ADHD in Adults

Mindcare Centre offers expert assessment and treatment of ADHD in adults. Call (02) 9212 4445 during business hours to make an appointment or email us your enquiry.

So What Is ADHD?

When most people think of ADHD they tend to think of noisy, hyperactive boys who can’t sit still and who cause havoc in the classroom. While some children with ADHD might fit this description this stereotype is narrow and misleading even in children. And most people do not consider that ADHD is a disorder that affects adults. ADHD does in fact affect adults right across the life span.

ADHD – also known by the older term of Attention Deficit Disorder (ADD) – is better thought of as a neurodevelopmental disorder that causes difficulties with executive functioning abilities. Our executive functions are important for regulating many of our complex mental processes such as organisation, planning, concentration, motivation, impulse control, time management, problem solving, working memory, sustained attention and attainment of future goals.

Common observable behaviours in adults may include:

• Procrastination and difficulties with motivation
• Difficulty working in the absence of a deadline
• Difficulty sustaining attention
• Failure to complete non-stimulating tasks and/or difficulty tolerating boredom
• Difficulty prioritising work or multitasking
• Forgetting things, losing things, making careless mistakes
• Poor time management and unreliability
• Blurting out socially inappropriate comments, talking over people, or talking too much
• Being overly busy and overcommitted
• Stimulation seeking behaviour (may include eating, substance use, shopping, constant socializing, sex, risky sports)
• Fidgeting and restlessness / discomfort if seated for lengthy periods of time
• Rapid emotional ups and downs including anger, sadness, impatience, and anxiety that are often short-lived
• Road rage, speeding, parking fines, accidents, loss of licence, driving unregistered or unlicenced
• Difficulty switching off at night to get to sleep
• Staying up late to get things done when there are fewer distractions
• Working long hours due to inefficiency

Some people with ADHD have more difficulty with the attention deficit side of the disorder and might appear to others as though they are pre-occupied, dreamy, careless or lazy. Other people might be more prone to the noisy, restless, stimulation-seeking hyperactive behaviours. Two people may both have ADHD but may present quite differently depending on which aspects of their executive functioning are most affected.

By definition the symptoms of ADHD have been present since childhood and affect a range of environments such as the workplace, educational settings, home life or social domains. ADHD can persist across the lifespan into old age. With brain development across childhood and adolescence some children will grow out of their ADHD although most children retain mild or moderate symptoms into adulthood. Adults with ADHD are more likely than other people to have children who have ADHD¹ making it very much a family affair.

Numerous researchers have found that emotional impulsivity (impatience, low frustration tolerance, hot-temperedness, quickness to anger, irritability and emotional excitability) can be as much a component of ADHD as the inattention and hyperactivity². Note however that these symptoms which have been reliably observed in ADHD research over the past decade are not yet listed in the diagnostic criteria used by most mental health professionals. Emotional impulsivity is associated with a range of life impairments including money mismanagement, being jailed, drivers license suspensions and lower levels of education³.

How common is ADHD?

International surveys indicate that ADHD affects approximately 2-5% of the population⁴with an Australian survey showing that males and females are equally affected⁵. More than 50% of adults with ADHD have received mental health treatment but mostly for problems other than ADHD. Only 10% of adults with ADHD have actually received treatment for ADHD itself³. The under-treatment of ADHD in adults probably stems from health professionals’ tendency to overlook the possibility of ADHD in their adult patients and also because most public mental health services do not provide treatment for ADHD.

What causes ADHD?

As with many mental and physical disorders it remains unclear as to what causes the symptoms of ADHD. ADHD tends to run quite strongly in families and in most cases ADHD is thought to be inherited. It is possible that some cases might be related to early adverse events such as exposure to toxins or oxygen deprivation in utero or around the time of birth or very low birth weight. Neurotransmitters in the brain are thought to be relevant along with abnormalities in the thickness of the brain cortex as the brain develops. It is thought that the rate of development of the brain cortex in children with ADHD lags about three years behind their non-ADHD peers with slower rate of development being associated with a greater severity of ADHD symptoms⁶. Neuroimaging studies have found that the volume of different parts of the brain (such as the cerebellum, hippocampus, and basal ganglia) is reduced in people with ADHD⁷.

Isn’t there a bit of ADHD in all of us?

Like many medical conditions such as hypertension, cholesterol, type II diabetes, obesity, social anxiety, depression or compulsions, ADHD symptoms lie on a continuum. Many of us might display some of the symptoms that are typical of ADHD such as being forgetful, losing things, avoiding boring tasks, feeling restless or not being able to delay a reward. Sometimes these behaviours are better explained by other factors such as tiredness, being over-worked or over-committed, illness, substance use or personality style. The diagnosis of ADHD is not made unless someone has symptoms on a persistent basis since childhood, and to a degree that causes significant impairment in everyday life activities such as study, work, relationships, self care or home management. It is also important to determine that the symptoms are not better explained by another mental disorder or personality style. Generally if there is a better explanation for the symptoms or if the person is not significantly impaired a health professional would not diagnose him or her as having ADHD.

