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Newly recognized, adultADHD threatens the

success and well-beingof 4 percent of adults.

A combination oftreatments can helpthe af fl icted lead a

more productive life

By Tim Bilkey, Craig Surman

and Karen Weintraub

ADHD

GROWSUP]

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Zoë Kessler went through the firstfour decades of her life thinkingsomething must be wrong with her.

When she was a child, Kessler could not

understand why she kept misbehaving.

“I spent a ton of time in the hall for talk-

ing and being the class clown,” she says.

“My mom couldn’t control me, and I

couldn’t control me.” In adulthood, her

behavior improved, but she was so un-

focused she had trouble figuring out

what she should be doing minute to min-

ute, and she struggled to complete the

projects she had once been so excited

about starting.

Then, at age 47, Kessler was diag-nosed with attention-deficit hyperactiv-

ity disorder (ADHD). She realized that a

lot of the traits that had long made her

feel out of place were actually symptoms

of a condition that could be treated. “I’ve

had to rethink my entire li fe,” she says.

“Why didn’t anyone tell me?”

During Kessler’s childhood, most

people thought only little boys could

have ADHD. Clinicians are realizing

that ADHD is common in girls, too. Fur-

ther, they are recognizing that restless-ness is not the only smoking gun. Al-

though Kessler was as hyperactive and

talkative as stereotypical boys with the

condition, now clinicians realize that

many children with ADHD seem more

spacey than fidgety. In fact, Kessler was

relatively lucky to be diagnosed at all. In

a study of mental health conditions in

the U.S. published in 2006, health care

policy professor Ronald C. Kessler of

Harvard University (who is no relation

to Zoë) and his colleagues screened3,199 adults for ADHD, conducting fol-

low-up interviews in 154 of them. They

concluded that only one in 10 adults in

the U.S. with the condition receives a di-

agnosis of ADHD.

That statistic most likely will im-

prove as more researchers and clinicians

acknowledge the adult form of ADHD.

During the past two decades multiple

studies have confirmed that the disorder

can persist across a person’s life span. In-

deed, the latest edition of the American

Psychiatric Association’s diagnostic

manual, the DSM-5, is thefi

rst to explic-itly recognize adult ADHD, which is

thought to af flict 4.4 percent of the adult

population, in its description of the dis-

order [see box on page 69].

The need for treatment in adulthood

has become increasingly apparent. Re-

cent studies have demonstrated that the

disorder can limit professional success

and income, strain relationships and di-

minish well-being. Fortunately, research

published during the past decade has

shown that stimulant medication, thestandard treatment for children, is also

effective in adults. Yet evidence also sug-

gests that adults with ADHD must learn

new habits to overcome the numerous or-

ganizational challenges they face daily.

Researchers have devised new strat-

egies to help these individuals plan, pri-

oritize and organize their lives so that

they can accomplish their goals, stay

healthy and keep their relationships in-

tact. Many of these techniques would

also benefit the vast majority of people,given that virtually al l of us could use

ways to more ef ficiently and effectively

run our own lives.

Recognizing Adult ADHD

With time, about half the children

treated for ADHD recover completely.

For those who do not respond fully to

treatment, aspects of the disorder none-

theless change as a person matures. At all

ages, people with ADHD face challenges

stemming from a combination of three

core symptoms: trouble paying attention,

restlessness and impulsivity. By adult-

hood, hyperactive and impulsive traits

tend to wane, whereas dif ficulties with

controlling attention more often persist.

In some instances, ADHD may seem

to show up suddenly in adulthood. In

cases such as Kessler’s, the symptoms aremissed in childhood. Yet often the signs

very likely are masked. After all, parents,

educators and other adults usher children

through each day, collecting their be-

longings, bringing them to school and ac-

tivities on time, cajoling them to do

homework and chores. Such supervision

can compensate for a child’s deficits in at-

tending to tasks and working toward

goals. As children grow up, much of that

support disappears just as responsibili-

ties accumulate, enabling previously hid-den deficiencies to become all too obvi-

ous. Without parents to remind them of

assignments, a college student may find

his or her grades dropping dramatically.

Later the demands of a job or parenthood

may create complexities that a person

cannot manage. As important matters

fall through the cracks and sufferers be-

come demoralized or overwhelmed, they

may finally seek help, leading to a diag-

nosis of ADHD.

Although the pattern of dif ficultyvaries from one person to the next, one

central problem that af flicts adults is an

inability to focus. They tend to have

trouble getting around to, sticking with

or finishing certain types of tasks. Al-

though they can generally focus quite

well on stimulating activities such as

playing video games or working in a fast-

paced environment such as an emergen-

cy room, they may be easily diverted

from tasks that are repetitive—sorting

66 SCIENTIFIC AMERICAN MIND January/February 2014

FAST FACTS

REMEDY FOR THE DISTRACTED

 Only one in 10 adults in the U.S. who is af flicted with attention-deficit hyperactivity disorder

(ADHD) receives that diagnosis.

