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77: Adult ADHD

May 04, 2021

Trouble focusing? Could it be adult ADHD? Psychiatrist Rachel Weir tells us how she makes the diagnosis and other factors that might lead to focus and concentration issues.

Episode Transcript

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Scot: This is "Who Cares About Men's Health," giving you inspiration, information, and a different interpretation to better understand and engage in your health so you can have the life you want today and into the future.

My name is Scot. I'm the manager of And I care about men's health.

Troy: And I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Dr. Weir: I'm Dr. Rachel Weir. I'm a psychiatrist at the University of Utah, and I care about men's health as well.

Scot: So we're going to talk today about adult ADD or ADHD. One of the things I do want to clarify right away is . . . I mean, are those the same? Are they different? I've always used them interchangeably.

Dr. Weir: A lot of people say ADD, attention deficit disorder, versus ADHD, attention deficit and hyperactivity disorder, because they don't feel like they have hyperactivity, especially for adults. Kids, you see the hyperactivity symptoms much more frequently than you do in adults.

But if you wanted to be strict in terms of the definition, it all is ADHD. So you would say ADHD predominantly inattentive type or ADHD predominantly hyperactive type or a combination of the two.

Troy: See, Scot, I didn't actually know that, so I'm glad we clarified that. But you're right. I had heard years ago ADD, and then now I always just use the term ADHD, but I did not understand the reasoning for that.

But it sounds like, Dr. Weir, you're saying if we're . . . basically, we don't use the term ADD anymore. It's ADHD, and then there are different subtypes within that.

Dr: Weir: Yeah, exactly.

Scot: So I'm going to make an admission here that's not going to make me look like a great person nowadays. And I think a lot of people out there do this as well. Joke at one time or another when they're having trouble focusing on something, or they get easily distracted, "Oh, man, I really got some ADD today." But just because I can't focus at any particular given time doesn't mean that I have ADHD, right?

Dr. Weir: No, absolutely not. And most of the time, it's not going to be ADHD in adults, especially adults who . . . if you're presenting with new symptoms in your 30s, 40s, 50s, that's not going to be ADHD. ADHD is a diagnosis originally of childhood. It can span the whole lifespan. It doesn't for everybody. But you do have to have symptoms present before the age of 12.

Troy: Scot, we're talking about adult ADHD today. But, Dr. Weir, it sounds like you're saying that it's not something that an adult would develop. Like, this has been a pattern and maybe it just wasn't diagnosed until they were an adult.

Dr. Weir: So it is possible that . . . sometimes I see people for an assessment that tell me, "Oh, gosh, I always struggled in school. My teachers, their comments always said I was hyperactive or always out of my chair or blurting answers out. And my parents didn't really believe in mental health and never really got me treatment."

So if you hear a story like that, even though someone didn't have a diagnosis at a young age, they still can have the diagnosis, of course. It's just that it wasn't picked up on when they were younger.

But if you're in your 40s and 50s and you're having symptoms of inattention, distractibility for the first time, it's very likely something else.

Scot: How many adults do you encounter that have the symptoms but just weren't diagnosed when they were younger? Is that something you encounter often?

Dr. Weir: That that does happen frequently, yeah. It also happens probably just as frequently that it's something else that's causing the problems now.

Scot: Oh, okay. On your definition, you kind of focused in on that example you told of the child. The hyperactivity part was kind of the theme I got there. Is that generally the case? So am I incorrect in thinking it's just kind of lack of attention even in a child? It's more about the hyper?

Dr. Weir: It can be both in kids. It is much easier to identify in kids who are hyperactive in a school setting. For the kids that don't have hyperactivity, if they're just distracted, they're kind of daydreaming, gazing out the window, they're not picked up on nearly as frequently as someone who's causing a lot of commotion in a classroom setting.

Troy: As we're talking about this, like I said, sometimes I joke that if I didn't have ADHD when I started my job, I do now. But it sounds like you're saying I don't have ADHD. I was a focused student. I was not hyperactive as a kid in elementary school, junior high, high school. Not an issue.

But I'll tell you, I struggle with just paying attention. If I'm in a lecture, 15 minutes in, I zone out. You've got to do something to keep my attention. Is that abnormal, or if someone has this experience, is this something abnormal where they should seek attention? Or is that just kind of typical for most people?

