April 4, 2022
What are we to make of adults who exhibit the diagnostic criteria for ADHD, but are nevertheless high-functioning and successful? A trio of British investigators has just published six case studies that explore this question. It would have been better for them to have conducted a much larger, controlled research study but, in the absence of such data in the area, these case studies are intriguing and may help guide more informative research.
The authors recruited six successful men between the ages of 30 and 65 from a National Health Service tertiary service in London. Four were in long-term relationships, with children. All had good jobs.
In open-ended taped interviews of up to an hour in length, each was asked three questions:
1. What do you think are the advantages and disadvantages of having ADHD?
2. Please describe a time when you felt that your ADHD helped you to achieve something?
3. What aspects of your ADHD would you miss if it went away?
Hyper-focus in ADHD is generally considered a deficit, inset-shifting, and task-switching. But the authors report that participants associated it with productivity. One said, “I think the energy that the ADHD brain seems to have....it’s unfocused, quite scattered, chaotic and a bit random...but give that brain something that you can tune into, and it’s your interest, then all that random stuff just goes boom... I get this incredible intense concentration and that’s great for work.”
Participants also saw advantages in divergent thinking, with one stating, “I’m an artist.... a creative type... a Bohemian.... you are most likely to be a creative person if you are a divergent thinker....and not convergent... I am very creative and that’s through and through... I’m a fine art graduate, a musician, a published poet, an entrepreneur, a performer.”
All the participants reported being seen as nonconformists. Depending on a viewpoint, that can be seen as either detrimental or advantageous.
Impulsivity is a core symptom of ADHD. Participants however related it to bravery, and more specifically adventurousness, spontaneity, and thrill-seeking. One said, “thrill-seeking is an ADHD thing... I can list in my life have done white water rafting, bungee jumping, hand-glider pilot … I have done a lot in my life and achieved a lot and experienced a lot... Furthermore, I would see a lot of that as being quite positive, and a lot of that is ADHD drive.”
Another common theme was high energy and “spirit.” One participant said, “I’ve got all this energy.... a lot of energy... whatever it's to do with... nature/nurture/spiritual stuff.”
These testimonials are useful as a check on the usual narrative of impairment. ADHD does not predestine all it afflicts to an unfulfilling life. Many, often assisted by medication, still lead exciting, successful, rewarding lives. Yet, we must be cautious in concluding that these individuals were successful because of their ADHD. It is possible, even likely, that they had other strengths such as high intelligence that compensated for their ADHD symptoms. We can not know from this report if their lives had been even more fulfilling or successful in the absence of ADHD. See, for example, my blog about highly intelligent people with ADHD: https://www.linkedin.com/pulse/20141126141502-65669938-smart-people-can-have-adhd-too/.
While the authors concede that “generalizing the findings of this study is not easy to do,” they inexplicably “also argue that the positive aspects we found are relevant to other adults with ADHD regardless of sample size, age, gender or ethnicity.” It is not possible to draw such a definitive conclusion without a much larger sample.
On a hopeful note, they conclude, “This is a study that reaches out to people with lived experience of ADHD: service users, patients, family members, carers, partners, to say that not all symptoms of ADHD are maleficent. Recovery, high functionality, and flourishing with ADHD are possible. Too often people with lived experience hear about ADHD deficits, functional impairments, and associations with substance misuse, criminality, or other disadvantages on almost every level of life (school, work, relationships). … This study affirms the positive human qualities, assets, and attributes in ADHD that can promote and sustain high functioning and flourishing.” I fully endorse the idea that those with ADHD can have wonderful lives, especially if they receive appropriate treatment, both medical and psychological.
Jane Ann Sedgwick, Andrew Merwood, Philip Asherson, “The positive aspects of attention deficit hyperactivity disorder: a qualitative investigation of successful adults with ADHD,” ADHD Attention Deficit and hyperactivity Disorders (2018), doi.org/10.1007/s12402-018-0277-6.
Antshel, K. M., Faraone, S. V., Maglione, K., Doyle, A. E., Fried, R., Seidman, L. J. & Biederman, J. (2010). Executive functioning in high-IQ adults with ADHD. Psychol Med 40, 1909-18.
Rommelse, N., Antshel, K., Smeets, S., Greven, C.,Hoogeveen, L., Faraone, S. V. & Hartman, C. A. (2017). High intelligenceand the risk of ADHD and other psychopathology. Br J Psychiatry.
Rommelse, N., van der Kruijs, M., Damhuis, J., Hoek,I., Smeets, S., Antshel, K. M., Hoogeveen, L. & Faraone, S. V. (2016). Anevidenced-based perspective on the validity of attention-deficit/hyperactivitydisorder in the context of high intelligence. Neurosci Biobehav Rev 71, 21-47.
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60% to 90% of youth with ADHD continue to have symptoms as adults. In older adults, about 2.5% are believed to have ADHD, but it often goes unnoticed because research is limited and current diagnosis methods are based mostly on studies of young people.
Our commentary discusses key points about ADHD in older adults. Although 2 to 3 percent of older adults have ADHD when using proper diagnostic tools, only 0.23% are diagnosed in medical records. This shows that ADHD is greatly underdiagnosed in older adults. Even worse, less than 40% of those who are diagnosed receive any treatment, which highlights the need for doctors to be better educated about ADHD in this age group. Current ways of diagnosing ADHD need to be improved for people over 50. Also, there isn’t much research on ADHD medications for people over 60, with most studies excluding them, which raises concerns about how safe and effective these treatments are for older adults, especially since stimulant medications can affect the heart.
