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ADHD Awareness month: October 1 - October 31, 2023

I have previously written about my experiences as an autistic adult working with autistic clients in therapy. As this is ADHD awareness month, I was keen to highlight the strengths and challenges involved with an ADHD diagnosis. This blog was written for The National Counselling and Psychotherapy Society and published here: https://nationalcounsellingsociety.org/blog/posts/adhd-awareness-month-october-1-october-31-2023




It was only when I started researching ADHD to teach a neurodiversity module that I wondered about a dual diagnosis for myself. Many autistic and ADHD presentations overlap, but equally some are distinctly different. For me, things like procrastination, impulsivity, time management and a difficulty getting started in the mornings made sense under the lens of ADHD. I had attributed a lot of these seemingly vague and unrelated symptoms to myriad different reasons before considering if there may be a single answer to them all.


Our understanding of ADHD is growing, but there are still misconceptions. The estimated prevalence of ADHD and autism co-occurring is around 38-40% (Rong et al., 2021). Recognition of autistic children with co-occurring ADHD happens much later than those with autism alone (Miodovnik et al., 2015; Stevens et al., 2016). Might that mean we need to be more open to a different approach to recognition, diagnosis, and support?


What is ADHD?


ADHD is a neurodevelopmental difference. The letters stand for attention deficit hyperactivity disorder. We can clinically describe it as a difficulty with maintaining attention on a single task, feeling, or acting hyperactive and being impulsive (Crimlisk and Niccol, 2023). However, human beings are unique, and every individual may differ in how their ADHD may outwardly present.



There are various multifaceted perspectives to understanding ADHD, e.g., the medical model, the social model, and a biopsychosocial model. Perspectives between the models don’t always align. For example, we can view terminology in the medical model as stigmatising. The medical model aims to expand or improve functionality, but the focus is on ‘deficit-based treatment’ (Botha, et al., 2023; Bury et al., 2023).

In contrast, the social model recognises systemic and institutional barriers that disabled people face (Botha et al., 2023; Bury et al., 2023). Patrick Dwyer explores succinctly the social model and its influence on the neurodiversity paradigm (Dwyer, 2018).


A biopsychosocial model considers biological, psychological, and social factors that contribute to ADHD. It acknowledges that ADHD is a complex interplay of genetic, neurological, environmental, and social influences. Collectively, the various frameworks or perspectives have the potential to advance our understanding, but the most important thing is to learn from everyone’s unique lived experience of ADHD.

Are there subtypes of ADHD?


There are 3 subtypes of ADHD listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013).

They are:

1. Combined type (meets the criteria in both the Inattention and Hyperactivity/ Impulsivity groups)

2. Predominantly inattentive type (mainly attention difficulties or poor impulse control)

3. Predominantly hyperactive type (doesn’t meet the criteria for the two above)


How does ADHD impact individuals?


ADHD can have vast effects on a person’s life, including their executive functioning skills, emotional regulation, working memory, time regulation, sleep and tolerance for stress and sensory information (Beale, 2022).


Everyone can have some of these difficulties from time to time, but they are more extreme in those with ADHD, have a significant impact and will probably have been around since childhood. ADHD is a lifelong difference estimated to be part of 366.33 million adults’ lives (Song et al., 2021).


Gender differences


Research on gender differences in ADHD suggests we do not recognise women for diagnosis (Slobodin and Davidovitch, 2019) because they display more inattentive presentations when compared to males (Biederman, Joseph and Faraone, 2004).

ADHD may change during transition times in life, such as childhood to adulthood and beyond. Some women experience more difficulties with ADHD because of hormonal changes such as PMS (premenstrual syndrome).


Many only learn about ADHD because of a particular stressor such as the menopause or perimenopause (Rowley, 2022). Despite this, there is very little literature exploring the relationship between ADHD, sex hormones and reproductive stages (Camara et al., 2022).


Sleep


It can take the ADHD brain about an hour longer on average to fall asleep (Bijlenga et al., 2013) and up to 80% of ADHDers have delayed-sleep difficulties (Van Veen et al., 2010). ADHD is also associated with a lower sleep quality and a difficulty getting up in the morning (Schredl et al., 2007). Long term, this causes difficulties with concentration, motivation, mood, and relationships; chronic sleep deprivation can also increase the risk of a mental health problem (Lewy, 2009).


I find there are two forms of tired, body tired and brain tired, I need to experience both to fall asleep. If I have not had enough brain stimulation during the day, I daydream/mind wander. Mind wandering feels like my brain goes into "standby mode" as soon as my head hits the pillow my brain opens 40 google tabs at once.


Is ADHD new?


ADHD is not new. It has a long history, spanning centuries. In 1775, a German physician wrote the first textbook description with the hallmarks of ADHD (Faraone et al., 2021). Some studies suggest there is a strong genetic link in ADHD (Biederman, J. et al., 1990), some suggest a combination of genetics and environmental factors (Faraone and Doyle, 2001), with genetic factors accounting for the majority probability cause (70%-80%) (Monuteaux et al., 2005).


