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April 4, 2022
What are we to make of adults who exhibit the diagnostic criteria for ADHD, but are nevertheless high-functioning and successful? A trio of British investigators has just published six case studies that explore this question. It would have been better for them to have conducted a much larger, controlled research study but, in the absence of such data in the area, these case studies are intriguing and may help guide more informative research.
The authors recruited six successful men between the ages of 30 and 65 from a National Health Service tertiary service in London. Four were in long-term relationships, with children. All had good jobs.
In open-ended taped interviews of up to an hour in length, each was asked three questions:
1. What do you think are the advantages and disadvantages of having ADHD?
2. Please describe a time when you felt that your ADHD helped you to achieve something?
3. What aspects of your ADHD would you miss if it went away?
Hyper-focus in ADHD is generally considered a deficit, inset-shifting, and task-switching. But the authors report that participants associated it with productivity. One said, “I think the energy that the ADHD brain seems to have....it’s unfocused, quite scattered, chaotic and a bit random...but give that brain something that you can tune into, and it’s your interest, then all that random stuff just goes boom... I get this incredible intense concentration and that’s great for work.”
Participants also saw advantages in divergent thinking, with one stating, “I’m an artist.... a creative type... a Bohemian.... you are most likely to be a creative person if you are a divergent thinker....and not convergent... I am very creative and that’s through and through... I’m a fine art graduate, a musician, a published poet, an entrepreneur, a performer.”
All the participants reported being seen as nonconformists. Depending on a viewpoint, that can be seen as either detrimental or advantageous.
Impulsivity is a core symptom of ADHD. Participants however related it to bravery, and more specifically adventurousness, spontaneity, and thrill-seeking. One said, “thrill-seeking is an ADHD thing... I can list in my life have done white water rafting, bungee jumping, hand-glider pilot … I have done a lot in my life and achieved a lot and experienced a lot... Furthermore, I would see a lot of that as being quite positive, and a lot of that is ADHD drive.”
Another common theme was high energy and “spirit.” One participant said, “I’ve got all this energy.... a lot of energy... whatever it's to do with... nature/nurture/spiritual stuff.”
These testimonials are useful as a check on the usual narrative of impairment. ADHD does not predestine all it afflicts to an unfulfilling life. Many, often assisted by medication, still lead exciting, successful, rewarding lives. Yet, we must be cautious in concluding that these individuals were successful because of their ADHD. It is possible, even likely, that they had other strengths such as high intelligence that compensated for their ADHD symptoms. We can not know from this report if their lives had been even more fulfilling or successful in the absence of ADHD. See, for example, my blog about highly intelligent people with ADHD: https://www.linkedin.com/pulse/20141126141502-65669938-smart-people-can-have-adhd-too/.
While the authors concede that “generalizing the findings of this study is not easy to do,” they inexplicably “also argue that the positive aspects we found are relevant to other adults with ADHD regardless of sample size, age, gender or ethnicity.” It is not possible to draw such a definitive conclusion without a much larger sample.
On a hopeful note, they conclude, “This is a study that reaches out to people with lived experience of ADHD: service users, patients, family members, carers, partners, to say that not all symptoms of ADHD are maleficent. Recovery, high functionality, and flourishing with ADHD are possible. Too often people with lived experience hear about ADHD deficits, functional impairments, and associations with substance misuse, criminality, or other disadvantages on almost every level of life (school, work, relationships). … This study affirms the positive human qualities, assets, and attributes in ADHD that can promote and sustain high functioning and flourishing.” I fully endorse the idea that those with ADHD can have wonderful lives, especially if they receive appropriate treatment, both medical and psychological.
Jane Ann Sedgwick, Andrew Merwood, Philip Asherson, “The positive aspects of attention deficit hyperactivity disorder: a qualitative investigation of successful adults with ADHD,” ADHD Attention Deficit and hyperactivity Disorders (2018), doi.org/10.1007/s12402-018-0277-6.
