and we marched out of there."
Today, in contrast, more than 5 million children have been diagnosed with ADHD in the United States, and the percentage of children who are diagnosed has increased each year over the past decade. But for Dummit's generation, who missed the chance to be diagnosed as children, psychologists and psychiatrists must devise a way to identify ADHD in adults.
And even today, some people may not realize the extent of their ADHD symptoms until later in life. ADHD symptoms can sometimes be masked until adulthood because childhood often is structured by parents, school and other activities, says Stephen Faraone, PhD, a clinical psychologist and psychiatry professor at the State University of New York's Upstate Medical University.
"ADHD is a disorder characterized by the inability to regulate one's behavior, emotions and attention. As we get older, we have fewer people telling us what to do," Faraone says. "When we get to college or a job, we're expected to show up without having someone tell us what to do."
Paul Wender, MD, a pioneer in ADHD research, developed one of the first rating scales for measuring ADHD in adults—the Wender Utah Rating Scale—in the 1990s, when he was a psychiatry professor at the University of Utah School of Medicine. The questionnaire, published in the American Journal of Psychiatry in 1993, helped retrospectively diagnose adults with ADHD based on their childhood symptoms.
"The diagnosis of ADHD in adults has occurred more and more frequently in recent years, and it has improved dramatically over the past decade," says Wender, now a psychiatrist in private practice in Andover, Mass.
While the DSM-IV lists symptoms for ADHD that are mostly geared toward children, the upcoming fifth edition most likely will contain symptoms that apply more readily to adults, such as having racing thoughts instead of racing around the room. "Adults obviously aren't on top of their desks, but they are restless and unable to sit still," Wender says. Several other scales have been developed to help diagnose ADHD in adults since Wender's work. Faraone helped develop a self-reporting screening scale that was adopted by the World Health Organization. Published in Psychological Medicine in 2005, the 18-question survey translates childhood ADHD symptoms from the DSM-IV into adult situations.
In a nationwide telephone survey of 966 adults, published in the Journal of Attention Disorders in 2005, almost 3 percent of respondents reported they often had ADHD symptoms, while almost 16 percent reported occasional symptoms. The study by Faraone and Harvard Medical School researcher Joseph Biederman showed that individuals who reported ADHD symptoms were less likely to graduate from high school or college than those who reported no symptoms. Individuals who reported more severe ADHD symptoms were almost three times more likely to be unemployed than adults with no symptoms.
"In the workplace, we know from studies of work productivity and income that adults with ADHD are not likely to achieve as well as their peers," Faraone says. "The estimates range into billions of dollars each year in lost productivity related to adult ADHD."
‘Playing defense every day'
Drew Brody, a 39-year-old father with two young children in Santa Monica, Calif., says he used to struggle through his daily routine because of ADHD. As a high-school tutor, he would lose track of time, miss deadlines and feel overwhelmed. "You're walking around with a fog around your brain. Just getting through normal daily behavior is hard, getting up, getting dressed, getting shaved, getting out the door on time," he says. "All of that stuff is 10 times harder than it should be."
Brody was diagnosed with ADHD about seven years ago after his wife, a middle-school vice principal, suggested that he be evaluated. Brody began cognitive-behavioral therapy with a psychologist to identify coping mechanisms, such as time management skills, exercise and a healthy diet. But his persistent symptoms interfered with the therapy. "After a year, I never really got my act together to do any of the improvements on a regular basis," he says.
Brody then was prescribed Concerta, the extended-release version of methylphenidate (Ritalin), and his life changed. He was able to start his own tutoring company, The Scholar Group, which now has 16 tutors who help students in more than 40 academic subjects and on standardized tests such as the SAT.
"It was a revelation," he says. "I don't think I would have created my business if I hadn't started taking Concerta on a daily basis. It's made a substantial change in my life. For bigger life decisions, I am able to think more clearly and work through the steps on how to get there."
His problems from ADHD haven't disappeared, but Brody says his symptoms are more manageable now than they were in the past. "Life with ADHD is like playing defense every day. Things happen to you and you have to address them," he says. "You're not proactively dealing with life. You're waiting to be late or to get in trouble because you can't get ahead."
