➲ Symptoms must have lasted for at least 6 months to be considered in diagnosing ADHD.

ℹ The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, uses 18 symptoms to diagnose ADHD—9 focusing on inattention and 9 on hyperactivity-impulsivity. But that list (see the Appendix) was developed for use with children only. My associates and I have compiled research data showing that the list of 9 symptoms above is more useful with adults. A research colleague of mine, Stephen Faraone, PhD, has done an independent study with his own groups of adults showing that these symptoms were very good at identifying those having ADHD.

➲ Wouldn’t it be an ever bigger relief to know you have ADHD than to just guess?

ℹ Most adults with ADHD have at least two disorders: 80–85% have ADHD and one other disorder, and more than half may have three psychological disorders.

➲ The success rate of ADHD medications is probably unrivaled by any other treatment for any other disorder in psychiatry.

ℹ Studies show that ADHD medications can:

• Normalize the behavior of 50–65% of those with ADHD
• Substantially improve the behavior of another 20–30% of people with the disorder

➲ Be prepared for the initial evaluation appointment to take several hours.

ℹ From 35 to 65% of people with ADHD can pass tests of attention, inhibition, and memory and yet still have the disorder. Researchers have found that if people do poorly on these sorts of tests, they probably do have a disorder. That does not mean that it is ADHD, however, because other disorders can interfere with performing these tests normally. On the other hand, getting normal scores on these tests does not mean the professional can rule out ADHD.

➲ It’s possible to have ADHD without having problem with impulsivity or hyperactivity. There’s a subtype characterized mainly by problems with inattention.

ℹ As my colleagues Michael Gordon, PhD, and Kevin Murphy, PhD, have written, your evaluation for ADHD should be designed to answer four fundamental questions:

1. Is there credible evidence that you experienced ADHD-type symptoms in early childhood that, at least by the middle school years, led to substantial and chronic impairment across settings?
2. Is there credible evidence that ADHD-type symptoms currently cause you substantial and consistent impairment across settings?
3. Are there explanations other than ADHD that better account for your array of current concerns?
4. If you meet the criteria for ADHD, is there evidence that you have any other disorders as well?

➲ If the evaluator says you don’t have ADHD because you have fewer than the five DSM criteria, ask to be evaluated again using our nine-item list

ℹ We used a variety of statistical methods to identify the symptoms that are most essential in distinguishing the adults with ADHD. In doing so we compared them not only to the community (“normal”) adults but to a second control group of adults seen at the same mental health clinic who had other psychological disorders but did not have ADHD. We also added into our analyses the 18 items from DSM to see just how good they were at identifying ADHD in adults. We found that, surprisingly, just 9 of the 109 symptoms we identified (see the Appendix) are needed to identify adults with ADHD…

ℹ Impairment = the social and other consequences or costs that result from expressing the symptoms of ADHD.

But there’s another element to the term that’s just as important as this definition: Impairment is defined relative to the average person in the population, known as the norm—it is where most “normal,” or typical, people are found to be performing in any domain of life. To be impaired, you must be functioning significantly below the norm or the average (typical) person. Why? Because the term disorder means just that—you are not functioning normally.

ℹ ADHD versus typical adults:

• Fewer than 5% of the typical adults answered “yes” to all but two of these questions [of the 18 DSM-5 symptoms to diagnose ADHD].
• Fewer than 12% did so for the other two questions.
• On average, adults in the general-population control group reported less than 1 symptom out of all 18, whereas adults with ADHD reported more than 12 (7 on the inattention list and 5 on the hyperactive-impulsive list).

ℹ The three subtypes of ADHD as of 2010:

• The combined type is the most common (approximately 65% or more of clinical cases) and severe and involves all the characteristics noted in the 18 DSM criteria. It’s also the most extensively studied of the “types” of ADHD, with thousands of scientific studies on this group published over the last 100 years.
• The predominantly hyperactive type was recognized in 1994. People with this type of ADHD don’t have sufficient problems with inattentiveness to be diagnosed with the combined type. It shows up mainly as difficulties with impulsive and hyperactive behavior. It’s now believed to represent simply an early developmental stage of the combined type in most cases. As many as of these people will develop enough problems with attention and distractibility to be diagnosed with the combined type within 3–5 years. The remaining cases appear to mostly represent a milder variant of the combined type.
• Individuals who exhibit chiefly attention problems but not excessive activity levels or poor impulse control are considered to have the predominantly inattentive type of ADHD. First recognized around 1980, this subtype makes up about 30% or more of clinically referred cases. Many of these cases are just milder forms of the combined type.

Accepting ADHD as part of your psychological makeup is what I mean by “owning your ADHD.” If you merely acknowledge the disorder at some distant intellectual level, paying public lip service to the diagnosis but privately rejecting it, you’ll be stuck where you are. People I’ve seen react that way don’t embrace treatment. They’ve wasted time and money on the diagnosis and end up with the same struggles they’ve always had.