Can I have ADHD as well as another disorder?

Research studies have indicated that 77% of adults with ADHD have other mental disorders in addition to ADHD with most adults having three to four additional disorders³. The most common comorbid disorders are social anxiety disorder, other phobias, bipolar disorder, depression, substance use disorders and post-traumatic stress disorder⁸. Learning disorders, sleep disorders and binge eating problems are also common. Two disorders that share a lot of symptom overlap with ADHD, and can co-occur with ADHD, are bipolar disorder and borderline personality disorder. Bipolar disorder shares many features such as mood swings, difficulty sleeping, and impulsive behaviour (such as careless spending, talking loudly or quickly, saying inappropriate things, or flitting from one activity to another). However in bipolar disorder the symptoms tend to come and go depending on the person’s mood state whereas in ADHD the symptoms are persistent, week after week, year after year and at their worst the symptoms in ADHD probably do not reach the extremes seen in severe cases of bipolar disorder.

In borderline personality disorder people can be emotionally volatile and tend to engage in a range of impulsive behaviours in areas such as spending, sex, substance use and decision making. However ADHD symptoms do not specifically include suicidal and intentional self-harm behaviours as seen in borderline personality disorder nor the sense of emptiness or the ongoing difficulties with maintaining emotional attachment that are hallmark features of borderline personality disorder.

Can ADHD develop once you are an adult?

Current consensus is that ADHD is a disorder that begins in childhood and for most people will persist into adulthood to some degree. There is disagreement as to how early in life the symptoms must be evident in order to be diagnosed with ADHD. The diagnostic criteria in widespread use currently indicate that symptoms should be present before the age of 12 years⁹. However there is limited clear scientific evidence to support this particular cut-off age. Older criteria required symptoms before age 7 years so the age limit for diagnosis has been increasing over time.

Many children have parents and teachers who provide a lot of support in terms of helping them remember to do things or organise themselves. Other children are very bright and do well in school with little or no effort during the primary school years. Once a child enters high school, responsibilities increase while most parents and teachers start pulling back on their level of assistance. Hence more significant problems with organisation, sustained mental effort, time management and concentration might only come to the surface in the high school years when the adolescent is juggling a bigger and more demanding academic workload, a busier social life, sporting activities and casual work. By this stage the individual is clearly over 12 years of age. A clinician who is experienced in the assessment of ADHD would take into account any factors that may delay the appearance of ADHD-related disability.

For other adolescents whose parents or teachers remain highly involved and supportive the difficulties might not be apparent until the new adult commences work, study or parenthood, leaves home or is otherwise expected to cope on their own. As life pressures and responsibilities build up in early adulthood the problems can become more obvious and the level of impairment might increase. However it would be extremely unusual for ADHD symptoms to be present in adulthood if none of these difficulties were present to some degree in childhood or adolescence. In such cases there is likely to be another explanation for the recent onset of symptoms.

How is ADHD diagnosed?

Unfortunately there is no specific test to determine whether someone has ADHD. Diagnosis is made on the basis of clinical interview. Current functioning would be assessed and may include seeking information (with permission) from partners, close friends or work colleagues. There needs to be evidence that the symptoms are currently causing significant difficulties in life in a range of areas. Given that ADHD is a disorder that starts in childhood there must also be some indication that symptoms started at an early age and have persisted constantly since that time. Hence it can be helpful to speak to parents or siblings to obtain developmental history and to review comments in school reports. School reports can be a goldmine when it comes to assessing ADHD so it is helpful to bring school reports to your assessment.

Because ADHD typically runs in families it is important to assess for a family history of ADHD or for difficulties in family members that might be consistent with the disorder. Rating scales are also useful for assessing severity of symptoms. In some instances additional testing such as quantitative EEGs or neuropsychological assessment might add further useful information but such tests are not reliable indicators of ADHD on an individual basis and can be expensive. Finally other disorders that might mimic ADHD need to be reviewed and ruled out as necessary such as head injury, mood disorder, personality style, substance abuse, sleep disorders, hearing impairment along with other hormone, blood or neurological disorders. It is also possible that ADHD can co-occur with any of these disorders so sometimes it takes time along with trial and error to develop a clear picture.

What if the diagnosis is wrong and I don’t really have ADHD?

Like all mental disorders and many physical disorders diagnostic mistakes can sometimes be made particularly when there is no single test that can accurately rule the disorder in or out. Even specimen samples and x-rays can produce wrong diagnoses because they rely on a human being interpreting cells on a slide or on making an interpretation from a visual image. Sometimes people might be diagnosed with ADHD when they do not have it while other people who have ADHD might see health professionals and the diagnosis is never picked up. Other people might be elevated on the ADHD spectrum and a decision needs to be made as to whether the symptoms are severe enough for a diagnosis or not. Both scenarios of overdiagnosis or underdiagnosis can be problematic in different ways. We live in an imperfect world.

