Undiagnosed ADHD in Adults

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Interviewer: Hi and welcome back to HealthTalks NOW, a podcast brought to you by Baptist Health. Today on the show, I’m really excited to talk about something that’s taking over social media. If you’re an adult on Tik Tok, you’ve very likely seen the surge of videos about adult ADHD. It’s gone viral and content creators are raising awareness, which is causing people to self-diagnose and wonder if they may be affected these Tik Tok videos are gaining media attention all over the country from the New York Times to Mashable, Vox, and more. Today I’m joined on the phone with Dr. Jonathan Martin psychiatrist with Baptist Health Medical Group and an expert on ADHD. So we can dig in and ask the questions that matter. Dr. Martin, thank you so much for being on the show today.

Dr. Martin: Thank you for having me.

Interviewer: Of course, I’m excited about this conversation. I know just in my personal friend group, this is something that’s gotten a lot of attention lately. So let’s start right out the gate with just a quick overview of, what is ADHD? Years ago, growing up, I remember hearing ADD. Is that just an evolution of the term or is there a difference there? Walk us through kind of the basics.

Dr. Martin: So it is kind of an evolution of the term. So ADD is a subgroup of ADHD. There’s two types. You have ADHD combined type, which means hyper activity. And then you have just ADHD inattentive type, which would be what we would refer to as ADD before. So hyper activity is included with the combined type and it is just like you expect. Hyperactive, restless, getting up and down. And then the more common type, probably, for adults is just ADD, which is without the hyper activity, just the concentration and attention deficit.

Interviewer: Okay. That makes sense. Another buzzword I’ve been hearing a lot is neurodivergent. Can you explain that term?

Dr. Martin: So neurodivergent is kind of, it is a popular term lately, that encompasses a lot of different psychiatric diagnoses, but it basically means that your thought or your overall concentration and view on things is a little bit different. So people use that term to refer to Autism Spectrum Disorder, ADHD and then a variety of other diagnoses and kind of symptoms that would relate to the way that you think or perceive things.

Interviewer: Okay. And so I guess the opposite of that would be called neurotypical. Is that right?

Dr. Martin: That’s right, yeah.

Interviewer: Okay. So let’s start with the symptoms then. We’ve mentioned a couple just in the first question there, but we know that these follow the DSM criteria for diagnosis. And if you’re not familiar with that, as you’re listening, that is kind of the manual of criteria gathered that is used by mental health professionals to diagnose a variety of different behavioral and mood disorders. So what are some of those classic symptoms of ADHD and how is it diagnosed?

Dr. Martin: So some of the classic symptoms we did talk about earlier, but inattention is the main one, and that is pretty self-explanatory, but it tends to be more related to long-term or sustained attention or being on task for a longer period of time. Impulsiveness is another common symptom of ADHD. That sounds pretty vague, but it can be related to things like job loss, relational issues, recklessness, restlessness, executive dysfunction, which is another big and vague term. But generally just means you’re working memory, shifting tasks, initiation of tasks, inhibiting yourself. So stopping things or controlling of behaviors, and then long periods of focusing on tasks or organizing activities. It can also have emotional dysregulation, which just means you get frustrated easy, have outbursts, low frustration tolerance, and then difficulty making decisions can be a symptom of ADHD.

Interviewer: One of the videos I’ve seen a lot on Tik Tok that talks about this is, it shows a woman in her thirties, forties, and she’s starting to clean the house and she starts one task and then she sees something else, gets distracted, goes and stops that task. Starts a new task. And before she knows it she’s gotten 15 or 20 tasks started, but nothing completed. Is that part of the inattention?

Dr. Martin: Yeah, that would be, I’d say, inattention and executive dysfunction. So that would be time management or setting goals and accomplishing those before moving onto the next goal. And the inattentive part would be where you see it. And so then you get distracted to go do that. So they both kind of play a role with that.

Interviewer: Right. Okay. And so then obviously there are criteria here of people may have difficulty focusing or they may have some of these symptoms and not necessarily meet the criteria for ADHD. So what is kind of the bar for the list of symptoms? And then versus someone who may just have a couple of symptoms, but not be classified as ADHD.