I find, in fact, that accepting the diagnosis can be rather liberating for adults. They no longer have to play mind games with themselves or others in which they deny, excuse, defend, distort, massage, or in other ways avoid accepting the disorder. I am bald, color blind to reds and greens by about 60% or more, not well coordinated, cannot draw or paint a lick, am not very mechanically inclined or talented, am musically rather inept, now have to wear reading glasses, have nearly completely gray hair (what is left of it), find the remainder, now migrating south into my nose and ears, and am developing a slow but progressive left facial weakness when talking, among other psychological and physical inadequacies I certainly possess. And I am fine with owning them, warts and all. Because when I decided to do so, my next thought was “So what? No one is perfect; big deal. Now just own it and get on with life.”

I hope you can do the same: get on with all the learning, loving, living, and leaving a legacy that a happy and productive life ought to entail. Happiness can come only from accepting yourself as you are, and that includes ADHD. Owning your ADHD doesn’t have to demoralize you, because when you really own it, you too can then conclude “So what?!” Admit that you have it, accept the diagnosis, own it as you own other features of your self-image, and then you can really begin to work with and master it.

If you haven’t accepted that you have ADHD, you can’t get all those things listed at the beginning of Step Two that should be the benefits of getting a diagnosis. Accepting your ADHD can lead to:

• Being able to seek help
• Discussing ADHD rationally with others
• Evaluating what types of accommodations, if any, you may need at work, school, or home
• Adapting to the condition
• Coping with it as necessary

In my years of counseling adults with ADHD, I’ve come to believe that reframing your view of yourself and your life to put ADHD in the picture is in fact among the most crucial changes you can make to master ADHD. It’s the only way I know to keep ADHD from running, or ruining, your life. Unfortunately, accepting ADHD as part of you may be a tall order if you’ve been trying to explain your problems in some other way or people have been telling you forever that there’s nothing wrong with you that you couldn’t fix with a little willpower. Fortunately, changing your perspective on ADHD is not a single leap you need to make. It’s a process: you start by coming to know it, then you own it, and finally you’re able to work with it.

➲ Mental avoidance of the diagnosis wastes enormous time and emotional energy.

ℹ Studies have shown that you probably inherited ADHD:

• Ten to 35% of the immediate family members of children with ADHD also have the disorder.
• When a parent has ADHD, 40–57% of his or her biological children will also have ADHD. This means if you have a parent with ADHD, you are 8 times more likely to end up with ADHD than if your parent does not have ADHD.

ℹ My recent studies have shown that 89–98% of adults with ADHD report having major problems in the five areas of life..., compared to just 7–14% of typical adults in the general population:

Adults with ADHD (%), Adults in the general community (%)

Self-reports:

Time management problems: 98, 8
Poor mental organization: 89, 11
Inhibition problems: 94, 7
Self-motivation problems: 95, 9
Concentration problems: 98, 7

Reports of others who know the adult well:

Time management problems: 96, 9
Poor mental organization: 84, 7
Inhibition problems: 94, 11
Self-motivation problems: 84, 9
Concentration problems: 99, 14

ADHD IN ADULTS IS NOT MERELY A TRIVIAL DISORDER OF PAYING ATTENTION!

Instead it’s a problem with the ability to organize behavior over time to prepare for the future. The five problem areas in ADHD add up to an exceptional nearsightedness about the future. And that, as you probably know firsthand, is a recipe for disaster in most major life activities.

What you will learn in the next three steps that can help you tremendously is this:

The problems that ADHD creates for you have more to do with not using what you know at critical points of performance in your life than with not knowing what to do.

Hold on to that thought. It’s important not just to your understanding of ADHD but to your confidence that you can improve your life—that you are not stupid, lazy, or “just not paying attention.” You know what to do. Let’s see how you can learn to use what you know when you need it.

➲ ADHD is a form of time blindness.

ℹ Dan’s wife might be more forgiving of his hyperactivity if she knew that the problem arises from poorly timed brain development in those with ADHD. The primary motor system of the brain—the part that gives rise to various and small motor movements—appears to mature too early in people with ADHD. And the higher-level brain center nearby, which gives us self-control and organizes our behavior toward future goals, develops too late, as shown in the National Institute of Mental Health (NIMH) study ... This means that kids with ADHD have the neurological impulse to move around constantly without the brakes that tell them not to. As development proceeds, the fabulous learning machine called the human brain catches up a bit, and that’s why Dan doesn’t tumble around his living room as an adult. But it never catches up to the capacity of those without ADHD, and that’s why Dan still feels that restless urge to do something all the time.

➲ The “time blindness” of ADHD starts with a lack of impulse control.

ℹ Self-control is defined in psychology as any response, or chain of responses, that leads us to change our own behavior instead of just acting on impulse so that we can change what will happen in the future. It is action directed at the self and toward the future.

➲ If it didn’t result in a net positive, why would anyone exercise self-control?

ℹ Psychologists have found that our preference for larger, delayed consequences increases from childhood all the way up to our early 30s, paralleling the development of the frontal lobes of the brain—the seat of our self-control. But ADHD derails that development and leaves even adults picking the smaller immediate outcomes, instead of the larger delayed ones.