How does ADHD affect the brain?


For motivation I could win awards for procrastination, if I don’t have a clear deadline, it is difficult for me to start. I pack a lot in, (possibly too much) as it is easier for me to keep going than to stop/start. Combined ADHD for me means I get lots done during hyperactive periods and not so much during inattentive periods (not to be confused with ADHD burnout). During periods when I don’t have a full schedule it is harder for me to find the motivation to start anything without the ‘buzz’ of being time constricted.


Neuroimaging studies have shown structural alterations in several brain regions (including a reduction in the amygdala and hippocampus) in children and adults diagnosed with ADHD (Hoogman et al., 2017). They link the differences in the amygdala to emotional regulation difficulties. This is important because it highlights neurobiological reasons for dysregulation. The structural alterations can also potentially contribute to difficulties in motivation and memory.


ADHD and mental health


Many with a diagnosis of ADHD also have a co-occurring mental health condition (Riglin et al., 2021). 80% of adults diagnosed with ADHD also present with a psychiatric difficulty at least once in their lifetime (Klassen et al., 2010).

Bipolar shares several similar presentations with adult ADHD such as impulsivity, distractibility, and restlessness (Salvi et al., 2021). This can make the correct diagnosis a challenge however, ADHD and bipolar may also co-occur. In a mental health survey conducted over 11 countries it would be possible to diagnose ADHD in 19.8% of the participants (Merikangas et al., 2011).


Adults with ADHD are five times more likely to try to take their own life than those without ADHD. One quarter of women with ADHD have tried to take their own life. (23.5% vs 3.3% without ADHD). One in ten men with ADHD has tried to take their own life (8.5% vs 2.1%) (Fuller-Thomson et al., 2022).


What might be helpful for individuals with a diagnosis of ADHD?


Medication


This is a personal choice between stimulants (to boost and balance levels of brain chemicals called neurotransmitters) and non-stimulants (i.e., atomoxetine). Psychopharmacological treatments have mixed results: some report emotional improvements (Craig and Walsh, 2022) and some report many side effects (Schein et al., 2023). Others highlight the need for a consensus-based treatment for ADHD medication choice (Brancati et al., 2023).


Antidepressants may be prescribed; however, they have reported low treatment responses in using selective serotonin reuptake (SSRIs) for depression for individuals with co-occurring ADHD (Kanarik et al., 2022). Atomoxetine and antidepressants work slower than stimulants but can be an alternative if medical reasons or adverse reactions rule out stimulants.


Physical activity

This may be effective at reducing depression and anxiety as part of a multimodal approach for (Silva et al., 2020). I have always been a keen gym goer. I love lifting weights. The heavier, the better. Studies show strength or weight training can support the clinical management of anxiety (Strickland and Smith, 2014; Gordon et al., 2020). Resistance training (weights training where you lift or pull against resistance) can significantly reduce depressive symptoms among adults regardless of their health status (Gordon et al., 2018).


Psychoeducation and ADHD coaching


This can support understanding of an ADHD diagnosis and ADHD coaching could support strategies to improve time management and organizational skills. The most frustrating suggestion I have ever received as a solution was to use ‘to do’ lists and set my phone for reminders for missed appointments. I write lists, start something on the list, go down a rabbit hole and before I know it, I’ve spent four hours searching for something I don’t need and is completely unrelated to my ‘to do’ list.


I always plan to be early, but I see something that can probably wait and think “I’ve the time to squeeze it” in and, yes, you’ve guessed it, that leads to something else, and I am late again. I put everything into my phone, set reminders, but those are only as good as the inputted information. For example, when you schedule an appointment in your phone, it auto defaults to the current time. I have turned up ridiculously early or late for appointments.


Should I mention my history with pots? I have lost way too many pots by wondering what the burning smell is while I’m folding towels only to realise the water has evaporated and the food has congealed and become one with the pot! The key takeaway is to ask individuals what they find works or doesn’t work for them and collaboratively plan achievable strategies and/or goals.


Therapeutic interventions


One systematic review combined 32 studies (Nimmo-Smith et al., 2020), examining the effectiveness of adult ADHD interventions, 14 of which were CBT (cognitive behavioural therapy) and reported a reduction in ADHD symptoms. However, these contained clinician-reported improvements and sample size varied. Four studies in the review examined mindfulness-based CBT (MBCT) and reported significant improvement in both observer and self-reported ADHD symptoms.


Another review examined 221 documents (Rebecca et al., 2021) and concluded that a single theoretical perspective (CBT) limited research for effective treatments. It highlighted a significant lack of studies in psychoanalysis and psychodynamic approaches for adults diagnosed with ADHD.


