Russell A. Barkley, Ph.D., is a Clinical Professor of Psychiatry at the Virginia Treatment Center for Children and Virginia Commonwealth University Medical Center. He holds a Diplomate (board certification) in three specialties: Clinical Psychology, Clinical Child and Adolescent Psychology, and Clinical Neuropsychology. Dr. Barkley is a clinical scientist, educator, and practitioner whose publications include 22 books, rating scales, and clinical manuals, 7 award-winning DVDs, and more than 260 scientific articles and book chapters related to the nature, assessment, and treatment of ADHD and related disorders. He is also the founder and Editor of the clinical newsletter, The ADHD Report, now in its 24th year of publication. Dr. Barkley has presented more than 800 invited addresses internationally and appeared on nationally televised programs such as 60 Minutes, the Today Show, Good Morning America, CBS Sunday Morning, CNN, and many other television and radio programs to disseminate the science about ADHD. He has received awards from the American Psychological Association, American Academy of Pediatrics, American Board of Professional Psychology, Association for the Advancement of Applied and Preventive Psychology, the Wisconsin Psychological Association, and Children and Adults with ADHD (CHADD) for his career accomplishments, contributions to ADHD research and clinical practice, and for the dissemination of science about ADHD. His websites are www.russellbarkley.org and ADHDLectures.com.
By Susan Herman
Did you know that adults can have ADHD? It’s true—ADHD is not confined to children and teens.
The trademarks of Attention Deficit Hyperactivity Disorder (ADHD) are inattention, combined (for some) with hyperactivity and/or impulsive behaviors. According to the National Institutes of Mental Health, some people with ADHD only have problems with one of the behaviors, while others have both inattention and hyperactivity-impulsivity. It is normal to have some inattention, unfocused motor activity and impulsivity, but for people with ADHD, these behaviors are more severe, occur more often, and interfere with or reduce the quality of how they function socially, at school, or in a job…Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed.
Professor, researcher, and clinician Russell A. Barkley recently published a self-help book with APA LifeTools for family members of adults with ADHD, titled When an Adult You Love Has ADHD: Professional Advice for Parents, Partners, and Siblings. You can find more information about the book and purchase it here.
I recently interviewed Dr. Barkley about his work with adults who have ADHD, and how loved ones in their inner circle can support them.
How recently was adult ADHD recognized?
A German-language textbook published in 1775 has a remarkably accurate description of what we now call ADHD in adults. But, aside from very periodic mentions in the literature—as “minimal brain dysfunction” in the 1950s, and as “hyperkinetic reaction” or “hyperkinetic disorder” in the 1960s—neither the public nor the research community much recognized it. It wasn’t until the 1970s that a series of longitudinal studies was conducted to find out whether ADHD continued beyond childhood. Interest in this picked up throughout the 1980s and 1990s as it was found that half to two-thirds of kids who were diagnosed with ADHD continued to have symptoms into their twenties. This was the first real evidence base that began to show us how ADHD, like mental retardation, dyslexia, and autism, can continue into adulthood.
What would you say has been your greatest contribution to the field of adult ADHD?
In 1991 I started an adult ADHD research clinic at University of Massachusetts Medical School, and the same year my psychiatrist colleague Joe Biederman started one at Massachusetts General Hospital in Boston. We were collecting data on a variety of domains of impairment and symptoms on these adults to see if it was equivalent to the childhood form of the disorder – it clearly was. Later, Alan Zametkin and colleagues at the NIMH did the first PET scan study showing brain related deficits in functioning in adults with ADHD. Other studies on never-before-diagnosed adults were done to learn whether they responded to the same types of drugs that children were being given for ADHD. Results showed that they did so.
In 2008 I published a monograph where I compared results of my own 20-year longitudinal studies on children with ADHD followed to an average age of 27. Drs. Kevin Murphy and Mariellen Fischer and I compared them with adults diagnosed with ADHD alongside data I’d been collecting in the
clinic from adults who were not diagnosed as ADHD. This was the first time anyone had compared the two groups directly (children with ADHD grown up vs. adults diagnosed with ADHD). The monograph was massive, but I chose that format over journals because with journal articles you have page limitations and you have to peel off tiny bits of your research and present it over multiple, disparate articles. Instead I presented it all at once, and this allowed adult ADHD to really hit the research map. Others followed up my work with various methods of neuroimaging to show differences in brain activity for adults with ADHD.
Why did you decide to focus on parents, siblings, and partners of people with ADHD in your latest book?
Ever since I wrote a self-help book for adults who have ADHD, called Taking Charge of Adult ADHD (in 2010), I’d been wanting to write one for the family members who support them. At the time there was no science-based trade book available for loved ones of people with ADHD. Also, ADHD is in my family. I had been trying to help various of my own family members, get them treatment and offer a safety net, so I knew there were others out there also feeling frustrated after picking up and dusting off their loved one again and again.
I was ready to write the book when my twin brother died. He had ADHD, and I know that it indirectly contributed to his death. He was driving 40 miles per hour on a country road in the Adirondacks. He never wore a seatbelt, and he had a habit of going too fast and drinking while driving. He ran off the road and was killed. I put the book aside while I was grieving him. Not long after my sister, who had physical disabilities, also died. And about three years after that, my deceased brother’s son, who also had ADHD, hanged himself. So I just “couldn’t go there” for a while due to all this grieving.
Finally, in 2015 the time was right. Several books on how ADHD affects marriage had appeared by that time. Writing about how to love someone with ADHD was cathartic for me. I feared that re-living events would make me feel worse, but actually I felt better.
