For 15 years, Marshall Lichty, 43, saw therapists on and off for depression and anxiety. He also has obstructive sleep apnea (OSA), a condition marked by brief, repeated interruptions in breathing during sleep, loud snoring, and daytime drowsiness. And although studies show that OSA may contribute to symptoms of attention deficit hyperactivity disorder (ADHD), no one ever suggested that Lichty might also have ADHD. At least, not until he and his wife took their 8-year-old son, Everett, to a child psychologist in 2018 to be evaluated for the disorder. "During the assessment, the doctor told us that ADHD has a strong genetic component, then asked if Everett's attention issues resonated with anyone else in our family," recalls Lichty, an attorney, law firm consultant, and executive coach from Minneapolis. "Suddenly everyone in the room was looking at me."

He wasn't entirely surprised. Before meeting with the child psychologist, Lichty had researched the condition and found that it can also affect adults. "I felt it was the only possible explanation for why it had always been so hard for me to pay attention," he says. He consulted his therapist, who referred him to a psychologist for evaluation. "She took my history, then said, 'You did great in college, got into a top 20 law school, passed the bar, and practiced law, so you don't have ADHD.' I left her office filled with shame and self-doubt. If I didn't have attention issues, then I must not be trying or working hard enough."

The child psychologist's question about genetic factors motivated him to schedule an evaluation at the same clinic where Everett had been diagnosed. "After a three-day assessment of everything from my medications, sleep, and mental and physical health to tests of my memory, IQ, attention, and mental skills, the doctor—who has also been diagnosed with ADHD—looked me in the eye and said, 'Marshall, you and I have brains that don't do "bored" very well.' After he diagnosed me with ADHD, I felt a flood of relief, gratitude, and empowerment. I finally had an answer to my struggles and had someone who could help me get the right treatment." 

He was prescribed methylphenidate (Ritalin, Concerta), a central nervous system stimulant drug approved for ADHD by the US Food and Drug Administration. "Within an hour of taking it for the first time, I felt a sense of clarity and focus that lasted all day, with essentially no side effects," says Lichty, who takes an extended-release pill every morning. To manage his OSA, he uses a CPAP (continuous positive airway pressure) machine to help him breathe evenly and regularly at night, which has improved his sleep (and lessened his snoring) and has made it easier for him to stay alert and focused at work.

Lichty meditates every morning and works out regularly. He has also joined a support group for lawyers with ADHD and uses timers and scheduling apps to avoid procrastination and stay on task. "Not only are my ADHD symptoms under control, but I no longer have issues with depression," he says. "I once heard an ADHD expert say that having the disorder is like learning to play a very difficult musical instrument: It can take years to master it, and can sound horrible while you are learning, but once you do, you can make some of the most beautiful music in the world."

Rising Rates in Adults

ADHD, which is characterized by distractibility, chronic disorganization, poor time management, getting easily sidetracked, restlessness, impulsive behavior, and talking excessively or interrupting conversations, is a neurobehavioral disorder that affects about 1 percent of young adults in the United States, according to a study published in JAMA Open Network in November 2019. The researchers analyzed health records of almost 5.3 million adults between the ages of 25 and 34 and nearly 1 million children who received care at Kaiser Permanente, Northern California, and reported that the percentage of adults with ADHD has more than doubled over the past decade, from 0.43 percent in 2007 to 0.96 percent in 2016. Among children ages 5 to 11, the percentage rose from 2.96 percent in 2007 to 3.74 percent in 2016.

"Although ADHD is defined as a disorder that starts before age 12, many people who had ADHD as children continue to experience symptoms into adulthood," says Michael L. Goldstein, MD, FAAN, former chair of the section of pediatric neurology for the American Academy of Neurology. "Several factors may explain why more adults are being diagnosed now, including increased awareness among both clinicians and patients, the latter prompting patients to seek help if they suspect they have it."