Some suggest that the best adult ADHD support strategies are multimodal ones (Williams, 2020). Most individuals try a variety of things to see what might work best for them. It may be a case of trial and error with different strategies and/or interventions. So, with that in mind, it may be better to try one thing at a time. That way, you can see if there are any personal benefits. Sometimes change takes time, so you may need to look for ways to adjust things to suit you better before deciding it is or is not for you.


Client preferences


Because of my mind going off in tangents, I try to get information out quickly and that has resulted in being asked to slow down. This can stop my train of thought completely and result in a little confusion. It can lead to feeling misunderstood, unheard, and stopped/silenced. Understanding what may go on and why can make such a difference in the therapeutic relationship.

There are many studies highlighting the peer-to-peer difficulties, misunderstandings, and exclusions children with ADHD face (Hodgens et al., 2000; Hoza, 2007; Landau et al., 1998; Dorani et al., 2021). For that reason, many adults find themselves drawn (consciously or unconsciously) to those who they feel more comfortable with, that may be towards fellow ADHDers. This can be a client consideration for therapy where individuals actively seek out counsellors or therapists who are also neurodivergent.


A recent study examined lived experiences of neurodivergent clients and what they needed from psychotherapy (Bowers and Widdowson, 2023). It shows that the psychotherapeutic community doesn't understand the needs of neurodivergent clients. It brought up assumptions about neurodivergence affecting the therapeutic relationship. This emphasises the importance of training before assuming competency in working with neurodivergent clients.


Recommendations for working with clients developed based on the findings of the study are:

1. Understanding and acceptance.

2. A therapeutic relationship where it feels safe to ‘unmask’.

3. A balance of tolerable structure and tolerable nurture.

4. A therapy that is different to historical relationships that have felt, shaming, unsafe or conditional.


ADHD strengths


Creativity and Hyperfocus


In a study examining creativity, individuals with a diagnosis of ADHD generated more original ideas when there was competition for a reward. In addition, ADHDers reported enhanced creativity (hyperfocus) in specific domains (Boot et al., 2020). Many individuals could excel in specific creative tasks if they matched their preferences and abilities.


High energy levels


When ADHDers are passionate about things they are doing, there is a high energy level involved which individuals have “positively attributed to their ADHD” (Sedgwick et al., 2019).


Resourcefulness


‘Out of the Box’, or divergent thinking and ADHD go hand in hand (Nolker, 2021) Entrepreneurship research has suggested that ADHD can drive unique focused plans luring individuals away from standard jobs (Barkley and Murphy, 2010) towards a more flexible entrepreneurial lifestyle (Wiklund et al., 2016).


Public figures with a diagnosis of ADHD


I make no apologies for my selections; I have absolutely and unashamedly chosen some of my personal favourites!


In 2021, at 21, Cat Burns was told she had ADHD, then two years later she received her autism diagnosis. Cat explains how the process has left her with a better understanding of herself, saying life now "makes sense" (Lawton, 2023). Cat performed at this year's Brit Awards where she was nominated for Rising Star, Best Pop/R&B Act and Song of the Year.


Will.i.am is the founding member of the Black-Eyed Peas, music producer and coach on The Voice, he describes having ADHD as “a gift, not a flaw” (Will.i.am, 2018-01-21T01:23:41+0000).


Justin Timberlake is a singer and actor. He has ten Grammy Awards, four Primetime Emmy Awards, three Brit Awards, nine Billboard Music Awards, the Contemporary Icon Award by the Songwriters Hall of Fame, and the Michael Jackson Video Vanguard Award. He talked about having ADHD in a 2008 Collider.com interview when promoting the film “The Love Guru” (Weintraub, 2008).


Considering an ADHD diagnosis?


It may be helpful to complete an adult self-screening tool before exploring your options further via your GP. You can find one here: https://adhduk.co.uk/adult-adhd-screening-survey/ ADHD UK have a wealth of strategies, products and Ideas listed here: https://adhduk.co.uk/adhd-strategy-discovery-platform/


There are various barriers to diagnosis, including lack of recognition, awareness, local government funding, and so on. However, England, Wales, and Northern Ireland follow the NICE guidelines on ADHD, which give a right to the provision of an ADHD service. That means if there is no local provision, then your local NHS has an obligation to fund you to receive the service elsewhere. You can access that funding through the Individual Funding Request process and can learn more about that here. Scotland has a different guidance system (SIGN). You can learn more about that here.


Does ADHD qualify for workplace reasonable adjustments?


The Equality Act 2010 in the UK means there is a legal requirement for employers to make reasonable adjustments in the workplace for current employees or job applicants, and ADHD qualifies for these adjustments.


This could be a look at the current work environment to minimise distractions or introducing flexitime. To be inclusive, the recruitment process may need to be changed to consider things such as switching from a criteria-based interview or allowing extra time to complete questions.


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