I felt fortunate to have had the chance to interview Dr. Kathleen Nadeau on May 3, 2022 as a tease prior to the release of her book in September, “Still Distracted After All These Years,” where she reported the results of interviews of older adult individuals with ADHD and their functioning in later life. My interview questions presented below were based on Dr. Nadeau’s presentations and writings as well as highlights of her findings from her interviews for her book.
Dr. Quinn’s interview of Dr. Nadeau is presented in two parts over the next two issues of Age in Action.
Katherine Quinn, Ph.D. is a clinical psychologist in private practice. She is a Past President and Fellow of SDPA. She was also previously Editor of the San Diego Psychologist.
Dr. Kathleen Nadeau, founder of The Chesapeake Center in Maryland, is an internationally recognized authority on ADHD. She is a frequent lecturer both in the United States and abroad and provides professional training seminars on topics related to ADHD. Dr. Nadeau is the author or co-author of over a dozen books related to ADHD that address ADHD issues across the lifespan, from her best-selling book for children, “Learning to Slow Down and Pay Attention”, to her current research and writing project on older adults with ADHD titled “Still Distracted After All These Years.”
Dr. Nadeau is especially known for her work with older adults with ADHD. At the 2018 annual meeting of the American Professional Society of ADHD and Related Disorders, she presented on the impact of ADHD over 60. Her work has brought attention to the impact of ADHD on the elderly and the importance of conducting a proper intake or screening in order to not overlook or mistreat this diagnosis.
ADHD AND LIFESPAN RISK FACTORS FOR THOSE WITH THE DISORDER
Q – Dr. Nadeau, what is an initial takeaway that you would like readers to know from the start about ADHD and older adults?
Well, to begin with, I think there is a tremendous lack of knowledge and awareness about ADHD and older adults. In particular everyone that is involved with ADHD will give lip service to it’s a lifespan disorder. We know it is something we’re born with and live with throughout our lives. And yet very little attention is paid toward ADHD and adults, especially older adults. There’s minimal research on older adults with ADHD and the research that exists is being done in Europe for the most part. It consists in mostly large demographic studies trying to understand whether the rates of ADHD decline as we get older. So, I would like to start right there. Dr. Russell Barkley approached the ADHD community with some very alarming news. He had done a demographic study in the United States and he found that the lifespan of individuals with ADHD is significantly shorter by approximately a decade.
Barkley says ADHD is the Number One factor affecting mortality for the people who have it. During a presentation at the 2018 Child and Adolescent Disorder (CHADD) Conference in St. Louis, Barkley demonstrated the complex ways attention deficit disorder (ADHD OR ADD) can shorten a patient’s life span. Barkley’s research team used data from a longitudinal study that followed a large group of predominantly white, male patients with ADHD from childhood through adulthood in Milwaukee, Wisconsin. The team uncovered a set of distinct risk factors — and adverse outcomes — during each developmental stage. These ADHD-related risk factors spanned cognitive, family, peer, educational, occupational, financial, sexual, driving, and health-related domains.
The researchers then used an actuarial database calculator from the University of Connecticut (UConn) to determine exactly how each risk factor may translate into years of lost longevity. The results of this analysis showed that expected life span is reduced by nearly nine healthy years (eight years overall), for those who had ADHD in childhood when compared to a control group.
Patients whose ADHD persisted into adulthood saw an additional five-year reduction in life expectancy. Compared to a control group, adults with ADHD could expect to have about 11 to 13 years cut off their lives compared to neurotypical peers of a similar age and heath profile.
Regression analyses determined that impaired behavioral inhibition was the primary factor that significantly reduced life expectancy in people with childhood ADHD. This includes the following behaviors:
Low conscientiousness
Poor self-regulation
High impulsivity
Q – What else is important to understand about lifespan risks?
I think what’s so important to comprehend is that right now the average lifespan in the US is 78 years. So, if the average lifespan is shortened by a decade, then that means that there are many, many fewer adults living with ADHD in older years. Not because it’s gotten better for them, but because they’re no longer alive. And we need to put things in that context.
Q – So, ADHD’s diminishing presence in the elderly is not so much that people with ADHD improve their management of the disorder with age. But rather, a great many of the people impacted are no longer alive?
Yes, and Dr. Barkley attributes that shorter lifespan to accidents and injury. For example, automobile accidents kill quite a few people. Many younger adults in particular with ADHD are killed in accidents because they are impulsive and exhibit risk taking behavior.
But among those who don’t die in accidents, Barkley basically says they die by lifestyle in that people with ADHD are less self-disciplined. So, they’re more likely to have very unhealthy or disordered eating patterns. It takes a lot of executive functioning to plan and prepare healthy meals. They are much more likely to live on the sort of traditional American diet of fast food and junk food, which we all know shortens our lifespan because of heart disease and Type 2 diabetes. When we consider people in their later years we’re really talking about the survivors or the more functional ADHD group. These are the less impacted adults that have managed to live into their retirement years. And this is a hugely important thing to be aware of.
