Distraction runs rampant in our society — we can all relate. But when you have ADHD, navigating a chaotic world can be especially challenging. And adult ADHD is on the rise. During the pandemic, diagnoses and prescriptions for ADHD in adults increased significantly. So what’s driving this increase in diagnoses? And how do you tell if you yourself have ADHD, or are experiencing a typical level of distraction?
On this episode of Health Matters, family physician Dr. Robert Wilfahrt joins us to talk about all things ADHD.
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Read the transcript:
Kristen Meinzer: This is Health Matters, a podcast from Mayo Clinic where we discuss the latest medical advice, news, and research to help you live a happier and healthier life.
My name is Kristen Meinzer—I’m a writer and journalist. In this episode, we’re talking about ADHD in adults.
Dr. Wilfahrt: One of the reasons I like treating ADHD, is that it’s really high yield. If I treat your ADHD, I’ll add six years to your life, and there’s not that many other things that have that big of an impact on people.
Kristen Meinzer: Why is that? What is happening that would cause people with ADHD to die six years earlier?
Dr. Wilfahrt: It’s forgetting to do self-care. For instance, a person who has diabetes who needs to take shots four times a day, if you forget them regularly, you will have poor control of your diabetes and then complications. 20 years ago, the government of Canada freaked out temporarily about Adderall and pulled it off their market.
They were worried that Adderall was hurting Canadian teens. And do you know what happened? Canadian teens died in car accidents. So they put Adderall back on the market and saved those kids’ lives.
Kristen Meinzer: For many of us, ADHD conjures images of a hyperactive child in the classroom, struggling to focus and being told they’re not reaching their potential. Or worse, being judged and thinking, incorrectly, they’re not as capable as their peers. It’s a thing a lot of kids and families struggle with.
But what happens when those struggles aren’t seen, get ignored or are misdiagnosed, and continue into adulthood? The exact numbers are hard to pin down, but recent estimates put the prevalence somewhere between 2.5% and over 6% of the global population. That means hundreds of millions of adults living with ADHD.
In 2020 and 2021, the initial years of the COVID-19 pandemic, we saw the largest single-year rise in prescriptions for ADHD medication through employer-sponsored health plans.
In this episode, we’re talking with Dr. Bob Wilfahrt to find out why there’s been such a rise in diagnoses, what life as an adult with ADHD might look and feel like, and how diagnosis and treatment work.
Kristen Meinzer: Dr. Wilfahrt. Thank you so much for joining us today.
Dr. Wilfahrt: Oh, my pleasure. Thank you for having me.
Kristen Meinzer: We’re so excited to talk with you about this subject because it is something that a lot of folks out there have questions about. There are a lot of people, especially in the last few years, who’ve been wondering, is this something that applies to me? So I think this conversation is going to touch a lot of people and help a lot of people. First and foremost, let’s just start with the bare bones basics. What is ADHD?
Dr. Wilfahrt: That’s actually a bigger question than you even knew.
Kristen Meinzer: Oh.
Dr. Wilfahrt: Yeah, I think it’s a spectacularly badly named condition. I would like us all to think of ADHD as a disorder of self-regulation. We’re not saying you can’t pay attention. ADHD refers to a group of people who actually can pay attention to things really well. Their problem is they can’t regulate their attention. They pay attention to each new thing, like a car that just drove past the window or some ambient noise. So it’s a problem of self-regulation of that attention or how to willfully and meaningfully direct it. But that’s not all it is attention gets top billing in the way the condition is talked about or named. The things that aren’t regulated in those people who are suffering from it, include your ability to put yourself to sleep, or your ability to manage your emotions and moods.
Kristen Meinzer: The condition reaches into, every corner of our daily lives, and can have really profound impacts on the way a person’s life course is shaped. Give some examples, if you could, of what you mean by not being able to self-regulate.
Dr. Wilfahrt: I can think of a patient in her late 60s who felt, easily frustrated and saddened by what she thought might have been her inability to read other people and felt judged by her social interactions. And that was the smart lady, a graduate of college, accomplished by many standards, but frustrated. She might stay up late at night working on school assignments and procrastinate so that she had a hard time putting herself to bed until she was finally exhausted. And then, didn’t have very many hours of sleep before the next day’s work. That combination of worsened fatigue and a sort of awareness of what she thought were her shortcomings, led her to assume she had a mood disorder.
