How ADHD Affects Adults
Attention-deficit/hyperactivity disorder (ADHD) was once thought of as a condition that affects only children. The belief was that children would grow out of it, but research has shown that the condition often persists throughout life. In fact, ADHD is the second most prevalent psychiatric disorder in adults, but many misconceptions still exist about it.
On this episode, host Sara Frueh is joined by David Goodman, an assistant professor at Johns Hopkins University School of Medicine and director of the Adult Attention Deficit Disorder Center of Maryland. Goodman has treated adults with ADHD for over 40 years. Goodman explains how ADHD affects adults, the complexities in how it’s diagnosed and treated, and open questions for research in the field.
Resources
Visit the Adult Attention Deficit Disorder Center of Maryland’s website to learn more about adult ADHD, and find links to more of David Goodman’s research, interviews, and publications.
The American Professional Society of ADHD and Related Disorders will release guidelines for diagnosis and treatment of ADHD in late 2025. Check out their website to learn more.
Read the New York Times article “Have We Been Thinking About ADHD All Wrong?,” which was discussed during the podcast episode.
Transcript
Sara Frueh: Welcome to The Ongoing Transformation, a podcast from Issues in Science and Technology. Issues is a quarterly journal published by the National Academy of Sciences and Arizona State University.
Attention-deficit/hyperactivity disorder, or ADHD, was once thought to be a condition that only affects children, but awareness has grown that it often persists into adulthood. As our guest today explains, ADHD is the second most prevalent psychiatric disorder in adults.
I’m Sarah Frueh, an editor at Issues. I’m joined today by Dr. David Goodman, who’s an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. Dr. Goodman also serves as the director of the Adult Attention Deficit Disorder Center of Maryland. On this episode, we’ll discuss how ADHD affects adults, the complexities involved in how it’s diagnosed and treated, and open questions for research in the field. Dr. Goodman, welcome.
David Goodman: Hi Sarah, glad to be here. Thanks for inviting me to talk about this.
Frueh: Great. We’re so happy you’re here. I’m hoping you can start by telling us a little bit about yourself and your work on adult ADHD. What kind of research and clinical practice do you do, and what drew you to work in this area?
Adult ADHD is the second most prevalent psychiatric disorder in adults, and yet the professional training and focus on this is sorely absent.
Goodman: Well, I’ve had an interesting professional trajectory on this because I got into treating adults with ADHD in the mid-1980s, so that’s 40 years ago, when people didn’t even realize that ADHD extended into adulthood. I identified a few patients, they got better remarkably, and I said, “There’s going to be something to this into the future.” Now, understand, during that time, my colleagues were saying, “You’re going to lose your license for writing stimulant prescriptions,” or “You’re going to lose your license because someone’s going to get addicted.” So, I ferried through four decades of people telling me that this was not a real psychiatric condition, and now we have the international research of the last 30 years justifying the fact that adults with ADHD ought to be identified and treated. Remarkably, adult ADHD is the second most prevalent psychiatric disorder in adults, and yet the professional training and focus on this is sorely absent. So, we have a lot of clinicians in the community who really don’t understand what this is and what it looks like.
Frueh: Has that clinician training in adult ADHD gotten better as the research base has gotten more solid? As it’s become more accepted that this is a real thing, are more doctors learning about this?
Goodman: Several things that happened over the last couple of decades, and that is the increasing public awareness through media and television and podcasts like this. So, people are now reflecting on their own experiences. The other is because Johnny or Sally got diagnosed as a child, the pediatricians turn to the parents and say, which one of you sounds like you have this? The other is that with increasing continual medical education lectures, that clinicians have now come up to speed—some more comfortable than others—but there’s been a sharp learning curve, but we still have a large number of adults with ADHD walking around who don’t even know this is what they suffer from.
Frueh: Let’s talk a little bit about that, and sort of about the basics of this disorder. How does ADHD show up in adults? What are the symptoms? And just from your experience with patients, how does it actually look in the context of people’s lives? What are the kinds of problems people might run into that might prompt them to think maybe there’s an issue here, and I should talk to my doctor about it?
Goodman: So, there are two presentations. One which is clear: the patient has reviewed symptoms, have talked to family members, they’ve had these symptoms since they were a child or early adolescent, and it’s pretty clear. They go to the doctor and they tell the story, get a diagnosis, and get prescribed.