➲ “Carpe diem”—seize the day—could be the motto of all adults with ADHD. It’s great on vacation; it’s terrible as a daily rule.

ℹ Researchers refer to bridging the gap between event, response, and outcome over long time spans as a capacity for the cross-temporal organization of behavioral contingencies. That’s a mouthful. Think of it as the ability to engage in time management, or, more aptly, to manage yourself relative to the passage of time.

➲ Poor inhibition leads to poor self-control and robs you of your free will—the capacity of choose wisely among possible options for responding to events or to your own thoughts.

➲ Knowing which of your executive functions is the weakest will help you understand which type of self-control to target in efforts to cope and compensate.

ℹ Nonverbal working memory allows not only imitation bet the opposite: staying away from what someone else did that proved ineffective. This is called vicarious learning.

➲ Hindsight → Foresight → Preparation to act

➲ Nonverbal working memory gives us a sense of time, a key to time management.

➲ Nonverbal working memory may be what makes selfish altruism apart of human nature.

➲ Play is training for inventiveness in adult problem solving.

➲ Ironically, the planning that you may find painfully slow can help you get a project done far faster.

➲ Anyone who tells you all you need to do is buckle down and pay attention should read Step Two of this book.

➲ ADHD is a disorder of performance—of doing what you know rather than knowing what to do.

➲ You don’t choose to skip planning or to bypass forethought. Your predicament is not your fault.

➲ Caution: Going on the Internet to check one thing like a sports score can lead to looking up 67 things. This is why knowing your own ADHD is so important: this reward may not be the right one for you!

ℹ There is no scientific evidence for the effectiveness of intervention outside the points of performance in your life where your major problems occur. Avoid talk- or insight-oriented therapy, psychoanalysis, weekly group therapy focusing on complaining, etc.

➲ Never stop looking for ways to compensate. You never know everything, so try to remind yourself not to get to confident once you start making progress in working with your ADHD.

➲ It’s hard to let go of the pain of lost relationships, jobs, education, and overall wellbeing that you’ve suffered as a result of untreated ADHD.

➲ Your future does not have no look like your past.

AN EXPLANATION, NOT AN EXCUSE

You are not a victim. ADHD is not a handicap. The fact that you’re reading this book says you are looking for answers, not excuses. But some of the people around you may be inclined to view you as a less capable individual because you have this condition. They may believe it’s OK not to hold you accountable for your actions now that you have an official diagnosis. I’m sure you don’t want to be treated that way any more than someone in a wheelchair would. Your job going forward is not to excuse yourself from the tasks made difficult by ADHD but to seek out the ADHD equivalent of wheelchair ramps into a building. Find those ramps whenever you can and build them into your life. The alternative is to wheel around and go back home defeated.

Not only should no one excuse you from the immediate or future consequences of your actions, but you should actually take action to tighten up that accountability by making consequences more frequent, immediate, and salient. You’ll succeed best when held accountable for your plans, goals, and actions across the day so you receive more frequent feedback.

So make (and accept) no excuses! Own your ADHD, own its consequences, and then seek to minimize or eliminate those disastrous delays in life that are preventing you from being as effective, productive, and successful as people who don't have ADHD. Find your ramps or build them as necessary, but don’t quit on your plans and goals.

ℹ What the research shows about the causes of ADHD:

• Studies of twins and families have made it abundantly clear that genetic factors are the major causes of ADHD. If a child has ADHD, nearly one out of three siblings will also have ADHD. A study done at UCLA examined 256 parents of children with ADHD and found that of these families had at least one parent affected by the disorder.
• An estimated 75–80% of variation in the severity of ADHD traits is the result of genetic factors, and some studies place this figure at over 90%—higher than the genetic contribution to personality traits, intelligence, and other mental disorders such as anxiety and depression and nearly the same as the genetic contribution to individual differences in height.
• Several recent studies have scanned the entire human genome searching for genes that carry the risk of ADHD and have found at least 20 to 25 sites on chromosomes to be associated with ADHD. It is therefore likely that ADHD arises from a combination of multiple risk genes, with each contributing a small likelihood of risk for the disorder. The more risk genes you inherit, the greater the number and severity of ADHD symptoms, and so the greater the probability you will be impaired by and diagnosed with the disorder.
• A very small number of cases are caused by early-development (often prenatal) neurological injury, such as alcohol and tobacco exposure during pregnancy, premature delivery, especially with minor brain hemorrhaging, early lead poisoning, stroke, and frank brain trauma, to name just a few.
• The frontal lobes, basal ganglia, cerebellum, and anterior cingulate cortex are 3–5% smaller in people with ADHD than in others of the same age and substantially less active.
• Studies show that the brains of those with ADHD react to events more slowly than the brains of those without ADHD. People with ADHD have less blood flow to the right frontal region of the brain than those who don't have ADHD, and severity of symptoms increases the more blood flow is reduced.