Antshel, K. M., Faraone, S. V., Maglione, K., Doyle, A. E., Fried, R., Seidman, L. J. & Biederman, J. (2010). Executive functioning in high-IQ adults with ADHD. Psychol Med 40, 1909-18.
Rommelse, N., Antshel, K., Smeets, S., Greven, C.,Hoogeveen, L., Faraone, S. V. & Hartman, C. A. (2017). High intelligenceand the risk of ADHD and other psychopathology. Br J Psychiatry.
Rommelse, N., van der Kruijs, M., Damhuis, J., Hoek,I., Smeets, S., Antshel, K. M., Hoogeveen, L. & Faraone, S. V. (2016). Anevidenced-based perspective on the validity of attention-deficit/hyperactivitydisorder in the context of high intelligence. Neurosci Biobehav Rev 71, 21-47.
The Background:
Management of ADHD relies on both medications and non-medication approaches. Clinical guidelines often recommend medication as the first-line treatment for adults, while non-medication interventions are often preferred for children. Medicines fall into two main groups: stimulants (for example, methylphenidate and amphetamines), which have strong and well-established evidence and are generally considered first choice, and non-stimulants (such as atomoxetine), which are typically used when stimulants are contraindicated, not tolerated, or ineffective.
How many people with ADHD receive medication is an important indicator of care quality and can be tracked at the national level. Untreated ADHD can affect many areas of life, from physical health, to school and work performance, to relationships emotional well-being. ADHD is associated with poorer quality of life, higher risk of accidents, substance use issues, criminal behavior, educational underachievement, and even increased premature mortality. The condition also places a substantial burden on families and caregivers, so understanding treatment rates matters for individuals and society.
Most epidemiological research has measured how common diagnosed ADHD is, but the share of those diagnosed who actually receive medication can vary a lot. That variation reflects differences in how ADHD is diagnosed, how easy it is to get treatment, what clinical guidelines recommend, and cultural attitudes toward using medication.
The Study:
This paper presents the first comprehensive meta-analysis to estimate how common pharmacological treatment is among children, adolescents, and adults with clinically confirmed ADHD. The analysis included only register-based population studies where diagnoses were confirmed by a qualified healthcare professional. Twelve studies meeting these criteria from Europe (the UK, Sweden, Denmark), Asia (Taiwan, South Korea), and North America (Canada, the United States) were used. Notably, these are all high-income areas, and thus unrepresentative of populations in lower-income countries.
The pooled estimate showed that about 73 percent of diagnosed individuals in prosperous parts of the world with well-developed health care systems were receiving medication, but there was very high variation between studies.
The Results:
The authors conclude there is substantial global variation in ADHD medication use. Overall, a relatively high proportion of people diagnosed with ADHD are treated with medication, which may reflect improved recognition and access to care. The large differences between studies probably reflect differing health systems, diagnostic rules, treatment definitions, study populations, and reporting practices, and they underline the need for more standardized definitions and reporting to make comparisons more meaningful.
There is also a need for information from lower-income regions, but that is complicated by an absence of register-based population studies in countries with more limited health care access.
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The Background:
Because impulsivity is a core feature of ADHD, researchers have suggested it may raise the likelihood that someone will use psychoactive substances (including alcohol) and go on to develop a substance use disorder (SUD). When ADHD and SUD occur together in adolescents, treating one disorder alone usually has little or no positive effect on the other; current guidance therefore recommends treating both conditions at the same time using evidence-based approaches for each.
Given how much ADHD can worsen outcomes for people with primary SUDs, it is important to identify ADHD in people who are being treated for substance problems.
The Study:
A recent systematic meta-review found that, by current official criteria, ADHD affects about 7.2% of children and adolescents and about 2.6% of adults (Chaulagain et al., 2023). When adult ADHD is defined without the requirement that symptoms began by age 11, roughly 6.8% of adults meet criteria. A large body of research links ADHD to higher rates of medical problems, poorer quality of life, greater risk of suicide, more accidental injuries, worse educational outcomes, and increased involvement with the criminal justice system.