Brody's experience is common for adults with ADHD who try cognitive-behavioral therapy without medication, says Ramsay, who wrote the 2010 book "Nonmedication Treatments for Adult ADHD." Therapy can be very helpful in teaching time management and organization skills, but ADHD symptoms can lead to late or missed appointments, failure to complete homework, and little progress on a treatment plan. Medication in conjunction with therapy can help bring ADHD symptoms under control through life coaching skills and counseling for underlying negative thoughts that can lead to procrastination and frustration, Ramsay says.
The public controversy about overmedication and overdiagnosis of ADHD is really a problem of misdiagnosis, which can result from quick visits to primary-care physicians, Ramsay says. "Some patients may get a diagnosis based on an all-too-brief evaluation and therefore may start treatment with a medication when maybe their symptoms are not a result of ADHD," he says. "Other people with ADHD may be misdiagnosed with some other mental disorder."
Stimulants on campus
Several studies have shown that stimulants such as Ritalin or amphetamine salts (Adderall) are effective in treating ADHD in adults, but the drugs also can be abused, especially by college students who believe stimulants will boost their academic performance. In a survey of more than 1,800 students at the University of Kentucky, a third of the students reported they had illegally used ADHD stimulants, mainly by obtaining pills from fellow students with prescriptions. Most of the illegal users said the stimulants helped them stay up late and cram for exams, and they believed the drugs increased their reading comprehension, attention and memory. The study was published in 2008 in the Journal of American College Health.
Every college in the United States faces problems with misuse of ADHD stimulants, but most students with ADHD are not faking their symptoms to get medication, says Lorraine Wolf, PhD, a neuropsychologist and director of the Office of Disability Services at Boston University. "Most students with ADHD are serious, hard-working young people who struggle in a college environment, but with accommodations and support they are very successful," says Wolf, an assistant psychiatry professor who researches adult ADHD.
Wolf's office offers time management skills for students with ADHD and provides academic accommodations, including extra time on tests and computer use during exams to help with spelling and grammar. Students must provide extensive documentation of severe ADHD symptoms before accommodations will be granted, Wolf says. "People who come to college with symptoms are pretty much going to have ADHD for the rest of their lives," Wolf says. "People become more refined in how they deal with it. They just get better at handling ADHD."
Almost 5 percent of teenagers in the United States were prescribed stimulants to treat ADHD in 2008, compared with just 2.3 percent in 1996, suggesting that many children aren't outgrowing their symptoms, according to a study by the National Institutes of Health and the Agency for Healthcare Research and Quality. The study was published online in September in the American Journal of Psychiatry.
Some college students who illegally use stimulants may have undiagnosed ADHD, according to a study of 184 college students in northern Virginia, published this year in the Journal of Attention Disorders. The study found that 71 percent of the respondents who misused stimulants also screened positive for ADHD symptoms. Students who illegally used stimulants were seven times more likely to have ADHD symptoms than those who didn't misuse the drugs.
Meanwhile, those symptoms aren't always entirely bad. ADHD can have some beneficial aspects, including the ability to multi-task, solve problems quickly and work with people, Wolf says.
Dummit, the criminal defense attorney in North Carolina, says he has embraced his ADHD and believes it helps him hyperfocus on detailed projects for short periods. He only takes a stimulant medication when he needs to concentrate for long stretches, such as during a trial. "I don't accept ADHD as an excuse for bad behavior, but I do try to talk openly about my strengths and weaknesses," he says.
Brendan L. Smith is a writer in Washington, D.C.
COGNITIVE BEHAVIORAL TRAINING RESOURCES FOR ADULT ADHD
"Cognitive Behavioral Therapy for Adult ADHD" by J. Russell Ramsay, PhD, and Anthony Rostain, MD, MA (University of Pennsylvania Adult ADHD Treatment and Research Program).
"Mastering Your Adult ADHD: Therapist Guide" by Steven A. Safren, PhD, et al. (Harvard Medical School/Massachusetts General Hospital).
"Cognitive-Behavioral Treatment of Adult ADHD: Targeting Executive Dysfunction," by Mary Solanto (Attention-Deficit/Hyperactivity Disorder Center at Mount Sinai School of Medicine).
"Succeeding With Adult ADHD: Daily Strategies to Help You Achieve Your Goals and Manage Your Life" by Abigail Levrini, PhD, and Frances Prevatt, PhD, APA LifeTools book for the general public (APA, 2012).
"Nonmedication Treatments for Adult ADHD: Evaluating Impact on Daily Functioning and Well-Being" (J. Russell Ramsay, 2010).