Judy Sandler, 62, could never control her fidgetiness in meetings with fellow teachers. At home, she would lose bills in the untamed piles that filled her office. Too often, she would forget simple tasks like locking the door of her home in Lincolnville, Maine.
But the worst was a few years ago when she decided to write a book. Her mind would skitter off in pursuit of a random thought, or she’d get up just briefly and never return to the task at hand.
“I had a goal I wanted to achieve. I was intelligent and willing to work hard. But I couldn’t get anything accomplished,” she says. “I felt lost.”
So Sandler sought treatment for her growing depression — and after an in-depth assessment, a psychiatrist diagnosed her with ADHD. “I was shocked,” she adds. “But so much about it made sense.”
Sandler is one of a growing number of U.S. adults diagnosed with attention deficit hyperactivity disorder. In 2023, the estimated prevalence of adult ADHD was tallied at 6% — or 15.5 million people. Previous estimates had set that number at around 4.5%.
What’s more, 1 in 4 U.S. adults now suspect they have the condition. And during the COVID-19 pandemic, stimulant prescriptions used to treat ADHD leaped 30% among Americans ages 20 to 39.
But whether the increased numbers are due to a long-overdue awareness, inappropriate diagnoses, or both is unclear.
“During the pandemic, many people felt very impaired, so they were approaching providers hoping it was ADHD and could be fixed with medication,” says Craig Surman, MD, director of the Clinical and Research Program in Adult ADHD at Massachusetts General Hospital in Boston.
“There’s also been a lot of misinformation, sensationalizing, and generalizing on social media,” he adds. “Diagnosing ADHD is complicated and needs to be based on specific criteria. It’s a lot to put into a TikTok sound bite.”
Leaders in the field point to other concerns as well. For example, the Centers for Disease Control and Prevention has called the lack of U.S. consensus guidelines for diagnosing and treating adult ADHD a public health concern.
And since few physicians are trained to treat the adult version of the condition, some may decide to prescribe medication simply to see if it helps. “Nearly all people, if you give them a stimulant, they will say, ‘Doc, you’re a genius. I’m doing great.’ But that doesn’t prove the person has ADHD,” says David Goodman, MD, an assistant professor of psychiatry at Johns Hopkins School of Medicine in Baltimore and director of the Adult Attention Deficit Disorder Center of Maryland.
At the same time, diagnosis has brought great relief to some patients who for years misinterpreted symptoms as a sign that they were somehow deeply flawed.
Goodman describes treating one patient with classic ADHD symptoms who went undiagnosed for decades. “At one appointment, she started crying from relief. She said, ‘I finally realized that I’m not stupid … like people told me.' Patients come to see that ADHD isn’t who they are. It’s something that they have.”
What, exactly, is adult ADHD?
Signs of ADHD include difficulty paying attention, impulsivity, and restlessness as well as disorganization, irritability, forgetfulness, and trouble completing tasks. Of course, most people experience such problems at some point. So to qualify for a diagnosis, a patient has to experience significant impairment in two or more areas of their lives, such as work and relationships.
Symptoms also must have started in childhood. “As the condition is currently defined, there is no such thing as late-onset ADHD,” says Ryan Sultan, MD, an ADHD researcher and an assistant professor of clinical psychiatry at Columbia University Vagelos College of Physicians and Surgeons in Manhattan.
Yet identifying the condition can take time, with more than half of adult ADHD patients reporting they weren’t diagnosed until 18 or older.
Recognizing ADHD in adults can be tougher than in children. “Children may be disruptive in school, run around, and interrupt the class,” says Goodman. “You don’t see adults bouncing around the office. They may tap their foot endlessly at their desk instead.”
Further complicating matters is that the adult version of the condition has been little understood until fairly recently, and skepticism lingers. “Some people think the symptoms are normal parts of the human experience that are being pathologized,” says Goodman. “But just like depression is different from sadness, ADHD is different from basic inattention.”
If so, some wonder, shouldn’t ADHD appear in physiological measures like brain scans?
“Many neurological pathways are involved in ADHD, so there’s no single fingerprint in the brain for it,” says Maggie Sibley, PhD, a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle. “Instead, there’s a combination of features that add up to it.”
For example, people with ADHD generally have less of the neurotransmitter dopamine, “which means they are in a less activated state of attention. That can make it harder for them to engage in activities that don’t particularly interest them,” says Sultan.
Research suggests that environmental triggers — parental smoking and early lead exposure, among them — play a role in ADHD. Mostly, it’s considered genetic, though. If your sibling has ADHD, for example, you’re nine times as likely to have it too.
But people with ADHD are not destined to struggle, says Goodman. Often, their creativity, intelligence, and skills help counterbalance their symptoms.
“We see people who come in for the first time because of a major life change like getting a new job,” he notes. “That change starts overtaxing their ability to compensate.”
Diagnostic dilemmas
For many patients, a diagnosis of ADHD begins in a primary care provider’s office. Early steps can include a brief screening questionnaire, such as the Adult ADHD Self-Report Scale Symptom Checklist. But such tools are insufficient on their own, says Lenard Adler, MD, a psychiatrist at NYU Langone Health in Manhattan who helped create the checklist.
In fact, a 2021 study estimated that some 90% of people who screened positive on a World Health Organization adult-ADHD screening questionnaire did not have the condition.