Dr. Martin: So I think it’s hard to determine because we all have all these symptoms sometimes. And sometimes we have a couple of those that last long and sometimes they resolve over time. The bar would be just persistent difficulty in maintaining your activities of daily living or functioning on a day-to-day basis. So once it starts to impair your life in a meaningful way, that’s generally where we set the bar for a diagnosis. Even if we all kind of have some of these, or you may have a good amount of those, they may resolve based on that situation or circumstance. So if it’s persistent and it’s impeding your life in a drastic way, that’s when we make the call.

Interviewer: Okay. So as you’re looking at this in adults, does it present differently than maybe it would, if you are looking to diagnose a child? Are you seeing different characterizations of the symptoms?

Dr. Martin: You do see a lot of the same symptoms, I’ll say that. So the baseline symptoms are generally the same, but they may present differently. So whereas a child might not be able to sit through a lecture, maybe getting out of his seat, maybe getting in trouble for talking, can’t sit and do homework, can’t finish an assignment. Adults, it presents more so with relationships and careers and maybe other activities of daily living. So unable to sit and finish the tasks you have at work, not finishing by your deadline, getting speeding tickets, being impulsive, being more forgetful, terminating relationships early because the sustained life focus and impulsivity isn’t there.

Interviewer: Okay. Is ADHD typically present from childhood and it just goes undiagnosed into adulthood? Or is this something that can develop later in life?

Dr. Martin: So generally you’ll have some symptoms in childhood, even if you aren’t diagnosed. It may be that you cope more appropriately or circumstances are different and the symptoms don’t present themselves in a meaningful way until your level of demand is higher. So you have a lot more on your plate. But there are some theories that there might be a later onset version of ADHD, which data behind it is kind of, I’ll say, questionable. People are arguing about that right now. There’s some good data there. Some people who refute that, but there could be a late onset version.

Interviewer: So then why does this go undiagnosed into adulthood? Like you said, is it that the symptoms were dismissed or that maybe they weren’t as prevalent until there was more responsibility on the person? Or is it a generational thing? The generation that we were raised in decades ago, there may have been a lack of awareness or a lack of acceptance for ADHD as an issue. I imagine it’s just difficult to pinpoint and easy to dismiss.

Dr. Martin: I’d say it’s a combination of those. And you’re right about that. We didn’t really look for ADHD as much in the past. We didn’t understand as much about it. And a lot of it was probably written off as a normal childhood behaviors. Even if those behaviors got to the point of being impeding on that child’s education or their day-to-day life. So the understanding of ADHD has grown. We also see that it’s mistaken a lot for other disorders sometimes, like anxiety or mood disorders. And then the fact that some kids can cope better with their symptoms and the level of demand they have at that time until they get to adults when they show to be more prevalent or more burdensome.

Interviewer: I just read a study, actually, that said ADHD diagnosis among adults are growing four times faster than ADHD diagnosis among children in the US. And I thought that was really fascinating that, whether that reflects more self-awareness in adults that they’re able to evaluate their own behavior and then seek help, whereas children maybe don’t even know to ask and their parents, like you said, could easily dismiss it as just kids being kids. But I thought that was fascinating that people are actually recognizing and reaching out and going and getting the diagnosis.

Dr. Martin: I think that’s a big part. And as an adult, you have more ability to get your own care and manage your own symptoms and really relate to others what kind of an impact they’re having. So that self-awareness and understanding is a big part.

Interviewer: I think, just talking, I’m sitting here thinking that there’s also a lot of these symptoms can easily be blamed on the self as lack of motivation or lack of follow through, or it’s very easy to look away from the clinical aspect of this, and really just kind of put some blame on self and say, well, if I just woke up earlier, I wouldn’t be late all the time. And always trying to find ways to overcome and just do better on your own. When in reality, there could be something like this causing this executive dysfunction and inattention, and that’s really making it challenging to achieve those things.

Dr. Martin: Right. And I think … it’s okay to look at some of that being on you, because taking personal responsibility is important, but if you try to make adjustments and you keep having failures of follow through or issues, then maybe it’s time to look into and behind that.