ℹ What the research says about popular myths regarding the causes of ADHD:

• Available evidence suggests that sugar plays no role in the disorder and that fewer than 1 in 20 preschool children with ADHD may have their symptoms worsened by additives and preservatives.
• No compelling evidence exists to support the claim that ADHD results from watching too much TV or playing too many video games as a child, other than that people growing up with ADHD may be more likely to watch television or play video games.
• Little evidence has emerged that child-rearing practices can cause ADHD. There is no question that families with children having ADHD show more conflict and stress than other families. But researchers found that this was largely due to the impact of the child’s ADHD in disrupting family functioning and also to the likelihood that the parent also had ADHD.

ℹ We now know that ADHD medications can normalize the behavior of 50–65% of those with ADHD and result in substantial improvements, if not normalization, in another 20–30% of people with the disorder.

*Dr. Barkley has worked as a paid consultant to and speaker for Eli Lilly (United States, Canada, Spain, Italy, the Netherlands, Sweden, United Kingdom, Germany), Shire Pharmaceuticals (United States), Novartis (United States, Switzerland, Germany), Ortho-McNeil (United States), Janssen-Ortho (Canada), Janssen-Cilag (Denmark, South America), and Medicis (Germany and Switzerland).

➲ Fewer than 10% of people with ADHD will not have a positive response to at least one or more of the ADHD medications currently available in the United States.

ℹ Here’s how the anti-ADHD medications work neurogenetically:

Brain imaging, EEGs, and a variety of other testing methods have shown that the brains of those with ADHD are different from those of others in several important ways:

• Certain regions of the brain are different structurally, mainly being smaller than in those without ADHD: the right prefrontal region, associated with attention and inhibition; the striatal region, associated with pursuing pleasurable or rewarding behavior; the anterior cingulate cortex, which helps you govern or self-regulate your emotional reactions; and the cerebellum, associated with the timing and timeliness of your actions, among other executive functions.
• People with ADHD have less electrical activity in the brain, particularly in these regions, meaning they don’t react to stimulation in these regions as much as others.
• Children and adolescents with ADHD also have less metabolic activity in the frontal regions.
• The brains of those with ADHD seem to be deficient in or show excessive reuptake of norepinephrine and dopamine. Other neurochemicals may also be involved.

Scientists believe the structural abnormalities in the ADHD brain underlie the development of the disorder: this is the genetic legacy that causes ADHD to appear in the descendants of those who have ADHD. We don’t know how to restore a typical structure to these brains.

We do, however, know how to correct the neurochemical imbalance found in those with ADHD, at least temporarily: medication.

When the neurotransmitters dopamine and norepinephrine are not available in the same measure as they are in typical adults, the messages these chemicals are supposed to send don’t get through as they should. Without the help of these neurotransmitters, the brain does not respond to stimulation (any input, like an event or an idea or an emotion) the way it should. Impulse control doesn’t kick in when it should. Memories of the past and visions of the future aren’t triggered to keep you mentally on track. And even when they are, they cannot be sustained for very long, leading you to forget what it is you were planning on doing. The motor-control brakes don’t keep you from fidgeting with restlessness.

This is why ADHD medications work (though some operate on other neurochemicals). By causing nerve cells to express more of these neurochemicals, or by keeping the nerve cells from pulling them back in once they've been released, they increase communication between nerve cells in regions of the brain linked to ADHD. The two basic categories of drugs approved by the U.S. Food and Drug Administration for use with adults who have ADHD—stimulants and a few nonstimulants—boost your mind’s ability to respond to whatever is going on in your day.

ℹ In the 2008 book ADHD in Adults: What the Science Says, my coauthors and I compared adults with ADHD who had been diagnosed as children with those who had been diagnosed as adults. We looked at the data collected in our Milwaukee study, which followed children from the late 1970s into adulthood in the new millennium, and also the data collected in a University of Massachusetts Medical Center study of adults who were evaluated in the years 2000–2003.

• We found remarkable similarities between the two groups. The evidence showed that at least half of the children diagnosed with ADHD still qualified for the disorder as adults.
• Those diagnosed as adults tended to be less impaired than those diagnosed as children.
• But those diagnosed as adults were more likely to have other disorders too, particularly anxiety and depression. Why? We don’t know for sure, but it could be that anxiety and depression were the result of having struggled with ADHD symptoms for years without treatment.
• Those diagnosed as kids had greater problems with educational and occupational performance, and in a substantial minority with antisocial behavior and drug use. Again, why? Perhaps these individuals were diagnosed early in life because their impairments were more noticeable, suggesting their symptoms may have been more severe.

What this means regarding medication for adults with ADHD:

• If you were diagnosed recently, you may need medication to ensure that you get help for anxiety or depression along with ADHD.
• If you were diagnosed as a child, you may need medication because your symptoms are moderate to severe.

ℹ Why are the stimulants frequently abused? In those who have typical levels of dopamine in the brain, the boost afforded by the stimulants provides a pleasant sensation of “speediness.” But that’s not all. The stimulants increase dopamine in the regions of the brain known to increase the likelihood of drug addiction—some of the same regions (the prefrontal cortex and cerebellum) where the drugs do so much good for people with ADHD. Some of these regions serve as the reward centers of the brain, determining how pleasurable or reinforcing certain stimuli or experiences will be. Increasing activity in these centers can result in increased sensations of euphoria, interest, or other reward-related experiences. These pleasurable altered states of consciousness are most likely to occur when stimulants are taken intravenously or snorted into the sinus passages as a powder, allowing the drug to enter into and then clear from these brain regions rapidly. It is this rapid alteration in conscious sensations that creates the euphoria or other pleasurable sensations.