She then tried different medicines and didn’t get better. Finally, we tumbled to the fact that maybe it wasn’t that the medicines were wrong. Maybe the diagnosis was wrong and it turns out that in adults who have so called treatment resistant depression, about 30 percent of them have actually just been mislabeled and it was attention deficit disease the whole time.
When a person becomes aware of repeated underperformance and feels judged by that, the judgment leads to a sense of anxiety and people come to the doctor saying, I feel nervous. But when you ask them, what are you nervous about? It’s that I just missed another deadline. Or, I feel nervous that I have failed in some way, which is quite different from a generalized anxiety disorder in which a person might be worried about, global warming, presidential politics, or things over which the individual has a bit less control. I think it illustrates the fact that many adults are prompted to use language that we would normally associate with mood disorders. I am saddened. I am worried. A hurried clinician might hear sad and worry and think they’re depressed or anxious and misprescribe or mislabel.
Kristen Meinzer: What exactly is happening in the brain that is causing a challenge in finishing the task or in paying attention when there’s this distraction?
Dr. Wilfahrt: Speaking, superficially, as is my understanding of how the brain works, we’ve got a couple of different neural networks that are engaged much of the time. There’s a neural network called the default mode and all of us are running the default mode pretty much all the time.
The default mode takes in-sense data. It notices things around us. For example, I hear your voice and it brings that sense data to my consciousness. Before it actually gets to consciousness, our body attaches an emotion to that sensory data. And so when I hear your voice, I might have a mood of interest or curiosity or happiness. Then, there’s another neural network called the task-positive network, which says, oh, that’s cool. Let’s talk to Kristen. Let’s concentrate on this thing, and the task-positive network sends a message to the default mode saying, now simmer down for a little bit.
I don’t want more sense data for a few minutes because I’m going to think about Kristen, and then ADHD makes it so that each time we get new sense data, we go off the rails and pay attention to it. Remember that each time there’s new sense data coming into consciousness, there is an emotional attachment to it.
And so that means each time I am thinking about a new thing, I’m having a new emotional input. You can imagine how if a person’s attention is bouncing from issue to issue, their mood might be bouncing from issue to issue. It can become quite an unfriendly situation for people.
So the brain is deciding this is important to pay attention to also, and this is important to pay attention to too, and this is important to pay attention to too. It’s not prioritizing one thing over the other. Everything is important. Correct, some people’s bodies are built in such a way that, without their permission, their body chooses to think about something else for a bit.
Kristen Meinzer: And do we know what causes that?
Dr. Wilfahrt: Well, it’s 10,000 things working together, we know that there are a couple of neurotransmitters that these neural networks use to talk back and forth. There’s a neurotransmitter called dopamine, and another called norepi. And so for some people, the body’s trouble producing these neurotransmitters might be at play. There’s an important interplay between genetics and environment. So ADHD is mostly genetic. It’s about as genetic as how tall you are. If your family members have ADHD, there’s like a 70 or 80 percent likelihood that you might too. And genetic burden, I’ll say, might show up in the form of not making the dopamine that you need for those networks to talk back and forth, But our families create the environment in which we live and play and work, right?
And so, while there is a heavy genetic load about who might end up having ADHD or not, the interplay of our bodies and our environments are such that a person’s ability to regulate their attention actually fluctuates a fair amount over the course of their life. Based on how well we’re taking care of ourselves, what kind of food we’re eating, if our supervisor has given us work that we can do in an environment we can do it in.
Kristen Meinzer: That’s fascinating to think about the nature versus nurture aspect of things. I’m curious, how do we tell the difference between typical attention issues that all of us might struggle with and ADHD?
Dr. Wilfahrt: There’s a set of 18 questions that we use to define the condition in adults. If we asked every adult how many of those are they having significant trouble with, the average person would say two or maybe three of the 18 things give them regular trouble. If we go two standard deviations to the extreme, who’s the worst off?
