Adult ADHD. Are you spotting it?
An ADHD diagnosis can be the missing piece in the jigsaw of your client’s life, writes Sarah Templeton.
I was in my third session with a CBT therapist, attempting to conquer my newly acquired but debilitating cat phobia. Towards the end, the counsellor said to me, ‘Has anybody ever suggested you might have ADHD?’ I looked at her incredulously. Wasn’t ADHD (attention deficit hyperactivity disorder) about nine-year-old boys acting out in class? I was a 51-year-old owner of a highly reputable nanny agency and a newly qualified counsellor!
‘No,’ I said. ‘Why?’ And she said, ‘Because I think you may be.’ And so I went home, went online and began my ‘self-discovery’ of something that the previous five years of counselling training had not revealed, despite all the soul-searching and self-reflection that it involves.
Since that day, I have gone on to be diagnosed with moderate to severe combined ADHD and have carved out a new career, helping adolescent and adult clients with the diagnosis and many more who are struggling, not knowing they are ADHD. This is not to mention those who have been misdiagnosed with a variety of other disorders when actually they too have adult ADHD.
Barriers to diagnosis
The journey has been far from easy. When I went to my GP, I was told there was ‘no money in the NHS for adult ADHD’. That wasn’t good enough for my counsellor; she suggested I went back again. I was seen by another GP, who repeated the ‘there is no money in the NHS for adult ADHD’ line. I was getting a bit fed up with this, so I contacted a private ADHD psychiatrist in London and, £400 later, he dismissed me with, ‘You weren’t diagnosed as a child, so you can’t have it.’
My counsellor (the hero of this piece) was livid. She adamant that they were wrong (I won’t repeat the word she used – it would be mostly asterisks). So, I thought I’d have one more go.
I found another, highly recommended ADHD psychiatrist. To save him time, in advance, I sent him several sheets of A4 paper on which I’d typed my ADHD traits. I was on a mission now: 51 years of not understanding why I felt different was long enough. But the night before the appointment, he telephoned me and said, ‘Don’t waste your time coming to see me. It’s obvious you are ADHD.’ He, kindly, having not being paid a penny, wrote to my GP insisting I be referred for an ADHD assessment on the NHS. This seemed to have the necessary effect and not long after I found myself sitting in front of an ADHD psychiatrist, in an NHS hospital, five miles up the road.
That day, in March 2015, I received my diagnosis, and to say my life suddenly made sense is a colossal understatement. It explained why I am so driven in my work; why I can’t stop – nothing is ever enough. This is why my brain works at 1000 miles an hour. This is why my boredom threshold is so low! It explained why I drop things, break things, damage things, have almost zero short-term memory and have been called clumsy all my life. And why I could never sleep without a concoction of medication. It wasn’t just one light bulb moment –hundreds lit up.
What is adult ADHD?
So just what is adult ADHD? And why should counsellors be on the alert for it in your own therapy practice?
Briefly, with ADHD the brain is wired differently, as with autism (although it is in no way connected to autism spectrum disorder (ASD), unless it’s a comorbidity, but more on that later).
It’s a disorder, not a disease. There is no ‘cure’. You’re born with it and you die with it. The only exception are people who acquire it from brain injury, but the percentage is very small. It’s a genetic condition and is hugely heritable. And it definitely, definitely is a medical condition, and one that is covered and protected by The Equality Act 2010. In recent years, using MRI scans, researchers have been able to establish that there are physical differences between an ADHD brain and a neuro-typical brain.
ADHD is highly treatable, usually with stimulant medication. This cannot cure the condition but it can help people concentrate better, be less impulsive, feel calmer, and be better able to learn and practise new skills. ADHD primarily affects the frontal lobes of the brain, which control memory, impulsivity, behaviour and self-regulation. People with ADHD also have a marked lack of dopamine, the pleasure hormone. This means an ADHD brain is constantly seeking pleasure / adrenaline, which accounts for the risk-taking, thrill-seeking, boundary-pushing traits of the condition. The ADHD brain is constantly seeking stimulation.