Why don’t adults (or children) with ADHD get hooked on the stimulants? Mainly because the drugs are taken orally, in pill or capsule form, and thus enter and leave the brain very slowly. Most people who abuse stimulants snort them or inject them into a vein in a solution, such as the stimulant mixed with water. By those delivery systems the drugs hit the brain all at once with a much more powerful wallop. Also, when these medications are used to treat ADHD they are only bringing the dopamine levels up to normal, not raising them rapidly well above normal levels as they would in someone attempting to abuse the drugs through intranasal or intravenous use.

➲ The stimulants increase heart rate and blood pressure, but only as much as climbing a half-flight of stairs. There’s no evidence that they cause high blood pressure in those who didn’t already have it.

ℹ Research shows that sudden death occurs in one to three of 100,000 people taking stimulants for ADHD every year, versus one to seven out of every 100,000 in the general population. So the rate of sudden death in those taking stimulants is no higher than that for the general population that is not taking stimulants. It was even somewhat lower in some research. That’s because people about to take a stimulant prescription get a physical exam and screen for possible cardiac problems. When cardiac problems are detected, they are typically not prescribed stimulants. This is not the case for the general population that is not being routinely screened for heart problems.

ℹ The research is somewhat mixed on whether stimulants worsen anxiety, but enough studies have found this to be the case (though more with children than adults) that you should be aware of this possible adverse effect. If you are concerned about anxiety, the nonstimulants might be a better choice…

ℹ In rare cases, stimulants make people more irritable or angry. Whether stimulants are likely to make you feel this way may depend on your own personality, what other disorders you may have along with your ADHD, and which of your executive functions have been affected most by ADHD. If you had a lot of trouble controlling your emotions in the past, and you haven’t been diagnosed with a problem like depression in addition to ADHD, the stimulants may actually improve your emotional self-control. Emotion regulation is one of the executive functions weakened by ADHD and improved by medication treatment.

ℹ Actual increases in muscle tension are not common side effects of stimulant treatment. But some people do experience them, especially if they are taking higher-than-typical doses. Unless you have a family history of tic disorders, the stimulants are unlikely to cause motor tics. If you have a family history, you might develop them while on stimulants. Up to a third of those who already have tics will see them worsen.

➲ Your choices of drug form will depend largely on matters of like how long your active day is and when you need to be on top of your game. All of these delivery systems have been proven safe and effective in hundreds of studies.

❔ Can the generics really be as different as they seemed in my case? The pharmacy I go to switched to generic versions of Ritalin, and the new generic did not work nearly as well. My doctor switched me to the brand-name drug, but do I really need to spend the extra money?

Your doctor was correct to believe there can be a significant difference. The generic medications appear not to be manufactured with the same degree of rigor as the brand-name medications. The generics have been associated with numerous reports of greater variability in controlling symptoms on a day-to-day basis and less success overall in managing symptoms. Should that occur, ask to be transferred back to the brand-name medicine.

ℹ How Effective Is Atomoxetine Compared to Stimulants?

• On average about 75% of people get positive effects from the stimulants or the nonstimulants.
• Some studies suggest that while 50% of people respond positively to both types of medications, 25% may respond better to a stimulant than to atomoxetine while the remaining may respond better to atomoxetine than to one of the stimulants.

ℹ Why Atomoxetine Is Rarely Abused ... and What This Means to You

Some research shows that by blocking the reuptake of norepinephrine atomoxetine also increases the amount of dopamine outside of nerve cells. But it does so only in certain parts of the brain, such as the frontal cortex. This means the drug can address dopamine-related ADHD deficits in the brain without affecting the brain reward centers likely to be related to drug addiction or abuse. Because it doesn’t have the same stimulant effect as methylphenidate and amphetamine, the drug has little appeal as a drug of abuse. In fact, research shows that the drug is no more favored by known drug addicts than other psychiatric drugs like antidepressants, which is to say very little. This is why it’s called a “nonstimulant” and why it’s not a controlled substance in the United States.

What does this mean to you?

• It’s much more convenient to fill and refill a prescription. Your doctor can phone in a refill, for example, which can’t be done with the stimulants.
• You don’t have to take the same precautions to keep the drug inaccessible to everyone else.
• This might be the treatment of choice for you if you’ve struggled with substance abuse of your own. (In fact one study of adult alcoholics with ADHD showed that atomoxetine improved ADHD and reduced heavy drinking at the same time.)

➲ Do not take atomoxetine at the same time as a monoamine oxydase inhibitor (MAOI)—the combination can have potentially life-threatening adverse effects.

➲ Using a medication to treat a condition for which it is not FDA approved is called “off-label-use” and can be perfectly safe (and even the best choice). But always ask your doctor to explain the pros and cons and why one drug is preferred over the alternatives.

