ADHD: A Physician’s Perspective

LENARD A. ADLER, MD, is the director of the adult attention-deficit/hyperactivity disorder (ADHD) program in the department of psychiatry at New York University (NYU) Langone Health. He is also a professor in the departments of psychiatry and child and adolescent psychiatry at NYU Grossman School of Medicine. He is an active investigator, frequent lecturer and is the author of the popular book on adult ADHD titled Scattered Minds.

BSTQ: What are the key characteristics of ADHD? 

Dr. Adler: ADHD shows up in three main forms, based on which symptoms dominate. The inattentive type struggles with distraction, organization and finishing tasks. These patients miss details, have trouble following instructions or conversations and often come across as careless. The hyperactive-impulsive type is different: constant fidgeting, excessive talking, restlessness and an inability to stay still. These patients tend to be impatient and impulsive, often interrupting others, speaking without thinking or acting before considering consequences, which can lead to more accidents and injuries. Some patients show a combined presentation, with symptoms from both categories.

BSTQ: How common is ADHD?

Dr. Adler: It’s quite widespread. ADHD shows up in roughly six to nine percent of children, and about 60 percent continue to have significant symptoms into adulthood. Globally, adult prevalence sits around four percent. In the U.S. alone, an estimated eight million adults live with ADHD, making it one of the more frequently diagnosed psychiatric conditions.

BSTQ: How is ADHD diagnosed?

Dr. Adler: In children, clinicians typically spot a pattern of behavioral and academic struggles tied to inattention or hyperactivity. Before landing on an ADHD diagnosis, other possibilities need to be ruled out. In children, that list includes learning disabilities, oppositional defiant disorder, mood disorders such as bipolar or depression, conduct disorder, anxiety and Tourette’s syndrome, since all can mimic ADHD symptoms. For adults, symptoms need to trace back to childhood and have continued since then. Clinicians look at both recent symptoms, typically over the past six months, and a history stretching back to early life. Other clues that might prompt an ADHD evaluation include memory complaints, chronic forgetfulness, mood swings, low self-esteem and weak self-discipline.

BSTQ: What medications are used to treat adult ADHD?

Dr. Adler: Stimulant medications such as methylphenidate and dextroamphetamine have been standard ADHD treatments for more than three decades. They’re available in pill, patch and chewable forms, and dosing is usually split across two or three daily doses. While generally effective, these drugs require ongoing monitoring, and studies show many patients don’t consistently stick with their medication regimen.

BSTQ: Are there effective alternative treatments?

Dr. Adler: Patients are often exposed to a wide range of unproven remedies, many accompanied by bold claims about their benefits. But, complementary and alternative approaches should be adopted only once solid evidence backs them up. Interest in researching these options for both children and adults with ADHD has grown, yet none has met the bar of rigorous, controlled clinical evidence to be considered a reliable alternative or complement to standard care. What’s needed going forward is more double-blind, placebo-controlled research involving properly diagnosed ADHD patients.

BSTQ: What are the long-term effects of untreated ADHD?

Dr. Adler: A lot of adults with ADHD were never diagnosed as children, often because the relatively low demands and structured support of childhood masked how much their symptoms affected them. As adulthood brings heavier academic, career and social expectations, that impairment becomes much more apparent. The toll of untreated adult ADHD is steep, contributing to higher rates of academic failure, unemployment or underemployment, divorce and separation, substance abuse, smoking and car accidents. Many adults with ADHD end up performing well below their potential, weighed down by low self-esteem and a lack of motivation tied to their persistent symptoms. Earlier recognition and treatment would likely make a substantial difference in both their functioning and overall quality of life.