All through elementary school, that pesky “N” appeared on my report card. “Needs Improvement” in listening. My parents and I laughed it off, the endearing sign of a flibbertigibbet. Just as we joked about my stance in T-ball, my gaze toward the sky or the action in another field, immune to the coach’s call to “look alive!” (Not that it mattered in the outfield.)
Any trouble with attention was something to work on, a quirk, we figured. After all, I made and kept friends. And my grades didn’t suffer. Back then, in the ’80s, attention-deficit/hyperactivity disorder was the province of hyperactive boys, not of a girl who managed relatively well. It wasn’t until my late 30s that I first heard the term “executive functioning,” when a friend’s daughter struggled with organization. “She reminds me of you,” my friend said lovingly.
And this is, very often, how adults come to realize that perhaps ADHD—one of the most common disorders of childhood—helps explain their own life story. A child’s diagnosis or trouble in school will sound strikingly familiar. And because the disorder is highly genetic, parents very often see themselves in their children.
Still, it’s a tough diagnosis to tease out. As we now know, ADHD can show up in a range of ways, whether through inattention or hyperactivity and impulsivity, or a combination of behaviors. It often looks different in kids than adults, and in men as opposed to women. Plus, it’s often masked by and coexists with other conditions, which tend to exacerbate with age.
“What we’re finding is that ADHD is actually systemically misdiagnosed and underdiagnosed,” says Lauren Finney, a clinical social worker in Washington, D.C.’s Tenleytown neighborhood. “A generation ago, it was the class-clown boys—those were the ones who clearly have ADHD.” Despite a new understanding of the disorder, myths remain. “Even today, I certainly run into parents who say, ‘My child is way too smart to have ADHD. She gets good grades,’ ” Finney says
Finney diagnosed herself at the age of 37, after starting in private practice. “I realized that I fit all of these symptoms for ADHD in women that are not the stereotypical symptoms that I was taught about in grad school,” she says.
Among them, she was accident-prone (even now, Finney doesn’t own nice things for fear of breaking them). She struggled to remember dates and appointment times and would get so overwhelmed by paperwork she’d feel paralyzed to tackle it. As a kid, her ADHD came through as shyness, anxiety and feeling somewhat out of step.
“I learned to hide the feeling that I didn’t always fully understand what was going on or what I was supposed to be doing,” she says. She compensated with a planner so excruciatingly detailed that her friends at Woodrow Wilson High School (now known as Jackson-Reed High School) ribbed her about it. “The older I got, and especially as I tried to start my own business, I was like, Why is juggling these things so hard for me?” she says.
I get that. For better or worse, what worked when I was younger doesn’t anymore. In high school, I survived by brazenly reading the Cliffs-
Notes of novels, and in college I routinely pulled all-nighters thanks to procrastination and a shockingly bad sense of time. I doubt I could pull an all-nighter now if I tried. And if Cliff has any notes for life, someone please tell me about them. I thought having kids would force me to get organized. And to some extent, it has. But I just end up dropping the less emergent things—like bathing. Kidding, but you get the idea. Child care trumps self-care.
While a new ADHD diagnosis for adults can feel affirming, even liberating, it also can spur a sense of grief over lost time. “It’s not uncommon for people to break down and say, ‘I wish I would have known this 20 years ago, and maybe I wouldn’t have beaten myself up,’ ” says Jennifer Reesman, a neuropsychologist with the Bethesda-based Chesapeake Center, which specializes in ADHD, learning and behavioral health.
An estimated 6 million, or 9.4%, of kids in America have a diagnosis of ADHD, according to the Centers for Disease Control and Prevention. Data on adults is more difficult to pinpoint, but estimates hover around 4% to 5% of U.S. adults. But diagnoses are climbing by as much as quadruple the rate of children’s, according to a 10-year study lead-authored by a Harvard Medical School professor and published by the American Medical Association in 2019 in JAMA Network Open. That’s due to a growing awareness of ADHD, a reduced stigma around mental health issues, and self-proclamations about the condition on social media, Reesman says.
Less than 20% of adults with ADHD were being diagnosed or treated as of a widely cited 2014 study published in the Primary Care Companion for CNS Disorders. In part, that’s because adults don’t have a built-in detection system like kids, whose diagnoses often come by way of school referrals. Instead, desperation at work or home drives adults to a counselor for help. Meanwhile, the current diagnostic criteria address symptoms in children, which can differ from those in adults.
A diagnosis first requires ruling out many red herrings, which become more numerous with age. “ADHD lookalikes” include learning disabilities, hearing loss, menopause, poor sleep and, especially, depression and anxiety, Reesman says.
Consider the case of William Stixrud, founder of an eponymous Silver Spring-based neuropsychology practice. As an anxious young man, further stressed by the death of his father, Stixrud flunked out of his Ph.D. program at the University of California, Berkeley. “I didn’t turn
in a single assignment because I was so anxious,” he says. “I was the most nervous person they’d ever met.” Stixrud’s body shook, his fingers tapped, and he could endure only 12 minutes of reading. When he went home to Seattle, he learned Transcendental Meditation, which essentially cured him, he says. After a month of meditating, his facial tic faded away. In two months, he could read for two hours at a time. Stixrud didn’t have ADHD. But his anxiety appeared exactly like it.
So what does adult ADHD look like?