Instead, an accurate diagnosis requires a thorough patient interview, a medical and developmental history, and when possible, input from close contacts familiar with the patient’s moods and behaviors, says Adler. It also involves ruling out other possible causes — there are many — for ADHD symptoms.
Although failure to evaluate patients carefully can drive overdiagnosis, it’s not clear the extent to which it contributed to the recent bump in reported ADHD cases.
Possible explanations for the increase include that the pandemic exacerbated existing symptoms, says Sultan. Also possible is that the loosening of telehealth rules during the pandemic — which included allowing the prescription of stimulants without an initial in-person appointment — increased access to much-needed care. After extensive debate, the U.S. Drug Enforcement Agency (DEA) recently extended those flexibilities through December 31, 2025.
But inappropriate prescribing of stimulants is also worrisome, says Sultan.
On an individual level, “a person who doesn’t have ADHD likely has more normal levels of dopamine, which stimulants increase. When you get to higher levels of dopamine, you can start to get psychotic.”
At a societal level, excessive prescribing can fuel medication misuse and diversion as well as stimulant-use disorders. In 2023, nearly 4 million Americans misused prescription stimulants.
But prescribing is a balancing act, given that underdiagnosis also can be problematic. “People with untreated ADHD are more likely to smoke, have substance-use disorders, and get into car accidents. They’re also more likely to get divorced. Those are significant consequences,” says Adler.
How is adult ADHD treated?
ADHD treatment often involves medication, but the type, dosing, and duration require careful thought, says Sultan. Among the considerations is that symptoms fluctuate over time as, for example, a young adult’s brain matures.
When it comes to choosing medications, some patients prefer to avoid the potential downsides of stimulants such as Adderall (dextroamphetamine and amphetamine). Those include difficulty sleeping, feeling on edge, and upset stomach. Particularly concerning for older adults are elevated blood pressure and heart rate.
But compared with non-stimulant medications such as Strattera (atomoxetine) and Intuniv (guanfacine), stimulants work faster and are considered more effective. “Stimulants for ADHD are the most effective medicine in all of psychiatry. Anxiety, depression, schizophrenia — none of the medications for any of those work as well,” says Sultan.
Maria Camin,* 40, a Manhattan fitness instructor and entrepreneur, started medication last year. “My brain can be all over the place. I can’t even read a long email,” she says. “Medication slows things down. I never realized how noisy just living felt until I tried medication. It helps me block out some distractions.”
Meanwhile, shortages of stimulants, driven partly by DEA efforts to prevent misuse by limiting their production, have left patients scrambling in recent months. Some have even turned to illegal markets.
Despite the focus on medications, Sultan advises against relying on them alone. He shares a pithy caution: “In ADHD, skills are as important as pills.”
Cognitive behavioral therapy — which addresses both attitudes and actions — is considered the most effective counseling method for the condition. “Let’s say random thoughts about your to-do list keep popping up. The patient learns to write them down and address them later, to make them much less distracting,” says Surman.
Self-care behaviors that improve brain function, like sleep, nutrition, and exercise, are important too, he adds. “For one, we know that physical activity, especially cardiovascular activity, raises dopamine levels.”
A significant aim of counseling is helping ADHD patients build supportive structures. “Therapy asks some key questions,” says Sibley. “‘What environments and people boost you up? What kind of work and activities hold your interest? What really helps you be your best self?’”
The hard road ahead
Much work remains for physicians and researchers aiming to better understand and treat adult ADHD.
For one, two-thirds of providers who treat adults report being ill-equipped to address the condition. So a key goal is educating providers trained back when ADHD was seen solely as a pediatric issue to identify and treat the condition in adults, as well as to ensure better integration of the topic into current medical education.
Sibley, Adler, and others have been working on a tool to help educators and providers: the first U.S. consensus guidelines for diagnosing and treating adult ADHD. After years evaluating evidence and drafting recommendations — a process overseen by the American Professional Society of ADHD and Related Disorders — the document is expected to be published in 2025. Providers seeking help applying the guidelines will be able to turn to specialty-specific toolkits crafted by the nonprofit CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder).
Among the guidelines’ aims is addressing inequities experienced by underserved populations. Black and Brown men with ADHD are more likely to have been misdiagnosed with oppositional defiant disorder in childhood, for example, and women’s symptoms are more frequently misinterpreted as depression.
Expanding adult ADHD research is also crucial, says Sibley. The gap between adult and pediatric research funding is large: $5.5 million for the former versus $42 million for the latter, according to one estimate.
Among the questions researchers would like to tackle is how to better diagnose adults. Currently, diagnostic criteria tweak those that are crafted for children — even though symptoms can appear quite different in adults.
Numerous treatment-related questions remain unanswered too. How might menopause affect ADHD medication? How do medications stack up against behavioral therapies among specific populations? What are the particular risks and benefits of ADHD medications for older adults?
Researchers also aspire to create a brand-new medication that targets the same brain mechanisms as stimulants — but without their potential downsides. That’s an extremely slow, complicated, and costly process, though.
Meanwhile, patients say they are grateful for the support that advances allow. “I’m excited that people are researching and talking about adult ADHD much more,” says Camin. “I’m so grateful that people with ADHD are learning how we can use our many strengths to succeed and feel valuable in the world we live in.”
*Not her real name