Interviewer: So then what is the difference? We mentioned that ADHD can easily be mistaken for other mood disorders like depression or anxiety. What is the difference then if you’re looking at someone who maybe thinks that they have anxiety or has been diagnosed with anxiety or depression versus ADHD? And then as a follow up to that, if someone has been diagnosed with anxiety, how do they maybe approach the possibility of being screened for ADHD?

Dr. Martin: So I think it can be difficult. I actually see that a lot. A lot of my adults that have ADHD have been misdiagnosed with anxiety, sometimes their whole lives, sometimes to childhood, sometimes just as an adult. Because a lot of the symptoms do overlap. And I think anxiety can be kind of a coping mechanism for ADHD, because if you’re worried about everything all the time, you’re more likely to get those things done. You also get a little more overwhelmed because you have so much going on in your head and it’s really hard to maintain that focus on one thing because you’re thinking about a lot of different things or you’re going a lot of different directions.

And so that does increasing anxiety. So sometimes, you’ve been treated for anxiety and you haven’t had a significant response to most of the traditional treatments of anxiety. I think it will be good to get tested for ADHD and really just talk to your primary care provider or mental health care provider about that. And they can refer you to testing or just someone who can evaluate you further. In mood disorders, it’s a little bit more difficult, but if a lot of the mood changes come from things like not getting things done, not being reliable, having impulsivity and getting frustrated easily, which leads to poor mood or depressed mood. Can look at the cause behind it then you could start thinking about ADHD.

Interviewer: That’s a great point. I mentioned earlier at the top of the episode that a lot of people were taking to social media and then subsequently self-diagnosing. Some in jest, but some in all seriousness saying, wow, this makes total sense. I’ve had ADHD, who knew? But what is the danger of self-diagnosing versus seeking out a professional?

Dr. Martin: I think the danger of it is, you may use it as a crutch, or you may rely on that or have fears that you maybe shouldn’t be having. Worrying about being labeled as something. And also self-diagnosis, it’s good to a point because you know yourself more than other people, but, and to put it into a diagnostic context, it’s recommended and more appropriate to get a professional to weigh in. It’s fine to say that I have some of these symptoms, that I relate to and I feel this could be something that’s going on and then allow professionals to go further and evaluate you and ask the follow up questions and put it into context of mental health so that they can make an accurate judgment.

Interviewer: That’s smart. If someone’s listening and they’re like, I can handle this. I’ll make lists. I’ll put myself on an improvement plan, so to speak. What are the potential consequences or complications of letting ADHD go untreated? In other words, what kind of fallout do we see in adults who are living with ADHD, but not seeking any help to actually manage or treat it?

Dr. Martin: I think those are good things to try. And those are things that are recommended for ADHD if you don’t want to seek professional treatment or you don’t want to use pharmacologic measures. But if those aren’t working and it remains untreated for adults, it can have some consequences that can be pretty impactful for every part of your life. So we talked a little bit about occupational issues earlier, not meeting deadlines, being late to work, being forgetful about tasks that you’re having to do, not being able to focus and maintain doing your work. And a lot of times the impulsivity can lead to lots of jobs that you didn’t last long at.

It can lead to relationship issues, really due to the same impulsivity. It’s hard to, if there’s any kind of frustration or burden on the relationship at baseline, then people with ADHD tend to terminate that relationship prematurely, maybe. So there may be a person with a lot of relationships that they’ve gone through in a short period of time. It can lead to anxiety and depression, due to having failures in these other aspects of your life. Low self esteem, feeling like it’s all you and you can’t do things, you can’t accomplish things and having that self blame. Adults with ADHD tend to have more traffic accidents or citations, or speeding tickets or minor collisions or minor accidents. And there is a study out of Europe where adults with ADHD have increased mortality rates, probably due to some of these impulsive and risky behaviors and inattentive.