Then you’d only need four or five of the 18 symptoms. And so, it’s not that there are some people who are perfect, who can brain whenever they want to. It’s that some people are more frequently frustrated than others. We would define ADHD as the group of people who are most frustrated. We’d figure that out based on talking to them.
To see, if the frustrations are happening in every circumstance. Not just on the job or just at home.
And so we would want to make sure that we’re talking about people whose difficulties are significantly more than the average person’s and aren’t caused by some environmental circumstance that we could manage better some other way.
Kristen Meinzer: Can you give me, some more examples from that list of 18 things that are on the checklist?
Dr. Wilfahrt: Sure, so it turns out that I have beef with the checklist.
Kristen Meinzer: Ah.
Dr. Wilfahrt: I can talk with you about the checklist, but I don’t actually like it that much. For a long time, ADHD was thought of as something that seven-year-old boys struggled with, right? And so the ADHD diagnostic checklist was built with elementary school kids in mind.
Some of these diagnostic criteria make a lot of sense if we’re thinking about a second grader.
It would be uncommon for a person in her 50s to feel the same physical hyperactivity that a second grader feels. I’m 51. I’m too tired to be hyperactive.
Nonetheless, that’s what we’re working with. 18 diagnostic criteria, nine of which are symptoms of inattention, such as making silly mistakes. Inattention and distractibility, a common symptom would be, being in a conversation with someone, but having already anticipated the end of their sentence and thinking about the next sentence. And before you know it, you’re thinking about something else. There are also a couple of executive function criteria. In that inattentive subset. And by that, I mean, it’s one thing to pay attention to things, and it’s another thing to be able to prioritize and enact your plans.
One of the diagnostic criteria would be deciding how you’re going to use your time. And the second would be actually using your time the way you thought you were going to. Those are the examples of the inattentive subset. Hyperactivity, the second subset, It’s a mixture of physical restlessness, which in adults is, I think, perhaps most often manifest at bedtime.
Because remember, if you have ADHD, you have it all day, even when you’re trying to go to bed. Often the hyperactivity in an adult, is manifested as a kind of a quick switch or an intense switch from one mood to the other. Then there’s also some impulsivity. If you’re someone who pops off in traffic and is a road rager, or you choose your grocery store checkout line based on which one’s moving the quickest.
And if the person ahead of you is taking too long, you’re raging inside. That kind of inability to sit still because you got to keep moving can be a sign of impulsivity. Again, the diagnostic criteria are defined in a way that would be most useful for a young kid. We sometimes manipulate the way we talk about these criteria a little bit to reflect better what an adult might be perceiving.
Kristen Meinzer: Thank you for clarifying all of that. Those are concrete examples. So Dr. Wilfahrt, how does the brain typically or ideally distinguish between distraction versus information?
Dr. Wilfahrt: Well, I’m not sure it does, right? If it did, it’d be a lot easier to manage our way through life. Society changed so much quicker than our biology did, and so we’re living in these Stone Age bodies that are attuned to listen or look at each new stimulus.
If I was walking through the woods and I heard a twig snap, I better look, because maybe there’s a saber-toothed tiger coming. And you might say, that is a distraction.
Kristen Meinzer: And if I was telling you about the thing I dreamed last night and you got distracted, I would think, why are you looking over there at that?
Dr. Wilfahrt: Because it might a saber-tooth tiger.
And my biology wants me to know if it’s a saber-tooth tiger, right? We’re not living with saber-tooth tigers anymore. And instead, as you mentioned, that was a good comeback, because the base unit of mental health is not the individual, is it?
Unfortunately, in the United States, we think that every individual is supposed to be an island with perfect health all unto themselves. But instead, the base unit of mental health is the family. And so, if I heard a twig snap and turned my head while you were trying to talk with me about something that was important to you, in this time, when there isn’t a saber-tooth tiger, I should be dedicating my attention to you, my loved one, my friend,
I don’t think our brain can tell the difference between what’s a distraction and what’s good information. And that’s a problem, but that takes time, right? It’s not automatic. We already have these bodies that are misbehaving without our permission and diverting attention before we have a chance to correct it.
