ADHD: Adulthood

Most conversations about ADHD start and end with children. But for a significant number of people, ADHD doesn't stop at eighteen. It follows them into adulthood, quietly reshaping relationships, careers, and the story they tell about who they are, usually without a name for what they're experiencing.

In this episode, we break down Wender, Wolf, and Wasserstein's foundational 2001 overview of ADHD in adults, published in the Annuals of the New York Academy of Sciences. We cover what ADHD actually looks like across a lifetime, including the seven core features that show up in adults specifically, why it went undiagnosed in so many people for so long, what the research says is happening in the brain, and what treatment approaches actually have evidence behind them.

This one is for anyone who spent years being told their struggles were personality, or attitude, or potential that never quite arrived. The research has a different explanation.

Transcript

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I want you to imagine a cash booth. One of those that you've probably seen at the mall or fair, the kind where money and tickets are flying everywhere, and you see people trying to grab as much as they can before the time runs out. You've probably seen them, or you've been in one, and you know that the tickets or the money is flying every single direction. Some that are close enough for you to grab, some that are just spinning out of reach, and you reach for one and you lose three, or you've turned around and there's more, and the whole time the fan that's making all of these tickets or money fly doesn't slow down. It doesn't care how full your hands are, it doesn't care that you've caught something or not caught something. It just keeps going. Now I want you to imagine if that booth was your brain. And of course, in this case, the money is in cash, it's everything else. It's your emotions that show up faster than you can name them, the thoughts that interrupt your other thoughts, the urge to say something before you've even decided whether or not it's a good idea to say it, a mood shift that happens in the middle of a conversation, and now suddenly you're trying to manage your emotion and the conversation at the same time. That's the version of ADHD I want to talk to you guys about today. I don't want to spend a lot of time talking about the ADHD that gets mentioned as a punchline, the I'm so ADHD, I opened 17 tabs version. I'm talking about the version that's been there since childhood. The version that made simple things feel harder than they seem to be for everyone else. The version that people didn't understand, the version that followed people into adulthood and just kept going while quietly reshaping their relationships, careers, and stories, um, and the story that someone tells about who they are. Because here's what took the research a long time to catch up about ADHD: that it doesn't stop at a certain age. For a significant number of people, it actually persists into their adulthood. And for decades, clinicians stopped looking for ADHD in adults. So adults were not finding it. They were finding other explanations instead: depression, anxiety, personality, laziness, potential that somehow never quite showed up on time. And I'm sure a lot of you have probably been in a conversation with your teacher or parent. You're like, you have so much potential. Why don't you just tap into it? This episode is about what the research says, what ADHD is, how it presents across a lifetime, what is happening in the brain, and what actually helps. If you've ever been in the booth and wondered why everyone around you just seems to be standing still, maybe this episode can give you some answers. I'm your host, Nafisa Golwala. I'm not a clinician, I'm someone who believes that good research deserves a wider audience and that most people, given clear and honest information, are capable of doing something meaningful with it. Today's paper is Wender at All Adults with ADHD, an overview, published in the annuals of the New York Academy of Sciences 2001. Okay, so before we get into the research, I want to spend a moment with the name. Because ADHD has had a lot of names, and those names have changed quite a bit over history. What we now call ADHD has at different points been called minimal brain damage, minimal brain dysfunction, minimal cerebral dysfunction, hyperkinesis, and the hyperactive child syndrome. Each name reflects what clinicians thought was the most important thing about it at the time. Early on, it was about motor activity, so the fact that the child couldn't sit still, and then the focus shifted to attention, not being able to do one task for a very long time. Then to impulse control. Now it's all three. The DSM, the main diagnostic manual used by clinicians, has renamed this condition multiple times since 1968. So hyperkinetic reaction of childhood became attention deficit disorder, which became attention deficit hyperactivity disorder, which eventually got divided into sub-types. So primarily inattentive, primarily hyperactive impulse, or combined. So what this history is telling us is that it's not that we keep getting it wrong, it's that we keep looking at different parts of the booth and thinking that's the whole picture. So in this case, it would mean motor activity, which is one bill, attention, another bill, impulsivity, another bill, emotion, which we will get into also another bill. The idea is that the booth was always the same, but the bills inside kept changing. So what is actually in the booth? Let's talk about what ADHD actually looks like. Not a checklist, but in life. The paper describes seven core features of ADHD in adults. I want to go through each one. The clinical language around them makes them feel more boxed than they actually are. And I want to give weight to each of these concepts. So the first one is motor hyperactivity. In children, this looks