Clues to adult ADHD
Currently, in the UK, ADHD is diagnosed as one of three types: ADHD primarily inattentive, ADHD primarily hyperactive/impulsive and ADHD combined. The ‘combined’ category is by far the largest.
The easiest way I’ve found to explain the difference in the types is to imagine there’s such a thing as an oomphometer. At one end of the scale are the inattentive types – struggling with not enough motivation, too much procrastination, constant distraction and nowhere near enough oomph! At the other end are those with way too much oomph – driven by an internal motor that won’t let them stop or relax. Nobody with ADHD walks the middle line. The types share many traits – including a low boredom threshold.
It is estimated that one in 20 adults have ADHD, so the likelihood of it appearing in your therapy room is high. Clients who know they are ADHD are likely to seek out a counsellor or coach with specific expertise in the condition. But many more without a diagnosis will go to see a generic counsellor in the hope that they can help with their unexplained anxiety and depression, or (like Caroline, over page) an accumulation of lifelong difficulties with memory and thinking.
So, why is it so important that counsellors are alert to this possibility? The first and most obvious reason is that people with ADHD are at 30% greater risk of suicide and self-harm than the general population; the more complex the ADHD (ie. comorbidity with other mental health diagnoses) the greater the risk. Also, we are well placed to do so. Clients with undiagnosed ADHD are very likely to seek therapy – for several reasons. One is that anxiety and depression play a part in the condition and the symptoms of ADHD and depression are very similar. They can affect eating and sleeping, relationships, work and study. A GP may well have misdiagnosed anxiety and/or depression if they haven’t been trained to spot adult ADHD traits, and might refer a client for counselling if antidepressant medication hasn’t helped.
‘Dysregulated emotion’ is another ADHD trait, and very often the person will have been given antidepressants by their GP, usually with very little effect.
So, what do you need to be looking for?
■ clients who speak very quickly – often so fast words get missed – or speak incessantly
■ mention of struggling to concentrate or maintain focus
■ feelings of underachievement – specifically unfinished college/university courses, or restarting them several times
■ disorganised life/sense of overwhelm – knowing what needs doing but being unable to do it
■ school reports from their childhood that describe them as ‘the clown of the class’ or ‘lacking concentration’
■ job-hopping – inability to settle. This also applies to frequently moving house and changing cars
■ risk-taking/thrill-seeking but without pleasure; having affairs despite being happy with their partner
■ poor short-term memory
■ involvement in crime.
A lot of women with undiagnosed ADHD get diagnosed during the menopause. This is because ADHD is a hormone-connected condition, so it ramps up at the beginning and end of puberty for boys and girls and then again in women during pregnancy and menopause.
Undiagnosed ADHD can have catastrophic effects. Ant McPartin (of Ant and Dec) is a very good example. Happily married, with a stratospheric career, he nearly lost the lot when (as was widely reported in the media) he could no longer keep the depression/anxiety at bay. His marriage broke down; he crashed his car while over the alcohol limit, and he didn’t appear on TV for a year. Ant isn’t the only celebrity with ADHD. The entertainment world is full of them. The ‘clown of the class’ element means comedians are very likely to have the condition. Rob Beckett, Lee Mack, Russell Brand, Will Smith and Jim Carey are all publicly open about their ADHD diagnosis.
Combined and hyperactive/impulsive ADHD people have huge amounts of drive to achieve. Successful entrepreneurs with ADHD include the rapper will-i-am, entrepreneur Richard Branson and chef and restauranteur Jamie Oliver. Successful actors include Woody Harrelson, Channing Tatum, Eva Longoria and Whoopi Goldberg. Having ADHD is nothing to be ashamed of: we are in good company! Yet there is still a very real stigma around the condition, meaning a lot of people aren’t happy to disclose it. I am now part of an All-Party Parliamentary Group that meets at the Houses of Parliament quarterly with the aim to push through an ADHD Act. The Act will tackle,
among many things, the length of waiting times for ADHD assessment in this country, which range from 12 months to more than three years. It will also call for better training for teachers, GPs, CAMHS staff and all those who are likely to come into contact with the condition and are in a position to help somebody undiagnosed access assessment and diagnosis.