There are also biases among doctors that make it harder to diagnose and treat ADHD in older adults. Many doctors aren’t trained to recognize ADHD in this age group and still see it as a condition that only affects young people. Some think that if a person hasn’t been treated for ADHD by this stage in life, they don’t need treatment now. But this ignores the fact that untreated ADHD can cause lifelong struggles and reduce the person’s quality of life. Some doctors are also worried about the risks of ADHD medications for older patients, even though research shows that these medications are usually safe when properly monitored.
Diagnosing ADHD in older adults can be tricky because its symptoms can look similar to other conditions, like mild cognitive impairment or dementia. This makes it important for doctors to do a thorough assessment that looks at medical, psychiatric, and psychological factors. Since older adults often have other health issues, it’s crucial for doctors to tell the difference between ADHD symptoms and those caused by other conditions.
In the end, we need more awareness, training, and research on ADHD in older adults. Doctors need to push past biases and consider the benefits of treating ADHD in this age group, carefully weighing the risks and rewards. As the population of older adults grows, so does the need for studies and guidelines to provide better care for older people with ADHD. Filling these gaps will ensure that older adults with ADHD get the attention and treatment they need.
A large international research team has just released a detailed analysis of studies looking at the connection between parents' mental health conditions and their children's mental health, particularly focusing on ADHD (Attention Deficit Hyperactivity Disorder). This analysis, called a meta-analysis, involved carefully examining previous studies on the subject. By September 2022, they had found 211 studies, involving more than 23 million people, that could be combined for their analysis.
Most of the studies focused on mental disorders other than ADHD. However, when they specifically looked at ADHD, they found five studies with over 6.7 million participants. These studies showed that children of parents with ADHD were more than eight times as likely to have ADHD compared to children whose parents did not have ADHD. The likelihood of this result happening by chance was extremely low, meaning the connection between parental ADHD and child ADHD is strong.
The researchers wanted to figure out how common ADHD is among children of parents both with and without ADHD. To do this, they first analyzed 65 studies with about 2.9 million participants, focusing on children whose parents did not have ADHD. They found that around 3% of these children had ADHD.
Next, they analyzed five studies with over 44,000 cases where the parents did have ADHD. In this group, they found that 32% of the children also had ADHD, meaning about one in three. This is a significant difference—children of parents with ADHD are about ten times more likely to have the condition than children whose parents who do not have ADHD.
The researchers also wanted to see if other mental health issues in parents, besides ADHD, were linked to ADHD in their children. They analyzed four studies involving 1.5 million participants and found that if a parent had any mental health disorder (like anxiety, depression, or substance use issues), the child’s chances of having ADHD increased by 80%. However, this is far less than the 840% increase seen in children whose parents specifically had ADHD. In other words, ADHD is much more likely to be passed down in families compared to other mental disorders.
The study had a lot of strengths, mainly due to the large number of participants involved, which helps make the findings more reliable. However, there were also some limitations:
Despite these limitations, the research team concluded that their analysis provides strong evidence that children of parents with ADHD or other serious mental health disorders are at a higher risk of developing mental disorders themselves. While more research is needed to fill in the gaps, the findings suggest that it would be wise to carefully monitor the mental health of children whose parents have these conditions to provide support and early intervention if needed
Meta-analysis finds vocal emotion recognition accuracy is significantly lower in ADHD
Emotion dysregulation (ED) refers to the difficulty someone has in managing their emotions. People with ED might experience strong reactions like anger, irritability, emotional outbursts, or even excessive happiness. This issue affects 25% to 45% of children with ADHD and 30% to 70% of adults with ADHD. ED may come from challenges in recognizing emotions—like anger, sadness, fear, or happiness—based on facial expressions or tone of voice. People with ADHD struggle to control their emotions in a similar way that they have trouble controlling their attention and behavior.
One way researchers study ED in people with ADHD is by testing how well they recognize emotions. In these studies, participants are shown faces or hear voices expressing different emotions, and they are asked to identify which emotion is being shown. This helps measure how accurately people with ADHD recognize emotions compared to people without ADHD (referred to as typically developing, or TD, individuals).
A group of psychologists from the UK reviewed many studies that compared how well people with ADHD and TD individuals performed on emotion recognition tasks. They focused on studies that looked specifically at how well participants could recognize emotions through vocal expressions (such as changes in tone of voice).
They combined the results of 20 different studies, which together included 1,651 participants, and found that people with ADHD had more difficulty recognizing emotions than those without ADHD. The overall difference between the two groups was moderate, meaning the ADHD group consistently had more trouble, but the differences weren’t extreme. Only two of the 20 studies showed slightly different results, and there was no sign that the studies were biased. Whether or not participants were taking medication for ADHD didn’t change the outcomes.
The study found that people with ADHD had more trouble recognizing both positive and negative emotions compared to the TD group:
The study found that emotion recognition difficulties were more pronounced in children with ADHD than in adults. Among children, the deficit was large, while among adults, the difference was moderate.
The psychologists concluded that their analysis provides strong evidence that people with ADHD struggle with recognizing emotions, particularly through vocal expressions. They also found that these difficulties aren’t specific to certain emotions (like only anger or sadness), but rather seem to affect emotion recognition in general. This supports the idea that ED in ADHD is partly due to the same attention problems that make it difficult for people with ADHD to focus or control their behavior. The findings highlight that emotion dysregulation in ADHD may be a secondary problem caused by these underlying attention issues.
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