like running, climbing, not being able to sit still. In adults, of course, it changes. It becomes restlessness, an inability to relax, discomfort sitting through a film, a long dinner, a meeting, a feeling of being genuinely dysphoric, which is actually a word that the paper uses when they're inactive. The second one is attention difficulties. And I want to be clear about what this actually means because it gets misunderstood quite a bit. It is not that people with ADHD cannot pay attention. It is that their attention, it's not under their voluntary control the way it is for most people. So conversations that drift, reading that doesn't stick, things that get forgotten, um, like for example, keys, appointments, and the things that you were gonna say about 10 seconds ago. And then, of course, there's emotional difficulties of regulation that come with it. And for a lot of the times, it can feel more like your brain never learned how to adjust the volume of what was important when there were multiple things happening in your brain. The third one is effective liability, which is the one I actually want to spend the most time on. Effective liability means mood shifts, not the long, slow shifts of depression. And I'm also not talking about week-long cycles of bipolar disorder, but I'm talking hour to hour shifts, day to day, normal to down, from flat to excited, from fine to not fine, without any clear cause or without or cause that seems completely unreasonable. You've probably seen this as well. Someone said something and immediately your friend's mood shifted, and you don't understand why. Logically, it wasn't something that was so deep or so big to begin with. There was no reason for such an extreme reaction. But the thing is, for people with ADHD, there is no like zero to a hundred scale. There is no, it increases by 10, increases by 20, increases by 30. It literally goes from zero to a hundred. And I think the point is when you're already in, when you've already had that big reaction and other people are reacting to it, you're compelled to continue because why stop now? You've already caused this. Why should you take a break? Why should you stop? You should fully commit now. I think that's a thing that people don't understand is it's not necessarily about them or the thing that they did. It's more about the fact that this reaction wasn't warranted. And now that it's come out, there's no way to justify it. So you might as well commit to the reaction. The paper describes these shifts as usually lasting hours, at most a few days. So no significant physiological component, like there's no change in your sleep or appetite or the way that there are in depressive episodes. It's just mood that moves faster than any situation calls for. And they can happen spontaneously or be reactive. The fourth is temper, a short fuse, a low boiling point. Outbursts that are intense and short-lived. The paper makes a specific note here. People with ADHD often calm down very quickly after an outburst, which can be confusing for other people on the receiving end, which is fair. Because from the outside it can look deliberate, but like I mentioned before, the 0 to 100 is not something that people actually want. They wish they could control that. Okay, the fifth one is emotional overreactivity. This is a little bit different from the temper piece. It's not specifically about anger, it's about the inability to take ordinary stress in strides. So I'm talking about small problems, don't necessarily stay emotionally small. Maybe a changed plan, a difficult email, a weird conversation, situations most people would manage with maybe mild frustration can create overwhelm, which causes confusion, anxiety, a sense of emotional shutdown, if you will. This paper calls this a repeated crisis in dealing with routine life stresses. And I want to sit with that for a second. Not extraordinary circumstances, not trauma, just the pressure of daily life. Experienced repeatedly at crisis level while trying to look like you're handling it. So a lot of the times you see that when you're changing a plan with a friend, they get unbelievably distraught or it's become like a really big thing. And most people don't think that this is a big deal. But to people with ADHD, it is because their mind is grasping for anything that seems remotely like structure. And when you take away that structure, their entire day gets kind of planned around smaller things, and you don't necessarily know what their bigger, what their focus plan is. So, say for example, if that day the focus plan was for them to go out and you change that, that disrupts their entire routine. And to reorganize that or to understand the stress of that may not seem like something that is reasonable to most people, but it is a really big deal to come down and calm down after having a very weird outburst about something that you didn't even want in the first place. The sixth one, of course, we all know this, is disorganization. Tasks left incomplete, moving from one thing to another without finishing, difficulty organizing time or activities, not because of a lack of intelligence or effort. Uh, and the paper is very, very clear about this. The seventh one is impulsivity. This one ranges from minor, which is like talking before thinking, interrupting others, impulsive buying, to major, which are abrupt relationship changes, decisions made on insufficient information, difficulty delaying actions, even when the cost of acting is so obvious. So they might know that this decision that they're gonna do or have this outburst or this thing that they're gonna do is gonna cause a much bigger reaction, but it's not in their control. It's just like they have to do something in order to stimulate their mind. The paper describes it as making decisions quickly and easily without reflecting, often to the person's own disadvantage. And I'm sure that you probably know someone who's been doing all of