Another common scenario is for parents to be diagnosed with ADHD shortly after their children receive the diagnosis, says Roberto Olivardia, PhD, clinical psychologist at Harvard Medical School. "A lot of young people with ADHD will say, 'I knew my mom or dad had ADHD,' but their parents may not have recognized the symptoms or known that it can persist into adulthood until they educated themselves during their child's assessment. That's when they start thinking about their own struggles in school, work, and other settings."

Coexisting Neurologic Conditions

The 2019 JAMA study also found that people with the disorder are much more likely than those without it to have anxiety, depression, bipolar disorder, and eating disorders. It's also more common for them to have sleep apnea, migraine, and autism spectrum disorder (ASD), says Stephen V. Faraone, PhD, distinguished professor and vice chair for research in the department of psychiatry at SUNY Upstate Medical University in Syracuse, NY. "There is very good scientific data documenting an extremely high rate of sleep disorders in people with ADHD, raising the question: Do sleep difficulties cause inattention—or do the two issues have a common cause?" says Dr. Faraone.

According to a 2011 study published in Annals of Clinical Psychiatry, up to 30 percent of patients with ADHD also have OSA. "It's so common for people with ADHD to have co-occurring sleep disorders that, in my opinion, problems with sleep should be added to the diagnostic criteria," says Dr. Olivardia, who has ADHD and OSA.

Similarly, a small study of people with ASD published in Autism Research in 2013 reported that nearly 37 percent of them also have ADHD. A 2018 study in Frontiers in Psychiatry of 107 young adult males with ADHD, ASD, or both explored the question of whether these conditions stem from a shared disorder of the brain. To find out, the researchers conducted functional MRI scans on the young men's brains as they performed tasks requiring them to choose between getting a small reward immediately or a bigger one later. These types of tasks activate several areas of the brain, including the frontal lobe, which regulates decision making, and the limbic system, which is involved in emotions and impulsivity.

The study found that the group that had both ASD and ADHD had distinct differences in how their brains operate compared with those who had only one of those disorders. That led the researchers to conclude that people with both disorders may be neurologically different from those with ADHD or ASD alone.

"One of the biggest scientific questions that remain to be answered is if there are as yet undiscovered genetic and/or environmental causes that contribute to both ADHD and all or some of the conditions that can occur with it," says Dr. Faraone. He and other scientists from the Brainstorm Consortium—a team of hundreds of researchers from around the world—recently discovered intriguing genetic links among 25 common disorders of the brain, including ADHD. Their research, which was published in Science in 2018, analyzed genetic data from more than 1 million individuals, a quarter of whom were affected by neurologic or psychiatric conditions. "We found that ADHD shares significant genetic risk with such psychiatric disorders as depression, bipolar disorder, and schizophrenia," says Dr. Faraone.

The study also found that neurologic disorders appeared to be more genetically distinct from one another and from psychiatric disorders, including ADHD, with one major exception, adds Dr. Faraone. "Our study demonstrated a very strong genetic correlation between ADHD and migraine."

Migraine and ADHD

Many of Bray Patrick-Lake's relatives have migraine, ADHD, or both. She's had migraine with aura since she was a teenager. In 2011, she started to suspect that she also had ADHD after taking one of her sons to be evaluated for the disorder. "When the child psychologist described the symptoms, I felt like I was hearing the story of my life," she recalls. "I've always had very high energy, and as a child I frustrated my teachers when I couldn't stay on task and get my work done. I was frequently punished by teachers and parents because I couldn't sit quietly at my desk like everybody else. I also have no concept of time and think I can stop at 10 stores on the way to an appointment and still get there on time."

After returning to the clinic where her son was diagnosed, she underwent a comprehensive assessment that included a battery of cognitive and other testing and was diagnosed with ADHD. "I embrace ADHD as a strength because I love how fast my brain works," says Patrick-Lake, 49.

Because her prescribed medication, amphetamine and dextroamphetamine (Adderall), worsens her chronic insomnia, Patrick-Lake takes it rarely and only when her attention needs an extra boost for tasks such as creating spreadsheets or finishing publications.