 The latest edition of the American Psychiatric Association’s diagnostic manual is the first to

explicitly recognize adult ADHD.

 ADHD can limit professional success, strain relationships and diminish well-being. Yet medica-

tion, along with therapy that teaches patients better habits and attitudes, can help individuals

meet their goals, stay healthy and maintain friendships.

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laundry or filling out forms—or mental-

ly challenging, such as writing a speech

or term paper. Of course, a person canchoose to work in a deadline-driven at-

mosphere that keeps them invigorated,

but laundry still has to be sorted, bills

paid and complex problems solved.

Impulsiveness, though often less se-

vere in adulthood, can produce other

predicaments. With short-term interests

and ideas repeatedly trumping long-term

goals, a person with ADHD lives a reac-

tive rather than proactive existence. He

or she may be unable to curb the urge to

check e-mail or Twitter so as to focus ona challenging project. Spontaneous

spending can lead to unnecessary finan-

cial burdens and bankruptcy. Sexual im-

pulsivity can cause unwanted pregnan-

cies, and reckless driving may result in

accidents. Cutting people off in conver-

sation or blurting out inappropriate re-

marks—signs of verbal impulsivity—can

harm relationships.

Such reactivity, and its consequenc-

es, may stem in part from a lack of emo-

tional control. In a study published in2013 one of us (Surman) and his col-

leagues at Massachusetts General Hos-

pital used a questionnaire to assess emo-

tional self-regulation—a construct that

includes frustration tolerance, temper

and emotional impulsivity—among 206

adults with ADHD and 123 without the

disorder. They found that 61 percent of

those with ADHD had trouble control-

ling their emotional expression, overre-

acting with anger more often than 95

percent of those without

ADHD. Such dif ficulty was

associated with poorer

quality of life, worse social

adjustment in many realms,

a higher likelihood of di-

vorce (and of having never

been married), and a higher

risk of traf fic accidents.

Many adults with

ADHD also display significant problems

with organization and planning. Indi-

viduals may fail to maintain a schedule,prioritize tasks and keep track of time.

At work, they often struggle to finish im-

portant assignments—becoming side-

tracked by minutiae—run late and spend

too much time getting their work done.

Sometimes their scattered lives prevent

them from making it to the of fice at all.

Results from the World Health Organi-

zation’s World Mental Health Survey

published in 2008 demonstrated that

untreated adults with ADHD missed the

equivalent of 22 more days of work thanthose without the condition. This under-

performance may explain why adults

with ADHD are often passed up for pro-

motions and unable to reach their pro-

fessional potential.

Challenges with planning and orga-

nization also lead to irregular or un-

healthy patterns of self-care. Quality of

sleep, which can affect health, happiness

and success, is often poor in adults with

ADHD. In a study published in 2009

Surman and his colleagues found thatmore than half of 182 adults with ADHD

reported either restless sleep or dif ficulty

getting to sleep. Those with ADHD also

said they went to bed more than half

an hour later, on average, than did 117

adults without the condition. Individuals

with the disorder also had a wider range

of bedtimes and greater daytime sleepi-

ness, which can, of course, compound

attention problems.

Pills and Skills

Reducing the frustrations and dis-

abilities that accompany ADHD in

adults usually requires a multifaceted

approach that includes drug and behav-

ioral therapy. Medication can amelio-

rate distractibility and impulsiveness in

the 6 percent of children diagnosed with

ADHD. Several studies have now shown

that stimulants such as Ritalin and Con-

certa (both methylphenidate) or Adder-all, which is a combination of amphet-

amine and dextroamphetamine, can im-

prove focus and decrease restlessness in

adults as well. Individuals taking medi-

cation for ADHD often report that they

are better able to get around to, stick

with and finish tasks.

But medication alone does not hone

the more complex organizational and

planning skills that help people hew to a

regular routine. For example, in a clinical

trial published in 2011 Joseph Biedermanand his colleagues at Mass General found

that 40 percent of adults who took meth-

ylphenidate for six weeks still reported

significant challenges planning events

and staying organized.

Thus, many adults with ADHD also

need therapy to learn and practice orga-

nizational and self-regulatory skills. In-

dividuals need different types of sup-

port, but therapists may teach them to

rank items on to-do lists in order of im-

portance, recognize what distracts themfrom tasks, and establish new habits,

such as setting aside time for planning

and prioritizing.

THE AUTHORS

TIM BILKEY is an adult psychiatrist specializing in adult ADHD in Canada. He has produced two films

on adult ADHD and star ted one of the world’s first clinics for women with ADHD. CRAIG SURMAN is

assistant professor of psychiatry at Harvard Medical School and Massachusetts General Hospital.

