Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

Anesthesiologist Maire Daugharty, who expanded her expertise by earning a master’s degree in clinical mental health counseling, discusses her article “Why ADHD isn’t just a childhood disorder and what that means for adults.” Maire discusses the critical importance of timely diagnosis and treatment of ADHD, highlighting its negative impacts on self-esteem, mood disorders, substance use, and even criminality when left unaddressed. She clarifies that ADHD is not solely a childhood disorder, with many adults having missed diagnoses, particularly girls due to different symptom presentations. Maire delves into the predominantly genetic nature of ADHD and discusses factors contributing to its complexity and the reluctance to treat it. She emphasizes that accurate diagnosis requires a careful history and medical examination beyond assessment scales, and outlines multi-modal treatment approaches, including psychoeducation, behavioral therapy, and medication. Maire also discusses the core role of executive function deficits in ADHD and offers practical strategies for environmental modification and task management that benefit both children and adults.

Our presenting sponsor is Microsoft Dragon Copilot.

Microsoft Dragon Copilot, your AI assistant for clinical workflow, is transforming how clinicians work. Now you can streamline and customize documentation, surface information right at the point of care, and automate tasks with just a click.

Part of Microsoft Cloud for Healthcare, Dragon Copilot offers an extensible AI workspace and a single, integrated platform to help unlock new levels of efficiency. Plus, it’s backed by a proven track record and decades of clinical expertise—and it’s built on a foundation of trust.

It’s time to ease your administrative burdens and stay focused on what matters most with Dragon Copilot, your AI assistant for clinical workflow.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Maire Daugharty. She is an anesthesiologist and counselor. Today’s KevinMD article is “Why ADHD isn’t just a childhood disorder and what that means for adults.” Maire, welcome back to the show.

Maire Daugharty: Thank you.

Kevin Pho: All right, so tell us what your latest article is about.

Maire Daugharty: So, my latest article is about ADHD, and it was a response to an article written in the New York Times fairly recently, within the last handful of weeks, a month or so ago. And I read that article with great interest. I was really excited to see information about ADHD in the general public, which is so needed.

As I read the article, I initially was excited and then became more and more dismayed as I made my way through it because there was just so much misinformation and cherry-picking about the robust data that is available about ADHD. And I really spent quite a bit of time thinking about why there still is a controversy around ADHD, why somebody who’s written in the developmental arena for twenty years would perceive things the way that he does, which clearly guided the data that he chose to focus on in this article. And rereading it a couple of days or so ago, just thinking about all of those issues, he came through the back door full circle saying, well, ADHD as a diagnosis is stigmatizing, and maybe we’re thinking about it all wrong.

Maybe it’s just a difference in the brain that we have to accommodate in people who have ADHD. And he’s not wrong about that. There is a stigma associated with mental health diagnoses in the United States. It’s robust. It’s pervasive. I face it continually with the people that I work with in talking about how they want to navigate things.

It is a true fact, so that is a reality. However, having said that, just because there is a stigma doesn’t mean we say we’re just going to ignore all this data and pretend like this is a simple difference that we can make a change with in association with the environment. It is true that a mismatch between a person and the environment is really problematic for everybody, and particularly with people who have ADHD who spend a lifetime figuring out how their particular differences work in the world, what works for them, and what allows them to thrive as adults in our contemporary society.

And so while I would agree that there is a stigma, there is also very robust data supporting the diagnosis of ADHD. It is not controversial in the world of people who understand that data. It is not controversial in the world of people who have ADHD and struggle with those differences in their brain in multiple environments on a daily basis.

So what I thought I would do with my article is talk a little bit about what it means to have ADHD and address some of the data that he opted not to mention in the article that he wrote for the New York Times.

Kevin Pho: So in talking about that, and for those who did not read that New York Times article, just give us the key points that you had contention with.

Maire Daugharty: Yeah. So, the first thing that really struck me was, we take a child whose behavior is actually normal but annoying, and we make that into a diagnosis. Well, that is a common thing to hear a layperson say who doesn’t understand the data, who doesn’t understand psychiatric diagnoses. It isn’t that you bring your child in and say, little Joey is so active. He drives everybody nuts. What can we do about this? We’ll medicate him and calm him down and make life easier for everybody around him. That’s not actually how it works. There is a robust process to identify ADHD as a diagnosis as compared to any other number of diagnostic possibilities, including, is the environment wrong for this child?

Are there some trauma circumstances happening that are contributing to his behavior? You have to tease all of those things out. Sometimes you tease all of those things out and the child has ADHD, and fortunately, there are robust, effective treatments for ADHD. The second issue I took with his perspective is he talked about medication as not making people able to perform better.