Kristen Meinzer: So over the years–many thousands of years–our brains have gotten pretty good at helping us observe and respond to the things happening around us. And most of us can control and direct that ability reasonably well as we go about our lives. But for those of us living with ADHD, that control knob doesn’t quite work as intended, and so we have more difficulty directing our attention to go where we want it.
And, especially for adults, life with ADHD can mean having a hard time regulating emotions, or even falling asleep.
The condition is mostly genetic. But our environments at work and at home can have a big impact on how we experience the symptoms.
As it turns out, our modern world isn’t the most ADHD-friendly place. This might have something to do with why so many adults are wondering if maybe they have ADHD.
Kristen Meinzer: Now, do people develop ADHD as adults? I have to say, a lot of my friends in the last few years, in their 30s, in their 40s, have been diagnosed with ADHD. Is this something they just developed in recent years, or is it more likely that they had it throughout childhood and were never diagnosed back then?
Dr. Wilfahrt: That’s a great question. There’s been an increase in social awareness of ADHD in the last few years. That’s great, and we should be happy that happened because it turns out if you treat ADHD with a combination of meds and counseling, all cause mortality goes down by about a third.
Kristen Meinzer: Wow.
Dr. Wilfahrt: Treatment adds years to lives. So I’m glad that there has been an increase in awareness of the condition. However, you asked if a person could develop ADHD in adulthood. I think the answer is no. I think if you were born with ADHD, you were born with ADHD.
Remember how we said that there are so many different ways that a person might come to have an attention deficit. There are genetic components and environmental components. In the last few years, when your friends might have been diagnosed, the environment got weird, right?
Cause, a bunch of people were sent home during the pandemic and now we’re all working over Zoom. Zoom is perfectly designed to mess up somebody who has ADHD, cause you’re expecting me to attend to this little box in front of me when there’s all this stuff around. And as engaging as you might be, Kristen, it’s not the same as having you in the room with me, right?
To some extent, in the last few years, people’s environments have changed so much that it has a cognitive burden on people, especially moms. To some extent, we might have seen the destructive effects of this manifest as their inability to cope with all of the new tasks that they have to manage. That’s a little bit of what happened is that the environment has changed on us. The other thing that happened was that some people’s symptoms became severe enough to make it worth labeling during the pandemic. We’re kind of struggling already, before the pandemic and then the pandemic came along and they lost their social habits. They stopped exercising. So, it might have revealed to us that there are a lot of people who are barely making it anyway. As the pandemic did in lots of ways.
There have been a lot of people getting diagnosed lately. But we should be realistic about what that means to say a lot of people have been diagnosed. So in 2006, a clinician named Barkley wrote a paper that suggested that maybe 10 or 11% of adults with ADHD were getting treated, which is shockingly low for a condition that shaves between six and 12 years off your lifespan.
If the only thing that happened was we doubled our ability to take care of adults with ADHD so that instead of one-fourth of them getting care, now it’s half. We’re still under-treating. I think the CDC has reported that about 4 percent of people on commercial healthcare plans are now getting care for ADHD. Up from 3 percent a few years ago. But It might be five to seven percent of people who have it. And so, we still got ground to cover. Of the people who made up that growth in diagnosis, the vast majority of them were women or people of color. So now I want you to imagine for a second, when I say ADHD, what’s the first person that pops into your head?
Kristen Meinzer: I would say for most of my life, the focus has been on those seven-year-old boys you mentioned earlier. The boys who can’t sit still. It’s never the girls. It most certainly isn’t adult women or people of color. Yeah.
Dr. Wilfahrt: On behalf of all physicians, I apologize that that is true. Because we’ve really done a disservice to people. Somehow we’ve fallen into this pattern, in which we allow little boys to have two moods. They can either be happy and playful, or pissed off.
We don’t expect boys to have, an emotional repertoire that’s better than that. Whereas girls we ask more of. And so that second-grade girl who has ADHD might realize that she can’t get in the face of her classmates. She might have enough social awareness to not be a disruption to her teacher.