The negative consequences of ADHD when you’re not treated are enormous.
More often than not, though, ADHD individuals don’t realize they have ADHD, so they present to a clinician with anxiety and depression. They say, “I’m so anxious. I’m not able to get my work done and my job is in jeopardy,” or “I’m depressed because my spouse is giving me a hard time, complaining I can’t follow through and finish things on time, that they’re threatening to leave me.” And so, the presentation in mental health clinicians is anxiety and depression as a function of the impairments that are developing from the ADHD. It’s easy when someone comes in and says, “I think I have ADHD,” and they give the traditional history of chronic symptoms. It’s harder when people are not presenting with symptoms of ADHD, and the clinician who hasn’t been educated and trained on ADHD won’t be able to see what they don’t know. And this is why there’s been an increasing awareness amongst clinicians and the public about making the diagnosis. The negative consequences of ADHD when you’re not treated are enormous.
Frueh: What are the list of symptoms that you might look for if you’re trying to figure out if someone has ADHD?
Goodman: So, someone with ADHD will say that they’re inattentive, disorganized, easily distracted, they may be verbally impulsive or behaviorally impulsive, they may be restless and fidgety. What does that look like? They don’t show up on time for parties, to pick up their children, they forget to sign papers for their children, they forget their phone regularly. Now, everyone is going to listen to this and say, “Well, I do that sometimes, so maybe I have a little ADHD.” But the cornerstone of the diagnosis for ADHD is that these are symptoms since you were a child or early adolescent that have continued relatively unchanged, and they cause impairment in your life. Now, sometimes ADHD individuals don’t realize these symptoms and the other people in their lives will say, look, you’re always forgetting things. We just had this conversation yesterday. You’re misplacing things. We spend a lot of time looking for stuff. You never run on time. You’re always procrastinating. Everything’s last minute. It takes you longer to get things done.
One of my patients said, “I have a husband with ADHD, he’ll run around the block to go to the next door neighbor.” And what that means is that they just are not able to sequence a task in an efficient fashion. They may be verbally impulsive at a party. They’ll say an inappropriate joke, or make an inappropriate remark, or over-talk, or interrupt. They’re restless. They’re fidgety. Their feet are always moving in a meeting. And these are chronic daily symptoms, they cause problems.
The problems are the negative consequences. So, someone with ADHD is less likely to finish high school. They’re less likely to finish college. It takes them longer to finish college, which means it’s more expensive to finish college. They may get a job and lose the job because they’re chronically late, or they’re not finishing the tasks in a timely fashion. As you get older, then, if you get married, then you have to be responsible to someone, and that someone expects you to exercise your judgment and execute tasks consistently. So, when you’re a child, you may get diagnosed because of academic difficulties or because you’re disruptive in school. As an adult you get diagnosed or it comes to your attention because of the impairments that you experience during the course of your life. ADHD individuals are more likely to have starter jobs over the course of 10 years, which means you never develop a career, you never develop a financial base. They’re more likely to spend money impulsively, and as a result they find themselves in debt. They’re more likely to be involved in substance and alcohol and smoking, the list goes on and on. It doesn’t apply to everyone, there are a lot of people with ADHD who are reasonably successful, but they’re peddling twice as hard as everyone else. So, those are the kinds of symptoms that people will note about themselves or other people will bring it to their attention.
Frueh: You mentioned before about a patient showing up at a doctor’s office and having symptoms of anxiety and depression, when really what’s causing it is the underlying condition of ADHD, driving problems that are causing their anxiety and depression, and I’m wondering if you can talk a little bit more about how clinicians diagnose ADHD and some of the complexities in that. How do they tell that it’s ADHD and not something else?
The symptoms of ADHD, which are inattention, impulsivity, and hyperactivity, generally start in childhood and early adolescence.
Goodman: I’m going to repeat this over and over so I drive the point home, and that is that the symptoms of ADHD, which are inattention, impulsivity, and hyperactivity, generally start in childhood and early adolescence. So, when I talk to my patients looking for retrospective symptoms, I say, “Let’s think about you in grades 5, 6, 7.” So that’s about 10 to 12. And generally people can tell me how their experience was in school. I’ll ask them, did the teacher move you to the front of the class because you weren’t paying attention or you were bothering people? And the reason I ask that is because if you got moved to the front of the class or you got moved to a corner to remove you from the class, it means your symptoms of ADHD were significant enough that the environment was responding to them. Then, as we move forward into high school and college and first job, the difficulties of compensating become more challenging.