ℹ Other nonstimulants may be prescribed for you, but not necessarily for ADHD since none are particularly effective in improving ADHD symptoms. However, ADHD medications are often combined with drugs used to treat other conditions, such as antidepressants, antianxiety drugs, antihypertensive drugs, and even some mood stabilizer or antipsychotic drugs.

The antinarcoleptic drug modafinil (brand name Provigil) has shown some initial promise as a treatment for ADHD symptoms in children, but even these results have not always been replicated in other studies. There is also no research to date on use of the drug for adults with ADHD. The drug increases wakefulness and arousal and sometimes has been used to treat sleep apnea (disrupted breathing while asleep). But it has not received FDA approval for treatment of ADHD as of this writing; the FDA has required that it be studied further for certain rare side effects before receiving approval. Stay tuned for news on this medication.

➲ Once you’ve started medication, immediately tell your doctor if you experience any significant heart functioning problems—palpitations, rapid heart rate, chest pain, dizziness, or fainting.

➲ Designing the best possible treatment plan is as much art as science. Try to be patient during the process: You’re the one who has everything to gain!

➲ If you think you’re not benefitting from a drug you’re trying, be sure to ask for feedback from someone who lives with you or is otherwise close to you. Sometimes the changes you’re experience are easier for others to see.

ℹ The chances are quite good that the first medication you try will work for you:

• You have only a 10–25% chance of not responding to the first drug tried.
• You have only a 3–10% chance of not being able to tolerate the drug at all.

➲ Your doctor should always treat the most impairing or life-threatening condition first. If, for example, you have bipolar disorder or serious depression, the first medication tried should be for that condition, before you start an ADHD medication.

➲ Disorders belong to people. Handicaps belong to situations.

Rule 1: Stop the Action!

➲ What Rule 1 can do for you:
Buy you some time before you respond.

If you have adult ADHD, Rule 1 is for you. It’s as simple as that.

Strategy: Perform a simple action to save off the urge to act.

Strategy: Pick a slow-talking model and play that role when you converse.

Rule 2: See the Past…and Then the Future

➲ What Rule 2 can do for you:
Help you see what’s coming next.

When a problem arises during your day, are you often completely thrown about what’s likely to happen and what to do? Do you constantly beat yourself up for making the same mistakes again and again? Rule 2 is for you.

Do you hit every problem with a “hammer,” because they all look like “nails” to you?

Adults with ADHD haven’t compiled a large store of remembered past experiences, so the subtle differences among problems and the need for different tools to solve them often elude them.

Does learning anything new require you to go through a long, slow trial-and-error process?

If you can’t call up mental images easily, you have to keep trying one thing after another.

Do you have trouble saving money, sticking to a diet, or perfecting an athletic skill?

Deferring gratification is tough when you can’t keep calling up the mental image of the prize that lies ahead.

Strategy: Use an imaginary visual device to turn on your mind’s eye.

Strategy: Use tangible visual aids to give your mind’s eye extra help.

Rule 3: Say the Past…and Then the Future

➲ What Rule 3 can do for you:
Help you analyze the situation before deciding what to do
Help you develop rules you can use for the same situations in the future

Do you see what’s coming and still go with the knee-jerk response? Do you feel like you keep having to learn the same lessons over and over? Rule 3 is for you.

Strategy: Become your own interviewer.

Strategy: Narrate what’s happening out loud.

Rule 4: Externalize Key Information

➲ What Rule 4 can do for you:
Give you something to rely on besides your own memory

Are you forgetful and scattered? Do people treat you as if you’re unreliable and untrustworthy? Are you beginning to agree that you have no self-discipline or stick-to-itiveness? If you have adult ADHD, you probably answered yes to all of these questions. Rule 4 is most definitely for you.

Strategy: Put physical cues in plain view in problem situations.

➲ Your physical cue must be in plain sight, right in the place where you need the reminder.

➲ An external cue not only helps you stop what you were impulsively about to do but also tells you what to do instead, and even why you were trying to change yourself for the better in the first place.

Strategy: Make a list of steps or procedures you want to follow the next time you encounter a problem task.

Strategy: Carry a journal with you at all time.

➲ A journal is invaluable: It’s your external working memory.

ℹ Digital recording devices seem ever present and may seem like an obvious choice for your journal. But I’ve found that people are likely to use and remember to read a small pocket journal, whereas they often misplace their little digital recorder or just forget to replay it to hear what they said earlier.

Rule 5: Feel the Future

➲ What Rule 5 can do for you:
Keep you motivated to reach your goals

If the purpose of the task you need to compel feels flat and abstract to you, leaving you uninspired to keep at them, Rule 5 is for you.

ℹ Scientists studying human emotions have concluded that a major function of emotion is to cause or motivate us to act. Although emotions are complex, certain emotions generally lead to certain types of actions. Here are just a few examples:

• Fear leads to “fight or flight”—attacking the source of danger or running away.
• Anger leads us to right a wrong.
• Joy and pleasure lead to the urge to keep doing what we’re doing.
• Shame dissuades us from repeating the shameful act.