Dr. Weir: The key to really making a diagnosis, other than some of the things that we'll go into and, like I said, the symptoms presenting in childhood, would be, "Is this impacting your life? Is this interfering with your functioning day to day, in multiple settings too, not just in a work environment, but at home? Is it somehow affecting your relationships? Have you had repeated school failure, maybe legal problems, car accidents, job losses?" Those types of things that really, obviously, can contribute to a lot of impairment and functioning for people versus just, "Sometimes I'm not quite as on task and as sharp as I could be."

Troy: And that's a great point, because I think we all look at ourselves, and like you said, sometimes you feel down, sometimes you're depressed, you're sad, but it doesn't meet that clinical definition, or distractibility or tough time focusing. But it's not really a clinical thing unless . . . We all experience that, but it's not necessarily an issue where you need to be on medication or have treatment unless it really does affect function and personal relationships, jobs, etc. So yeah, I think it's helpful for all of us to know that.

Dr. Weir: Yeah, absolutely. A lot of the screeners if you just Google . . . because everyone does Dr. Google now, right?

Troy: Yeah.

Dr. Weir: Like, "Do I have . . ."

Troy: Such a bad, bad doctor.

Scot: Everything is going to kill you according to Dr. Google.

Troy: That's why people come to the ER, Dr. Google.

Dr. Weir:But if you Google, "Do I have adult ADHD?" it's probably going to guide you towards a rating scale that's based on symptoms. So it's not going to be very sensitive in terms of actually giving you a diagnosis and saying, "Do you have some functional impairment?" It's just looking at symptoms. So I've seen a lot of people bring those kinds of screeners to me saying, "I'm pretty sure I have ADHD."

Scot: I understand you developed a protocol to help diagnose people that may have adult ADHD. Can you talk about that a little bit? What are some of the things that you do look for?

Dr. Weir: Yeah, that's part of my work. I supervise psychiatry residents who rotate through our university community clinic system in primary care clinics. The first year we did it, I was expecting to see a lot of depression, anxiety, possibly bipolar disorder. And we were really surprised at the number of requests we got for adult ADHD assessments.

So we really had to come up with a protocol that was thorough but reasonable to kind of help our primary care colleagues in how to really make this diagnosis.

So one thing I would say is if, as a patient, you're wondering about this, and you're going to a provider, and you're just saying, "Oh, I can't really focus, and I filled out this scale," and there's not really much of a discussion of, "Is this lifelong? Is there collateral information maybe from a school or a parent?" and screening for other mental health conditions or other medical conditions, and you're leaving that appointment with a diagnosis and a prescription, that probably wasn't an adequate assessment.

So we developed . . . it's still shorter than doing a full neuropsych testing and neuropsych battery. But it is a two-part evaluation. At that first appointment, what we can focus on is screening for possible comorbidity, other mental health problems, substance abuse problems, underlying medical problems that could be contributors, giving the patient some scales to take home and fill out and maybe have a spouse or a parent fill out.

And then coming back and kind of looking at all that information together in the second appointment, and going through if an ADHD diagnosis looks like it's likely.

Troy: So what's the downside then of . . . let's say someone takes a scale in, they see their doctor, and their doctor says, "Yeah, it looks like on this scale you have ADHD." What's the downside of going on treatment? Is that a detrimental thing for these patients? Does it help them function better?

Dr. Weir: That's a . . .

Scot: Well, there are two questions, if it was a misdiagnosis and if it's a proper diagnosis. Right?

Troy: Yeah. It sounds like what you've seen is maybe a lot of potentially overdiagnoses, where people are maybe just going in and saying, "Hey, I did this scale." Obviously, a lot of primary care physicians are very busy and sometimes the easiest thing is to say, "Here's a prescription."

Dr. Weir: Yes.

Troy: I guess, number one, are you seeing that quite often? And number two, what's the what's the downside of that?

Dr. Weir: I'll try to remember all the parts to that question.

Troy: I'll ask you first, does that happen often?

Dr. Weir: Yeah, it certainly does. And that's kind of why we wanted to come up with a good way to really screen people and make sure we were treating comorbidities.

There was one very good study done that was published in the last few years. And this had actually been a longitudinal study of kids with ADHD, and then they had kids without ADHD in the control group, and they followed them over time.

In fact, the length of time that they followed them was into . . . the average was about 14 years. So this was long-term follow-up.

Now, of the children that they followed who were in the control group, we knew at age 10 that they did not have ADHD because they had very good assessments at that time. When they did screeners as they became adolescents and adults, almost half of them had what would be considered a positive screen for possible ADHD.

