Transcript: ADHD can disrupt adult life: Here’s how to own it

Interview conducted by Aaron Warnick, a reporter with The Nation’s Health newspaper.

Listen to this interview as a recording on our podcast page.

 

ADHD can disrupt adult life — here’s how to own it.

This is The Nation’s Health Podcast, part of the APHA Podcast Network. I’m Aaron Warnick, your host and reporter for The Nation’s Health. 

In addition to producing award-winning news stories, The Nation’s Health lets you hear directly from the people we’re talking to. In this episode, I’ll chat with Russell Barkley. He is a professor of clinical psychiatry at the Virginia Commonwealth University Medical Center and a leading author and researcher on attention deficit hyperactivity disorder.

We will discuss ADHD in adults — what ADHD looks like beyond childhood and implications for public health.

But, before the call, here’s a primer on ADHD.

ADHD is a common neurodevelopmental disorder.  It shows up in early childhood — and it can exhibit itself in a wide range of ways, but there are three main presentations of ADHD — inattentive, hyperactive-impulsive and combined presentation. 

The list of symptoms of ADHD is long. But, to provide some examples — inattentive types may have difficulty sustaining attention or make frequent careless mistakes. Those with hyperactive-impulsive presentation can feel as if they are driven by a motor; they may fidget or have difficulty waiting for their turn in social or classroom settings. It’s also common that someone with ADHD will experience a blend of being hyperactive and being unable to focus.

It’s important to note that everyone will experience some of the symptoms of ADHD at some point or another. When we’re talking about an ADHD diagnosis, a person has to have a number of symptoms that have persisted over time. And it rarely develops beyond adolescence. However, just because a person wasn’t diagnosed as a child does not mean that they have not had the disorder.

And with that, Russell Barkley has joined us.

 

Are there any groups that are more likely to have an ADHD diagnosis that might have been missed in childhood?

It used to be girls. For years, they were the underdiagnosed group — of course along with teenagers and adults, which back in the 70s and 80s nobody thought should have this disorder. But the girls are getting increasingly recognized, thankfully. As are the teens, though not as much. And the adults are certainly are improving, but we still have a long way to go there.

The other, in my opinion, would be high-IQ individuals that were able to kind of skate through the early grades in school on the basis of their intellect. But, as they get older, the work gets more difficult and then they have to try to cope with the work demands on top of just learning information. So, they can have a later onset of impairment even if their symptoms came on early.

 

How does ADHD affect adults and children differently?

You have to understand that ADHD is a disorder of self-regulation of the executive functions of the brain. And once you assume that then you know that there’s a 30-year span — at least — over which the prefrontal lobes and their executive functions are likely to be developing. And in young children, you may not see as many of the executive deficits apart from the distractibility, the impulsivity, and maybe the hyperactivity.

But as they get older, we start to see problems with time management. Three-year-olds don’t have to have a sense of time. Thirty-year-olds do. We see problems with self-organization. Self-motivation, emotion regulation and control, among others. So with those...those take time to emerge. And the adults are going to have much more difficulty in those areas and a lot less trouble with hyperactivity and with just inhibition per se.

 

To what degree are adults aware of how ADHD impacts their lives?

Interestingly, until they get to be about 30 to 35, they’re not as aware of their disorder as other people around them are. And they even deny having it up until their late teens or early twenties. For instance, our longitudinal study showed that there is a tenfold difference between ADHD if you ask a person who has it at age 21 and you call their parents and others. The difference is maybe 4 -5% self-report, to 50- 60% when you talk to their parents. That’s marked difference in self-awareness and acknowledgment of symptoms. But once into their 30s and so on, they become more aware of the impact that their symptoms are having on their life.

 

And so, adults with ADHD that are young do not appreciate the scope and depth of symptoms and impairment the way others around them are. But as they get older, they do. And they have kind of an “a-ha” moment where they finally realize that “I’m the key to all of these difficulties and failures and incomplete projects I have in my life.” And then they pursue a diagnosis and treatment. At that point they’re pretty cognizant of their disorder and its effects on time management and self-motivation.

 

What might you say to an adult who has had such an “a-ha” realization?

To me, the most important piece of information for adults to have is this is a neurobiological disorder. It’s not a moral failing. You didn’t cause this. Your parents didn’t cause this. It’s not a result of screen time or too much caffeine and those sorts of things. This has a strong biological, neurological and genetic basis to it.