And so then she just goes unnoticed until maybe she’s 40 and has the chutzpah to bring it to the attention of a physician who listens. I hope that’s what’s changing. I don’t think it’s overdiagnosis.
Kristen Meinzer: What about the internet or social media or modern technology? We frequently hear people pointing their fingers at all of those saying, that’s why you have ADHD. Is there any truth to that, to our current technology?
Dr. Wilfahrt: For ADHD. No. I have met people who are really struggling at work because when they’re on their Zoom call, Outlook pops up with an alarm, right?
That didn’t cause ADHD. But it’s a terrible environment for a person who is prone to distraction to have to work in. Now I have met patients who are really struggling at work, but then when you ask them, what’s your home life like? Fine. Like how is inattention affecting your friendships? Oh, it doesn’t seem to be. Okay. That’s not ADHD. That’s just that work is terrible.
Kristen Meinzer: Now, on the flip side, when it comes to technology, some people with ADHD find themselves hyper-focused on technology. For example, they might find it impossible to tear themselves away from a video game. Is that just part of the ADHD brain that it can just decide it really loves focusing on this one thing?
Dr. Wilfahrt: A couple of things to that. So remember, part of attention is willful, and some video games are lovely.
Kristen Meinzer: Oh, yeah.
Dr. Wilfahrt: They’re pretty skillful at maintaining engagement. You used the word hyper-focus, and that’s a word that I think is a bit of trouble because it doesn’t have an official meaning.
I think a lot of people, when they say hyper focus, they just mean focus. So perhaps if they had been distressed for much of their week and then found themselves able to engage in the video game on Saturday night. Maybe that felt unusual to them, so they added hyper to the focus. I guess I don’t begrudge people for taking pleasure in things that give them pleasure, I like to garden. I can spend a lot of time in the greenhouse, but I don’t think it’s hyper-focus. I think it’s the pursuit of a hobby.
Kristen Meinzer: Oh, I like that point of view.
Kristen Meinzer: Like most things, everyone’s ability to regulate their attention and emotions exists somewhere on a spectrum. And while you can’t necessarily develop ADHD as an adult, there are conditions in our lives that may cause our position on that spectrum to fluctuate over time.
So while you may have been a little spacey in the past but generally coping, when something like a global pandemic comes around, your ability to juggle life and work responsibilities might suddenly feel woefully insufficient.
And that can be an indication that you might be someone with ADHD who’s been misdiagnosed, or gone undiagnosed.
So let’s get into what diagnosis and treatment looks like.
Kristen Meinzer: Do you think that diagnostic tools have also improved in the last few years?
Dr. Wilfahrt: No, they’re still lousy.
We still have criteria that were built for kids, right?
The other thing about it, there are tremendous process hurdles because, for most people, their access to healthcare is still a primary care clinician. There are not enough psychiatrists to go around, right?
If you had a psychiatric problem, you were seeing a family doctor who may or may not know very much about ADHD and that family doctor might’ve been working in a 15-minute office visit, but really to make a diagnosis of ADHD, it takes a couple of hours of conversation. Physicians have to consciously uncouple from the straitjacket of the 15-minute office visit, step back, slow down, and say, is this a pattern that started in childhood? Has it been forever? How did it manifest in childhood? Was it only at school? Was it only at home? Was it everywhere? We’re going to set up 3 or 4 visits in the next few weeks so that piece by piece, we can work through this. And so, it might be that you need some Adderall and I prescribe it, but if I haven’t addressed the eating disorder, the history of assault, the disability, I will still not have maximized your potential for you. And that’s what it’s about, I don’t think that patients just want pills thrown at them. I think they want problems to be solved. So the conversation is the diagnostic tool. It would be easier if we could just do an MRI scan, tell you if you need pills, right?
Kristen Meinzer: Great. Either that test or something simple like that would be easier, right?
Dr. Wilfahrt: It would be lovely. Yes. But no, that’s not the case.
My hope is that some of the trend of increasing diagnostic rates that we’ve seen in the United States in the last few years might be that, patients are better self-advocates, better explaining to their clinicians what it is they’re experiencing. And that some of these deficiencies are being corrected.