The present study is the first meta-analysis to estimate how common clinically diagnosed ADHD is among adults (age 18+) who are in treatment for psychoactive substance use disorders, and to provide those estimates by sex and by the specific substance used.
The authors included only studies of adults treated for a SUD (including alcohol). Eighty-four studies met the criteria, representing more than 34,000 people. Across all studies, the pooled prevalence of clinically diagnosed ADHD was 22%.
To put that in context, 22% is about eight times higher than the 2.6% adult prevalence using the stricter official definition, and about three times higher than the 6.8% rate when the childhood-onset requirement is relaxed. By substance, the prevalence was similar for alcohol (24%) and opioids (22%), with no significant difference between males and females. Prevalence among people treated for cocaine use was somewhat lower overall (18%), driven largely by lower rates among women, for whom the rate was no higher than in the general population. Estimates were higher for people using benzodiazepines and cannabis, but those figures are based on a very small number of users (256 and 249 people, respectively) and are therefore less certain.
The Results:
The authors conclude: “These findings underscore the need for early identification and treatment of ADHD as most substance use disorders develop in adolescence and young adulthood. While in treatment for ADHD, appropriate screening and management of substance use is possible.”
The Background:
Stimulant medications (like methylphenidate and amphetamines) and non-stimulants (like atomoxetine and guanfacine) remain the first-line treatments for ADHD, but their long-term use is often constrained by parental concerns, side effects (reduced appetite, sleep disruption, cardiovascular effects), and the fact that roughly 30% of children respond only partially or not at all. These medications tend to help with attention and behavior, but they do less to address emotional regulation or broader physical health, leaving some parents to seek other safe, complementary treatments.
Nutritional approaches, including omega-3 fatty acids, are one such avenue. Oily fish is the natural source, but clinical trials typically rely on supplements instead, since they allow for precise dosing, avoid the heavy-metal exposure that can come with high fish intake, and sidestep the problem of inconsistent dietary habits. Two omega-3s stand out as particularly relevant: DHA, which supports brain structure and cell-to-cell communication, and EPA, which helps reduce brain inflammation and improve blood flow. Both influence the dopamine and serotonin systems implicated in ADHD.
The Study:
Previous meta-analyses have generally found only modest overall benefits with mixed results. This mixed-results pattern may reflect the fact that children who had low omega-3 levels to begin with stand to benefit more than those whose levels are already adequate. This meta-analysis set out to test that idea directly, asking whether a child's baseline omega-3 status predicts how well they respond to supplementation.
To be included, studies had to be randomized controlled trials (RCTs) involving children diagnosed with ADHD who did not have major coexisting medical conditions. Trials that used broad multinutrient interventions, where the effect of omega-3s specifically couldn't be isolated, were excluded.
The resulting analysis of seven RCTs covering 654 children found small overall improvements in ADHD symptoms with omega-3 supplementation, consistent with earlier meta-analyses. There was little variation across studies, but a clear signal of publication bias, which the authors did not attempt to statistically correct for.
Among four RCTs involving 369 children with low baseline omega-3 levels, supplementation produced a moderate improvement in ADHD symptoms, with consistent results across studies. By contrast, the six RCTs covering 559 children with normal or high baseline omega-3 levels showed no improvement at all, again with consistent results across studies.
The Results:
The authors concluded: this systematic review and meta-analysis offers preliminary evidence that children’s response to long-chain omega-3 supplementation for ADHD may depend on their starting omega-3 nutritional status. Larger effects emerged in the subgroups defined by individual studies as having low baseline levels, while normal, high, or unstratified groups showed little evidence of benefit. In other words, there may be a benefit to children with ADHD taking omega-3 supplements, but only if they are already deficient.
Even still, a sensitivity analysis limited to ADHD symptom-rating scales found only a numerically higher effect in the low-baseline group. This means that these results, though positive, are not considered statistically significant.
The Take-Away:
Given that the evidence rests on just seven trials, that “low baseline” was defined differently across studies (using different biological markers and thresholds), and that several subgroup comparisons were not planned in advance, the authors caution that these findings should be treated as hypothesis-generating rather than conclusive.
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