So, if you are a bright student, you might get through your academics of middle school and high school, but when you get to college, you have to construct your schedule on your own and that’s when things start falling apart for college students. If you then have your first job, or you get a promotion. So with each developmental phase of your life, you’re increasing the responsibilities you’re taking on, and the environment expects you to execute consistently. If you execute inconsistently, the environment moves away from you. If you execute consistently, then the environment moves towards you. If the environment moves away from you, you lose opportunities, if the environment moves towards you, you gain opportunities.
And so, this is the trajectory that ADHD individuals who are not treated will experience. The other element of ADHD that’s not part of the diagnostic criteria, but research has consistently shown this as an element, is emotional regulation. The people with untreated ADHD tend to be short-fused, impatient, easily frustrated, and reactive. This may be ascribed to either a mood disorder, like depression or bipolar disorder. It may be ascribed to anxiety. It may be ascribed to stress, but their emotional tone is a bit more fragile, and it’s that emotional reactivity that gets them into social difficulties.
Frueh: It sounds like ADHD in adults, even though people may first go to their doctor when they’re adults, may first be diagnosed when they’re adults, starts in childhood. Am I understanding correctly that you don’t just develop ADHD as an adult, that when you’re screening for people, you need to make sure their symptoms started a long time ago?
Goodman: If we follow the diagnostic criteria, that’s correct. You have to have had symptoms in childhood and early adolescence. Now, the caveat here is that if you’re an adult with ADHD, and you were not diagnosed as a child, it doesn’t mean you don’t have ADHD, it just means that nobody noticed it. So, in the National Comorbidity Replication Survey, which is the largest psychiatric epidemiologic study in the United States, published in 2006, it looked at adults age 18 to 44, looking for those who had ADHD who had never been diagnosed. 75% of the adults that were judged to have ADHD were never diagnosed as children. So, in order to have a diagnosis as an adult, you don’t necessarily have to have been diagnosed as a child, but you do have to have symptoms which an interviewer can solicit as they inquire about the childhood symptoms.
Frueh: I want to talk a little bit about treatment. So, once you’ve gone through this process and diagnosed a person with ADHD, how do you think about how to treat them and what do you usually do?
Goodman: Well, usually I back up. So, the first step here is to solicit the symptoms. Now, you have to solicit not only ADHD symptoms but also symptoms of other disorders. So, do you have an anxiety disorder? Do you have obsessive compulsive disorder, panic disorder, social anxiety? Do you have a mood disorder, bipolar disorder, major depression? Do you have a substance use disorder, alcohol, marijuana, narcotics? We’re looking for other psychiatric disorders that will decide whether you have ADHD or whether the cognitive symptoms that look like ADHD are part of another psychiatric disorder. That’s the first concept, and that’s called differential diagnosis.
The next concept is, do you have a coexisting disorder? And that means you can have ADHD and a depressive disorder, ADHD and an anxiety disorder. If you have several psychiatric conditions, then you have to decide which gets treated first, second, and third. So, there’s a diagnostic prioritization to choosing both the pharmacologic sequence and the psychotherapeutic approaches. Now, this does sound complicated, and if the clinician is doing a comprehensive psychiatric evaluation, this is the nature of that evaluation. It is not filling out six symptom checklists, 30 minutes of questions, and coming to a diagnostic conclusion, that’s not the standard of care for doing an evaluation.
Frueh: After all of this evaluation goes on and you do determine that a person has ADHD, and that’s the primary thing that’s going on, and the first thing that you want to treat, how would you treat it?
Goodman: The first thing I want to inquire about is the receptivity to the diagnosis. Is this something that resonates with you or do you think that I’m off the mark? If the patient feels I’m off the mark, then I have to recalibrate the approach. So, it’s very much in trying to keep with the patient where they are. But let’s assume that this patient says, “Okay, finally I have an explanation. Thank goodness that somebody has said that this is what I have, and not who I am as a person.” And this latter attribute of what I have versus who I am is very important in psychotherapy, because as we move through the treatment and the person gets better, they become to understand that they are not as the environment had accused them: lazy, disorganized, stupid, unmotivated. That’s actually very resurrecting for self-esteem. In specifics for treatment, we often talk about organizational skills and psychotherapies and/or medication. Both are usually employed, but it’s up to the patient as to how they want to pursue this.