The rest of the time, she manages her ADHD through a combination of cognitive behavioral therapy, technology tools such as calendar alerts and electronic reminders, and lifestyle changes. "Sleep is really important, so I have worked with a sleep specialist. I take medication for my insomnia and make it a rule to turn off all electronic devices at night," she says. The thing that takes the edge off most effectively is exercise. "I work from a remote office and have told my employer about my ADHD and that I need to spend an hour at the gym or go for a run during the day to help me remain focused and productive."

Changing her diet—eating more protein and fewer carbohydrates—and getting more sleep have also reduced her migraine attacks, which she treats with two ibuprofen tablets at the first sign of aura. If that doesn't work, she takes sumatriptan (Imitrex), a prescription migraine drug.

Sex Differences

Both the neurologic conditions that often occur with ADHD and the disorder itself affect men and women at different rates. For example, migraine is three times more common in women than in men, while OSA and ASD occur at a higher rate in men. Men and boys are more often diagnosed with ADHD than are women and girls, according to the 2019 JAMA study. Earlier research reported similar findings, says Dr. Goldstein. "Differences in symptoms may explain why ADHD is diagnosed more frequently in males. Impulsive/hyperactive behavior is more common in males, and inattentiveness is more common in females," he says. "It is believed that quiet, inattentive females may be considered lazy or are overlooked and not referred. Disruptive, hyperactive boys stand out more, so are more likely to be identified and diagnosed. Yet both can benefit from identifying and treating the problem."

Despite having obvious symptoms of hyperactivity and impulsivity as a child, Peter Shankman, 47, went undiagnosed until he was in his thirties. "I was constantly being told, 'Be quiet, you're disrupting class!' and 'Don't you know how to sit down?'" says the entrepreneur and author from New York City. "Although I got A's in the subjects I loved, I was suspended a few times and was viewed as a chronic troublemaker and screwup. I got through high school and college by the skin of my teeth and have always felt that on any given day I was three bad decisions away from ruining my life, due to impulsivity."

Now that he's learned how to manage it, Shankman, who also has OSA, says his ADHD diagnosis is the best thing to have happened to him. "Before I was diagnosed, I was overweight, never exercised, and slept poorly due to my sleep apnea," he says. After his diagnosis, he quit drinking, changed his diet, and lost weight. He started using a CPAP machine and now sleeps eight hours every night. He also wrote a book called Faster than Normal: Turbocharge Your Focus, Productivity, and Success with the Secrets of the ADHD Brain (TarcherPerigee, 2017). To improve his focus, he takes the stimulant methylphenidate (Concerta, Ritalin) when needed and works with a therapist, who has helped him reduce distractions and simplify his life.

"You can view ADHD as either a blessing or a curse," he says. "I've tried to make the best of the situation, understand what I'm great at doing—such as coming up with creative content and working under pressure—and appreciate the value of having a brain that works faster than normal. It's like having a Ferrari: Once you learn how to drive it skillfully, you can win every race."

How Is ADHD Diagnosed?

There are three types of attention deficit hyperactivity disorder (ADHD): hyperactive/impulsive, inattentive, and a combination of both. Symptoms of inattention include chronic disorganization, frequently forgetting or losing things, making careless mistakes, poor time management, and getting easily sidetracked, says Michael L. Goldstein, MD, FAAN, former chair of the section of pediatric neurology for the American Academy of Neurology. People with hyperactivity and impulsivity may struggle to sit still or to engage in quiet activities. They may fidget frequently, interrupt conversations or talk too much, and find it hard to wait for their turn or stand in line. To be diagnosed with ADHD, an adult must have at least five symptoms of inattention, hyperactivity/impulsiveness, or both, says Dr. Goldstein.

"Although everyone has some of these issues at times, the difference is that adults with ADHD have symptoms that started before age 12 and affect them to a degree that causes distress or interferes with their ability to function well in work, school, relationships, and daily activities," explains Roberto Olivardia, PhD, clinical psychologist at Harvard Medical School. "Because ADHD doesn't affect intelligence, it's possible for people to get straight A's in school and still struggle with inattention. A common pattern is for people to excel at tasks, activities, and classes that interest them, and feel tortured when doing things they consider boring."