Thank you for sharing that personal story. I’m glad you decided to include some of it in the book, too.
Let’s back up a bit and talk about how ADHD can affect adults who have it. Also, how many adults have ADHD—how common is it in the population?
Four to five percent of adults in the USA have ADHD. The percentage is closer to 3-4% worldwide. It’s higher in Western countries because of longer life expectancy and better access to care. In children the ratio of boys to girls with ADHD is three to one; for adults there’s less of a split; it’s closer to 1.4 to 1 male to female. It’s been great seeing more women come out of the woodwork to talk about ADHD. I recently consulted on articles in Elle, Glamour, and Cosmopolitan magazines about adult ADHD.
ADHD is genetic in about two thirds of all cases; in about one third it is acquired either prenatally or after birth because of head trauma or environmental conditions that affect the brain’s frontal lobe development.
Adults who have ADHD typically achieve a lower level of education than they are capable of, and they have problems in the workplace with boring tasks that require sustained attention. Adults with ADHD tend to do well in non-traditional careers, often those that involve performing, music, athletics, police work, and the military. There are people with ADHD in law and medicine, but fewer than you’ll find in the more physically active careers.
Money management is a challenge for many people who have ADHD, as is driving. Adults with ADHD are 2-3 times more likely to be dead by age 46 from accidental injuries, many of which involve driving. About one third of adults with ADHD exhibit antisocial behavior and may even get involved with crime.
New research areas in adult ADHD include risky sexual behavior, along with marriage and parenting problems. ADHD is really one of the most impairing outpatient disorders there is—I would venture to say it’s even more impairing than depression—because it affects so many diverse areas of life. Clinical care and family counseling for adult ADHD exists and is increasingly available but is far from where it needs to be. As of ten years ago, only about one in ten adults with ADHD was diagnosed. The percentage is better now but there is still much progress to be made.
What do family members and partners need to understand about ADHD to best support their loved one who has it?
It’s important to adopt a biologically-based view of ADHD. ADHD is a neuro-genetic disorder. You can’t attribute your loved one’s behaviors to personality quirks, defective morality, laziness, or poor lifestyle choices or say they deserve whatever they get. You can’t be a good support person if you keep thinking, “My loved one could change if they wanted to, but they don’t want to.” People in the inner circle are their loved one’s best safety net and closest influence, but they can’t step up as stakeholders if they don’t adopt a more compassionate outlook about ADHD.
What kinds of support can family members provide to an adult who has ADHD?
In my clinical work I walk through six steps with adults who have ADHD and their families. Step One is to get a thorough mental health evaluation to document not only ADHD, but any other disorders that the person might also have. Eighty percent of adults with ADHD have an additional disorder, and about half have two additional disorders. These might be anxiety, depression, a learning disability, bipolar, or something else. Detecting secondary disorders affects the course of ADHD treatment. Psychologists, psychiatrists, and behavioral neurologists can diagnose ADHD.
So the support person might offer to set up various appointments for their loved one and help them follow through getting to the specialist’s office.
Step Two is to help the patient “own” their ADHD as a part of their identity. It’s easier to accept a diagnosis intellectually than it is to incorporate it as a part of your own view of yourself. Treatment will be superficial if the person doesn’t accept ADHD as a part of their self-view. When the patient starts to grieve their old self-image, that’s when we know we are getting through. Accepting the new you is also a positive thing because it means you’re giving up the old view of yourself as stupid, lazy, or immoral.
Step Three is to read widely and educate yourself about ADHD. I like to say that “truth is an assembled thing.” You can’t just depend on one source for all your information. Jeff Copper’s podcast, Attention Talk Radio, is a great resource, and I offer many more in the book. Think about it: if you’re diabetic, you have to understand how diet plays into your condition, and hygiene [for blood tests and insulin monitoring], and a host of other things. Because ADHD is a chronic disease I sometimes refer to it as the diabetes of psychiatric conditions.
Step Four is to get on medication. Medication is the best treatment for ADHD. And I’m saying this as a psychologist—there is no longer any “us versus them” going on between psychologists [who typically do not prescribe medication] and psychiatrists when it comes to ADHD treatment. Medication is two to three times more effective than behavioral methods alone for treating ADHD. Most adults with ADHD, 80-90%, need medication as part of the treatment package. Family members can help their loved one remember to take their ADHD medication regularly.
Step Five is behavior modification. Cognitive behavioral therapy (CBT) boosts the benefits of ADHD medication for self-control and executive functioning. Outside of formal therapy, there’s a lot family members can do to encourage their loved one to adopt exercise routines and other healthy habits. Often times people with ADHD need to get additional treatment to cut back or eliminate their use of alcohol, tobacco, and marijuana.
Step Six is accommodation. This means altering the environment so the person with ADHD is more likely to succeed. It might mean dedicating one computer for work only and another one for games and social networking. Family members can help their loved one find and download software that blocks distracting content. At home and on the job, adults with ADHD can advocate for themselves by finding support people to keep them accountable for changes they want to make and goals they want to accomplish.
A new type of accommodation that’s becoming more popular is called ADHD coaching. An ADHD coach makes daily contact via text or other channels to help the person stay organized, cope with frustration, and/or work through social problems. The field of ADHD coaching is still developing and is beginning to police itself. Some people are coming to ADHD coaching from financial planning or life coaching and are not currently held to a specific standard of knowledge or experience within psychology or behavior modification. I expect within five years certification requirements and accreditation for ADHD coaching will be in place.
Note: The opinions expressed in this interview are those of the author and should not be taken to represent the official views or policies of the American Psychological Association.