He studies and treats adult ADHD. KAREN WEINTRAUB is a freelance health and science journalist

based in Cambridge, Mass. Surman and Bilkey are co-authors of  FAST MINDS: How to Thrive If You

Have ADHD (or Think You Might) (Penguin/Berkley, 2013), written with Weintraub.

Adults with ADHD may have

difficulty sticking with a

challenging task or attending

to an extended dialogue at

a meeting with colleagues.

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Adults with ADHD also often need

help setting up an organizational struc-

ture—typically, a consistent location—

for important objects and pieces of in-

formation. House and car keys should

have a home rather than being tossed in

various places. Appointments and phone

numbers should similarly be entered into

a calendar or contact list that is readily

accessible rather than scribbled on the

back of an envelope that could get

lost or tossed in the trash. People

may program an alarm to remind

them of an appointment or to pick

up the kids or use an electronic

calendar that synchs with e-mail

and their cell phone so they can

easily enter a meeting or event as

soon as they learn about it.In a study published in 2005

psychologist Steven A. Safren of

Mass General and his colleagues

showed that 12 training sessions,

focused on adopting organization-

al strategies, combined with medi-

cation, was more effective for

ADHD symptoms than medication

alone in 31 adults with ADHD. In

a follow-up study published in

2010 Safren found that 12 weeks of

training in organizational tech-niques relieved the burden of

ADHD in 79 adult patients more

than relaxation therapy of the

same duration did.

Therapy can also curtail impulsive

decision making. In our own clinical

practices, we ask clients to pick “critical

moments” in which they tend to stray

from their intended course. Such a mo-

ment might be deciding to play one more

video game instead of going to bed on

time or hitting snooze on the alarmclock, until a person is so rushed that

gym clothes are forgotten and the

planned exercise never happens. Once

patients become aware of the moments

they go astray, we help them craft a plan

for making a better choice. For example,

a patient may decide to read rather than

play games before bedtime or set aside a

time for gaming as a reward for hard

work that does not disrupt their ability

to wind down from the day. If someone

surfs the Web or compulsively checks e-

mail at work, they might download an

app that turns off Internet and e-mail ac-

cess for hours.

Technology such as computer re-

minders, distraction blockers or planning

tools can serve as “peripheral brains” to

support the human brain in completing

challenging cognitive tasks. People can

play a similar role. An assistant might

keep a calendar for you; a spouse might

protect family time; a colleague might re-

mind you of a regular meeting. Profes-

sionals, such as mental health therapists,

rehabilitation specialists and ADHD

“coaches,” can also keep people on track

and accountable. Coaches may suggest

adaptive strategies, teaching clients to

prioritize and set realistic goals, amongother skills.

Many adults with ADHD use sup-

port groups, such as those organized by

Children and Adults with ADHD or the

Attention Deficit Disorder Association,

to meet and confer with others struggling

with similar challenges. In these gather-

ings, group members can discuss their

new habits and own up to their failings,

a conversation that may help them stick

to the strategies they have learned. In

2010 psychologist Mary V. Solanto of the

Mount Sinai School of Medicine and her

colleagues found that teaching organiza-

tional habits in a group setting is also ef-

fective at relieving symptoms of ADHD.

“Why Do I Keep Doing This?”

One critical component of therapy is

aimed at an emotional barrier to change:

a self-critical internal voice that saps the

motivation to learn new skills and

adopt better habits. Adults with

ADHD often suffer psychologically

from a sense of unfulfilled poten-

tial, the sting of criticism from oth-

ers or regrets about the mistakes

they have made.

“The default was that I was a

bad, out-of-control kid who will-fully misbehaved,” Kessler says.

“My self-esteem and self-confi-

dence were pummeled as a child.”

Before her diagnosis and the hard

work that followed, Kessler would

often see herself as “screwing up.”

“Why do I keep doing this?” she

would angrily ask herself.

Cognitive-behavior therapy is

based on the idea that thoughts,

feelings and actions are interrelated

and that changing any one of thoseelements influences the others. In

one cognitive technique, called a

thought record, a person describes

a situation in which he or she experi-

enced distress and a therapist helps that

person identify how much of the distress

is rational versus emotional—that is,

rooted in his or her own perspective.

This process can help people see the

mental traps that they tend to fall into

when coping with dif ficult situations.

These snares may include catastrophiz-ing (thinking that something is far worse

than it is); mind reading (believing you

know what others think of you); or tak-

ing an all-or-nothing approach toward

self-worth (you are either a winner or a

loser with no middle ground). Thera-

pists help patients adopt a more rational

point of view so that they can focus on

problem solving. Individuals with

ADHD then have the energy to come up

with strategies for getting tasks done or

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Identifying impulsive decisions, such as hitting the

snooze on the alarm clock, that derail your day canlead you toward better choices in the future.