Interviewer: It makes sense. It’s really fascinating how easy it is to, I think, like we were talking about, take on that blame and say, if only I could just be better. If I could just get it together. But how, if you overlook the clinical implications and you don’t treat the root of the problem, that it can really just spiral and spiderweb into so many areas of your life. Financially, relationally, into your physical and mental health. So it’s fascinating to me. But I want get into some of the nuances with you now. So let’s talk about ADHD and caffeine. What is the relationship there?

Dr. Martin: I would say the big one is kind of self-medication. Caffeine can help you stay focused a little bit more and it can make you maintain attention better than you would have baseline. And some people with ADHD who use caffeine, it actually does improve, but they tend to overuse the caffeine more than a normal person would in a day. And then for some people it can kind of slow things down too much and have the opposite effect. So that’s what I see anyway, in the clinic.

Interviewer: What are the risks of over caffeinating?

Dr. Martin: There could be some recipe based on your health issues that you have going in. If you’re overusing caffeine and you have hypertension, or you have a high heart rate, or you’re at risk of anxiety, or you have anxiety, can worsen than all of those things. There is a crash. You can become reliant. And then at the end of the day, not get anything done because you’re crashing from the caffeine.

Interviewer: Ah, interesting. So if people are using the caffeine and it’s positively improving their symptoms, they think they’ve kind of found the magic ticket and then they get a little bit dependent on it and take it a little too far.

Dr. Martin: Yep.

Interviewer: Gotcha. I want to look now at the difference in ADHD symptoms, if there are any, between the sexes. For example, would we expect different presentation in someone who identifies or presents as male versus female? I did read that boys are more likely to be diagnosed with ADHD than girls. And I just wondered, does that mean that ADHD is more prevalent in boys or that they’re presenting with more visible symptoms?

Dr. Martin: So it is not more prevalent. It’s the same frequency in both genders, but there are differences. So males tend to have more hyperactivity and they, as children, display more disruptive behavior with ADHD. Whereas females, they don’t have the hyperactivity as often, or when they do have it, it’s not as severe. And they tend to have more learning problems and they have more internalizing of their problems. So I think it’s just more apparent in males and that’s why they’re diagnosed more often.

Interviewer: Some of that’s probably cultural too, or societal, that the old adage kind of, boys will be boys. Their rambunctious behavior is more tolerated than say if a girl, classmate or a peer of theirs were acting the same way and girls are more taught to be delicate and mind the rules and be a little gentler than boys are. So part of that’s probably they may be experiencing the same symptoms, what I hear you saying, but they express those differently based on the expectations and the kind of cultural norms.

Dr. Martin: Yeah, that’s exactly right. And males do tend to have a higher level of impairment to day-to-day life with ADHD. So might get to the level where intervention is needed more often, but I think a big part of it is cultural, how we’re raised. Boys are rambunctious. They’re going to go wild and jump around and do all that. And girls are supposed to be quote, ladylike. So we don’t see that, them expressing it in the way that boys do.

Interviewer: Looking at, as these children grow and become adults. Do you see any correlation between people who do have ADHD and sensory issues like overstimulation or having a really hard time when there’s too much sensory input?

Dr. Martin: So I do see that they get overstimulated, but I don’t think that it’s really due to sensory issues as the cause. It’s more that, there’s a lot going on and thinking about a lot of things, they’re kind of multitasking in their head and then having to juggle trying to pay attention to a couple of different things and that can get burdensome, especially if there’s a lot going on and you have a lot to think about or a lot to do at that moment. It’s easy to get overwhelmed and overstimulated if there’s a lot of exogenous noises or sounds or talking or action.

Interviewer: It’s almost like, I’m envisioning as you’re talking, having multiple tabs open in an internet browser. And that being kind of like your brain, where you’ve got all these things running in the background and you’re switching around like, oh, now I need this. What, wait, what about this? Let me flip over to that.

Dr. Martin: Yeah. And then if you throw in trying to juggle all that, and then there’s music playing or people talking, or there’s some kind of event going on, it can be difficult. So then it’s easy to feel overstimulated, but I don’t think it’s due to the sensory issues themselves, the sounds or the sites or the activities. It’s more so being overwhelmed with everything that is going on.