these things or has done these things, and you can never seem to quite understand it. But the thing is, the reason that I also do these podcasts is because a lot of the times we misinterpret things in society just for the sake of it. A lot of people are like, oh, I have ADHD, I can't focus. But like ADHD is so much more deeply rooted than people realize. It's not just the fact that you can't focus, there's so many other things that are happening in your body that you don't understand or know about. I think for the longest time, and from a lot of people that I've spoken to, it made me realize it's just easier to find coping mechanisms or strategies that work for you when you have a language for what you have. And I think a lot of people find a lot of peace in getting a diagnosis and knowing that. Not necessarily to go on meds or do all of the other things, but just to feel more understood by themselves and hopefully that's something that they can explain to other people. So, anyway, here's something the paper is direct about. These are not character traits, they're not chosen, they're not evidence of a weak personality or a lack of willpower. They are the clinical presentation of a neurological condition that is strongly genetic, that begins in childhood, and that does not simply resolve with maturity or effort or enough years of being told to try harder. Basically what I said. So here's the part that changed how I thought about this condition. Most people, when they think about ADHD, picture children, a specific kind of child bouncing off the walls, can't sit still, disrupting class. That image is part of the picture, but it is not the whole picture, and it is not the end of the story either. Because for a significant number of people, ADHD persists into adulthood. The symptoms just don't go away at 18. The presentation may change, so in this way, hyperactivity may look less like physical movement and more like internal restlessness. Disorganization might be better hidden through systems developed over decades of necessity. But for a lot of people, the underlying conditions still remain the same. The research on this is striking because studies following children with ADHD into adulthood found that at age 18, 40% still met full criteria. At 26, that number dropped to around 11%. And I really like this paper because the paper flags the drop. It says that the later figures were based entirely on self-reports. And adults with ADHD frequently don't report their symptoms accurately. Not because they're being dishonest, but because they've been doing something for so long that they've normalized it. This is just how they are. The paper is explicit that the Utah studies consistently found that many adults with persistent ADHD don't report their symptoms or don't report how severe they are. When informants reports are added, partners, family members, people who actually see how someone functions day to day, the picture changes. The persistence is actually a lot higher than the numbers suggest. So the paper estimates that somewhere between 1 and 6% of the general adult population continues to show significant ADHD symptoms. That is not a small number. That is a substantial portion of adults walking around with an undiagnosed condition, being told by themselves and sometimes by clinicians that what they're experiencing is depression, anxiety, stress, personality, or simply not trying hard enough. And part of why this has happened is because of the diagnostic criteria themselves. The DSM criteria for ADHD were developed for children. Behaviors like often runs around or climbs excessively simply doesn't translate to adult life. Like you don't see adults running around or climbing things excessively. The presentation changes as people age, which I think is pretty normal. But the underlying condition doesn't. You just learn how to mask it better. And shout out to the previous episode where we talked about masking and how most people who mask don't even know that they've been doing it. And it's not only neurodivergent people that mask, neurotypical people mask too, which is really interesting. Um, anyways, so what happened? Adults went undiagnosed, or they were diagnosed with something else: depression, anxiety, bipolar. Sometimes those diagnoses were accurate, and these conditions do co-occur with ADHD, but when ADHD is genuinely the underlying driver, treating only one of the co-occurring conditions often isn't enough. The surface may look good, but underneath there's a lot that's going on. So, what's actually happening here? Why is the booth the way that it is? The answer, according to decades of research, is largely genetic. And it comes down to dopamine. Let's start with genetics. ADHD is one of the most heritable conditions in psychiatry. Twin studies show a heritability estimate of between 75 and 91%. Identical twins who share essentially all of their genetic material show concordance rates between 58 and 83%. If one identical twin has ADHD, there is a very high probability that the other one does too. Adoption studies confirm the same thing. The rate of ADHD-like symptoms is higher among biological relatives of children with ADHD than among their adoptive relatives. It follows the genetic line, not the household line. This matters for one specific reason. If you have ADHD, there is a meaningful chance that a parent, sibling, or child also does. And understanding that shifts the narrative from what is wrong with this person to what does this family actually need. Now, let's talk about dopamine. The working hypothesis for what is actually happening in the brain is called the catecholominergic hypothesis. Long word. Easy idea. The brain's dopamine system is functioning differently, especially because there appears to be reduced dopamineic activity in certain brain regions. Dopamine is a neurotransmitter, a chemical messenger that plays a central role in motivation, reward, attention, and the regulation