For a long time, the model of attention deficit hyperactivity disorder has been a neurodevelopmental disorder that starts in childhood. Neurodevelopmental simply means an abnormality that affects how your brain develops. As a reminder, the symptoms of ADHD are inattentiveness, hyperactivity, and impulsivity. Executive dysfunction is often associated with ADHD.
The expected course of ADHD has been that about 50% of people with childhood ADHD continue to have symptoms into adulthood. But a study from earlier this year found that only 10% of children grow entirely out of ADHD.
That leaves 90% of people who have it as children to continue to live with it in adulthood.
Another finding against the grain of established characteristics is that disorder is not binary like you have it or don’t. You can have aspects of it that don’t cause many problems for you, or you can be fully loaded with the symptoms that cause a lot of impairment. It’s a threshold issue.
We also thought that once it manifests in a way that comes to the attention of others, like your teachers or caregivers, those problems stay that way forever unless you’re in the group of people who grow out of it.
But this recent study looked at 558 children with ADHD combined type, meaning they have inattention and hyperactivity symptoms. They monitored their symptom progress over 16 years. That’s a long time for a study follow-up.
They found that only about 20% of the children had persistent symptoms for 16 years. They found that the natural course of the illness for most people was that it has a zig-zag course. The symptoms fade in and out depending on your circumstances.
These study findings are consistent with what I’ve seen in my practice.
I only treat adults. I’ve seen adults start taking medication in elementary school and continue it into adulthood. That’s the traditional, standard course. But I’ve also seen scores of people who come to me as the first doctor they’ve seen for an ADHD evaluation. They may have had mild symptoms as a child, but they got by. But now, something has changed to where the demands of their life outstrip their ability to compensate for whatever mild deficit they had.
These breakpoints that cause worsening of mild symptoms or a relapse of symptoms that disappeared at one point usually correspond to changes in academic or work demands. For example, you may have been a slow reader in school and had some extra energy, such that you had trouble settling down in class. But you never really became a discipline problem, and you settled with being a C student, or you spent a lot of time studying to keep up with your work and make A’s or B’s. You make it through high school, but you struggle to keep up with the college-level work. So, you see a psychiatrist for the first time in college.
Or you squeak by in college, but graduate studies become your breaking point. Another scenario is you do okay in your first job because the work doesn’t tax your attentional resources too much. But when you get a promotion or higher intensity job, that depletes your mental reserves so that you find yourself unable to keep up. These are examples of how you can seem okay for a while and then not be okay.
What happens to the person who starts having more problems with ADHD as an adult? Are they stuck having problems and needing to take medication forever? Not necessarily. These study findings and my experience support that your symptoms can come and go.
How problematic they are can depend on how much your school, work, or life stresses your weaknesses. Not everyone with ADHD has the same attentional weakness.
For example, you may have trouble working continuously for more than an hour without becoming irreversibly distracted or losing all motivation to continue. But you’re okay with meetings as long as there’s interaction with others. This works for you because you can pay attention in a conversation, but you don’t have as much control when your thoughts are all internal, and you’re left to yourself to think and focus.
In this case, you may do just fine in a job where you work in teams, and there are lots of meetings and collaborations. Or you may do well with the kind of job where you travel and meet people. But sitting at a computer for 3 hours and working on a spreadsheet would be the end for you.
ADHD does not create a generic, blanket level of deficits everyone has. There will be things you’re good at and not good at. Going back to the previous example, you could have an outside sales job where you meet and greet people, and that fits your vibe very well because you never stay stagnant for more than 40 minutes at a time. If you don’t know what you can and can’t do well, you could change jobs and get one that requires you to spend hours reading emails and creating spreadsheets and not understand why you’re failing miserably.
Then you come to see me for medication treatment because you took it as a child, but you stopped and did fine for years, and now here you are having trouble again. You get on medication and can keep up with your work, but you don’t like that you’re now back taking medication. With some exploring, we discover what kinds of tasks let you fly under the radar of your ADHD and which ones stir up the problems for you and make your symptoms unmanageable.
You may not have complete control over changing your job responsibilities, but now you’ve got something you can shoot for to find a job you can do that exploits your strengths and doesn’t require much of you in the areas where you’re the weakest.
If you don’t have a therapist, you can still try to figure this out by looking back and seeing the tasks you’ve done and the environments in which you worked where things seemed to flow for you. You still may have had some bumps, but your ADHD symptoms were manageable. Then, what have you done where it felt like you were trying to put a square peg in a round hole?
Other circumstances that can affect the severity of your symptoms or how much impairment they cause are your diet; the cleaner, the better. Clean means a minimal amount of processed foods and sugar. Also, your exercise level and how much sleep you get matter. If you have another disorder like depression or substance abuse, the course of those illnesses affects the severity of your ADHD symptoms. If you get depressed, your ADHD can destabilize.
I will say that the executive dysfunction tends to be something that hangs in the background even when you have reasonable control over your attention, focus, hyperactivity, or distractibility. Take a look at this video for more on executive dysfunction. I plan to talk more about how ADHD can affect your emotional control. But in the meantime, watch my ADHD skills playlist for managing some of your ADHD symptoms without medication.
References
Sibley MH, Arnold LE, Swanson JM, et al. Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. 2022;179(2):142-151. doi:10.1176/appi.ajp.2021.21010032
Moffitt TE, Houts R, Asherson P, et al. Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study. Am J Psychiatry. 2015;172(10):967-977. doi:10.1176/appi.ajp.2015.14101266
Craig B.H. Surman, Joseph Biederman, Thomas Spencer, Dayna Yorks, Carolyn A. Miller, Carter R. Petty, and Stephen V. Faraone. Deficient Emotional Self-Regulation and Adult Attention Deficit Hyperactivity Disorder: A Family Risk Analysis American Journal of Psychiatry 2011 168:6, 617-623
Haavik, J., Halmøy, A., Lundervold, A. J., & Fasmer, O. B. (2010). Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert review of neurotherapeutics, 10(10), 1569–1580. https://doi.org/10.1586/ern.10.149
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