Interviewer: That makes so much sense. I experienced that as a mom, I have two toddlers and there’ll be times where I am so deeply invested in what’s going on in my own head that the song they’re listening to, and the two of them talking over top of the song and me cooking and something happening in the kitchen. It feels like there is so much going on when in reality, probably 90% of it is happening in my head where no one else can see or experience it. Yeah. So let’s then talk about causation. Let’s back up. And if the sensory issues are not the cause but just kind of an accelerant, then what actually does cause ADHD, and are there risk factors that people need to know about?

Dr. Martin: There’s not really a particular cause for ADHD, but there are some contributing factors that increase risk. So there is a genetic component to ADHD, we do know that. We see it in families, we see it in siblings, we see it in parents and their children. So there’s a big part that genetics play. There are risk factors. They’re hard to really pinpoint, but there’s some good data about some different types of things that you may experience in development in childhood that may increase your risk of ADHD.

So particulate matter, which by that, I mean air pollution exposure early in life. And [inaudible 00:24:34] tends to increase risks that kids will have ADHD in that environment. Exposure to toxins developmentally during pregnancy can increase risk of ADHD. Pregnancy and delivery complications themselves actually increase risk for ADHD. And that can be anything from preeclampsia, poor maternal health, older maternal age, the duration [inaudible 00:24:56] and then fetal exposure to alcohol, which kind of goes into toxins a little bit, but that increases the risk as well. And then maternal smoking is a risk factor for ADHD.

Interviewer: Okay. That’s interesting that something so seemingly minor or seemingly unremoved, I guess, or removed from the adult or the functioning child, can have such a great impact on their quality of life and on their outcomes. Well, if someone is listening and they’re resonating with what you’re saying and they think they may have ADHD, how do they go about getting diagnosed and treated? Where do they start?

Dr. Martin: I think the best thing to start would be to go to your primary care provider or your mental health provider if you have one and just talk about your concern and just bring it up with them and discuss what symptoms and signs that you’re experiencing that you think may be related. And then get a clinical evaluation and a good history, the provider may then refer you to testing. There are some tests that, they don’t diagnose ADHD as it’s a clinical diagnosis, but they help kind of lead us that direction. And they tell us, differentiate it a little bit, if it is more so ADHD, or if it’s something more like anxiety or kind of sensory or learning issue. And they’re pretty simple and quick, but I think the first place to start would just be whatever care provider you have, be it primary care provider or a mental health care provider, just start there and talk to them.

Interviewer: And then kind of on the flip side, if someone is listening to this and it’s resonating with someone that they love, do you have any advice or tips about how they can voice their concerns or have a conversation about ADHD respectfully and maybe encourage that person to look into some resources?

Dr. Martin: I think the good thing is ADHD has been a little bit less stigmatized recently than it has in the past. So a lot of people probably wouldn’t take it poorly if you just mentioned it. Have you thought about maybe having ADHD before? But I think a good place to start would just be to mention some of the concerns and some of the symptoms. Bring that up, you realize that you’re forgetful a lot, or that you miss assignments a lot, or what do you think that is? Have you considered maybe that you have ADHD because it does seem like you struggled a lot in these different areas. And then just go from there.

Interviewer: I love that call to self-reflection. What do you think that’s about? So kind of involving the other person in the conversation rather than just simply talking at them. So if someone does take that step, then what treatment options are available? How can someone cope with this condition daily? Let’s start first with, I know you mentioned that there can be kind of some self directed, just tips and tricks that people can try before they move into something more clinical or pharmacological. But what’s your take on how somebody can cope?

Dr. Martin: There’s a couple of different ways. So you kind of have to know yourself and how you function best. And I think that’s a learning curve for all of us, how we learn best, how we function best, what we need to get things done. Things like, do I need to take breaks? Give yourself a 10 minute break here and there, don’t try to just power through the whole task or the whole assignment. Do I need to make lists? Am I forgetful? Do I need to check things off?

Do I need to set reminders on my phone because I have an issue with due dates or bills and things like that. Do I need to limit the amount that I’ll take on, on a daily basis or the amount of tasks I take on at work? Should I limit it and do a certain amount before I take on another one? So some of those things, and it’s different person to person because I guess we all learn different ways and we all function and maintain in different ways. Knowing yourself and what works best for you is the best place to start with what coping skills would work for you.

