Addressing the Complexities of ADHD in Adults: An Expert Interview With Thomas E. Brown, PhD

Editor's Note:  Recent research and expert opinion points to a new paradigm in our understanding of attention-deficit/hyperactivity disorder (ADHD), particularly in adulthood. In his new book,^[1] renowned authority Thomas E. Brown, PhD, Assistant Clinical Professor of Psychiatry at the Yale University School of Medicine and Associate Director of the Yale Clinic for Attention and Related Disorders, describes 6 key points that will enhance understanding of this complex disorder: (1) ADHD involves the unconscious self-management system of the brain; (2) impairment usually includes chronic difficulties with self-regulation of emotion and regulation by emotion; (3) although symptoms may be present in early childhood, often they do not become apparent until the person encounters the challenges of adolescence or adulthood; (4) ADHD may look like a problem of willpower, but it is actually a disruption in the chemical dynamics of the brain; (5) the cause is primarily genetic, but symptoms can be modified for good or ill by environmental stressors and supports; and (6) ADHD is a foundational problem that substantially increases a person's risk of experiencing additional cognitive, emotional, or behavioral disorders across the lifespan. On behalf of MedscapeCME, Craig Surman, MD, discussed this new paradigm with Dr. Brown just prior to the annual meeting of the American Psychiatric Association.

Dr. Surman: You are teaching a course at the American Psychiatric Association annual meeting entitled, Advanced Assessment and Treatment in ADHD. There is a wealth of topics we could discuss under this umbrella, but I want to begin by asking you where you think we are going in terms of the conceptualization of ADHD. This may be especially timely given the anticipated adult criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

Dr. Brown: We are in the process of shifting our understanding about what this disorder we call ADHD is. I think the big shift is from thinking about it essentially as a behavior disorder. Originally, we thought of ADHD as a problem with little kids who were hyperactive, and, incidentally, they can't pay attention very well. Then we were thinking that this problem persists for some people as they get older, and now we recognize that there are many people who have ADD or ADHD -- I use those terms interchangeably -- who have never had any significant behavior problems. And even for those who have had behavior problems, often those behaviors are the least of it. The difficulty over the longer haul, particularly during the adult years, is far more with problems of attention. What we have begun to recognize more and more in recent years is that this whole notion of inattention symptoms includes a much broader range than the phenotype as defined in the past. ADHD is really best conceptualized as an impairment of executive function, the management system of the brain. This includes not only being able to focus on one thing that you are paying attention to, but also and perhaps more so, the focus that is involved in driving, for example, when you are attending to multiple different stimuli at the same time; you check your rearview mirror, you are looking at what is going on through the windshield, paying attention to the light changing down the street, pedestrians crossing the street to catch the bus, the truck that is backing out of the driveway, and you are needing to sustain focus and shift focus back and forth while using your working memory to keep the whole picture in mind. Executive function includes this kind of focus, this complicated ability to pay attention to many things at once and keep track of them and manage one's self.

Dr. Surman: You are emphasizing self-management conceptually as the key to understanding ADHD. In my practice, working with adults with ADHD, I am struck by the diversity of presentation: not everyone has the same problems. What do you make of that? How straightforward is this diagnosis?

Dr. Brown: It is complicated, but I think when you sit down and do an in-depth clinical interview with a patient, often they can tell you if they are not managing themselves very well, and you are absolutely right, there is a diversity of presentations. When we are dealing with children and adolescents with ADHD, the focus is usually on the difficulties they have in school, although that begins to expand as they get a bit older. But with the adults we see, sometimes the problem has to do with trouble at work, they can't get themselves up in the morning and get to work on time; or they can't manage their priorities and they procrastinate on some tasks and get stuck on others, spending too much time on them; or in meetings, they are unable to recall what has just been said, they tend to drift off a lot; or they have a lot of trouble organizing themselves to be able to prepare reports and so forth. So for some people, the problems have to do with their jobs, whereas others may be pretty effective at managing themselves within the structure of the job, where they are working with other people and things are being kept organized by the structure of the environment, but their difficulties are much more related to how they drive their car or how they manage their money, how they carry on relationships with important people in their lives, a spouse or a dating partner or their children. I have seen a number of people who have been really quite successful, even CEO-level folks in businesses, who are able to manage quite well because they have structure and support provided by the work environment. For example, some business executives employ 1 or 2 secretaries or administrative assistants who can help them keep track of meetings, appointments, proposals, and so forth when they are in the office, and yet their lives outside the office might be a mess.

Dr. Surman: What questions do you ask adults, including young adults when they present that help you determine whether they have a self-management problem?