➲ Visualize it → Verbalize it → Feel it

Strategy: Ask yourself point blank, “What will it feel like when I get this done?”

➲ Feel that future, and keep feeling it, all the way, until you get there!

Rule 6: Break It Down…and Make It Matter

➲ What Rule 6 can do for you:
Bring the future a lot closer

If pictures, words, and feeling are too fleeting to keep you on track, Rule 6 is for you.

Strategy: Break down longer-term tasks or goals into much, much smaller units or work quotas.

➲ Sign to post on your desk or work area: CHUNK IT, BABY!

Strategy: Make yourself accountable to someone else.

➲ Making yourself accountable brings in the internal motivator of emotions too. Letting someone else down doesn’t feel good; receiving admiration feels great.

➲ Make yourself accountable to someone for reaching each small subgoal and also the final project goal.

Strategy: Give yourself little rewards as you accomplish each small objective.

Rule 7: Make Problems External, Physical, and Manual

➲ What Rule 7 can do for you:
Simplify problem solving

If you typically get lost in all the possibilities when you ty to mentally solve a problem, Rule 7 is for you.

ℹ Our studies have shown that difficulty solving problems in their head keeps affecting people with ADHD as they get older, though in different ways. Young children may have trouble with mental arithmetic. They may not be able to recite backwards a string of digits read aloud to them. As they get older, they can’t hold all the parts of a story in mind (characters, places, dates, actions, etc.) as well as other adults when asked to explain the story concisely or write a paper analyzing the story in some way. Our research now shows that this problem affects adults with ADHD just as much.

Strategy: Use physical, external tools to solve problems whenever you can.

Rule 8: Have a Sense of Humor!

➲ What Rule 8 can do for you:
Help you accept your imperfections and get on with your life

If you’re still having trouble owning your ADHD, Rule 8 is for you.

➲ ADHD may be serious, but you don’t always have to be.

Strategy: Learn to say, with a smile, “Well, there goes my ADHD talking [or acting up] again. Sorry about that. My mistake. Now I have to try to do something about that next time.”

ℹ In recent research, my colleagues and I found the following in studies examining the educational history of both people diagnosed as adults and people diagnosed as children. The information on those diagnosed as adults came from the reports of people who knew them well as kids, mainly their parents. The information on those diagnosed as children came from the study I did with Mariellen Fischer, PhD, that followed children with ADHD in Wisconsin into adulthood (average age 27 years), at which time they still had the disorder.

School outcome, Adults with ADHD (%), Children with ADHD as adults (%)

Graduated from high school 88, 62
Graduated from college 30, 9
Retained in grade 25, 47
Received special education 35, 65
Received other assistance 48, 42

ℹ The same studies cite above showed that adults diagnose with ADHD as children had more learning disabilities than adults diagnosed as adults:

School outcome, Adults with ADHD (%), Children with ADHD as adults (%)
Diagnosed learning disorder 28, 45

ℹ Our research has found that adults with ADHD:

• Made a lot of impulse purchases
• Had high credit card balances
• Exceeded their credit limits more than others
• Made bill, loan, and rent payments late or not at all
• Had their cars repossessed more often than others
• Had lower credit ratings
• Were more likely to have no savings
• Were less likely to save for retirement
• Bounced checks more often than others
• Often failed to save receipts that could document money-saving tax deductions and other documents for their income tax returns
• Lost friends after borrowing money and not repaying it

➲ You can get software programs to help with setting up a budget, but I favor good old-fashioned pencil and paper—just as easy and cheaper.

➲ If you don’t save at least 10% of your income, you are having your vacation/retirement now and you will be working the rest of your life to pay for it!

➲ The only time you should buy something whose value goes down the minute you buy it is when it’s a necessity.

Yet there may also be times when going off the medication might make sense, at least temporarily. In my clinical experience some adults have found that the medication they were taking greatly restricted their range of emotions and even creativity. While this is not common and has not been documented in research studies, these individuals were in unique employment situations where their complaints made some sense.

One such person was a poet. She took her medication most days because of the responsibilities she had running a household, paying bills, driving, and the like, but found that she was far less creative as a poet on the days that she set aside for writing. So she would stop her medication for just those days, the arrangement worked well for her. Poetry is nothing without its emotion imagery, and metaphor, and she found her emotion was greatly restricted by her medication.

Another was a talented musician who played with a nearby symphony. Like the poet, he found that the medication was very useful for days when he was not playing his cello in the symphony. But when he performed with the orchestra, he was much more connected to and expressive of the emotional tenor of his music—the qualities that had made him such a successful musician—if he went off his medication.

➲ Emotional control problems may make you act boisterous, silly, or melodramatic, but it’s uncontrolled anger that threatens your relationships most.

ℹ Our adult patients have often told us that they simply did not realize just how poorly they were coming across to others during social encounters. At least not until it was too late. Some of the social violations they reported committing:

• Dominating conversations with endless monologues or storytelling that went nowhere
• Failing to listen closely for any length of time
• Having trouble reciprocating or taking turns during conversations or social encounters
• Making tactless comments
• Failing to honor social etiquette appropriate to the situation

➲ Reading entrance and exit cues is just as important as what you do onstage.

