I am a child and adolescent psychiatrist who specializes in diagnosing and treating patients with Attention Deficit Hyperactivity Disorder (ADHD). I’d like to share a story about one of my patients: LJ is a 19-year-old female who presented to the clinic as she was failing her college classes. She had attended a local public high school and graduated with a 3.9 GPA. However, in college, she struggled to keep up with her academic workload and navigate some of the complex social dynamics. She often spent many hours trying to focus on her schoolwork, with little success. She took up occasional marijuana usage to help her with her anxiety.
Her recollection was that her struggles with focus and hyperactivity began in grade school. She got good grades, which she attributed to her excellent memory. Her mother often helped her by making checklists and keeping her organized. LJ's hyperactivity was helped by physical exercise, which also helped her gain a scholarship to college.
LJ’s story of undiagnosed ADHD is quite common. Once she was formally diagnosed in college, she responded well to medications and passed all her classes. Furthermore, the functional impairments she experienced with relationships and communication improved as well.
What is Attention Deficit Hyperactivity Disorder, ADHD?
ADHD is a neurodevelopmental disorder, with early onset in childhood and a prevalence of around 3–5 %. The symptoms at the core of the disorder are characterized by deficits in the attention span (inattention), impulsive behaviors (impulsivity) and an increased level of activity (hyperactivity) [DSM-5]. ADHD causes significant impairment in cognitive and executive functions and results in behavioral problems that affect relationships, academic functioning and work performance, leading to a lower quality of life.
Although generally recognized as a childhood disorder, the characteristic impairment is often lifelong. It continues to affect both the personal and professional life of patients once they grow into adulthood. Though clinical settings often focus on the diagnosis and treatment of children with ADHD, there has been an increase in adult diagnoses in recent years. Since clinical settings appear to be less focused on detecting and treating adult ADHD, many adults are diagnosed and treated only after their children or grandchildren have been diagnosed.
ADHD and its presentation throughout the lifespan
ADHD presents at different ages for treatment: most commonly in elementary and middle school. High school teens do not present as often, as they may have developed ways to compensate. This may be unfortunate; if they go to college, they may perform poorly or even drop out. It often seems that college-age kids with undiagnosed ADHD are having trouble adjusting to college life, but many struggle because of untreated ADHD. They may hesitate to reach out to the college counselors out of confusion or embarrassment. Furthermore, it can lead to poor academic achievement and, in some cases, self-medication, which may evolve into substance abuse.
ADHD may present among working adults around issues like promotion, tardiness and underperformance. Relationship issues around peer friendships, significant-other relationships or even entering parenthood may exacerbate the symptoms of ADHD. Older adults with ADHD show serious impairments in quality of life comparable to the levels found for younger adults. Impairments may increase further as these individuals grow older. Clinics need to meet the needs of this increasingly larger group of patients.
Based on the clinical guidelines, the broad treatment of ADHD is four-fold:
Psycho-education: evidence shows this to be 40% effective. It consists of understanding the different aspects and impacts of ADHD.
Medications: methylphenidate, amphetamine salts, atomoxetine.
Work/school accommodations.
Therapies focused on the treatment of the functional impairments of ADHD.
Once a patient is on medicine, is this a lifelong plan? What is the likely path of someone who is on ADHD meds?
One of the common concerns that people express concerning the medications used to treat ADHD and other psychiatric conditions is whether they’ll have to take them for the rest of their lives. Medications for ADHD are meant to be taken until the precipitating life stressor passes (e.g., finishing their education). These medications are not to be taken for long periods of time. However, untreated ADHD or under-treated ADHD can lead to anxiety and depression. Patients with these diagnoses may need to take anti-depressant/anxiety medications for a more extended period of time.
Though pharmaceuticals are effective, are there safe, holistic approaches?
Withania somnifera (aka Ashwagandha) is used effectively in Ayurvedic medicine, particularly for depression. It can be prescribed and regulated by Ayurvedic practitioners, and it is available over the counter in a pill form.
Fish oil.
Gluten-free diets are relevant for those who are gluten-sensitive or who have been diagnosed with Celiac disease. Eliminating gluten from the diets of these individuals helps with inattention and hyperactivity.
If you need more information about ADHD:
Look up CHADD, an organization dedicated to ADHD.
Consult your primary care physician.
Consult a psychiatrist familiar with ADHD.
Make dietary modifications.
What not to do:
Do not self-medicate with alcohol, marijuana, cannabinoids, cocaine or any other illicit substances.
Do not try any holistic preparation without first consulting with a practitioner familiar with ADHD.
Do not use another person’s prescription; it is a felony!
ADHD is present throughout the lifespan, but many patients develop coping mechanisms that mask its presence. A life stressor can alter the ability to compensate, which is when individuals bring their concerns to a clinician’s attention. The good news is that there has been an increase in the diagnosis of ADHD among adult patients in the past few years, indicating a growing understanding of the myriad ways ADHD impacts people throughout their lives.
Resources
Goodman DW, Mitchell S, Rhodewalt L, Surman CB. Clinical Presentation, Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in Older Adults: A Review of the Evidence and its Implications for Clinical Care. Drugs Aging. 2016 Jan;33(1):27-36. doi: 10.1007/s40266-015-0327-0. PMID: 26659731
Kooij JJ, Michielsen M, Kruithof H, Bijlenga D. ADHD in old age: a review of the literature and proposal for assessment and treatment. Expert Rev Neurother. 2016 Dec;16(12):1371-1381. doi: 10.1080/14737175.2016.1204914. Epub 2016 Jul 4.PMID: 27334252
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015 Mar;56(3):345-65. doi: 10.1111/jcpp.12381. Epub 2015 Feb 3.PMID: 25649325
Sarris, Jerome. Herbal medicines in the treatment of psychiatric disorders: 10-year updated review. Review Phytother Res. 2018 Jul;32(7):1147-1162. doi: 10.1002/ptr.6055. Epub 2018 Mar 25.PMID: 29575228 DOI: 10.1002/ptr.6055
Thorell LB, Holst Y, Sjöwall D. Quality of life in older adults with ADHD: links to ADHD symptom levels and executive functioning deficits. Nord J Psychiatry. 2019 Oct;73(7):409-416.PMID: 31380715
Sonia Gaur, MD
Sonia Gaur, MD is a clinical assistant professor at Stanford. She has been treating ADHD in children and, more recently, ran the adult ADHD clinic at Stanford.
She offers assessments as well as ongoing medication management, drawing on her years of experience with treating complex, high-risk adolescents and her in-depth knowledge of psychopharmacology and ADHD across the lifespan. Her vision is to improve patient care through service. She sits on the State of California board for policy and legislation for mental health for children and adolescents (www.calacap.org).
Facebook: @soniagaur