He pulled out some studies which showed, you give a child a stimulant and they quietly sit in their chair and work on their work, but they don’t get smarter. Well, that’s a misperception of what the medication is for. The medication doesn’t make anybody smarter; it’s not magic. It actually allows the child to sit and focus on the work in front of them rather than being distracted by everything around them at all times.

And one of the most poignant things you will hear an adult say, who has an adult diagnosis and who starts stimulants as an adult is, “Oh my God, this is the first time I’ve ever been able to tune out all that noise and actually concentrate on the work in front of me. I’ve never been able to do that.” You can imagine moving through life where your brain does not distinguish between relevant input and irrelevant input with an ability to put that aside, put it in the background, or tune it out what a chaotic daily experience people with ADHD have. That misunderstanding of how the medication is meant to be used is really problematic. The other thing he talked about is outcomes: thirty-six months from now, children on stimulants are not in fact doing better.

The reality is there is robust data that supports the difference between somebody who’s diagnosed and treated in childhood and somebody who is not. The difference is the quality of life that that person has: their ability to get through school, their ability to have an intimate, sustainable relationship, their ability to engage in a profession that’s meaningful, that they enjoy, that they feel good about. People who aren’t diagnosed and aren’t treated have a higher incidence of suicidality, failed relationships, inability to get through college, and criminality.

They have a very different life path. You hear that in people who are diagnosed in childhood versus people who come in as adults and say, “I’ve struggled with this problem my whole life. I don’t really know what it is. Can we talk about it?” When they ultimately get a diagnosis of ADHD, there’s a tremendous experience of first relief. “Now I understand why I felt so different. Now I understand why I’ve struggled so much with this and felt so bad about this, and laid awake at night worrying, feeling terrified about what am I going to forget for the next day that everyone else doesn’t seem to forget.” That moves into a process of grief, recognizing that their whole life could have been different if they’d been diagnosed and treated at an earlier age.

That has an enormous impact on people. So I think it’s really important to understand that ADHD is a diagnosis. It’s robustly supported by the data. It is not a simple diagnosis; you’re teasing out a lot of different contributing factors to people’s particular circumstances. And while he does state that there’s an overdiagnosis and overmedication, and I agree there probably is some overdiagnosis—the pill mills that came out and offered an online interview for thirty minutes and said, “You have ADHD, here’s your stimulant medicine”—that clearly is not an appropriate approach to diagnosing ADHD. Clearly, there are adults running around thinking they have ADHD when they do not because they haven’t been appropriately worked up.

So while he addressed some of the issues, he addressed them in such a way that he really shared more misinformation than information in the end.

Kevin Pho: So this is the New York Times, so I assume there’s a fair amount of fact-checking. Why do you think that those misperceptions or misconceptions were included there? Does this article represent a sphere of thought within the ADHD community?

Maire Daugharty: Oh, absolutely. There’s a sphere of thought in the ADHD community that is supported by some of this. There is a real discussion between, do I have a disorder because my brain works differently, or does my brain work differently and it’s not a disorder? That is an ongoing discussion, absolutely. Thinking about my brain as functioning differently and I have to do things differently or find my way forward in a little bit of a different way is an absolutely legitimate approach.

But I think we have to be very careful to recognize that there is still a diagnostic criteria that describes what it is that you’re experiencing, regardless of how you choose to perceive or conceptualize it. Yes, there’s a lot of fact-checking in journalism and in particularly the New York Times, which I read on a daily basis.

I think in this instance what we see is the distinction between a scientist who understands how to approach data and somebody who doesn’t. If you’re going to approach this with a preconceived notion that this is controversial and you want to change the idea, you’re going to cherry-pick the articles that are going to support the idea that you want to put forward, versus looking at the data and seeing what it shows.

And so none of what he described… he used data, he used scientists, he used information, but the problem is he used it in a very constricted way, in the context of the robust data that’s available. So he ultimately ended up propagating misinformation, in my opinion, and in the opinion of people who work with ADHD.

Kevin Pho: And these days, you could always find data and studies that support a preconceived point of view, right?

Maire Daugharty: Absolutely. Absolutely. The difference is being able to understand good data versus bad data, and some data versus more data is really important to bring to the table when you’re going to draw conclusions and then share them with the public.

Kevin Pho: So talk about the unique factors when it comes to ADHD in adults. As you know, I’m an internal medicine physician. I only see adults in a primary care setting, so this is something that I’m going to routinely see. So tell me about some of the things that I need to look for and some of the unique factors that I need to consider when it comes to ADHD.