Dr. Brown: The first question is usually, "How did you decide to come see me? What are the concerns that bring you here for this evaluation?" I think it is important to ask not only about what the patient is having trouble with, but also what is going well, so that one can appreciate the strengths of the patient and not simply their limitations, and also to get some sense of the variability in their performance and what they are able to do well. One thing I have learned to ask all of the patients I see with ADHD is: "What are the things on which you can focus very well?"

The biggest problem most people have in understanding ADHD is that every patient, at least every child or adult patient with ADHD I have ever seen, has a few domains of activity in which they are able to focus very well. Maybe it is a sport that they really get turned on to, or it might be working on the computer, or taking car engines apart and putting them back together, or it may be creating art. Every patient I have ever seen who has ADHD can tell me about one or several different domains of activity in which they are able to function perfectly well and don't have trouble paying attention, don't have trouble remembering what is going on.

Dr. Surman: Yet they will have impairments in other domains.

Dr. Brown: They will have massive difficulties in other areas of their lives, and they and others have often looked at that situation and asked the question, "If you can do it here, if you can focus here, why can't you do it here, here, and here, in these other domains?" Typically, if you ask patients why is it that you can focus so well in this and this, and still have so much trouble focusing elsewhere, what they will say is that either it is something that I am really interested in, or it is a situation where I feel I have a gun to my head. Either it is something that they have a strong personal interest in, not because someone else tells them they should have it, but because they just do, or they have a strong sense, from their own perception, not because of someone else forecasting, that if they don't take care of this right now something very unpleasant is going to happen very quickly. What many people don't realize is that although this may look like a problem of willpower, it is not. It results from the chemistry of the brain changing instantly when we are faced with something that really interests us or with something that scares us.

Dr. Surman: What other questions are important to ask someone who presents with generalized distress and problems that would help you detect that they have trouble with self-management? We use rating scales in ADHD, but I am asking more about the broader strokes of life that you try to address.

Dr. Brown: I always want to find out what has been going on in the person's life over the last 6 to 12 months because this provides some sense of whether something has changed, for good or ill, in the support system or the challenges he or she is facing. I have found that many adults have managed to get along reasonably well up until a certain point when something changes, for example, they have been promoted at work and have new responsibilities. I am thinking of a very fine intensive care unit nurse who had no trouble at all focusing when she was taking care of 2 or 3 patients in the ICU. Then she was promoted to manager of her unit, and things started to fall apart very quickly because now she not only had to deal with the immediacy of these patients, but she also had to deal with arranging coverage and changes in schedule, she had to attend meetings, plan budgets, order supplies, and so forth. The additional administrative management tasks stressed out her system in a way that made it impossible for her to really manage. I have found that some parents may function reasonably well with 1 child to take care of, but suddenly when they have a second child, that is enough to push things over the edge. Or, I recall a business executive who had an amazingly good administrative assistant who kept him organized and edited his correspondence and reminded him of what needed to be done. When she left the job, he was just totally lost.

So those environmental supports and the challenges of the environment that confront the person can make a huge difference in the degree to which their ADHD is impairing or not. If someone else takes care of some of your tasks or helps you take care of the things you have trouble with, when you lose that support or are promoted to new responsibilities or are somehow put in a situation where there are now more challenges, then suddenly you may see stresses in the system.

Dr. Surman: I am always struck that modulating brain chemistry with stimulants or nonstimulants that work for ADHD allows people to function behaviorally in a way that is perhaps better for them, but there are often areas that still cause them a lot of difficulty. If you think in terms of executive function domains, it is almost as if there are different subtypes of executive function, and some don't seem to improve even when the patient has better focus.

Dr. Brown: That varies from one person to another in terms of which medicines they will respond to and also which aspects of their ADHD do and don't respond to medication. That is why it is so important to take a look at not just the symptom list, but also the environment, the demands people are facing in their work environment, their home environment, and their overall life. This would include how they function socially, because a lot of folks with ADHD get along very well socially, but many others struggle with social interactions; they have difficulty carrying their end of the relationship in a way that makes it a reciprocal and mutually satisfying connection. So sometimes it is also a matter of learning certain skills.

Many times when we have adults coming in for an initial evaluation, they have this basic complaint: "I can't remember what I have just read," or "I can't keep track of what is going on in a business meeting," and so we try to find a medication that will work and get the dosing right, remembering that the amount of stimulant a person needs has nothing to do with how old they are or how much they weigh or how severe the symptoms are. Dosing is a matter of how sensitive an individual's body is to a medication. But we also need to take a look at the demands they face in terms of different time frames in the day. A significant number of patients that I see need coverage not only during their work day, but also through the late afternoon and early evening when they are dealing with social or parenting issues, or household management tasks, or driving. I have learned to ask about what is happening at different times of the day and to what extent the problems with the ADHD seem to be getting in the way or not.

