Undiagnosed ADHD symptoms in adults can lead to chronic anxiety and low self-esteem.

Terry Matlen was diagnosed with ADHD in her forties. Matlen stated, “My whole life was off.” It included anxiety, academic and behavioral problems that began early. Matlen initially resisted her diagnosis and even sought out a second opinion. However, she eventually accepted that she had ADHD.

This makes sense. Matlen explained, “I can’t focus; I’m unable to finish projects; the mess in my home is out of control; and I’m unable to get dinner on a table.” “Anxiety does not explain the extent to which I am disorganized.”

Matlen’s ADHD was diagnosed in the mid-1990s when many experts still did not understand how ADHD manifested in girls and adults. Matlen did not look like a stereotypical little boy with ADHD who could never sit still. She struggled with many symptoms, including the inability to pay attention or be organized in class. However, no one realized that she had undiagnosed ADHD.

ADHD has three subtypes: hyperactive-impulsive, primarily inattentive, and combined. The inattentive type is characterized by internal restlessness. Peter Jaksa, Ph.D., a psychiatrist who treats ADHD, said that many kids with inattentive ADHD are overlooked. For example, many children with inattentive ADHD daydream in class instead of paying attention. Since they’re not disruptive, it is easy to manage their symptoms.

ADHD is more commonly diagnosed and treated among males due to the differences in symptoms (Skogli E.W. et al., BMC Psychiatry Vol. 13, 2013). Untreated ADHD can adversely affect academic performance over the long term (Arnold L. E. et al. Journal of Attention Disorders Vol. 24, No. 1, 2015). Several studies have shown that people with untreated ADHD do worse than people with ADHD treated or without ADHD (Harpin V. et al. Journal of Attention Disorders Vol. 20, No. 4, 2013).

Adults can be diagnosed using a variety of methods.

ADHD symptoms must have appeared before age 12. Diagnoses for adults are more difficult because they require a timeline to determine when the symptoms began. Jaksa says that, besides speaking with his patient about their symptoms, it is helpful to review old report cards. Comments such as, “Struggles to pay attention at school,” “Often forgets homework at home,” or “Isn’t Living Up to Potential” can give him an idea of when the symptoms first appeared.

He said, “We need to examine a longer history.” The best indicator of ADHD isn’t test scores but rather history. Jaksa uses a structured interview better to understand their academic, social, and emotional history. For example, he will interview a family member with a unique perspective on their child’s behavior.

Jaksa stated that adults often have comorbidities such as depression and anxiety. Untreated ADHD can cause or worsen these comorbidities. When ADHD isn’t diagnosed, when it’s not effectively treated, chronic stress and frustration can lead to anxiety over time,” Jaksa explained. This hurts your self-esteem. This is a common problem for adults with ADHD. They often grow up feeling like they are not doing enough.

Some patients may show signs immediately, such as delay or forgetting necessary personal items. Others might fidget in the waiting area. While no single symptom is definitive, the sum of all signs can give a good idea of how the symptoms appear, the duration of the symptoms, and the level of functional impairment. Lisa Green, a 40-year-old oncology nurse diagnosed with ADHD, said her mind constantly shifted.

A family history of ADHD is also helpful in diagnosing the disorder since it is highly heritable. Matlen began seeking a diagnosis for the younger daughter when she discovered that she also had the disease. It’s well-established that ADHD is 70% to 80% genetic, according to Eugene Arnold. He is a professor at The Ohio State University specializing in ADHD research.

Diagnoses can be complex.

The presence of other comorbidities in adults can make diagnosing them difficult. Some of these comorbidities may mimic ADHD symptoms. These comorbidities may be due to another disorder or caused by ADHD. Matlen is one of many people with ADHD who can develop mood disorders like anxiety and depression due to the lack of treatment. Treatment for comorbidities can be ineffective if the underlying ADHD has not been diagnosed and treated. Ginsberg, Y. et al. Primary Care Companion CNS Disorders Vol. 16, No. 3, 2014). Matlen stated, “my anxiety is triggered by my being disorganized, unprepared, and constantly overwhelmed.”

ADHD and autism spectrum disorders (ASD) share some similarities. Arnold stated that “about half of those with autism have ADHD.” The reverse is also true, with a smaller proportion of those with ASD having ADHD.

