Recognizing ADHD in High-Performing Adults

Attention-deficit/hyperactivity disorder (ADHD) often goes underrecognized in adult patients, particularly those deemed “high-performers.” In this video, Timothy Wilens, MD, discusses the unique challenges in assessing and diagnosing ADHD in this patient population. 

While exploring the factors that may contribute to underdiagnosis, Wilens highlights practical strategies for recognizing compensatory behaviors that may be masking telltale signs of adult ADHD. Given its high comorbidity with other mental health conditions, he also emphasizes the importance of assessing for ADHD, even when the patient is presenting with a different concern in clinical practice.

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• ADHD in adults remains underrecognized, with approximately 1 in 7 to 1 in 8 affected adults currently diagnosed and treated.
• Adult ADHD co-occurs with other psychiatric or substance use disorders at an estimated 20% to 30% frequency, underscoring the importance of considering ADHD in these clinical populations.
• ADHD in high-performing adults may be masked by compensatory strategies, and clinicians should assess the effort required to manage symptoms, particularly when increasing workloads or multitasking overwhelm previously effective coping systems.

Timothy Wilens, MD: My name is Tim Wilens, and I'm the chief of the Division of Child and Adolescent Psychiatry at Massachusetts General Hospital, and I'm a professor of psychiatry at Harvard Medical School.

Psych Congress NP Institute: What are the factors driving the underdiagnosis or overlooked cases of ADHD in the adult population?

Wilens: We've known for some time that ADHD in adults has been underdiagnosed and basically underrecognized. People didn't think about ADHD in adults. 

We've actually done pretty well as a society in identifying cases in childhood, but for the many adults who grew up many years ago as children, there's still underdiagnosis. 

It's gotten better. We used to diagnose about 1 in 20 adults with ADHD, and now about 1 in 8 or 1 in 7 adults with ADHD are diagnosed and being treated.

What are the factors? I think if you don't look you don't see and if you don't see you don't look. It's one of these, we call it tautology, a tautological concern. That is people don't think to look for [ADHD], and because they don't think to look for it, they don't see it. 

I can tell you one thing. If you're in psychiatric practice or treating people with substance use disorders, it's definitely there. It's co-occurring with other disorders at a roughly 20% to 30% frequency. So, [ADHD] there in front of you. You just need to look for it.

PCNPI: What are the specific challenges of diagnosing ADHD among adult high performers?

Wilens: It can be difficult to diagnose ADHD in high-performing individuals for a number of reasons. First of all, high-performers typically are individuals who have high IQ, who don't have a lot of learning disabilities, don't have a lot of other executive function issues, etc. Because of that, they can compensate for many of their symptoms. 

For example, they may have impulsivity. They may have the urge to speak out during meetings or to react adversely to something, but they've been able to stop themselves from doing that. Another compensation that a lot of adults have is that they will just avoid situations. Certain high performers have been able to find individuals around them who may do their tasks, or they simply don't do them and have figured out a way to get away with that. 

One of the things that really helps when you're going through the symptoms of ADHD, particularly in somebody who may be doing well, is to ask how hard [a patient may] have to compensate for that symptom. Yes, they may not push or get aggravated in line overtly, but how much are they fighting that urge? 

The same way if you were to suppress a cough, you're still coughing, but you're suppressing the cough. [Ask,] “How hard is it for you to stand in line without getting agitated? How hard is it to be in a meeting without saying something? How many special systems do you have that you're making lists with or you're keeping reminders?” Things like that. 

So, ask about compensation. If people are spending a lot of effort compensating for a specific symptom, I would consider that symptom positive. Our experience is that individuals who are treated for their ADHD will tell you that that urge, symptom, whatever you want to call it at that point, is much better and they don't have to spend as much effort compensating. 

One final thing I would say about high performers. Often, these individuals can get through primary, secondary schools, they can go to graduate schools. When you see them presenting for treatment is often when they have multiple tasks that are being thrown at them simultaneously and what used to work, their compensation systems, etc, can no longer keep up with the amount of work and amount of multitasking that they're asked to perform or to complete. That's when they'll start presenting for treatment—I've treated a number of, let's say, physicians or attorneys who have had issues because they simply haven't been able to keep up with letter writing, task completion, finishing their charts, etc, etc. 

Timothy Edwin Wilens, MD, is Professor of Psychiatry at Harvard Medical School. Additionally, he is Chief of Child and Adolescent Psychiatry at Massachusetts General (MGH)/McLean/Brigham and Women’s Hospitals; and is senior staff and director of substance use services in the Pediatric Psychopharmacology Clinic and Research Program at the MGH in Boston, MA.

Dr Wilens earned his medical degree from the University of Michigan Medical School in Ann Arbor. He went on to complete his residency in psychiatry at Massachusetts General Hospital. He is certified by the American Board of Psychiatry and Neurology in General Psychiatry, Child and Adolescent Psychiatry, and Addiction Psychiatry.

Specializing in the diagnosis and pharmacological treatment of children and adults with ADHD, bipolar, substance use disorders, and other psychopathological conditions, Dr Wilens cares for patients, supervises clinical trials, and consults on difficult cases.

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