Ultimately, we get to medications that are FDA approved and have been used in treatment for the last decades, and stimulant medications remain the gold standard. The effect size that is the magnitude of benefit you get from stimulant medications is substantial. In fact, many people don’t know, the benefit of stimulants for ADHD is stronger than most medications in all of medicine, and you have to digest that for a moment. And then, people will push back and say, well, they’re addictive, they’re toxic, I don’t want to get dependent on them, and that’s a discussion that we have in follow-up.
The first point here is, let’s see if it works. If it works, you can decide whether or not you want to be on medication. If it doesn’t work, then we’ll reorient and approach it differently. There are non-stimulants also. Stimulants are the standard, but there are non-stimulants, so there are medications that are not stimulants that can be used. They tend to work a little less effectively, and they take longer to figure out if they work. So, if I give you a stimulant and I increase the dose, we’re going to know over a few days. If I use a non-stimulant and increase the dose, it’s probably going to take about a month to figure out whether it’s helpful or not.
Frueh: So, if a patient decides to try stimulants and it works for them, and they like the effect it’s having on their quality of life and they want to keep going, but they’re worried about addiction risk, how do you work with them to manage addiction risk with stimulants?
Goodman: When people say the word “addiction,” they instantly think about narcotics. They think about stopping narcotics and going through terrible withdrawal symptoms, and that’s a physiologic reaction. That tends not to happen with stimulants. I have patients who are on their stimulants, they go on vacation, they forget their medication, and what they notice is that their energy level, their motivation is down. After two or three days, that washes away and they’re fine. So, this idea that you’re going to go through a major withdrawal by abruptly stopping your stimulant medication for ADHD is incorrect.
The other aspect of this though is that you ought to take medication as prescribed, and that’s particularly true for stimulant medication. We tend to use long-acting stimulant medications, which can be taken once a day in the morning and last 6, 8, 10 hours, and then the dose gets adjusted so that we can cover your symptoms over the course of eight to 12 hours. But it makes it very easy just to take one pill or two pills in the morning, and have your ADHD symptoms improved over the course of eight hours. If you take it regularly like that, the addictive quality is almost non-existent.
Now, are there exceptions? There are always exceptions to the rules, but I’m talking about in group data, these are much less serious concerns weighed against the benefit of the medication. So, it’s like having blurred vision, you can walk around in your life with blurred vision, you won’t be able to read as well, and you won’t be able to see as well, but you can get through. If I put glasses on you and you walk around for a month, at the end of the month, you have to decide is the quality of your life and your functioning on the glasses better than without the glasses? And the glasses are the metaphor for the medications. That gets complemented with psychotherapy, it’s pills and skills. So, we have to teach people how to time manage, organize sequence, and then the next order is if you are living in a house with other people, we need to coordinate their understanding with how to interact with you in a productive fashion that’s less frustrating to people around you.
Frueh: So, when this goes well and you find treatments that work, medication, behavioral treatments, therapy, that sort of thing, what are some of the benefits of treatment, whether with medication or behavioral things, what kinds of changes do you see in a patient where their response to these treatments is successful?
People will often focus on the risks of the medications. What they don’t talk about is the risks of not treating.
Goodman: Well, that’s an interesting question. It’s interesting because people will often focus on the risks of the medications. What they don’t talk about is the risks of not treating. And I had mentioned the negative consequences, which can be rather dramatic and traumatic to people whose lives are continually stumbling over the obstacles. The benefit of treating is that it’s a remarkable improvement. So, unlike depression, if I treat your depression, I get you back to where you were before. If I treat your ADHD, I take you to a level that you’d never experienced before, and this is where people go from, “oh, I’m not very good at functioning in the world” to “I can’t believe how much better I actually can function if my ADHD is treated.”