Kristen Meinzer: How do you structure those 3 or 4 visits to determine if a patient might actually be dealing with ADHD?
Dr. Wilfahrt: I think ideally, your clinician would ask why do you think that? And what is your goal in talking about it? As an example, if you are studying for the CPA examination and it’s a booger and you’re distractible you need accommodations for test taking, maybe you’re here because you just really want a letter for the CPA test.
You have to set your goals upfront and make sure everybody understands why you bring it up and what you’re hoping to achieve changes as a result. And then I think step one is just a good physical.
So Kristen, let’s pretend for a second you had severe asthma. If you spent your whole day worried about the next breath, you’re probably going to be distractible, right? So your family doctor should be making sure that your asthma is well controlled. That you’re not iron deficient. That you can see, and that you can hear. A good checkup is the base upon which everything else is built. I think a good checkup is a half an hour visit right there.
And we haven’t even started talking about ADHD. Then maybe, in visit two, your clinician might ask you about childhood. Part of the reason that needs to be answered is because whatever was happening that kept it from being known as a kid might need a treatment plan. There’s an awful lot of trauma in the world. and trauma is distracting. If you were a victim of abuse in childhood, an Adderall pill isn’t going to fix that. Instead, that’s the kind of thing that a good counselor fixes, teaching you that you don’t need to be hyper-alert and defensive at all times.
It turns out that ADHD and eating disorders arise in the same families. There’s a strong genetic link there. An awful lot of the women in particular who’ve got ADHD had anorexia when they were teens. And often that anorexia was, unrecognized or incompletely treated.
It turns out that a lot of girls who have ADHD, as the menstrual cycles kick in, just go off the rails. It takes three chemicals working in conjunction to access working memory. Dopamine, iron, and estrogen. And so if estrogen varies through the menstrual cycle, then one week out of every four, you might have struggled. If your menstrual cycle was heavy or irregular, maybe you were iron deficient and then you might have really struggled. It’s also the same point in a young person’s life in which they’re attuned to the perceptions and judgments of others. If you’re someone who has trouble regulating their attention and you’re a bit forgetful and you miss details. That shows up as frustrations between you and your friends. Frustrations can lead to judgments. And judgments can lead you to feeling anxious.
That cascade can really hit in the junior high or middle school years, which is about the same time that lots of teens, girls more than boys but either one, can develop eating disorders. If you’re undernourished, you tend to be inattentive. So, I would ask, What was your family of origin like? What’s your menstrual history? Tell me about eating disorders.
And then we keep going. Later in life, did you start experimenting with alcohol? How much pot are you smoking? Pot is a big issue for people with ADHD. Some cannabis plants probably do help a little bit with feelings of hyperactivity, but they probably worsen attention. And so, It’s sort of a seductive net negative that then you have to talk through.
Now I’ve just rattled off a bunch of things that I might try to cover in the second 30-minute long appointment. I haven’t even asked you about ADHD symptoms yet. I might save that for the third 30-minute appointment. I might then move to actually asking what attention span questions you have. I try to use a standardized set of questions to measure them.
There are a few surveys that we use to try to measure your attention, and my favorite is called the RS 4. I like it because it talks about those 18 symptoms in ways that seem to hit right for adults. Together, we might try to measure how distracted or how impulsive you are, so that we can track it over time. What tends to happen is if we do think you have ADHD and we come up with a treatment plan for you, your first reaction might be, hey, this is great. I’m better. And if the doctor is trying to race through a workday and just hears you say, I’m better, they’ll say, Oh, great. I guess we got it right. But many patients are so happy to be any better at all that they didn’t get all the way to good.
Using the surveys to measure over time and track it is quite important because I’m not just looking for you to be halfway better. We’re looking for you to feel normalized. If it seems clear that we understood what your other body illnesses were like by getting a good physical, and that we know what other conditions are contributing to your distractibility in that second office visit.
And then the third office visit, we’re willing to say, Hey, it’s ADHD. Then we can talk about treatments.
Kristen Meinzer: Yes. I want to learn all about the treatments.