ℹ Our research and other studies have shown that adults with ADHD are more likely to have:

• Fair to poor dating relationships (four to five times more likely!).
• Lower-quality marital relationships (our studies found more than a twofold difference).
• Extramarital affairs.

➲ Adults with ADHD report much higher parental stress than other parents.

ℹ Research suggests that 30–40% of the children of adults with ADHD will have ADHD.

ℹ Our own study found that the children of adults with ADHD were also more likely to be oppositional and defiant even if they did not have ADHD.

➲ Guilt, fear, and a desire to avoid more stress may make you downplay signs of ADHD you see in your child. In that case try to trust your spouse or other close relative without ADHD who reports the same concerns.

ℹ Several studies show that parents with ADHD are less likely to monitor their children’s activities than other parents. Lack of monitoring is one of several factors that raise the risk of accidental injuries in those children. This may explain, in part, why children with ADHD have more injuries of all types than other kids, and that is because many of their parents have ADHD.

ℹ Research has found that at least 50% and as many as 70% of children with ADHD had no close friends by the time they reached second or third grade. It didn’t take weeks or years for other kids to start rejecting those with ADHD but minutes to hours after the child with ADHD entered a new peer group, such as other children at a summer camp.

➲ ADHD makes you “probability blind”—you don’t look ahead to consider seriously and rationally what might happen as a result of whatever actions you’re considering taking.

➲ Adults with ADHD not only get three to five times as many speeding tickets but also get more parking tickets—impulsively parking wherever they are because they lack the patience to look for a legal spot.

➲ Adults with ADHD are 2.5 times more likely than other adults to die prematurely from misadventures like car accidents.

ℹ Studies show that adults with ADHD:

• Already drive as if they are legally intoxicated even if they have had no alcohol
• Are more adversely affected in their driving by even low doses of alcohol than drivers without ADHD

ℹ One recent study found that children with ADHD (and other disruptive behavior problems) were three times more likely to die before the age of 46 than children without these disorders (3% vs. 1%).

ℹ My recent research and studies done by others have found that adults with ADHD are:

• Almost 50% more likely to have experienced a serious injury in their lifetimes
• Four times as likely to have had a serious accidental poisoning
• More likely to file claims for worker’s compensation than other adults

ℹ Several studies by my friend and colleague Eric J. Mash, PhD, and his students at the University of Calgary (Canada) found that pregnant women with ADHD were less likely to be married and less likely to have planned their pregnancies than women without ADHD. The mothers with ADHD were also more likely to be anxious and depressed both before and after their children were born. Before birth the mothers had less positive expectations about motherhood, and after birth they had more difficulty with child rearing.

ℹ Studies show that half of all deaths in the United States are the result of lifestyle choices in areas such as:

Tobacco use (19%)
Diet and physical activity (14%)
Alcohol use (5%)
Firearm use (2%)
Sexual behavior (1%)
Driving (1%)
Illicit drug use (1%)

Canadian research also found that 50% of all premature deaths could have been prevented through lifestyle changes across similar domains.

ℹ People diagnosed with ADHD in adulthood were about as active physically as adults in the general population. But adults (age 27) who had had ADHD since childhood were significantly less likely to get regular routine exercise (44% vs. 69% of the general population). If this pattern continues, these adults will be more prone to health problems stemming from lack of exercise later in life.

➲ If you’re overweight, ADHD medication can be doubly beneficial to you since it often causes weight loss.

➲ Having another disorder besides ADHD doesn’t make you unusual or beyond help. Only 1 in 5 adults with ADHD has ADHD alone.

ℹ A few studies have suggested that adults with ADHD might be more at risk for bipolar disorder (manic depression), but most studies, including my own, have not found this to be the case. Adults with bipolar disorder do, however, have a higher risk for ADHD. That risk is 20–25% for adult-onset bipolar disorder, 35–45% for adolescent onset, and 80–97% if the bipolar disorder started in childhood.

➲ Use of cocaine and other hard drugs and abuse of prescription drugs are associated more with CD [Conduct Disorder] or other antisocial behavior than ADHD.

ℹ Scott Kollins, PhD, and colleagues at Duke University recently published a study that shows a direct connection between ADHD and risk for smoking cigarettes. Following 15,197 adolescents into young adulthood, they found a linear relationship between the level of ADHD symptoms and regular smoking. Specifically, the risk of regular smoking increased significantly with every additional ADHD symptom. Not only that, but the more ADHD symptoms the teens had, the earlier they started smoking.

ℹ Caffeine is also considered a stimulant. Not surprisingly, we found that young adults with ADHD in particular were likely to consume more caffeinated drinks per week than young adults without ADHD.

➲ Antisocial behavior predisposes you to substance use, and substance use predisposes you to antisocial behavior.

ℹ The type of crime most associated with ADHD in my research was using, possessing, and selling illegal drugs and stealing money to buy drugs. About one in four people with ADHD, at a minimum, are likely to have drug use and abuse issues as adults.

Are you sure you want to be among them?