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even caring for themselves—important

tasks such as eating, exercising andsleeping on a regular schedule. The be-

havioral interventions, such as instruc-

tion in organizational techniques and

decision making at critical moments,

represent another key part of this type

of therapy.

For Kessler, medication, along with

cognitive approaches, has transformed

the way she lives. “Before, I was just too

overwhelmed and couldn’t really bring

anything to term,” Kessler recalls. Today

she uses a pen-and-paper system to keeptrack of appointments and the great ideas

that bubble up at random times. She also

does meditation to lessen her mood

swings and improve her focus and time

management. Being in nature similarly

quiets her mind, stabilizes her mood and

helps her manage her hyperactivity. She

channels her drive to talk into standup

comedy, public speaking and writing.

Cultivating friends who are supportive

helps her feel better about herself.

Her organization and stamina have

improved dramatically through theseefforts. Kessler’s second book, part

memoir, part self-help, entitled ADHD

According to Zoë, was published in

September, and her freelance writing and

speaking careers are thriving. Emotion-

ally, she also now understands that when

she does say something inappropriate

it is not necessarily a catastrophe. If

she needs to apologize to someone,she does, without beating herself up

about it. That way she can focus on other

aspects of her life. And Kessler’s im-

proved mental and organizational disci-

pline has reinforced her sense of self-

worth. “I actually get a kick out of my-

self,” she says. M

Attention-deficit hyperactivity disorder (ADHD) begins in

childhood, but recent work shows that it often contin-

ues into adulthood. The latest edition of the American

Psychiatric Association’s diagnostic manual, the DSM-5, has

revised its criteria for ADHD to explicitly acknowledge the adult

form of the disorder. In one change, symptoms must be pres-

ent before age 12 instead of age seven, the cutoff in earlier

editions, meaning adults only need to recall having troubles

by middle school age. In another, the description of symptoms

now includes examples more relevant to adults. For instance,

one that relates to attention reads, “Often fails to give close

attention to details or makes careless mistakes in school-

work, at work, or with other activities.” Another in that catego-

ry states, “Often does not follow through on instructions and

fails to finish schoolwork, chores, or duties in the workplace

(e.g., loses focus, side-tracked).” Children require six or moresymptoms from each set—attention and hyperactivity/impul-

sivity —to qualify for a diagnosis, whereas people 17 years and

older need five or more.

The World Health Organization has developed a test called

the Adult Self-Report Scale Screener that incorporates the

most common dif ficulties in adults with ADHD. Answer its

questions (at right) to find out whether you could be at risk for

the disorder.

Could You Have ADHD? Test Yourself

FURTHER READING

 ■  Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program Client Workbook

(Treatments That Work). Steven A. Safren, Susan Sprich, Carol A. Perlman and Michael W.Otto. Oxford University Press, 2005.

■  Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical

Approach. J. Russell Ramsay and Anthony L. Rostain. Routledge, 2007.

 ■  Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction.

Mary V. Solanto. Guilford Press, 2011.

 ■  Understanding Deficient Emotional Self-Regulation in Adults with Attention Deficit Hyperactivity

Disorder: A Controlled Study. C. B. Surman et al. in ADHD Attention Defi cit and Hyperactivity

Disorders, Vol. 5, No. 3. Published online February 13, 2013.

 ■  How to pick an ADHD coach: www.adhdcoaches.org/how-to-pick-an-adhd-coach

 From Our Archives

 ■  Are Doctors Diagnosing Too Many Kids with ADHD? Scott O. Lilienfeld and Hal Arkowitz; 

May/June 2013.

Check the box that best describes howyou have felt and conducted yourself overthe past six months. Please give the com-pleted questionnaire to your health care

professional during your next appointmentto discuss the results.

1. How often do you have troublewrapping up the final details of aproject once the challenging parts havebeen done?

2. How often do you have dif ficulty gettingthings in order when you have to doa task that requires organization?

3. How often do you have problemsremembering appointmentsor obligations?

4. When you have a task that requiresa lot of thought, how often do you avoidor delay getting started?

5. How often do you fidget or squirm with

your hands or feet when you have to sitdown for a long time?

6. How often do you feel overly activeand compelled to do things, as if youwere driven by a motor?

Add the number of checkmarks that appear in the darkly shaded areas.Four or more checkmarks indicate that your symptoms may beconsistent with adult ADHD. It may be beneficial for you to talk withyour health care provider about an evaluation.

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SOURCE: “ADULT ADHD SELF-REPORT SCALE -V1.1 (ASRS-V1.1) SCREENER,” FROM WHO

COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW, © WORLD HEALTH ORGANIZATION