Dr. Surman: Are there particular modalities that you think are more ADHD friendly, to help people overhaul their environments? Having a child who can get accommodations in school is quite different from an adult in a workplace.

Dr. Brown: Accommodations for adults in a workplace are not easy to come by, and many employers do not like to be asked to make accommodations or change people's work schedules or office location and so forth. The Americans With Disabilities Act provides some support for that, but many of the patients I've seen who have asked for it have found that it is complicated and that some employers will try to comply but will get frustrated pretty quickly and then find ways of making life more difficult for the employee who is asking for accommodations that may seem burdensome to the employer.

Dr. Surman: You mentioned that you ask your patients, "What can you do well?" I have been struck that although some patients gravitate toward jobs that match the answer to that question, a good proportion of them don't.

Dr. Brown: I agree. Sometimes people are in jobs that simply don't work for them, but it is also true that many times people will think about what they would like to do. However, particularly in today's economy, it is not just about what you would like to do, it is also about what is available that you can get paid for, thinking of ways you can make things work within the system and realistic alternatives that you might be able to function better at. That is something that takes a lot of inquiry, but it is also a matter for many people of lifestyle. For example, one of the areas I have found to be really important to talk with patients about is their sleep. A lot of folks with ADHD seem to have enormous difficulty shutting their heads off so they can get to sleep at a reasonable time. Many, once they fall asleep, sleep like the dead and have a hard time resurrecting themselves in the morning. Some are then running late all day or running on empty in terms of energy level, and they get drowsy if they have to sit still to listen or read or do paperwork. So I try to get some sense of how sleep is going, which is often tied to issues of exercise.

Dr. Surman: And comorbidity.

Dr. Brown: Absolutely. One of the most problematic aspects of ADHD diagnosis is that many psychiatrists and psychologists who evaluate these patients are used to looking for depression or anxiety symptoms, or obsessive compulsive disorder (OCD) or substance abuse, any of which is likely to be found in a person with ADHD. We have good evidence that an adult with ADHD is 6 times more likely to have at least 1 other psychiatric disorder at some point in his or her life,^[2] so what often happens is that the initial presentation may be such that one of these other disorders is diagnosed and the ADHD is overlooked. Russ Barkley and I published an article in November 2008 on unrecognized ADHD in adults who present with other psychiatric disorders.^[3] Sometimes the problem is that the comorbidity is recognized as the primary diagnosis and there is no recognition of the ADHD because people stop looking after they think they have found the problem. For others, the diagnostician finds the ADHD but doesn't look for what else might be going on.

A simple example of that would be a patient that I saw not long ago who had been seen for evaluation of ADHD by another clinician and had been put on medicine for ADHD, but he was involved in a near fatal motor vehicle accident, which was in large part the result of him being sleepy. As he was driving, he fell asleep at the wheel. It just happened that the medicine was wearing off and he was having that rebound fatigue that often happens with stimulants, but the bigger problem that hadn't been looked at when they did the inquiry for the initial evaluation was that they didn't ask about sleep and they didn't ask about snoring.

It turned out that this guy had a pretty severe obstructive sleep apnea, and the medication he was taking for ADHD was helping him during those hours when the medication was active, but when it wore off, he crashed, and the underlying fatigue, which came from the obstructive sleep apnea, really clobbered him and he was unable to drive safely.

Dr. Surman: That case serves as a clear reminder that thorough evaluation of ADHD in adults includes ruling out other disorders in the differential diagnosis.

Dr. Brown: Exactly. One needs to check out issues around sleep. One needs to check on substance abuse, because a lot of the adults we see are drinking quite a bit, or smoking quite a bit of marijuana, or sometimes taking combinations of prescription drugs. Several doctors may be prescribing, and none of them knows what other medicines have been prescribed. Then, of course, in terms of comorbidity, one needs to screen for depression, anxiety, and OCD.

Dr. Surman: How do you teach clinicians about ADHD and the long-term process of helping a complex patient who presents with multiple conditions but also has an underlying lifelong history of self-management problems? Are there particular things that you recommend they do in their longer-term management of these patients?

Dr. Brown: The first thing I emphasize is to maintain contact with patients. We see a large number of patients for an initial evaluation and then maybe once or twice for follow-up to get medication stabilized, and then that is the end of it. Every time I see a patient, I will speak with him or her to reach an agreement about how soon we should meet again, and then I encourage them to make the appointment right then, when they're still in my office. I will have my staff call to remind them about the appointment because I find that if we don't call and remind people with ADHD about appointments, particularly when the appointments have been made weeks or a month or more ahead, they just don't show.