The first thing is to give up that sense of moral failure, as if there is some flaw in you that is of your own choosing. It’s not a lifestyle choice. But with that does come with the responsibility of ownership. This is your disorder, and only you are going to be the best person to seek out the appropriate management approaches to deal with this condition. So you may not have caused it, but you certainly are responsible for dealing with it.

 

If an adult persistently experiences the symptoms of ADHD, and they haven’t been diagnosed, what should they do?

I think the first thing is to speak to your primary care doctor, if they’re knowledgeable, and get them to refer you to a mental health provider. That’s usually required as part of people’s insurance plans, to have that kind of that referral. On the other hand, if it isn’t, you can call a local psychologist or psychiatrist or clinical social worker yourself and schedule an appointment. And the best way to find those people is to by one of three means. Either contact the local CHADD organization — go to CHADD.org — and see if there’s a chapter near you and the president’s name and phone number will be there. Contact them. Because they are going to know the lay of the land for children and adults with ADHD in that area. They’ll know which professionals are really good and which are not. And that can be very helpful.

But, failing that, you can contact the state psychological association or the state psychiatric association. And often on their website, they list their members and often identify what conditions they specialize in. And you can kind of use those as a guide. And if that doesn’t work, then contact your state medical school, in the department of psychology or the department psychology clinic there and see if they do such evaluations. 

 

Some of your research examines a potential association between ADHD and life expectancy. Could you tell us a little about that?

What we found was that by age 27, on average, if you were diagnosed as a child with ADHD, regardless of whether it persisted or not, you were likely to have between nine and 11 years reduction in your life expectancy. On the other hand, if your ADHD persisted until you were age 27, that reduction ran from about 11 to 13 years, depending on whether we looked at healthy years or total years of life expectancy.

So that tells you that if we’re going to take smoking and obesity and diet and sleep and alcohol use as seriously as we do — and we spend billions a year trying to reduce those risk factors — that we should be taking ADHD even more seriously than those. And we don’t.

This year, what we’re trying to do — me, the CHADD organization and many other professionals — is to broaden awareness of ADHD from a mental health or educational disorder into a public health disorder, which is clearly is.

 

Could you outline what treatment is like for an adult diagnosed with ADHD?

There are five key words I like to use to capture the treatment package you need to implement for adults — and kids too, but especially for adults. No. 1, you need an appropriate diagnosis and evaluation, as we have spoken about. That is always step one in treatment, because you’re going to find out whether you have the disorder or not and that’s going to help you further understand your condition and maybe your past history as well. The second thing is to get yourself very well educated about ADHD. You can do that through the CHADD website and through ADD.org, which focuses more on adults with ADHD as well. But learn about your disorder.

It’s kind of like diabetes. The first thing we do is not give you insulin, we teach you about diabetes, and why it’s important for you manage your symptoms on a daily basis. That’s why step two is so critical, this educational understanding of your condition. And that leads to ownership. Just like with diabetes, this your problem — not other people’s problem. It’s incumbent upon you to take responsibility and get help.

Step three, look at medication. Over 80% of the adults that we see require medication at some points in their life to help manage their symptoms, usually related to work or college or other educational pursuits. They’re the safest medications in psychiatry, bar none. They’re two to three times more effective than any of the other drugs used for any of the other psychiatric disorders. There’s a lot of hope that medication can be added into this treatment package to help you manage your symptoms.

The fourth thing we try to do is modify your own behavior, and that’s where cognitive behavioral therapy that focuses on those executive functions that I’ve spoken about can come in handy. There are three programs that are out there, commercially available, that focus on self-regulation and executive deficits.

And then finally, we like people to pursue accommodations. Accommodations are changes to the surrounding situation — the physical environments for instance — that allow you to be less impaired. They don’t get rid of your disorder, they may not get rid of your symptoms, but they will certainly help reduce the impairment that you experience.

And that being the case, we want people to look at ways to restructure their environment around them to help with self-motivation such as work or study with other people or exercise with them to promote your own motivation. That’s an accommodation, it doesn’t change the disorder, but it makes you less impaired. Things like that can be very helpful to adults in the workplace or at school or in their home life.

So, again, evaluation, along with education, followed by medication and then modification of your behavior where possible. And then make accommodations in the environment for your disorder.

You put those together and you’re doing a really good job at managing the condition.

 

And with that we thank Russell Barkley for his time and expertise.

 

For more information on ADHD, visit www.CHADD.org.

To read The Nation’s Health online, visit thenationshealth.org.

Thank you for listening to The Nation’s Health Podcast.