So, with treatment, what you would notice relatively quickly is that your sustained attention on a task is better, you get things done in a faster period of time, more gets done during the course of the day, your ability to plan your time is better, your degree of anxiety is reduced, your patience is increased, your restlessness may calm down, so you can sit for longer periods of time comfortably, you may be more mindful not to interrupt in conversation, or to blurt out things. So, there’s a break, a breaking to your impulsivity and your restlessness, and this is not a “maybe kind of sort of,” this is, “wow, this is a night and day experience.” And so, I could talk about this all day, I just love treating my patients and watching them get better.
Frueh: Do people, when they go through this, what sounds like a transformational process in some ways, like a lot of things are different about their lives… Is that always an unmitigated positive to people, or do some people struggle with having gone through their lives with their identity of being this way and then suddenly being able to do things that they weren’t before in a fairly quick fashion? What is that like for patients?
Goodman: It’s an interesting question, and it’s different for everyone. The later in life you get diagnosed, the more regret and grief there is about lost opportunities in your former years. And so, there’s an element of therapy that goes through the grief process of how your life was with untreated ADHD. As people get better, what you notice is the symptoms improve, your performance improves, your confidence goes up, you start taking on things you would’ve previously said no to, you become more successful with what you do. As you’re executing consistently, people around you notice that you’re better. At work, you may notice six months after treatment, you get a major project, you get a promotion, and people start saying positive things about you.
Your relationships at work improve because now people come towards you instead of moving away from you. At home, relationships improve because the frustrated spouse or partner or family member sees that you’re able to show up on time, sees that you’re listening better, sees that you’re finishing things in a dependable fashion. And so, the social relationships improve, and I often tell patients from the start of treatment, you’ll fully blossom into who you are, the potential of who you are in about a year on treatment, and your life will transform not only externally in your relationships, in your job, but also internally in how you see yourself and how you see yourself in the world.
Frueh: I’d like to switch gears a little bit and talk about a recent New York Times article, the general premise was that maybe we’ve been thinking about ADHD wrong, and this was not specific to adult ADHD. This was ADHD in general. And one of the premises was maybe the scientific basis for how it’s diagnosed isn’t as solid or as clear cut as it’s made out to be, and maybe we should be thinking differently about treatment. I’d like to get your thoughts on a couple of ideas that were in that article. First of all, the idea that, and you noted this before, there’s no clear biomarker, there’s no clear distinctive sign that doctors can say, if you have this in your blood or in your brain, then you definitely have ADHD, like a super clear biomarker that divides people from ADHD from those without. And that symptoms exist on a spectrum, so there isn’t a strong empirical basis for drawing a line. This person has ADHD, this person doesn’t. So, that there’s an element of arbitrariness to the diagnosis. So, what do you think of that?
This idea that ADHD is on a spectrum is actually conceptually incorrect.
Goodman: In regards to The New York Times article, it was disappointing that the journalist hadn’t completely understood the evolution of ADHD. So, ADHD has been recognized for decades. In 1955, Ritalin was approved for ADHD, which means that we now have 70 years of experience with these medications. There are thousands of controlled trials internationally looking at ADHD, defining ADHD, and seeing what treatments work, and what treatments do not work.
The conceptual issue in The New York Times article is a misconception, and let me explain what I mean. There’s the symptoms of ADHD, so inattention, distractibility, disorganization, impulsivity, restlessness. Each of those symptoms are distributed normally across the general population. So, you and I sometimes have inattention, you and I have sometimes forgetfulness and distractibility, that’s a normal human experience. What constitutes ADHD is the cluster of symptoms at the tail end of the bell curve that are so severe that they cause chronic and daily impairment. And so, this idea that ADHD is on a spectrum is actually conceptually incorrect. The symptoms of ADHD, the inattention, the cognitive difficulties, the distractibility, yes, that is distributed equally across the population, but the diagnosis of ADHD that requires impairment from childhood only applies to about 8 to 10% of children, and to about 4 to 5% of adults. So, it’s not that we all have a little ADHD, we all have some of the cognitive difficulties that we associate with ADHD.
Frueh: Thank you, that’s really helpful to draw that distinction. Another idea in the article that I just wanted to get your thoughts on was that the observation that a person who’s been diagnosed with ADHD, that their symptoms vary over time, and depending on the context or environment, sometimes they might meet the threshold, sometimes they don’t. The writer raised the question, are we focusing too much on biology and biological responses, meaning meds, as a way to treat it, and too little on focusing on changing people’s environments? Does that ring true at all to you?
