ADHD: About 1 in 20 adults may have a disorder usually associated with grade school

Correction: A previous version of this story got some dates of developments in the disorder wrong. The current name for the disorder, attention deficit hyperactivity disorder, came into use in 1987, not 1994. The three subtypes of ADHD were identified in 1994, not 1987. This version has been corrected.

December 16, 2013

Chris Ecarius had so much difficulty filling out his Social Security application online that the 62-year-old went to a doctor to find out why his brain didn’t seem to work properly. Over the years, he’d seen other doctors about similar struggles. He’d been told that he was depressed, but he didn’t feel depressed. This time, Ecarius got a different diagnosis: attention deficit hyperactivity disorder, a conclusion that seemed more appropriate for a child in grade school than an adult in retirement.

When Ecarius, who lives in Houghton Lake, Mich., was young, he had trouble paying attention. He’d dropped out of school and left several jobs, had several traffic accidents and had never quite gotten on track. “I could have been a doctor,” he said. “I could have been a pharmacist, I could have been anything I wanted to be,” had someone diagnosed his ADHD when he was a child. With the help of his wife, Ecarius was able to settle into a skilled trade job with General Motors, a position he held until age 58, when, he says, he became overwhelmed by the computers at work.

Ecarius is not alone. While ADHD — a condition marked by inattention, hyperactivity and impulsivity — is one of the most common brain disorders in children, it also occurs in approximately one in 20 adults, according to a 2006 study. A 2012 study based on interviews with almost 1,500 people by researchers in the Netherlands found that 2.8 percent of adults older than 60 have ADHD, with 4.2 percent of people in that age group reporting several ADHD symptoms and some impairment.

But just being forgetful or scatterbrained doesn’t mean you have ADHD. Of course, many people, especially those older than 60, have these problems, but they could be a sign of something else — or nothing at all.

Health professional differentiate ADHD from the memory-related conditions of aging by documenting symptoms that started before age 12. Although some of the symptoms may overlap, ADHD and dementia are not thought to be connected, and in fact a recently published study says that ADHD is not a risk factor for dementia.


Chris Ecarius recently learned that his distractability and impulsvity are traced to what's known as a childhood disorder: ADHD. (Nancy Ecarius)
A complicated diagnosis

Like other mental conditions, ADHD cannot be measured with something as simple as a blood test, said Benedetto Vitiello, chief of the treatment and preventive intervention research branch at the National Institute of Mental Health. Patients fall along a continuum, and a mental health professional must analyze a variety of responses to questionnaires and symptom checklists, including one created by Harvard researchers for the World Health Organization. Questions include “How often do you have difficulty getting things in order when you have to do a task that requires organization?,” “How often do you leave your seat in meetings or other situations in which you are expected to remain seated?” and “How often do you feel restless or fidgety?”

“You put together a tapestry of life,” said J. Russell Ramsay, a clinical psychologist who co-directs the Adult ADHD Treatment and Research Program at the University of Pennsylvania and is an associate professor at the Perelman School of Medicine at Penn. “You go through a developmental history looking at functioning in school, in the workplace, in relationships, and that’s when you’ll hear various examples of difficulties with time management, disorganization, being able to follow through on reasonable plans . . . that isn’t better explained by something else like depression or anxiety.”

That developmental history will reveal a story of an adult who has chronic difficulties following through on reasonable objectives, who makes the same mistakes repeatedly, who fails to live up to potential, or who simply has trouble being able to do what he wants or needs to do, said Ramsay.

That description fit a 65-year-old entertainment industry executive who asked to remain anonymous. The man says he suffered a lifetime of problems with attention and focus: At work he had succeeded by compensating — assiduously making notes and using humor to cover for his difficulties. Retirement a few years ago made things worse: He no longer had the excuse of being too busy to explain why he didn’t remember appointments or birthdays.

He had such troubles with focus and mental sluggishness that he went to a psychiatrist. He received a diagnosis of ADHD last year, was prescribed a long-acting stimulant and was given counseling. “Before, I thought I was old and over and done and washed up,” he said. “I fought it for 65 years.”

‘An emancipation of older people’

Research on ADHD in older adults in evolving. Psychiatrist J. J. Sandra Kooij, a co-author of the Dutch study, diagnosed her first such case a decade ago. The patient was the 71-year-old mother of one of Kooij’s ADHD patients; she had broken her hip and couldn’t sit still enough to get it to heal. Her doctor suspected the disorder was present in his elderly patient, especially after learning that the patient’s daughter and granddaughter had the syndrome. The woman was referred to Kooij, and the daughter recounted her mother’s lifelong symptoms. Her mother was eventually treated with medications for ADHD and depression.

