Dana G. Smith
Elizabeth’s two sons, ages eight and 10, have both been diagnosed with attention deficit hyperactivity disorder. So have Elizabeth, 37, and her husband, 41.
To manage it all, Elizabeth and her husband have implemented an elaborate system of medications and to-do lists. There are whiteboards all over their Southern California home to help with task management and communication.
“I joke that our house is half house, half classroom, half occupational therapist office,” Elizabeth says. (She asked to use only her middle name when discussing her family’s medical conditions.)
Elizabeth was diagnosed with ADHD two years ago, after recognising some of her sons’ symptoms in her current – and younger – self. “I didn’t know that the reason that it took me five hours to do my homework every night wasn’t because I wasn’t smart or because I didn’t try hard enough,” she says. “It’s because my brain was working against me.”
Now, with help from her systems and from medication, Elizabeth has learnt to manage her symptoms and has advanced in her career as an environmental health and safety manager. “I went from bouncing around between random jobs,” she says, to being able to “focus well enough to have some direction.”
But despite her own success, Elizabeth still worries about how her sons’ ADHD will affect them as they get older. “As a parent, my job is to teach them how to be a human, how to function in today’s world,” she says. “And they have a harder time than most because their brains don’t work the way most people’s brains work.”
Back-to-school season, with its executive-functioning demands and deadlines, can make these types of parental worries even more stark.
ADHD is a tricky condition to diagnose, study and track over a person’s life. It can present very differently in different people, and there are a wide range of symptoms, which exist on a spectrum from mild to severe. ADHD also often overlaps with other mental health, developmental and behavioral disorders, including anxiety, autism and oppositional defiant disorder. (With rising rates in children and adults, some psychiatrists worry the condition is now being overdiagnosed.)
It’s also not clear what percentage of children continue to have ADHD as adults. One frequently cited number is about 50 per cent, with symptoms more likely to persist in adults who had more severe ADHD in childhood and more overlapping conditions.
But according to a 2021 longitudinal study that followed children with ADHD for 16 years, only about 10 per cent experienced “sustained remission” into young adulthood. Another 10 per cent had ADHD for the entire time, and for the vast majority, symptoms waxed and waned. Notably, the study found that at any given time, roughly half the participants met the diagnosis for ADHD, but which people fell into which camp kept changing.
While much about ADHD is still up in the air, what has become clear is that it is not a static condition, and the types of symptoms people have, and how they affect their day-to-day lives, can evolve over time.
How symptoms change
There are two main categories of ADHD symptoms: inattentive and hyperactive-impulsive. To be diagnosed with ADHD, a child must meet six or more symptoms from one category or the other; people 17 and older need five or more. If someone meets the symptom requirements in both categories, they are diagnosed as having combined ADHD.
Inattentive symptoms include things like poor attention to detail, not finishing tasks, messiness and forgetfulness. Hyperactive and impulsive symptoms can look like frequent fidgeting, difficulty waiting one’s turn and excessive talking.
In general, when children are very young, hyperactive-impulsive symptoms tend to be more common. Michelle Martel, a professor of psychology at the University of Kentucky, says it is obvious when you’re working with a preschooler with these symptoms because “they’re getting into everything and running around the room”.
As children age and start to have more responsibilities and expectations at school, inattentive symptoms become more prevalent, and ultimately more persistent. And in some children, hyperactive-impulsive symptoms start to decline. According to one large 2023 review, in children under 12 there is a roughly even breakdown between primarily inattentive, primarily hyperactive-impulsive and combined presentations. Between ages 12 and 18, the numbers start to shift, with more adolescents qualifying as inattentive and less than a quarter as hyperactive-impulsive.
Very few adults have predominantly hyperactive-impulsive symptoms. One small study put the number at just 7 per cent, while roughly one-third of adults had the inattentive subtype and the majority had a combination of symptoms.
Hyperactive-impulsive symptoms also present differently in adults than in children, manifesting more as an inner, mental restlessness rather than an outward, physical restlessness, says Dr Deepti Anbarasan, a clinical associate professor of psychiatry at the NYU Grossman School of Medicine. For example, adults “may always feel a need to be busy, like they might need to exercise daily or otherwise they don’t feel so good,” she says.
Adults with inattentive symptoms may have trouble with life logistics and with completing chores that don’t have a deadline, or they might lose track of conversations during meetings or with their spouse, Anbarasan says.
Why symptoms change
There is mounting evidence that people’s environments can influence their symptoms. Having problems at home, like parents going through a divorce, may contribute to symptom severity in children and adolescents, says James Swanson, a professor of pediatrics at the University of California, Irvine.
Children may also struggle more with inattention in a “structured school setting where they’re having to do things they don’t like,” Martel says. A person’s symptoms may improve in adulthood when they find a job that better suits their temperament and personality, she adds.
Another reason ADHD can change with age is that many people eventually find ways to manage their condition so it’s less disruptive. In general, the experts say, people with predominantly hyperactive-impulsive symptoms are more likely to be treated with behavioral interventions, while those with inattentive symptoms tend to respond better to medication. But for many people, especially those with combined ADHD, a hybrid approach works best.
Finally, neuroimaging research suggests that some of the changes people experience with age may be partially attributed to brain development. One recent study found that children whose symptoms improved over the course of two years showed a different pattern of brain development than those whose symptoms persisted or got worse.
“Some children just grow out of it,” Swanson says. “You start with a group and you follow them over time, the symptoms decrease with age. That’s just an age-related effect. I call it maturation.”
The New York Times
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