Adult ADHD: Why diagnosis sometimes comes later in life

Leaving the routine and structure of school can make an adult Attention Deficit Hyperactivity Disorder diagnosis more obvious.

Though Attention Deficit Hyperactivity Disorder is often associated with children, it may not be diagnosed until adulthood for several reasons. First: the stigma.

“People often believe that difficulties in organization, attention and focus are due to a lack of discipline or effort,” said Dr. Bavani Rajah, a child and adolescent psychiatrist at Vanderbilt Behavioral Health. “But there really is a circuitry issue in the brain.”

Another part of that stigma is that ADHD medicines are controlled substances and parents might not seek treatment for children, said Rajah, who is a psychiatrist and treats both adults and children.

Diagnosis as an adult may also happen because symptoms were masked during childhood.

Because children have a school routine and structure, ADHD symptoms can stay hidden. Diagnosis may come later in life when days are less structured in college or even later when balancing a job, spouse and children. In addition, while the more obvious signs of hyperactivity may improve with age, deficits in attention and executive function tend to persist and go undetected.

Signs of adult ADHD at work and home

At work, the person might procrastinate on every project until it becomes urgent. Sometimes, especially at the beginning of a new project, work is efficient because it’s exciting. But, once the boring details come in to play, the project overwhelms and work stops.

At home, an adult with ADHD might notice his or her spouse is often frustrated by a perceived lack of attention.

The inconsistency is maddening to someone who doesn’t understand what’s going on.

“It’s all about the level of dysfunction and distress,” Rajah said. “Ask yourself, ‘How are these things impacting my life, socially and at work?”

ADHD affects about 5% of adults, and untreated ADHD can contribute to depression, anxiety and substance use disorders.

ADHD in the family

ADHD tends to run in families, across generations. Adoption studies have shown that it’s genetics, not environments, that are the main cause for the disorder.

Susan Leathers, who was diagnosed at age 52, and her sister can see ADHD tendencies in their mom, and in doing so, also see it in themselves. Two of her siblings, a younger brother who has passed away and her older brother, were also both diagnosed with ADHD.

“We tend to think horizontally instead of vertically,” Leathers said. Horizontal thinkers move from one thing to the next, get sidetracked, keep moving and end the day with five unfinished projects. A vertical thinker can prioritize, finish something, and move to the next.

ADHD struggles were always there

Leathers remembers teachers saying she didn’t live up to her potential. A solid “B” student, she probably could have made more “As” were it not for her ADHD.

“We need things to be urgent,” she said. “In school I was always the one writing a paper the night before it was due, but writing was a gift, so I could. I had to focus, it was urgent.”

She chose journalism as a career, which was perfect. It involved writing, daily deadlines and usually something new every day. It was later in life during a career transition when structure went away that her symptoms got worse.

Adult ADHD symptoms

Clinicians and patients often have trouble recognizing ADHD in adulthood, as the formal diagnostic criteria were developed for children and adolescents. Rajah provides the following examples of how ADHD may appear in daily life situations. Keep in mind that these signs can occur in a variety of psychiatric conditions and that an evaluation with a mental health professional can help put symptoms into context before making a diagnosis. Symptoms range from mild to severe and can include:

• Impulsiveness – like making decisions “on the fly” or starting a project or task without reading or listening to the instructions.
• Disorganization and problems prioritizing – like failure to follow through on promises or commitments to others or frequently misplacing/losing important items.
• Poor time management and planning – including being unable to stop activities or behaviors when you need to stop and having more difficulty with long-term planning.
• Problems focusing on a task to completion or multitasking – distracted by extraneous stimuli or irrelevant thoughts.
• Excessive activity or restlessness – difficulty engaging in leisure activities or downtime and driving much faster than others.
• Low frustration tolerance – trouble waiting in a line, irritable.
• Mood swings.
• Hot temper.
• Trouble coping with stress.

Once Leathers was diagnosed, she told few people. “It had a negative connotation,” she said. “I didn’t share about it for a long, long time.”

The importance of treatment, support

Leathers compared it to someone dealing with depression who’s told to snap out of it, a smoker who’s told to just stop smoking, or an overweight person who’s told to just lose weight. If symptoms are affecting your life, ask for help. (Read about how Leathers approached her diagnosis of adult ADHD.)

“You can say I’m NOT going to be late,” she said. “Maybe that works for a day. Most can’t do it themselves, they need help and support.

“If you have it, know that you’re not bad, and it’s nothing you’ve done,” she said. “It pays to be tested.”