Now, when they went back with that group and they did a really thorough assessment looking at all those things, impairment in functioning, multiple settings, not just self-report but parent report as well, psychiatric comorbidities, substance abuse, 95% of that group did not have a diagnosis of ADHD.

Troy: Oh, wow.

Dr. Weir: Yeah. So very, very high. It's not going to be that high in the real world, because like I said, they knew these kids didn't have ADHD, and obviously, we're treating people who most of them haven't had any kind of assessment, let alone a thorough assessment at age 10.

But usually, the symptoms they were experiencing were due to another condition. So trauma was one. Depression. That can affect concentration. Cognitive effects of marijuana use was one, and alcohol use as well.

So that is one thing. You want to make sure you're getting your diagnosis right.

Now, if you're not getting your diagnosis right . . . and let's say you do get an ADHD diagnosis, and you start a medication. Let's say it's a stimulant, because that's what most people get prescribed. So methylphenidate, or the common name would be Ritalin, or amphetamine salts, or Adderall would be the common name there. That can be very helpful for symptoms of concentration, but that's not diagnostic.

If all three of us took Adderall right now, it would help us focus better. That doesn't mean that we have ADHD, right?

So what would be the downside of doing something like that? Well, first of all, just improving your concentration alone doesn't inherently fix a lot of the problems that people with ADHD have around planning and being less impulsive, improving executive functioning. You still need some skill-based treatment for that.

And then if you're prescribed a stimulant, you might feel like, "Wow, this isn't really affecting me." But it could make anxiety worse. It could make you not sleep as well.

And then sometimes what we see is people get into these prescription cascades where they didn't really need that original prescription, and then they're prescribed something for sleep. Then they're feeling groggy the next morning from that, and then they want their stimulant dose increased.

You can see you can kind of get down these paths where you're treating more side effects than you are really treating a condition.

And then, of course, there can be some concerns about stimulant use, especially in men, especially as you get older. Blood pressure increases. Pulse increases.

Now, it's not that significant, but if you're talking about taking these medications for 10 or 20 years, then that can be a significant strain on your heart.

So those are just some things to think about.

Scot: That's interesting. But it sounds like that study . . . my takeaway from that study is if I go online and I do one of these self-assessments for ADHD, it's pretty much a coin flip as to whether I will be diagnosed based on that with ADHD versus not, and I probably don't have it even if I'm diagnosed by that.

Dr. Weir: Yes. There was actually a good "New York Times" article several years ago, where they had 1,100 adults take an online ADHD quiz, and almost 50% scored in that range that told them ADHD was possible or likely.

Troy: And of those, it sounds like the large majority, once they undergo a more rigorous assessment, don't have ADHD.

Dr. Weir: That would be correct, yeah.

Troy: Wow. Interesting.

Scot: So this is interesting. It's always interesting when we go into these conversations on "Who Cares About Men's Health," because when I came in, I . . . here's the way I thought it was going to go in my brain. We were going to talk about all these people that are adults and were misdiagnosed or undiagnosed for ADHD. Not misdiagnosed. Let me rephrase. That were undiagnosed. They are struggling in their life, they finally get the proper diagnosis, they get the proper treatment and medication, the . . . I can't remember what you referred to those as, impulse control, that sort of thing. Those exercises?

Dr. Weir: Oh, yeah. Mindfulness and skill-based therapy.

Scot: But what I'm hearing instead is it's a lot more likely that you're going to go in with some symptoms of something completely different, perhaps get a misdiagnosis, end up on some medication you don't really need to be on, and you're not really even solving the problem that you had in the first place. Which one is the bigger risk for an adult here?

Dr. Weir: Well, there's a reason that we've seen the number of stimulant prescriptions increase threefold in just a five-year time period. And at this point, adults make up the majority of those prescriptions. It's no longer that a majority of prescription stimulants are prescribed to children. Now, it's to adults.

Yeah, a lot of people wonder, "Well, if this helps my concentration and my focus, and I feel like I'm functioning better, what's the harm?" I think these medicines . . . I mean, we have to remember they are controlled substances. They are addictive, but they don't have the same . . . there hasn't been the same concern about them like you've seen with the opioid epidemic, with people overdosing and dying.

These medicines are very, very commonly misused, but most people are not getting addicted to them. So high misuse, high rate of diversion or sharing medication, especially when you get to college students, but low in terms of actual addiction.