People who think they may have ADHD should consult one of the experts who specialize in the disorder, including clinical psychologists, psychiatrists, neurologists, and nurse practitioners, advises Dr. Olivardia. "While a lot of patients get neuropsychological testing, these tests are expensive and usually are not covered by insurance," he says. "Moreover, such tests can miss some patients with ADHD, because they may find the tests interesting enough to score well on measures of attention." Whether or not the assessment includes testing, the provider should thoroughly evaluate the patient's symptoms, health, and family history, he adds.

It's also important for patients to be checked for other conditions that have similar symptoms or may coexist with ADHD. "For example, sleep disorders—including obstructive sleep apnea (OSA), restless legs syndrome, and delayed sleep-wake phase disorders—often mimic the symptoms of ADHD, leading to difficulties with attention, distractibility, and restlessness," says Dr. Olivardia.

A 2018 study published in Journal of Attention Disorders found that people with ADHD were more than three times more likely than those without it to meet diagnostic criteria for restless legs syndrome, a neurologic condition that causes unusual sensations in the legs (such as crawling or pulling) accompanied by an uncontrollable urge to move them. It's classified as a sleep disorder because the symptoms often occur at night and disrupt sleep, says Dr. Olivardia.

"Because restless legs syndrome, OSA, and other sleep disturbances are so prevalent in people with ADHD and make it even harder for them to pay attention, it is extremely important that their sleep problems get diagnosed and treated," he says. Sleep difficulties may be overlooked in a routine ADHD evaluation, so he advises patients who are chronically tired and have trouble concentrating to discuss their sleep patterns with their doctors.

Simple Ways to Manage ADHD

These strategies from doctors and patients can help increase your attention span and transform chaos into calm if you have been diagnosed with attention deficit hyperactivity disorder (ADHD).

Diagnose and treat coexisting conditions. Identifying and managing sleep apnea, restless legs syndrome, and other sleep disorders may lessen some of the symptoms of ADHD, says Michael L. Goldstein, MD, FAAN, former chair of the section of pediatric neurology for the American Academy of Neurology. The same may be true of migraine and autism spectrum disorder, he adds.

Make time for exercise. The symptoms of ADHD can be so overwhelming that sometimes people with the disorder may neglect their health, says Roberto Olivardia, PhD, clinical psychologist at Harvard Medical School. "Exercise is a great way to burn off excess energy, improve mood, and sleep better."

Eat well. People with ADHD often engage in "distracted eating," by grabbing sugary snacks, fast food, and caffeinated drinks on the go, which can lead to weight gain and other health problems. Have healthy foods on hand in your refrigerator at home and at work.

Develop soothing bedtime rituals. To address the sleep difficulties that often occur with ADHD, Dr. Olivardia recommends the following "winding down" routine: Dim the lights; turn off your computer, TV, and mobile devices; and listen to quiet music before going to bed. It's also helpful to go to bed and wake up at the same time every day and to avoid working or watching TV in your bedroom, which should be reserved for sleep and sex.

Try mindfulness meditation. Adults who participated in a pilot trial of mindfulness meditation for ADHD, published in the Journal of Attention Disorders in 2017, showed improvements in attention and impulsivity. It works for Marshall Lichty, 43, a lawyer and blogger in Minneapolis, who has ADHD, and hosts a podcast called JDHD for lawyers with ADHD. He says meditation helps him calm his mind and start his day.

Get rid of clutter. "Seeing piles of paper, mail, and unfinished projects around your home or office is extremely distracting if you have ADHD," says Peter Shankman, author of Faster than Normal: Turbocharge Your Focus, Productivity, and Success with the Secrets of the ADHD Brain. "However, organizing can also feel overwhelming." He suggests doing it in spurts. "Start with a small area, such as your desk, and put all the clutter in a box. Put it away and three months later throw out anything you haven't used." The fewer possessions you have, the easier it will be to keep them tidy.

