Untreated adult ADHD raises some risks

Having trouble concentrating? Can't sit still? Are you disorganized and always late? If so, and if you've always been that way, it might not be a flaw in your personality but a genuine clinical disorder known as adult ADHD. Everyone's heard of attention deficit hyperactivity disorder in children, but left undiagnosed and untreated, it can carry over into adulthood, says Dr. David W. Goodman, assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville.

What are the symptoms of adult ADHD?


The core symptoms of ADHD are inattention, of which there are nine symptoms, and impulsivity and hyperactivity, of which there are nine symptoms. In order to reach the symptom criteria that makes one ADHD, the person has to have six of the nine symptoms of one and or both domains.

So although there are several ways it manifests itself, it is considered one disorder?


Yes. Because the response to treatment is virtually identical.

How common is ADHD?

About 8 percent of children have the disorder, of which 60 percent have been treated in the past year. Up to 65 percent will continue to have symptoms to an impairing degree in adulthood. That means the prevalence rate for adults is 4.4 percent - 9 million to 10 million adults in the United States, of which less than 15 percent have been treated in the past year.

Does adult ADHD manifest itself in ways different from childhood ADHD?

In children as they grow older, if they retain ADHD, the hyperactivity tends to diminish with age. The adults aren't going to be disruptively hyperactive, but they can be left with an internal sense of restlessness and being fidgety. Impulsivity can remain. But what becomes paramount in adults is the inattentiveness and disorganization. Also in children, the ratio of boys to girls [diagnosed with ADHD] is 3 to 1, because boys tend to show more signs of the disruptive behavior. But in adults, the ratio of males to females with ADHD is 1 to 1, as inattention becomes the symptom driving impairment.

When should someone see a doctor?

One should see a doctor if you have these symptoms, you've had them your whole life and it causes impairment. People who are unaware they have this may go to their doctor with symptoms of anxiety and depression. The physician doesn't think of querying for adult ADHD. It's why I think it should be part of every adult mental health evaluation. Its prevalence rate is higher than many mental health disorders physicians screen for. Because it is a newly recognized disorder, it hadn't been included in medical residencies, so a lot of physicians aren't able to recognize this condition.

What are the risks of undiagnosed ADHD in adults?


Developmentally, there are a lot of negative consequences of ADHD. There is a two-fold higher risk for cigarette smoking, two-fold risk for drug and alcohol abuse, higher risk for sexually transmitted disease, tenfold higher risk for unplanned pregnancy, a two to five times higher risk for motor vehicle accidents. [Adults with ADHD] are much more likely to lose jobs, impulsively quit or be fired. There is a higher rate of divorce.

How can you tell if someone has a real clinical disorder or if the person is just a goof-off?

Everyone has periods of times when they are distracted or put things off. That is not ADHD. ADHD is a group of these symptoms that occur on a daily basis to an impairing degree and have since childhood without change. The diagnosis is based on the current symptoms and how they have presented over the course of the individual's life.

Twenty years of medical research in adults have established this as a valid psychiatric condition. It's not a reflection of bad character or poor parenting. It is easy to say someone is lazy, stupid, not interested in the activity, or doing this to bother me. But if people are aware of ADHD, they may consider it the next time they encounter someone like this.

How is adult ADHD diagnosed?

By a comprehensive interview. By an assessment of the symptoms, age of onset of these symptoms, the course of those symptoms over one's life and level of impairment. You can have mild, moderate or severe ADHD. We look for impairment in multiple domains, such as school, work, family and social. And we look at whether there was an onset before age 7.


How do you get childhood information?

Most adults will not be able to recall symptoms prior to age 7. Most adults can recall symptoms between 7 and 12. The other thing I do is get a mother to fill out a rating scale for childhood ADHD symptoms. It's very helpful to increase the accuracy of that childhood history.

What causes ADHD?

It is thought to be related to neurotransmitters dopamine and norepinephrine, whose lower levels in the brain produce ADHD symptoms. ADHD is highly genetic. If you have a child with ADHD, the likelihood a parent is ADHD is 35 percent to 40 percent. If a parent has it, the likelihood a child will have it is 50 percent. The idea it is overdiagnosed and over-treated is not supported by research.

What are the treatment options?

A combination of therapies and medication. Medications recommended for adults are all once-a-day, long-acting medications that fall into two categories: stimulant medications and nonstimulant medications. The stimulant medications work quickly and improve focus, attention and concentration and decrease distractibility. As for the behavioral therapies, some people need organizational training or social skills training.


Are there risks for adults taking ADHD medications?

There are potential side effects, such as decreased appetite, headaches, insomnia, irritability, nausea and dry mouth. If the medication is dosed up slowly, those side effects can be minimized.

What about long-term side effects?

We don't know long-term side effects. One concern people have is the medication is going to change their personality. They worry they'll be zombies. Although some children have this experience, it has not been an issue in my adult patients. I tell my patients that if there are side effects, they should tell me so we can find a comfortable medicine for them. So, given the effective nature of these medications, people have to decide if the benefit of medication and quality of life merits staying on the medication.