The best way to avoid an incorrect diagnosis is for the clinician and the individual to be well informed and to continually update the clinical picture as new information becomes available. The clinician needs to conduct a thorough assessment and the individual is wise to read up on the disorder so he or she can have an educated debate on the issue if the diagnosis does not feel “right”. Diagnosis of mental health issues is best viewed as a collaborative process where the individual and the clinician work together to develop a clear understanding and management plan. If uncertainty remains, a second opinion can be sought. Additionally psychological strategies can often be helpful for the presenting symptoms even if the level of severity of symptoms does not warrant a formal diagnosis.

How is ADHD treated?

A person with ADHD typically benefits from psychological treatment, medication or both^4,10. For moderate to severe ADHD, medication is considered the first line of treatment for achieving symptom reduction. Medications include long and short acting versions of methylphenidate or dexamphetamine. These medications are amongst the most widely studied and most effective medications in the mental health arena but do need to be prescribed and used with good care and supervision. These medications are considered to be very safe when prescribed appropriately but there is a risk of them being diverted for sale for recreational use so prescribing is tightly restricted. In NSW, only a psychiatrist can initiate medication treatment for ADHD in adults. It may be different in other states.

Psychological strategies might also be useful for helping people adapt to their diagnosis of ADHD, and to help them improve their everyday functioning and emotional well-being. Strategies might include learning how to use daily planners and reminders, manage time effectively, use goal setting and problem solving methods, improve motivation, reduce distractions, challenge negative thinking patterns that have built up over the years, and other cognitive behavioural strategies for addressing organisational and executive functioning problems. People also typically benefit from assistance with self-esteem issues or any additional mental health problems that may be present such as depression or anxiety disorders.

Some people do not wish to take medication or they have problems with side effects hence choose non-medication treatment options. Medication is typically more helpful for core symptoms of ADHD while psychological therapy may be helpful for improving overall life functioning and sense of well-being. Regardless of how well medication may treat the ADHD symptoms it does not necessarily help the self-esteem issues or comorbid mental health problems and is not always enough on its own for overcoming the unhelpful habits that have typically built up after years of untreated ADHD.

How to get help for an adult with ADHD

Call Mindcare Centre on (02) 9212 4445 or email us to enquire about an initial appointment. Due to a shortage of psychiatrists and clinical psychologists in Australia who have expertise in the assessment and treatment of ADHD in adults, the waitlist can unfortunately be quite long.

Where to find more information and support for ADHD

• ADDults with ADHD NSW Support Group (ADDults)
  
• Canadian ADHD Research Alliance
• Children & Adults with Attention Deficit/Hyperactivity Disorder (CHADD)
  
• “More Attention, Less Deficit” book plus free podcasts by Ari Tuckman (Specialty Press, 2009)
• “Attention Deficit Disorder: The Unfocused Mind in Children and Adults” by Dr Thomas E. Brown (Yale University Press, 2005)
• SMH Article: "Scientists' Lurid Claims About ADHD Do Parents No Good" (Sydney Morning Herald, Feb 2017)
• ADHD: Failing at Normal (Youtube video)

References

1. Biederman J, Faroane SV, Mick E, et al.(1995). High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: A pilot study. American Journal of Psychiatry, 152: 431-435.
2. Barkley R and Fischer M (2010). The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child & Adolescent Psychiatry 49(5): 503-513.
3. Faraone S (2011). ADHD and deficient emotional regulation; 3rd International Congress on ADHD from Childhood to Adult Disease. ADHD Attention Deficit and Hyperactivity Disorders; 3:81.
4. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA) (2011). Canadian ADHD Practice Guidelines. Toronto ON: CADDRA.
5. Das D, Cherbuin N, Butterworth P, Anstey KJ & Easteal S (2012). A population-based study of Attention Deficit/Hyperactivity Disorder symptoms and associated impairment in middle-aged adults. PLos ONE; 7(2) e31500.
6. Kessler RC, Adler L, Barkley R, et al. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163(4): 716-723.
7. Shaw P, Gogtay N and Rapoport J (2010). Childhood psychiatric disorders as anomalies in neurodevelopmental trajectories. Human Brain Mapping 31: 917-925 and Shaw P, Gillam M, Liverpool M, et al (2011). Cortical Development in Typically Developing Children With Symptoms of Hyperactivity and Impulsivity: Support for a Dimensional View of Attention Deficit Hyperactivity Disorder. American Journal of Psychiatry 168: 143-151.
8. Giedd JN and Rapoport J (2010). Structural MRI of pediatric brain development: What have we learned and where are we going? Neuron 67(5): 728-734.
9. American Psychiatric Association (2010). DSM-5 Development: A10 Attention Deficit/Hyperactivity Disorder.
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