The constellation of symptoms could include “time blindness,” or difficulty tracking time; impulsive behavior; procrastination; taking excessive time to complete a project or not completing it at all; and, along with the struggle to focus on something of little interest, the tendency to hyperfocus on something that is. That’s a mode of becoming so engrossed that a lunch break, or even a fire alarm, couldn’t derail one’s attention. The hyperfocus piece “trips people up,” says Reesman, who often hears a version of this refrain: “My husband or wife thinks that I have ADHD, but I can’t possibly have ADHD, Doctor, because I can focus on my tennis like it’s nothing else.”
“If this was the path that I had to take as a mental health professional to figure out that so much of what I struggle with is ADHD,” Finney asks, “then what about everybody else?”
Some argue that we all have a bit of ADHD, given our culture’s sleep-deprived, screen-focused, 280-character tweeting state. As Stixrud says, “People would listen to Lincoln and Douglas debate for six hours. Who among us could do that these days?” And yet, he adds, it’s “also true that some people have much more of a problem than others do.”
Around age 25, with the maturation of the brain’s prefrontal cortex, which manages executive function, many people outgrow their ADHD, Stixrud explains. Some get by. Some don’t, jeopardizing jobs and relationships and even their own lives due to distractions or risky behavior.
Others find a way to flourish with the disorder—in careers where the adrenaline rush of an emergency room or courtroom can capture their attention, or as creative entrepreneurs focused on what excites them.
It’s never too late for help with ADHD, according to Kathleen Nadeau, founder and clinical director of the Chesapeake Center and author of Still Distracted After All These Years: Help and Support for Older Adults with ADHD. “A lot of adults mistakenly think, I’ve lived this long. Maybe I have it, maybe I don’t, but why does it matter?” she says. But ADHD seeps into everything, Nadeau says, from the ability to manage one’s career and finances to relationships and health.
In fact, a lack of treatment can be life-threatening.
Nadeau cites a 2018 study by leading ADHD researcher Russell Barkley, who found that ADHD may shorten an adult’s life by as many as 13 years due to impulsive behavior, poor self-
control and carelessness. Given the coexisting conditions associated with ADHD, treatment rests on a detailed diagnosis, which Nadeau believes remains elusive. Older adults with ADHD are particularly overlooked, she says, noting a Johns Hopkins University finding that just one in five memory clinics screen for adult ADHD.
To improve life with ADHD, Nadeau stresses lifestyle changes: meditation, exercise, nutrition, exposure to nature, social connection and sleep.
Stixrud espouses the life-altering prospect of ADHD medication, stimulants such as Adderall and Ritalin. “When it works, there’s nothing that comes close,” says Stixrud, who estimates that for 30% to 40% of people with ADHD, it’s like “turning on a light switch.”
The FDA announced a nationwide shortage of Adderall, also known as mixed amphetamine salts, in October. That left more than 26 million people scrambling for the drug this past fall, according to the Los Angeles Times. Many ADHD patients found themselves driving for hours to pharmacies that had the drug in stock, or going without. Reports have chalked up the scarcity to a combination of two things: a labor shortage at Adderall’s main manufacturer, Teva Pharmaceutical Industries, and an increase in ADHD diagnoses in recent years, which has driven up demand. The supply was projected to return to normal by the end of 2022.
A combination of medication and behavioral strategies has helped Finney enormously. For instance, she sets multiple alarms for appointments and works with a friend who also has ADHD to keep each other accountable. “There are so many ways to compensate, and to practice acceptance and compassion and still lead wonderful, full, successful lives with this,” she told me in a text message.
By the time I recognized ADHD symptoms in myself, I was pregnant or working on it—a time when the medication isn’t recommended. But my case was never terribly problematic. In fact, I somewhat like my ADHD, even though it surely prolonged my finishing this article.
When I was dating my husband, he admired that I was the first “nonlinear thinker” he knew. (Another term I hadn’t heard.) The point was, in a type A town that prizes productivity (to say nothing of whether it succeeds), I tend to consider the beautiful distractions: the way light skips over an angle of a building, or a waiter whose face seems to belong in an impressionist painting. These observations delight me, and I indulge them with a slower pace. This means I often get sidetracked and run late, which does create stress. Still, I’ve long loved detours, from chatting with strangers to taking the scenic route home. When sending me on an errand, my mom used to joke: “Do not pass Go. Do not collect $200,” which was not to equate home with jail.
Though structure maybe what I need, I eschew it, likely to my detriment. (Admittedly, I thought “freelance writer” sounded like a dream job because it had the word “free” in it.) However, forsaking plans for spontaneity has almost always been worth it. I have consistently found that the very best moments on vacation, and in life, happen when open to whim. While being an incorrigible eavesdropper may merit some journalistic value, I feel bad about getting diverted from my own company to absorb the plot of someone else’s story and imagine where it leads. I also bemoan my unfinished stories that have stacked up along with the bills, creating a background tug of incompletion.
Would life have been easier had I been diagnosed as a kid? Probably. Maybe one day I’ll take ADHD medication and stick to a structure of circumscribed exercise and meditation. I’d become one of those moms who spends Sunday prepping the week’s meals in color-coded containers. Maybe I’d produce photo albums of my kids, organized by year and cuteness, in one productive weekend. Or I’d simply find matching socks. But to be honest, I don’t want to live in Real Simple magazine, repurposing toilet paper holders to hold my keys or fixed to any one regimen. At this point, it’s not exactly clear to me where my ADHD ends and I begin. But I like my pace, my style and my resistance to seeing success in a checklist. Would a little help help me? Of course it would. I’ll let you know how it goes. Once I get around to it.
Rachel Pomerance Berl is a freelance writer and editor who lives in Bethesda. She’s currently working on a collection of essays about motherhood.