of movement and emotion. When dopamine signaling is disrupted, the brain struggles to do things. Dopamine normally supports. It means that it now struggles to sustain attention, regulate impulses, manage emotional weights of ordinary day-to-day situations. Think of dopamine as the speed regulator on the fan in the booth. We're still talking about the cash booth. When it's working as expected, the fan runs at a pace you can manage. When dopamine functioning is reduced, everything comes faster than you can keep up with. Here's what supports this the medications that work best for ADHD, which are stimulants like methylfinidate and amphetamines, increase the availability of dopamine in the brain. And for about 60% of people with ADHD, they produce moderate to marked improvement, not slightly better, significantly better. There's also direct biological evidence from spinal fluid studies. Adults with ADHD who respond to methylfinidate showed decreased levels of the primary metabolite of dopamine in their spinal fluid. The same pattern found in Parkinson's disease, which is caused by degeneration of dopaminergetic neurons. This is a meaningful signal. What this means practically is that ADHD is not a motivation problem. It is not a character problem. It is a brain that runs on a different dopamine baseline. And the interventions that address that baseline through medication or through specific behavioral strategies can genuinely change the experience of having ADHD. So let's talk about what actually helps. The evidence is clearest for medication, specifically stimulants. About 60% of people with ADHD who received stimulant medication show moderate to marked improvement. The paper describes what that improvement actually looks like. And I want to share it because it is more human than clinical language usually is. Hyperactivity decreases. People are able to relax. They can stay at a desk, sit through dinner, watch a film. Your attention also improves. Not just the ability to concentrate, but the ability to concentrate when you want to. The mood shifts level out, the temper threshold rises, outbursts become less frequent, less intense, and sometimes disappear altogether. And then there's this line from the paper. People describe having their thin skin thickened. What does that mean? Which just means being able to take life's problem in strides, feeling less hassled about the daily existence. This is not a small thing. This is a different experience of being alive. And I don't think a lot of people understand that. Because when you've known things a certain way and you've kind of convinced yourself that you can change, when you're showed a different reality of things that are better, easier, less exhausting, you change as a person. But of course, medication is not the whole picture. The paper is clear that appropriate treatment is multimodal, which just means it involves more than medication alone. Here's why it matters. By the time an adult receives a diagnosis of ADHD, they usually spent years trying to force themselves to function as everyone else seemed to actually function. And the system that they created usually was for survival. They built up identities around coping mechanisms instead of understanding the condition itself. And some of these strategies stop being useful once the underlying condition is addressed. So unlearning them is actually hard too, because recognizing that you don't need to work as hard anymore and that you don't have to be this disoriented all the time goes a long way. The paper notes that these techniques that are compensating for something may resolve on their own with medication or they may need direct therapeutic attention. Either way, they need to be acknowledged. The paper also makes a point worth saying plainly, which is that ADHD does not prevent someone from having other psychological problems. It may contribute to them, it may have made them harder to address, but when ADHD symptoms are properly managed, other things often become more visible and more accessible to treatment. So let's pull all of this together. ADHD is a neurodevelopmental. Condition that begins in childhood and for a significant number of people persists across a lifetime. It is strongly genetic, probably mediated by dopamine, and has been consistently underdiagnosed in adults, partly because the diagnosis criteria were built for children, and partly because adults with ADHD are often very good at looking like they're managing everything just fine. Its core features are not character flaws, the mood shifts, the disorganization, the impulsivity, the emotional reactivity. These are symptoms of a condition, not evidence of who someone is. And they respond to treatment, not always completely or without complexity, but 60% of people who receive appropriate treatment show substantial improvement. That is a meaningful number. What I keep coming back to from this paper is the cost of not knowing. A lot of adults spend their life describing the same feeling. Not just years of struggling unnecessary, but years of building an identity around the struggle, around the coping mechanisms, around the belief that this is just who I am and who I am is someone I can't quite understand. That story matters. Not because the struggle wasn't real, it was because the explanation changes things. The booth was there the whole time. The overwhelm was also there the whole time. But understanding why the fan is running the way it is and finding support that actually matches what's happening in the brain is very different from someone spending their entire life believing that they were simply failing at being a person. Next episode that I'm actually really excited about, I'm gonna talk about why I decided to start the podcast. I know this is probably a first episode that I should have done, but you know, better late than never. Until then, remember things can be redesigned. They just have to be built brick by brick.