Encouraging patients to maintain follow-up contact is important, as is asking questions about what is going well and what is not going well. When we discuss longer-term management in my courses, I try to emphasize the unfolding process of diagnosis; that very often it is not possible to get a good clear diagnostic picture in just 1 or 2 initial sessions. Often, patients withhold information because they are embarrassed or ashamed about symptoms or difficulties they have, or there is not enough time to inquire about all of the different possibilities. The patients' life situations may change, or you alleviate one set of symptoms with treatment and then some other symptoms become apparent.

When people change jobs, when their child moves away from home, when they are dealing with the pressures of an aging or ill parent, or when they are faced with furloughs or cutbacks in their income, all these events are stressors. These stressors often affect people with ADHD in ways that allow you to see facets of their vulnerability, and of their strengths, that had not been clear before.

The role of emotional management in adults with ADHD is something the DSM IV criteria don't touch, but most of us who are clinicians and researchers who deal with adults with ADHD repeatedly encounter patients who have difficulty managing their emotions. For many persons with ADHD, when an emotion hits them, whether it is worry, or they are annoyed about something, or their feelings are hurt, or they begin to feel like they want something very badly, or they are just discouraged about things, that emotion often hits them in the same way a computer virus invades a hard drive: it just gobbles up all of the space inside them, it takes over, and it is really difficult for these patients to put the emotion into perspective and to put it to the back of their minds and get on with what they have to do.

Some of these patients are affected by bottom-up problems in the sense that they are very quick to get angry, very quick to worry, or very quick to get discouraged, and much of that is basically a temperamental body chemistry. But the other side of the coin, is the top-down regulation, which is an aspect of executive function. Many persons with ADHD have great difficulty managing these emotions. These are aspects of emotional intelligence, being able to read one's own feelings and the feelings of others, then being able to modulate and deal with those emotions, and also using them to guide one's actions. That is a domain that is not included in the DSM IV criteria. I don't know whether it will be picked up in DSM V, but the clinical reality is that this is an important domain of difficulty for a lot of folks with ADHD, particularly adults.

Dr. Surman: So, self-management challenges go beyond just behavioral function, as you said at the beginning of the interview. And these may include challenges in areas of people's vulnerabilities, whether it is emotional understanding or learning style issues. The diversity of presentations by adults with ADHD makes working with this population very engaging.

Dr. Brown: Absolutely. The diversity of presentation overlaps with so many other things -- for example, with reading. Most of the patients I see with ADHD will say to me, "You know, when I read, I have a lot of trouble remembering what I have read unless it is something that I am really, really interested in. I can read a report or an article or a textbook and understand the words perfectly well at the moment I am reading them, but then I get to the end of the article or the end of the chapter and realize that my eyes have gone over every word, I understood it all at the moment I read it, but I don't have the foggiest idea of what I just read."

One of my patients, a university student, described it like this: He said, "When I am reading something that is not really turning me on, it is as though I am licking the words and not chewing them. I am going over them, but I am not really digesting them in a way that I can then pull them back out of my memory." A recent article by Ben and Sally Shaywitz in the Journal of the Developmental Psychopathology^[4] talked about paying careful attention to reading. They contend that the phonological processing, which has been a big emphasis in the study of dyslexia, is only one piece of the problem of reading. When you begin to look at comprehension and fluency in reading, the attentional processes are primary. They even suggest that some dyslexic patients might benefit from treatment with the ADHD medications to help to improve working memory and their ability to focus and retain what they have read. I think that the whole issue of reading is another area that has not been adequately addressed by a lot of the research that has been done on ADHD, but it is a big one, not just for students, and certainly for high school and university students, but also for many professionals and business people.

Dr. Surman: Those themes bring our conversation back to the importance of attention dyscontrol in adults with ADHD -- at the core of most behavioral problems that adults with ADHD experience is a problem with self-regulation or self-management.

Dr. Brown: Exactly. Many times you talk about self-management or self-control, and people think that means you can't sit still during a meeting or refrain from telling your boss where to go when that boss says something that annoys you.

Dr. Surman: Medications help adults with ADHD control their attention, but they often also facilitate compensatory approaches that adults with ADHD and comorbid cognitive challenges need to function well -- I certainly see this in patients with learning disabilities like dyslexia, as you mentioned, but also frequently in individuals with interpersonal social challenges.

Dr. Brown: Exactly. The pills we have work on some aspects of ADHD, but they don't teach skills. They can make people more available to learn, but many of the patients we see have difficulty with those social cues. There is a wide range of people who have a lot of difficulty with getting along with other people because they are not paying enough attention or don't know quite what to make of nonverbal signals or between-the-lines messages that people need to respond to what is going on.

Dr. Surman: I want to thank you, Dr. Brown, for the remarkable contribution that you have made to helping understand ADHD, and for talking with me today. Readers who are interested in our themes today may want to look at one of your several publications; I know they have been helpful for my work.

This activity is supported by an independent educational grant from Shire.