Interviewer: You just heard my alarm go off a couple of minutes ago, I’ve got alarms set all day to remind me of different things. So I think that’s a great tip. But now let’s talk about some of the more provider introduced tactics for treatment.

Dr. Martin: So, I’d say there’s probably two main categories. There’s therapy and then there’s medication management. Medication management is what we all know about, we are hear about, what we think of when we think of ADHD. But I like to kind of reiterate, there’s a lot of different options even with medication management. We all know of the stimulant options and the various drugs for that, but there’s also non-stimulant medications that we can use to treat ADHD. And then the other side of things is therapy. So therapy has been proven to be beneficial, CBT, specifically, cognitive behavioral therapy.

Interviewer: If someone has been, I know we talked about people who have been maybe misdiagnosed with anxiety. Say someone’s been misdiagnosed that way, with anxiety, and they are being treated for that with an SSRI. Does that have any positive impact on ADHD? For example, is that masking any of the symptoms or maybe improving the symptoms, but being re-evaluated for ADHD and properly medicated could improve even further?

Dr. Martin: It can help some with ADHD. So it can help with the anxiety maybe that the ADHD is causing. It can help you from getting frustrated and anxious as easily, can maybe pick your battles a little bit better about what you get anxious or upset about. And so it can make things smoother. It will likely not make things marginally better from the compensation standpoint or the standpoint of not getting things done, being forgetful. And so the baseline things that cause anxiety may still be there, but the day-to-day may be smoother and easier to deal with.

Interviewer: So do you find that people end up needing to be medicated for both sometimes?

Dr. Martin: Sometimes, yeah. Sometimes if you have anxiety and it’s a big part and ADHD is treated, sometimes anxiety improves completely and you do not have to be treated for anxiety, you can just be treated specifically for the ADHD. But sometimes they’re comorbid. So that’s another issue is that they’re hard to differentiate which is which, or if they’re both there. But they can both exist in the same individuals. So sometimes you do need to treat both diagnoses.

Interviewer: Yeah. That makes sense. I think what I keep going back to, as you’re talking, is just having that relationship with a provider that who knows you and who you can trust and being able to have those conversations and then check in as your treatment progresses to kind of course correct or evaluate what’s going on and how it’s impacting you and what progress you’re seeing. The last question I want to ask you about treatment and medication is, are these medications addictive or can they have adverse effects?

Dr. Martin: So both. They can have both. So stimulants, the things that are controlled medications like your Adderall, your methylphenidate, the classic things that you hear about with ADHD, they do have an addictive potential. Generally, if used appropriately and for the right diagnosis of ADHD, that risk is more minimal. There are medications, like I said, that we use that are not simulate and they do not generally have an addictive potential.

The other question you asked me was about the side effects. So they can have adverse side effects. So stimulant medication can increase heart rate. It can increase anxiety. So specifically in people who have been misdiagnosed with ADHD, who also have anxiety, that may be contributing more so to ADHD symptoms that can increase that. They are activating medications. Sometimes you can get headaches or reduced appetite. And that just has to be kind of a trial process to see which ones are going to cause that and what you can do to mitigate those symptoms. The non-stimulant options, they have pretty similar side effect profiles. You can have increased hot flashes and sweating sometimes with treatment for ADHD as well.

Interviewer: Well, Dr. Martin, this has been really helpful. So thank you for taking time out of your day to have this conversation with me today.

Dr. Martin: Thanks again for having me. I enjoyed it.

Interviewer: Of course. Again, if any of this resonated with you today, be sure you’re teaming up with a professional who can properly diagnose and guide you through the process. If you’d like to get in touch with Dr. Martin’s office, we’ll be linking that information in the show notes of this episode. For more information about our behavioral health services at Baptist Health, or to find a provider near you, visit BaptistHealth.com. Be sure to share this episode with a friend and tag us on social media. Thanks for tuning in. We’ll catch you next time on HealthTalks NOW.

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