Goodman: So, I think whenever there’s impairments in one’s life that are largely influenced by the environment, we should certainly counsel people to alter their environments if they are able to and or develop compensatory skills that allow them to navigate through a stressful environment. That is a concept that applies to all of us. For ADHD though, the experience of ADHD will obviously worsen when the cognitive demands of an environmental situation are worse. So, if you are inattentive and distractible, and I put you in an environment with high stress, that’s going to get worse. It’ll get worse for anyone. With an ADHD individual, it gets worse to several fold. It’s a gradient of the worsening. Now, The New York Times journalist also focused on an article that came out showing a fluctuation of symptoms over the course of time. What it didn’t show was the level of impairments that people were having and what the environmental demands were in the course of these fluctuations of symptoms.
And so, I would say in order to be more diagnostically accurate, it’s best to stick to the diagnostic criteria of childhood symptoms, early adolescent symptoms, chronicity impairment over the course of time. It’s not typically something that comes and goes. It may fluctuate given the demands of an environment. So, if I have ADHD and my job is to sell hot dogs on a Caribbean beach, probably don’t need to be terribly aggressive in treating it. But if I’m an accountant at a top-ten accounting firm, I need my ADHD treated because I don’t want to make careless errors on tax returns.
Frueh: That’s helpful too, just the difference in context. Do you find that your patients sometimes are okay without medication if they have found their way into a profession or a context that doesn’t tax those cognitive abilities, that attention, as strongly as other professions might?
Goodman: The answer to that is yes, if you have relatively mild ADHD, you don’t necessarily need to be on medication. It would be helpful to have some psychotherapy of what this is, what your experience is, and how you could better polish up your organizational and social skills, sure. If you are an actor—and there are plenty of actors in Hollywood with ADHD who’ve declared it publicly—do you need to have your ADHD treated? Perhaps not. Perhaps your creativity is broader off medication than on medication. However, that’s a career environment, and you have to take a look at how are you functioning in your real world? Are you bouncing checks? Are you overspending? Are you impulsive? Are you drinking too much? And so, sometimes the ADHD doesn’t interfere with one area of your life and it becomes a disaster in other areas of your life.
I treat Olympic-level athletes. I treat people in the NFL and Division I, and so many of them like being on medication because they can remember their plays, and where they need to be, but I had a Division I soccer goalie who said, I can’t be on medication because my ADHD allows me to attentionally shift rapidly across the field, and they would prefer not to be on medication. So, in regards to the effects of medication, it’s not a cure-all and be-all, and it may help in many situations and not be helpful in other situations. Now, having said that, that’s not to say you should take your medicine when you think you need it and not take it at other times. You really should take your medicine consistently every day because the areas of your life that it causes problems are the areas in which your ADHD really needs to be treated.
Frueh: It’s really helpful to hear about your experiences with patients and their responses to navigating all this stuff, which sounds complicated sometimes, and widely varying. In addition to treating patients, you are also a leader in research in this field, and I’m wondering what you think are the big unknowns left in research on adult ADHD that you would like to see research answer, things that could really make a difference for patients and for doctors?
The two next frontiers are going to be women in ADHD and hormones, and ADHD in older adults.
Goodman: So, there are two areas in ADHD which will be the next clinical frontier. One is women. There is a real absence of ADHD research that’s focused on women, and in particular the hormonal fluctuations. So, onset of menses, premenstrual symptoms, pregnancy, postpartum, perimenopause, and menopause. My particular focus now is on the second group, and that is ADHD in older adults over the age of 50 who were never diagnosed. And almost 100% of those people who come to see me were never diagnosed because when they grew up in the 50s and 60s, nobody was attending to ADHD unless you were a six-year-old bouncing off the walls. And so, I have a number of adults with ADHD who are older, 50s, 60s, 70s, even early 80s, who have been diagnosed and treated. The degree of research on older adults is so lacking that there’s no guidance from the research as to what clinicians should do.
I spend my time lecturing on this subject in order to get the word out that when older adults present with cognitive complaints, ADHD should be part of the evaluation process, because if it’s not, you’ll simply assign a diagnosis of age-related cognitive change or perimenopausal cognitive changes, and you’ll miss the opportunity to make a diagnosis where you can treat them effectively. So, coming back to your original question, the two next frontiers are going to be women in ADHD and hormones, and ADHD in older adults.