Dr. Wilfahrt: So one of the reasons I like treating ADHD, I already mentioned, and that is that it’s really high yield. But the other reason that I like to treat this is because it’s something that the pills actually work quite good.
They come in two big categories. There’s a category called stimulants, which is badly named because they tend to make a person with ADHD feel calmer. That’s interesting because when people think ADHD, they often think, Oh, but aren’t you hyper already? Why do you need to be stimulated more?
It’s a pattern of bad names here that we just have to accept apparently. So those are medicines like Adderall, the Adderall family are called amphetamines or Ritalin. The Ritalin family is a chemical called methylphenidate. Within those two subgroups, there are probably 10 or so brand names in each subgroup. We choose amongst them based on how many hours a day you need coverage because those are pills that work the same day, but don’t last 24 hours. This is too bad because if you’re an adult, you probably need to adult all day. Their benefits are a little bit nonspecific and that’s a problem because people who don’t have ADHD will take them and get a little bit of a lift and think they’re doing better. Turns out they’re not. But they’ll like it, and for that reason, it is a controlled substance.
It might be abusable, and that’s the hang-up for ADHD treatment. So those are the stimulants. Now the other big category of medicine, non-stimulants, there are just a few members in the non-stimulant category. There’s a 20-year-old med called Stratera or Adamoxetine, a relatively newer thing called Kelbree, which is going to be lovely as soon as it’s affordable for people.
That’s a once-a-day pill that lasts 24 hours and seems not to be abusable, so you get all the refills that you like. In some parts of the world, a blood pressure pill is prescribed for ADHD. It’s a thing called Guanfacine. That’s not approved by the FDA for adults in the United States, although some people use it off-label. It’s a bedtime pill. Remember a lot of people with ADHD have difficulty initiating sleep. One of the big side effects of this blood pressure pill is it makes them tired. That can be a great thing for people with ADHD, improve their sleep. If the only thing you did was get better sleep, your ADHD scores would improve by 30%.
Kristen Meinzer: Wow. Can you explain for a moment here the difference between, what is the stimulant doing to my brain versus the non-stimulant?
Dr. Wilfahrt: Remember, there are those neural networks that are talking back and forth, the one that you would like to harness to pick a certain thing to focus on, and then the one that keeps dumping new stimuli in. The stimulants are causing a lot of dopamine to be released between these two networks so that they can talk back and forth effectively. The non-stimulants don’t dump dopamine into these networks. Instead, they cause your body to build more receptors for dopamine, essentially, so that you’re more awake to the neurotransmitters that you would have already been making.
Kristen Meinzer: Now, in addition to the medicines, are there behaviors or habits I can enlist to improve my ADHD?
Dr. Wilfahrt: Yeah, and I would hope that nobody thinks the meds alone are the only treatment. Exercise is a great treatment for ADHD and it’s dose dependent. If all you do is fidget a little bit, you’ll be less hyperactive. But if you went for a walk, you’d be much less hyperactive.
And if you went for a run, you’d be much, much less hyperactive. Their nutrition is important. There was an important study out of Australia 20 years ago that showed that teenagers who were fed fruits and vegetables had the same sort of cognitive response as teenagers who were fed Prozac.
Kristen Meinzer: Oh.
Dr. Wilfahrt: You need to put yourself to bed at night. So remember, there’s this difficulty initiating sleep that comes with ADHD.
A combination of improved sleep hygiene and the right medicines can help you rest better. Sleep hygiene can be learned. You can learn how to put yourself to bed with a good counselor, or even a good book.
Kristen Meinzer: We’ve talked about exercise, good nutrition, putting yourself to sleep, the pills, and then counseling.
Dr. Wilfahrt: There are a couple of different counseling styles that are quite good for ADHD. Remember, ADHD is sticky. It rolls through your life and accumulates comorbidities. A good counselor helps you untangle the mood-based consequences of ADHD and deal with them in a way that’s more effective. It relieves you of some of the guilt that adults have about what they perceive as their imperfections or the fact that they weren’t as productive as they should have been or didn’t have the life course they expected. If the only thing you did was take the worry out of your day, you’d have a lot more time to be effective.
