The Puzzle of Adult ADHD (And How Neuropsychology Can Help Solve It)

Do you find it extremely hard to focus?  Are you continuously distracted?  Do you have dozens of unfinished projects? Does it take you significantly longer than other people to complete tasks? Do you have debilitating procrastination habits?  Are you unusually restless, impulsive, or impatient?

If you answered a resounding “YES!” to many of these questions, then you may want to read on and learn more about ADHD in adulthood.

Most people know of ADHD as a childhood disorder. But few people are aware that ADHD can continue into older adolescence and even well into adulthood. In fact, there are adults who remain undiagnosed and untreated, suffering from its effects for years or even decades.

The good news? If you are properly diagnosed – and an accurate diagnosis is essential – there are many treatment options that can help.

Meet Mr. Inattentive

Mr. Inattentive is an adult with undiagnosed ADHD who has trouble concentrating, finds himself daydreaming during work meetings, and forgets important details from conversations.

His wife describes him as forgetful and feels that he doesn’t listen to her.

His boss frequently tells Mr. Inattentive that he doesn’t seem to apply himself or reach his full potential, which is something he’s been told by teachers and bosses throughout his entire life.

At this point, Mr. Inattentive’s symptoms have led to major problems in his career and marriage.

People like Mr. Inattentive will recognize this familiar pattern: problems with attention have likely plagued them throughout their education and early careers. Those failures, in turn, create a cycle of emotional distress.

People like this may gravitate towards tasks that are more positive to reduce their level of frustration – like starting an interesting new project instead of finishing that boring task your boss keeps asking for – not realizing that it will hinder their productivity even further.

Repeat this cycle over the course of years, and they often develop chronic distress, hopelessness, poor self-esteem, and other symptoms analogous to depression. Often people who suffer this way then seek psychotherapy in response to emotional distress, not realizing the cognitive deficit underlying much of their issues.

Knowing is Better

Indeed, it’s common for individuals with ADHD to experience mood disorders, such as depression or anxiety, at some point in life. There is also a high rate of learning disabilities and substance use disorders that co-occur with ADHD. These conditions can seem like the primary issue for many patients, when in fact they may be rooted in ADHD.

Though, of course, it’s a two-way street. Mood disorders can interfere with cognitive abilities like attention in people who don’t have ADHD.

With so much left unknown about ADHD, particularly as it relates to the course of ADHD throughout the lifespan, it’s crucial that individuals suffering from these symptoms get accurate information, diagnoses, and treatment whenever possible.

“Knowing is Better” – this is the central message right now for October’s ADHD Awareness Month.

In my role as a neuropsychologist, I’m devoted to helping answer those questions. An accurate diagnosis is perhaps the most critical step, and the beginning of how neuropsychology can help.

What is Neuropsychology and How Can It Help?

If you’re not sure what neuropsychology is, you’re hardly alone. I’m asked about it all the time, and not just by patients — other clinicians and mental-health providers are curious too.

Neuropsychology is a specialized area within psychology that focuses on the link between brain functioning and behavior.

In this broad description, behavior refers not just to our actions but also to our underlying thought processes, or cognition, as well as our emotions. Cognition includes skills like learning and memory, attention, problem solving, and how quickly information is mentally processed.

Numerous conditions can interfere with cognition, from neurological problems like stroke or multiple sclerosis to medical, neurodevelopment, and psychiatric disorders.

A neuropsychological evaluation aims to address what is contributing to an individual’s cognitive symptoms; to figure out the degree to which the cognition and behavior are affected; and to determine what can be done about it. I recently joined the team at Union Square Practice as a clinical neuropsychologist to do just that for our patients.

What Happens in a Neuropsychological Evaluation?

When a patient comes to a neuropsychologist, we go through several steps with them:

– First, a clinical interview is conducted. I collect details about the individual’s personal concerns, how their symptoms impact their daily life, and, together with a detailed history, conceptualize this information within a framework of behavioral functions and underlying neural processes.

– The next step is neuropsychological testing. I administer a variety of tasks and questionnaires with the individual; their performance across neuropsychological tests reveals a unique pattern of their cognitive strengths and weaknesses.

–  Once neuropsychological tests are scored and interpreted, the results are summarized in a report. All this information is used to help make a diagnosis or clarify existing diagnoses. Perhaps most importantly, this information determines what recommendations are appropriate for the individual’s ability level to guide treatment planning.

– The deductive process doesn’t end once a diagnosis is reached (or ruled out). The neuropsychologist must bring all the pieces together and suggest possible solutions, or treatment recommendations, to resolve, reduce, or compensate for the individual’s difficulties.

However, the brain is enormously complicated. We have a long way to go before we truly understand its inner workings. This can make it next to impossible to determine a diagnosis with absolute certainty.

To me, the beauty of neuropsychology is that it requires a strong foundation of clinical psychology skills, because it can be as much a therapeutic process as it is a diagnostic one. Combining the two, I strive to understand patients’ concerns from their own unique perspectives in order to best solve their individual puzzle.