Frueh: What was the age of the oldest patient that you’ve ever diagnosed? How late in life might someone find out about this?
Goodman: 79. And I have patients who are still in their early 80s on medication, and I say, “You’re getting older, maybe you don’t need to be on the medicine. The demands of your life aren’t that great. You have medical issues that maybe we should subtract your ADHD medication.” And they say, “Please, please, please don’t do that.” The other issue I have now is that having been in practice now for 40 years. I have aged with my patients. And so, I understand what ADHD looks like as people age. And some people go on to develop dementia. So, there is an association between ADHD and developing Alzheimer’s and dementia. The question though is, when you get presented with somebody who’s 65, who’s complaining about cognitive difficulties, do they have ADHD? Do they have age-related normal forgetfulness? Or do they have an early prodrome of an Alzheimer’s picture? And so, it’s important to try to sort this out.
I do have a 62-year-old successful academic patient, who has ADHD diagnosed just by me a year ago, and also has early Alzheimer’s diagnosed by the new biomarkers that are available. Is there any research that offers me guidance on how to treat this person? Not a single publication. So, I’ve treated this person with a long-acting stimulant, and his functioning has improved 50 to 60%, and while he knows he has Alzheimer’s, he’s very much relieved that he can resume his work as a researcher for the next 2, 3, 4, maybe 5 years. And so, treatment for his ADHD has given him a quality of life for the next three to five years, which is, if you’re that person, boy, you are eternally grateful for getting an accurate diagnosis. Now, it’s not to say that everybody who presents is going to have ADHD, but for older adults, if you figure the prevalence rate’s about 3 to 4%, it’s important to add this to your diagnosis. And the difficulty here is that the memory clinics, the Alzheimer’s clinics and those who are seeing older adults haven’t been trained on ADHD and often don’t even actively look for it.
Frueh: Thank you, that is really helpful. So, it sounds like the big areas for research are women and the different hormonal life stages that affect their ADHD, and also older adults and how to differentiate that and untangle it from symptoms of dementia, things like that. Is that right?
Goodman: Correct. That’s correct.
Frueh: Before we go, I’m wondering if you see any other hopeful developments on the horizon. Is there anything happening in the field that you think will improve how ADHD in adults is diagnosed and treated?
Goodman: The organization I mentioned, the American Professional Society for ADHD and Related Disorders (APSARD), is going to be putting clinical practice guidelines for the diagnosis and treatment of adults with ADHD, and it’s only going to rely on the adult research. So, it will be the first international guidelines for adult ADHD that only looks at the adult guidelines. And why is that important? Because when you look at the research, you begin to see what supports clinical practice, and you also begin to see where the absences are, where research needs to fill in the blanks. And the same thing is true for women and hormone and fluctuations in their symptoms. So, we’re hopefully looking for that to be published in probably a year from now, and we’re doing that in conjunction with the Children and Adults with ADHD Association, which is a grassroots, patient-oriented organization nationally, that’s going to partner with APSARD to get this accomplished.
We’re hoping that it becomes a tsunami for change in a positive light.
It really is a big deal because these guidelines will then set a minimum standard for care across the country, and it will also influence educational programs, it’ll influence insurance policies to cover ADHD in parity, it’ll affect the legislative body and the regulators who are going to issue guidelines in regards to policy. So, we’re hoping that it becomes a tsunami for change in a positive light.
Frueh: That’s great to hear that that’s all underway, and I will keep an eye on that next year. Anyway, thank you so much for taking the time to share your knowledge with us and also some of your stories and experiences of your patients, which was really helpful.
Goodman: Thank you, Sara.
Frueh: To learn more about adult ADHD and Dr. Goodman’s work, check the show notes.
Subscribe to the Ongoing Transformation wherever you get your podcasts. You can email us at podcast@issues.org with any comments or suggestions. And if you enjoy conversations like this one, go to issues.org, where you can also subscribe to our print magazine. Thanks to our podcast producer, Kimberly Quach and audio engineer Shannon Lynch. I’m Sarah Freuh, an editor for Issues. Thank you for joining us.