Jon Stevens, MD, a Houston-based psychiatrist, compares the onset symptoms to layers on an onion. The first layer is developmental disorders like autism. The second layer is ADHD, and the symptoms of this disorder can be seen quite early. Next, mood disorders such as anxiety or depression can appear as early as high school. The outermost layer is schizophrenia or bipolar disorder. These disorders tend to occur during college or later.

Stevens stated, “These conditions develop from the inside out.” The earliest symptoms of developmental disorders, such as autism, are those that show up first. ADHD symptoms appear a bit later. Parents will notice some of the more apparent symptoms early, like hyperactivity. Other symptoms, like inattentiveness, will become more evident once children begin school.

A significant difference is also the persistence of symptoms. Will Canu, Ph.D., professor of psychology at Appalachian State University, said that anxiety and depression are more situational, and their symptoms tend to be more cyclic. ADHD is a disorder that has symptoms all the time, but it can become worse under certain circumstances, like stress, anxiety, or depression.

COVID-19 and Adult ADHD

COVID-19 was tough on people with ADHD due to the disruption of routine. Routines can be important for those with ADHD as they help with executive function issues such as staying organized or on track. But developing and maintaining habits can be difficult, making managing significant changes at work and home more challenging.

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Stevens has observed patients in his clinical practice cope with the pandemic’s stress through various methods. Adults who were receiving treatment found that working from home was beneficial. He said that as long as they continued to take their medications, they would do well. Many of my patients find working from home more practical, as there are fewer distractions like water cooler chatter and people coming into your cubicle.

Canu stated that the constant upheaval combined with disruptions in childcare created challenging circumstances for women with undiagnosed ADHD and their young children. Likewise, parents with young children have faced several challenges, including significant disruptions to their routines and the unpredictable closures of schools and daycares.

Diagnostic and treatment are advantageous.

Diagnoses can change the lives of many patients not diagnosed in their youth. For example, researchers compared 444 adults diagnosed with ADHD to 1,055 adults with symptoms but no formal diagnosis in a study conducted in 2020. After matching age and gender, adults with diagnosed ADHD reported a better quality of life. This included work productivity, self-esteem, and functional performance (Pawaskar M. et al. Journal of Attention Disorders Vol. 24, No. 1, 2020).

Canu says that being diagnosed can help people better understand themselves, including gaining perspective about the reasons behind some of their struggles. In addition, Canu says a diagnosis can help people feel better about themselves.

Working with an expert, such as a psychiatrist with experience treating ADHD patients, can be very helpful. Cognitive behavioral therapy is one of the most effective treatments for ADHD. It focuses on executive functioning issues such as time management and organizational skills. Impulse control, emotional self-regulation, and impulse control are also addressed.

Medication can be used to manage symptoms when necessary. Psychologists who don’t have prescribing rights can work with primary care providers, psychiatrists, or integrated care teams. Many patients find that the most effective treatment combines behavioral strategies and medications. Canu explained that if the treatment is effective, patients can perform better.

In a study conducted in 2014, 250 adults who had never been medicated before were given the ADHD medication methylphenidate for the first. Those who could not tolerate it or did not experience symptom relief switched to an alternative stimulant or the non-stimulant atomoxetine. Compared with their peers who discontinued medication, those who were still on medication had reduced the severity of symptoms (Fredriksen, M. et al., European Neuropsychopharmacology, Vol. 24, No. 12, 2014). Green stated, “Medication allows me to think and breathe.”

Dealing with the late-life diagnosis

When you receive a diagnosis in adulthood, it can bring up a variety of emotions. You may feel grief for lost opportunities, relief that you finally understand specific struggles, or anger at having ignored symptoms for so long. Instead, Matlen felt a sense of overwhelming relief. She said, “There was a concrete explanation.”

Others may regret missed opportunities due to their ADHD symptoms being ignored and untreated. This could be because they failed out of school or struggled to establish a successful career. Matlen explained that there is a great deal of grief to work through years of struggle and not knowing why. In her experience, however, “once all those pieces and parts are looked at in this new understanding people really take off in a positive way,” said Matlen. In addition, therapy is often a key component to thriving following a diagnosis.