Kristen Meinzer: We could all do with a little bit less worry. Yeah, absolutely.
Dr. Wilfahrt: My favorite thing is a person who is exercising, eating some fruits and vegetables, going to a counselor, and taking medicines. That would be the ideal.
Kristen Meinzer: Now, are people with ADHD eligible for workplace accommodations? And if so, what are those accommodations?
Dr. Wilfahrt: Well, yes, but, here’s the thing, while we want our other humans to be gracious and understanding and forgiving, and to take from us what we can offer, turns out not everybody’s like that, right? The unfortunate truth is that sometimes if you tell another person that you have ADHD, it becomes a way of causing them to look for your inadequacies instead of prompting them to help you more. Instead of becoming a prompt for goodness, it’s a prompt for judgment.
There’s an awful big caveat there about who gets to know.
Kristen Meinzer: What about families or partners, people in our personal lives? How should we communicate about our ADHD with them?
Dr. Wilfahrt: I hope that everybody feels able to talk with their loved ones about what they need or how they could, better perform in a situation. You asked about accommodations, and the accommodations that a person might seek at work aren’t really all that different from the accommodations that a person might use around the house
For instance, if I was a person with ADHD and was getting, a complex assignment at work, I might get a voice recording on my phone of what it was I was being told to do so that I could go back to it later.
You could probably do that at home too. It would be reasonable for your partner to know that you might do better if things were written down. Coming to understand that a person might do better at their weekly bill-paying session if they did that not in front of the TV, but instead downstairs in the office. That can be a gentle reminder that can be of benefit.
There are entire books about this, the one that I am most familiar with is called “The ADHD Effect on Marriage,” if you have ADHD, it can be hard on a relationship. If you had ADHD and now don’t or are treating it, that can be hard on a relationship because maybe your partner used to like the fact that they were helpful in certain ways, but now you don’t need that help and you still have to talk about it.
Kristen Meinzer: Interesting. Now, you said earlier that, your brain once benefited from seeing the world the way an ADHD brain sees the world.
You have to be aware of threats. You have to know that a saber-toothed tiger is coming. But now that we live in today’s world, are there words of reassurance you can give folks about their brains who have ADHD right now?
Dr. Wilfahrt: The first thing I’d like to make clear is that many people have the misunderstanding that ADHD implies a lack of intelligence, but it doesn’t at all. You can be a loving, creative, smart person who’s a bit distractible, I wish for people that they didn’t perceive themselves as something less than or something that doesn’t fit. There’s a place for them in our lives. And if you find a plan of treatment that unleashes your potential, man, that’s going to be fun to watch. Take the park and break off and see what you can do.
Kristen Meinzer: Oh, I love those words of optimism. I think it’s such a great perspective coming from you with your knowledge base. And I think it’ll give hope to a lot of our listeners out there. Thank you so much.
Dr. Wilfahrt: Well, thanks, Kristen. I appreciate that you did this.
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Kristen Meinzer: Even though living with ADHD can sometimes be a struggle, there are lots of ways to cope and reliable treatment options are available. But it’s also important to remember that an ADHD diagnosis has nothing to do with your character or intelligence. In Dr. Wilfahrt’s words…
Dr. Wilfahrt: it’s more a description of how you engage with the world. And it doesn’t mean anything bad about you.
Kristen Meinzer: If you think you meet the criteria for ADHD, make sure to talk to your primary care provider or a behavioral health specialist, and make sure they give you the time needed to get to know you, your history, lifestyle, struggles, and goals. It might be that you have ADHD, or there’s another issue that they can help you solve. But it all starts with a conversation.
Okay, that’s all for this episode. But if you’ve got a question or topic suggestion, please send us an email at mc podcasts — that’s podcasts with an s — @mayo.edu or leave us a voicemail at 507-538-6272.
Thanks for listening, and until next time, take care and stay healthy.
Relevant reading
The Doctors Mayo
The classic biography of a family of physicians and the medical center that bears their name. This book has been acclaimed as the authoritative biography of Dr. William Worrall Mayo and his physician sons since it first was published in 1941. Page count: 437