Kooij, who heads the adult ADHD center PsyQ, the largest outpatient mental health organization in the Netherlands, said that as more people become aware that ADHD persists and can be diagnosed in older age, she expects to see “an emancipation of older people suffering from a lifetime as victims of ADHD that were never recognized or treated.”

Many older patients “had ADHD before there was ADHD,” said Ramsay.

The definition and diagnosis of the disorder have evolved. In the 1940s, a variety of brain disorders were labeled “minimal brain dysfunction,” which was refined to “immaturity” of attention and impulse control in the 1950s. This immaturity was labeled “hyperkinetic impulse disorder” in 1957. That name evolved to “hyperkinetic reaction of childhood” in 1968, “attention deficit disorder” in 1980 and finally “attention deficit hyperactivity disorder” in 1987. Three subtypes of ADHD were identified in 1994: inattentive, hyperactive-impulsive and combined.

Inattention, not hyperactivity

Some adults did not receive a diagnosis of ADHD because their inattentiveness was not recognizable as hyperactivity. “Historically, children who were getting diagnosed were the disruptive children, the children that couldn’t sit still,” said David W. Goodman, a psychiatrist who directs the Adult Attention Deficit Disorder Center of Maryland in Lutherville.

“We thought that disruptive kids would [later] have disruptive lives,” Goodman said, “but we discovered that it’s actually the inattention and the disorganization that causes greater difficulties in adulthood.” Goodman, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, said that parents and teachers act as an inattentive child’s support system. But “as we get older, the support falls away,” he said.

Some older adults curious about their own condition head to a doctor once the disorder is diagnosed in their children. Research has shown that if a child has ADHD, there’s a 30 to 40 percent chance that one of his or her parents has it, said Goodman.

On occasion, Goodman has seen three generations in his practice: A teenager might get an ADHD diagnosis, which brings in a parent and even a grandparent who recognize symptoms in themselves.

Getting coverage for meds

The treatment for older adults with ADHD is similar to the protocol for children with the disorder — usually a combination of “pills and skills,” according to Goodman.

Medications for ADHD include stimulants such as Adderall XR, Concerta, Focalin XR and Vyvanse, or non-stimulants such as Strattera, according to Goodman.

Since older adults are more likely to have multiple illnesses, including diabetes and high blood pressure, and to take multiple medications, it’s very important to give them a full medical assessment, Goodman says. Stimulants can elevate pulse and blood pressure. “We don’t have systematic studies for adults in middle and old age, so it’s left to the clinician to monitor blood pressure and cardiovascular system,” said Vitiello.

Older adults can have difficulties getting insurers to cover ADHD prescriptions, and they sometimes need to get a waiver to have medications covered. Many of these drugs have been FDA-approved and tested in patients only up to age 55 or 65, Goodman said. At age 62, Ecarius had to wait several weeks for preauthorization of his medication.

Older people coping with a new diagnosis of ADHD often must relearn a lifetime of behaviors. In one approach, cognitive behavioral therapy, a therapist works with the patient to understand how thoughts and behaviors mix. “Once we have an understanding about all the steps that go into being disorganized, not being on time, procrastinating, then we can get in there with more specific coping skills, time management skills, using the planner,” Ramsay said. Then the patient has to learn how to use these skills for maximum benefit. Ramsay said that in many cases, that requires a dozen or more one-hour sessions over four to six months.

Coaching is another option for ADHD patients. “So often [with] adults with ADHD, their lives have been like a train wreck. And they have self-fulfilling negative scripts about themselves,” said Terry Dickson, a medical doctor who is founder and director of the Behavioral Medicine Clinic of NW Michigan in Traverse City.

Patients are directed through a series of exercises, such as having a conversation with their spouse in which they really listen and ask questions. Such coaching can be done over the phone or by video chat, typically for three months of hour-long weekly sessions, according to Dickson. Sessions can cost around $120 to $150 an hour, Dickson said, and are not typically covered by insurance. Adults with ADHD who feel they have deep-seated issues to address may also choose more traditional psychotherapy.

Not stupid

Goodman says older patients shouldn’t feel ashamed of their condition. “I don’t care what age you are, you should not be denied the opportunity to pursue happiness,” Goodman said. “And if happiness is a product of getting diagnosed and treated to get a condition under control, I don’t care if you’re 14 years old or 75 years old, you shouldn’t die thinking that you were just stupid and an idiot like everybody told you.”

Since his ADHD was diagnosed three months ago, Chris Ecarius has been treated with medication — first Ritalin, then Concerta — and plans to try online group therapy or a coach. Knowing his problem and treating it properly has brought him “a new life,” he said, and he hopes to continue to volunteer at boot camps for troubled youth — especially those with ADHD.

Levingston is a writer based in Bethesda.

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