Set alarms. If you tend to lose track of time, use your computer, mobile apps, or even a kitchen timer to remind you when it's time to change tasks, Shankman suggests. "Also, use calendar alerts to stay on top of deadlines, appointments, and important tasks that you can't do right away." And always set a deadline for any task, he adds. "Without a deadline, your task isn't real."

Just say no. Like many people with ADHD, Bray Patrick-Lake thrives on multitasking and sometimes takes on more than she can handle. "I get very passionate about new projects, and also love to volunteer and help others," says the 49-year-old health-tech worker. However, she's learned to be more selective about the commitments she makes, to avoid overload. "You have to recognize that you can't please everybody and that it's okay to say that you need to think it over or don't have time."

Causes of and Treatments for ADHD

People with attention deficit hyperactivity disorder (ADHD) often say their brains are different from those of people without the disorder—and studies suggest that that's true, says Stephen V. Faraone, PhD, distinguished professor and vice chair for research in the department of psychiatry at SUNY Upstate Medical University in Syracuse, NY. "Two types of research have identified specific ways that ADHD may affect the brain. The best data we have from structural MRI imaging studies show that in people with ADHD, certain parts of the brain are a little smaller."

A 2017 study published in The Lancet Psychiatry of MRI brain scans of children and adults with and without ADHD identified five structures in the brain's subcortical region that were smaller in children with the disorder: the amygdala (which is involved with emotions and memory), the caudate, the accumbens, the putamen, and the hippocampus (all of which are associated with attention). Another 2017 study, published in PLOS One, found such distinct differences in the size, shape, and volume of gray matter and white matter in many brain structures of young adults with and without ADHD that in up to 83 percent of cases, the researchers were able to tell which study participants had the disorder simply by looking at their brain scans.

"Another branch of research, neuropsychopharmacology, has looked at how the brain's subcortical region communicates with the frontal lobe, the region involved with problem solving, self-regulation, control of impulses and emotions, decision making, attention, and time management," says Dr. Faraone. "On a molecular level, neurotransmitters, including dopamine and noradrenaline—both of which play a role in ADHD—carry signals from one nerve cell to another." Brain imaging studies have counted the number of receptors for these brain chemicals in people with and without ADHD, he adds. "People with ADHD have a higher number of dopamine receptors, which act like vacuum cleaners that suck up dopamine, leading to low levels of dopamine in the brain."

ADHD is considered a disorder of the brain's dopamine and noradrenaline systems. These two neurotransmitters are involved in learning, working memory (the ability to keep something in mind for a short period of time), alertness, motivation, and attention, says Michael L. Goldstein, MD, FAAN, former chair of the section of pediatric neurology for the American Academy of Neurology. "That's why medications that increase levels of dopamine and noradrenaline—such as stimulants amphetamine/dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), and methylphenidate (Concerta and Ritalin), and nonstimulants atomoxetine (Strattera) and clonidine (Catapres)—are so helpful for treating the symptoms of ADHD."

While many people find medications effective, the disorder also can be treated without them. It's important to note that ADHD medication can be addictive and is often abused, especially on college campuses, says Scott Hirsch, MD, associate professor of neurology at NYU School of Medicine.

Nondrug treatments include cognitive behavioral therapy, working with a life coach, and using mindfulness meditation to sharpen focus and enhance self-control, says Dr. Goldstein. "It's also helpful to reduce clutter at home and the office and avoid overstimulation. Assess your daily routine and think about how you can streamline and simplify it."

For Peter Shankman, who has both ADHD and sleep apnea, getting dressed every morning was an ordeal. "I'd get distracted by all the choices in my closet," says the 47-year-old entrepreneur and author from New York City. "I eliminated this problem by putting my work 'uniforms'—jeans and T-shirts—on one side of my closet and my business clothes for meetings and speeches on the other. That way, I can just grab something appropriate for what I'll be doing and get dressed in five minutes."