ADHD SYMPTOMS IN ADULTS AND HOW TO ASSESS THEM
Q – So it sounds like those with ADHD that have better learned how to manage their lives from early on are going to do better and maybe live longer than their cohorts because they figured things out. They have made some kind of a plan for themselves and adapted to their symptoms. So what should we look for in assessing the older undiagnosed ADHD adults that are still surviving?
Well, the fact of the matter is that symptoms are really not that different in older years than in middle aged years. Both groups are less likely to be hyperactive. We know that at about 50 years old, they’re less hyperactive than at 25 years old. The hyperactivity levels decrease and they may have found meditation and other techniques to manage it. Still, quite a few of the older adults that I interviewed in talks preparing for my book, discussed what I would call ‘remnants of hyperactivity’ in that they still felt restless. Their body may no longer be racing to the same degree, but their mind still was.
And I actually interviewed several older adults who were clearly still physically hyperactive, although that is a rarity. But when you ask, what do we look for? The symptoms are very similar. The problem is that as we age, if individuals are having difficulty with remembering, losing things, forgetting what they have been told, and they are 65 or 70, psychologists and others are much more likely to mistake it for age related cognitive decline. Because that is what is on everybody’s mind when there is an assessment in later years.
Q – So with the younger children and with adolescents, we do a very comprehensive examination in order to provide the best understanding of the type of ADHD, and to assist in accommodations in school. What kind of assessment is needed for older adults?
We don’t need to do a comprehensive exam. Those comprehensive neuropsych evaluations exist initially for children and adolescents because they’re helpful and appropriate for people during the school years and in the early employment years where individuals may be required to provide a full assessment by some employers if someone is going to claim a disability. But typically, and Russ Barkley, who is a psychologist has said this for years, a neuropsych evaluation is not necessary to make a good ADHD diagnosis. But what is necessary is that a very strong clinical interview be done by somebody who has expertise in ADHD. A lot of people rely on questionnaires simply because they have norms and they feel more confident in making the diagnosis or the norms may be necessary in order to receive educational accommodations. But, The Brown ADHD Scales, for example, which is one that we use at my clinic, is a really good one for diagnosing. And if they score in the ADHD high range on this, then the clinician will feel confident about the ADHD results.
But, more importantly, there is no substitute for both a knowledgeable clinician that performs a thorough in person intake. For example, I just did a consultation on a woman who’s 70 years old. She’s been in therapy and psychiatric treatment for years. And she was only very recently diagnosed with ADHD at her own initiation. She is a bright, educated woman, and a retired school teacher. She finally went in and asked her therapist and psychiatrist, “Do you think I could possibly have ADHD?”
They did some questionnaires and decided, yes, indeed she had it. This woman talked very rapidly in order to get her story out. Now, had that same woman walked into my office, I wouldn’t have needed a single questionnaire and I wouldn’t have needed more than five minutes to make that diagnosis. And so it’s kind of alarming to me that there’s so little awareness in the general mental health community regarding what symptoms to look out for.
The woman talked tangentially, constantly hopping from one topic to another. I had to constantly bring her back. For example, I said, “Now you were telling me about your mother…” And she would say, “Oh, that’s right. I’m so sorry…” and then she would come back to that topic. Her symptoms were just very classic ADHD, and yet the symptoms had not been picked up by her treatment specialists. And the signs from her history were not subtle. She was a risk taker with an adventurous spirit.
She definitely fell into the more hyperactive impulsive end of the continuum. She left home at 19 and never went back. And because she was determined she managed to get herself educated. But if you heard her life story, you would recognize it as one of following her impulses. And even today at 70, she’s interested in traveling the world and wants to get involved with international habitat for humanity because she is willing to go. So she is still just bouncing around and full of energy and curiosity and shows lots of the positive traits of ADHD. I bring her up to emphasize that even she who shows all the signs of ADHD, wasn’t diagnosed until now. Instead, she was diagnosed previously with anxiety and depression, which are more common than not among women with ADHD.
But nobody picked up the signs. So, what I think is important to look for is if, if anyone is talking about memory problems and they are 60 or older, we shouldn’t immediately leap to it being cognitive decline. Instead, we should immediately leap to, “has anybody in your family been diagnosed with ADHD?” We know it’s highly genetic and so the first thing to look for is the potential genetic context or makeup. So I would ask, “Okay, you have grown children that have been diagnosed. Do you have grandchildren who have been diagnosed? Or do you have family members with learning disabilities?” We know that learning disabilities are commonly linked with a history of anxiety, depression, substance use disorders, and ADHD. And, ask if the person has had multiple failed relationships? Have they jumped from job to job? Does this person have difficulty managing their finances and other paperwork? Would they describe their home environment as cluttered or chaotic or messy? It is important to look for these things in an adult in the same way as we would in a child or adolescent. ADHD in the older person is not a different set of symptoms.
Q – So, we need to take more time and we have more work to do in looking at older adults that present with ADHD symptoms. And is that your protocol for your clinic?
We have a complete initial consultation to do at our clinic, and we have paperwork we give for completion. And many older adults with ADHD really struggle with keeping up with the paperwork. They are already behind on their taxes and health insurance forms and finance issues as well. And that inability to handle paperwork is a good initial sign that they may have ADHD.
Stay tuned for Part 2 of Dr. Quinn’s interview in the September issue of Age and Action.