One Size Does Not Fit All

Patients with ADHD, whether children or adults, show a lot of variability in symptoms, as well as in response to treatment.

Not only do symptoms vary from person to person, but an individual’s symptoms can also vary throughout the course of life.

For instance, an adult who had combined inattention and hyperactivity in childhood may experience improved activity level and inhibition in adulthood, yet continue to have significant problems with concentration and planning.

Adults with undiagnosed ADHD don’t always recognize, or at least appreciate, the cognitive component of their difficulties until they go through proper testing and diagnosis. More often, they arrive in a clinical setting due to some period of crisis or chaos in life, rather than due to pure cognitive complaints.

Paying Attention to Executive Functioning

Countless adults have asked me if they have ADHD because they lose focus at work or can’t pay attention when their spouse recites them a to-do list. Individuals with ADHD do struggle with these symptoms, yes. But those with ADHD can struggle with a lot more than inattention, while there are several other considerations that could account for isolated attention problems.

Meet Ms. Disorganized

Ms. Disorganized is between jobs and feels lost about what to do next.

Her most recent position, which she quit rather impulsively, was just one in a long string of dead-end jobs.

Employers frequently have trouble with Ms. Disorganized’s behavior and performance at work. She leaves tasks unfinished, is inefficient, and seems to be much slower than others to get anything done.

Adults with ADHD struggle with numerous cognitive, behavioral, and/or emotional symptoms, all of which interfere with their day-to-day life.

The most common problems noted in both children and adults with ADHD involve executive functioning.

Though executive functioning has no agreed-upon definition, most concur that it’s a multi-part system of working memory (the temporary mental storage of information), planning, initiation, regulation, and inhibition.

Executive functioning drives our most complex capabilities — our ability to identify key elements of a problem, develop a solution, monitor performance, and modify our approach as needed.

Put another way, executive functioning allows us to organize and manage our cognitive resources in order to achieve our goals. Thus, when there’s a deficit in executive functioning, an individual can have a hard time getting things done!

Disentangling Mood and Other Factors that Contribute to Symptoms

Just as the symptoms of ADHD can lead to, or exacerbate, feelings of depression or anxiety, it is also possible for mood-related disorders to cause cognitive issues like inattention and poor planning.

Remember, being inattentive does not mean you have ADHD. This is a crucial distinction to make because it guides the course of treatment.

Interventions for ADHD like a stimulant medication might help someone increase their focus temporarily. If the underlying issue is depression, however, then targeting ADHD is ineffective in the long run. This brings us back to the importance of a comprehensive evaluation for the most accurate diagnosis.

Some adults have disabling problems with executive functioning yet don’t technically meet criteria for ADHD — but they also lack other conditions or injuries that explain their symptoms. Despite not fitting into specific diagnostic criteria, they often still respond well to the same interventions as adults with longstanding ADHD diagnoses.

A neuropsychological evaluation can tease apart the often-messy mix of cognitive, mood, and behavioral factors in order to solve the diagnostic puzzle and develop the best treatment plan.

Beyond the Diagnosis

When ADHD is suspected, a thorough assessment of all contributing factors can lead to the most accurate diagnosis and comprehensive treatment approach.

There are many ways to approach ADHD treatment in adulthood, and not just with medication.

  • Growing evidence supports the use of certain approaches to psychotherapy to improve aspects of cognition, like executive functioning.
  • Neuropsychologists can help patients develop specific strategies and compensatory techniques to meet the individual’s unique needs.
  • Innovative new assistive technologies can also help, like apps that guide you through planning and solving problems, help you organize to-do lists, and provide reminders for those easy-to-forget details.

The risks of undiagnosed ADHD are too grave to ignore. For instance, ADHD in adulthood is associated with significant risk for lower academic achievement, more cognitive impairment, lower occupational attainment, and poorer social functioning.

Just like there’s variability in symptoms, there’s also variability in patients’ responses to ADHD treatment. That means figuring out the right path may be a complex process of trial and error. While science hasn’t yet solved all the mysteries of ADHD, I can tell you for sure that there is a realistic chance for significant improvement through the steps we can take together.

Amanda Hahn-Ketter, Psy.D.

Clinical Neuropsychologist

Dr. Hahn-Ketter is a licensed psychologist who specializes in clinical neuropsychology. She has extensive experience working in medical and mental health settings, including Mount Sinai Hospital and the VA. Her expertise entails assessment, diagnosis, and treatment planning with patients who have neurocognitive issues. She also provides cognitive rehabilitation to help individuals compensate for and cope with cognitive difficulties.

Outside of clinical work, Dr. Hahn-Ketter is committed to teaching and leadership in the field of neuropsychology. She also participates on professional committees and is an active member of the American Psychological Association (APA) Division 40 (Society for Clinical Neuropsychology), International Neuropsychological Society (INS), and New York State Association of Neuropsychology (NYSAN), and an affiliate member of American Academy of Clinical Neuropsychology (AACN).