Maire Daugharty: Yeah. So when I was reading this article, one of the things that really occurred to me was the experience of an adult who has ADHD, and it is delineated in the DSM: you fulfill the criteria with six of the inattentive symptoms or six of the hyperactive symptoms from a particular period, from a particular age, in multiple environments that lead to distress and/or impairment.

A lot of mental health diagnoses are really made on a continuum. We’ve all had symptoms of anxiety. We’ve all had times where we’ve felt depressed. How do we distinguish between depression as a diagnosis and a limited experience? Well, that’s what the DSM is for, right? It has to rise to the occasion of a diagnosis.

So when an adult comes in and they’ve filled out a screening test which says, “I have four out of the six. I may have ADHD. What do you think?” You have to realize a lot of adults will fill that out and say, “I have four of the six, and I think I have ADHD.” So what you’re doing is you’re pulling out their subjective experience and trying to understand it.

Is this a result of how I learned to move through the world because of childhood trauma? Is this a result of a substance use disorder that I haven’t shared with my physician? Is this a result of any number of other different possibilities? So when I’m assessing somebody for ADHD, I may be asking them specific questions, but I’m very careful not to ask leading questions.

I don’t say, “Do you have trouble focusing on work? Did you have trouble focusing on homework as a student?” Instead, I’ll ask open-ended questions and listen for red flags. “What was school like for you as a kid? How did your teachers discuss you? What was life like for you at home?”

I’m listening for, “Oh my God. My mother was always so irritated with me because I always left my jacket on the bus.” My teachers always said, “Man, she is so smart, if only she’d bother to turn her homework in.” Things like that are pretty classic ADHD symptoms throughout the course of a lifetime.

So I’m listening for those. I’m listening for consistency. Was this a problem for a certain number of years and then all of a sudden it resolved because it wasn’t really ADHD, it was the environment? Or is it a consistent experience? “I just can’t seem to remember things that other people remember.”

So, impairment in working memory. “I just can’t seem to keep track of the appointments that I have. I’ll write myself a note and then I’ll get involved in something, get totally engaged, and completely forget about it. So frustrating.” You’re listening for those experiences that somebody with ADHD has consistently over time in multiple environments.

So I’m interested in their childhood experiences, their home life, their school life, their social life, and then their more adult experiences.

Kevin Pho: So one of the things that you wrote in your article is that a lot of these adult individuals have coping skills that allow them to function well without that formal diagnosis.

Maire Daugharty: Yeah.

Kevin Pho: So tell us some examples of these coping strategies and what are some of the dangers of just relying on coping strategies without a formal ADHD diagnosis?

Maire Daugharty: Yeah. One of the questions I see frequently is, “Well, for example, my spouse got through medical school and is successful in their profession, how could they possibly have ADHD?”

The reality is, first of all, ADHD exists on a spectrum ranging from mild to moderate to severe. So perhaps somebody has mild ADHD. The other thing is people do develop robust coping strategies. They’re able to do incredible things despite the differences in their brain. Does that mean that they wouldn’t benefit from treatment, where all of a sudden all of that energy going to trying to keep it together in these environments can be used for something else because with a stimulant on board, they don’t have to use those coping skills?

The other thing that’s really important is people who develop coping skills and are able to get through it still wonder about themselves. “Why is it that this is so much harder for me?” And then they develop self-esteem issues around that.

“My compatriots have no issue doing this at all. I can do it, but man, it means I have to study sixteen hours a day and I don’t go out with my friends and I don’t really socialize much because I’m so focused on trying to do well in this arena.” So there’s a big cost that comes with relying on coping skills only, particularly if somebody has more moderate, more severe ADHD compared to a milder version. One thing I do tell people who are trying to decide, “Do I really want to know if I have ADHD or not?” is you don’t have to treat it. You don’t have to take stimulants. You can do what you want with the information, but it might be helpful to understand why it is that you feel so different.

It may just be having the information that ultimately ends up being very helpful for you.

Kevin Pho: We’re talking to Maire Daugharty. She is an anesthesiologist and counselor. Today’s KevinMD article is “Why ADHD isn’t just a childhood disorder and what that means for adults.” Maire, let’s end with some take-home messages you want to leave with the KevinMD audience.

Maire Daugharty: Oh gosh, yes. So I always encourage people to seek professional help if they think that they need it. I think there is a stigma associated with mental health, so I always find myself leaning into that message. There is so much to be gained by understanding yourself a little bit more deeply.

Kevin Pho: Maire, thank you so much again for sharing your perspective and insight. Thanks again for coming back on the show.

Maire Daugharty: Thanks very much. I really appreciate it.