Troy: You mentioned that increase in the last five years. Just in the last year with the pandemic, are you seeing kind of anecdotally significant increases in the number of stimulant prescriptions and diagnoses of ADHD?

Dr. Weir: I am not aware of that. I don't know. Certainly, the effects of the pandemic I think are going to be very long lasting. Typically, mental health sequelae of something like this, it develops a little bit more after the fact. But people are very concerned about that, especially with depression, anxiety, and post-traumatic stress disorder.

But I do think there are some things going on related to the pandemic that might make more people think that they have ADHD. So one is a lot of us started working from home. That can be much more distracting than being in your office. And just kind of dealing with those distractions, especially if you have kids at home, you have other things you look up and see and think, "I have to go do that right now instead of focusing on work."

And alcohol use has increased as well. So any time you have an increase in alcohol use, people might think, "Oh, gosh, this isn't really affecting me. I'm just having a couple extra glasses of wine a night," or whatever. But it is likely impairing sleep, which if you're not getting great sleep, you're not going to be very focused and energetic. And then that can kind of carry over into a sluggish feeling the next day.

And then just depression and loneliness as well. So one of the core symptoms of major depressive disorder is impairment in concentration. That is also one of the core symptoms of anxiety, generalized anxiety disorder, is impairment in concentration.

So it makes sense that we might see more people presenting with this concern than we already do. But yeah, I think those are some reasons.

Troy: That's what I wondered. We talked to Dr. Ben Chan as well, who I'm sure you know . . .

Dr. Weir:Yeah.

Troy:. . . who works at Primary Children's. He talked about that same thing, how we're all experiencing that, distractions and difficulty concentrating. And I've wondered how many of us have thought to ourselves, "Wow, I must have ADHD. I just can't focus. It's so difficult to get tasks done." And then potentially doing online assessments and potentially being diagnosed and prescribed medications.

Yeah, it's interesting, but sounds like maybe that is something we might see as more data comes out in the next couple of years in terms of prescriptions and diagnoses during this time.

Scot: It also seems as though that distraction could be a symptom of a lot of different things.

Dr. Weir: Absolutely.

Scot: I'm kind of understanding that just because you're distracted and can't focus, you think, "Well, I've got ADHD." Probably not. It's probably something else. So go see somebody who can help you sort through some of those things if they are actually impacting your life in a negative way.

Dr. Weir: Yeah, absolutely.

Scot: Dr. Weir, help me sum up what we've learned today. We set out on this journey talking about adult ADHD. Is that something that somebody could have? Would they want to seek treatment for that? We kind of ended up someplace else. What would your ultimate summary be of what we should take away from this?

Dr. Weir: Well, I'd say that ADHD in children and adults is a very real condition, and it can cause some very significant problems for people. So it is important to get it assessed and treated if you think that you suffer from it, or if you know you do, if you've had the diagnosis or testing in the past, but maybe you kind of stopped getting treated and now you're noticing some problems again, especially when we get to that kind of functional impairment.

I think it would be worth noting that medication is very helpful for this condition. It's very helpful. However, it can't really help with some of the skills that people need in terms of being able to plan, multitask, think about future, planning things like that. So it is important to do some skill-based work as well, and maybe mindfulness too, being able to learn how to stay in the moment, stay on one task. That can be very helpful as well.

And then I think just reiterating that this is a diagnosis that originates in childhood. So if you're noticing something now, if no one ever noticed any problems when you were younger, a parent, a teacher, yourself, and you don't really have that functional impairment, you're noticing things like, "Oh, my work performance isn't top notch. I'm not at the top of my game. I forget what I'm doing," you probably don't really meet the criteria, even though you might have some symptoms.

And then I just always think it's important to think about what some other underlying conditions are that could be contributors. We talked about depression, anxiety. Sleep problems, for sure. We didn't get to that too much. But especially in men, thinking about sleep apnea, and what that can do to your thinking and concentration throughout the day. That's all very important.

Scot: Troy, do you have any final questions you'd like to throw out there?

Troy: I mean, my takeaway from this is if you have concentration difficulty that's affecting your function, relationships, work, etc., you should really talk to someone. But again, it sounds like you're saying it probably is something else. Maybe adult ADHD, but probably not.

Dr. Weir: It's probably something else. And if it's a new problem, it is definitely something else.

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