Comorbid conditions are definitely something else to look out for, as 80% of people with ADHD don’t only have ADHD; they have one or more comorbidities. This can be a clue to undiagnosed ADHD. Addictive behaviours (drugs, alcohol, food) go hand in hand with ADHD. The impulsive and compulsive elements of the condition mean clients with adult ADHD are likely to present with alcohol, drug, gambling, sex, shopping and other addictions, and to be frustrated by their inability to conquer their addictive behaviour when they see others doing so. However hard they try, their ADHD brain is a powerful driver and the crossover between addiction and ADHD is very high. Sometimes people may use drugs or alcohol to try to manage the symptoms of the ADHD, and impulsivity and struggles with self-regulation are, of course, key features of the disorder.
Dyslexia is one of the biggest comorbidities. So is social anxiety. In my opinion, anybody presenting with either of these two should be further investigated for ADHD – it has so often been missed. Other comorbidities include dyspraxia, dyscalculia, learning difficulties, ASD and emotionally unstable personality disorder (EUPD) and bipolar disorder (BPD). I’ve met numerous clients diagnosed with EUPD or BPD who have turned out also to have ADHD. The medication mainly used for EUPD and BPD can be disastrous for ADHD brains. Antipsychotics are not recommended to adults with ADHD as they can provoke self-harm in people who have never self-harmed before and have also been associated with suicide attempts.
If you work in addiction or with offenders, the likelihood of coming across ADHD in your therapy room is much higher. Such clients will talk of having absolutely no control over their impulsive behaviours and are likely to have tried numerous ways of curing their addiction, with no success. Many have also been through rehab without their ADHD being spotted. I’ve witnessed this for myself with clients diagnosed with ADHD – they go into rehab and the condition is not taken into account when dealing with the addiction. Probably as a consequence, there’s also a crossover with homelessness. The homeless charity where I volunteer has had 10 new counselling clients this year and all have been subsequently diagnosed ADHD.
The greatest thing you can do for any of your clients who are either going through the ADHD assessment process or are diagnosed is to understand the condition better yourself. There are some fabulous books on adult ADHD. The one I recommend over all the others is Delivered from Distraction by Edward M Hallowell. Hallowell is actually a psychiatrist who is diagnosed ADHD.
It’s also important to understand the effects of ADHD medication. Somebody unmedicated will be battling constantly against their brain. Medication is usually amphetamine or methylphenidate. For the last two years, the NHS have used Elvanse as their first-line medication in the treatment of adult ADHD but I come across people still taking older brands like Concerta and Strattera.
ADHD medication is notoriously difficult to get right, so you need to be prepared for clients to talk about titrating, switching medication, adding ‘top ups’ in the afternoon when the medication effect lessens and the ‘crash’, which can come in the evening when it’s stopped altogether. It’s a very delicate balance to get ADHD medication working perfectly and your client might want to spend time discussing this with you. It can be hugely frustrating for them and there are numerous side effects, including insomnia, weight loss and anxiety. You may also find your clients are very alert and switched on in the morning and much more groggy by the afternoon.
It’s highly likely that people with ADHD will come to you for myriad reasons but not because of their ADHD. So many have no idea they have it. My counsellor changed my life because she knew what ADHD traits to look for. She made sense of my 51 years of feeling different and being hard on myself for what I perceived as my failings. So look out for clients who talk about struggling to control their anger or violence or experience huge extremes of emotions for no apparent reason, or unexplained anxiety. If you can do for your clients what my counsellor did for me, they will thank you for the rest of their lives.
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Article written by Sarah Templeton for BACP magazine.