ADULT ADHD AND ASSOCIATED PROBLEMS
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that first presents in early childhood (sometimes from as early as two years old). Over more recent years researchers have found that ADHD persists into adulthood far more than it was intially believed to. Around 70% of children or adolescents diagnosed with ADHD will persist with clinically significant symptoms into adulthood. ADHD affects one of our most important grouping of brain functions, broadly described as executive functions. You can think of executive functions as forming the chief executive of your brain, whose job it is to coordinate information from lower brain regions to form organised and sustained responses to the tasks of daily living.
The problems associated with ADHD affect self-control, focusing and maintaining attention on tasks (especially boring ones), distractability, poor memory, hyperactivity, problems with impulse control, increased sensitivity to negative emotions, anger and frustration, poor time concept and time management, and are associated with other developmental difficulties such as learning disabilities, dyspraxia, and austim, among others. It's not surprising that these difficulties can often lead to problems with depression, anxiety, low self-esteem, poor educational attainment, poor work performance, relationship difficulties, financial issues, drug and alcohol abuse, and criminal justice issues. Unfortunately ADHD also puts people (males especially) more at risk of car crashes, accidental and early death, and even unplanned parenthood. Please see this
link for more information on symptoms.
For adults, hyperactivity tends to become less physically obvious (less running, climbing on furniture and constant motion which would be seen in young children with ADHD) and can be felt more internally as a restless energy and difficulty in relaxing (including when trying to fall asleep). Adults can also develop sophisticated ways to manage some of the other symptoms (e.g. by use of schedules, alarms, and by outsourcing organisation to other people). But receiving diagnosis and treatment can still be immensely useful both for understanding why a person is the way they are, and in the ability to access effective treatments. There is a heriditary component to ADHD, with some adults not realising they may have ADHD until their child is themselves diagnosed. It's never too late to get a diagnosis in order to receive treatment.
Many adults with ADHD have been previously diagnosed with anxiety and / or depression due to the presence of negative emotion, and that these two disorders are much better known and understood by health professionals. Many people find that antidepressants don't work the way they expected they would. These issues can look like treatment resistant depression and anxiety, when sometimes it is underlying ADHD which needs to noticed, diagnosed and treated. Persisting depression and anxiety also need to be treated in their own right.
Thankfully the idea of ADHD persisting into adulthood is increasing in the medical community and it is slowly becoming easier to obtain assessent and treatment. However, there is still a bottleneck in assessment which means that most adults will need to access assessment privately rather than through the public health system.
Diagnosis in NZ must be performed by a psychiatrist or psychologist (most likely a clinical psychologist). Only psychiatrists can obtain the special authority number required to prescribe stimulant medications (i,e, Ritalin), but a psychologist assessment can be used to obtain medication through the public health system in a fast-tracked system through a person's GP. Huge amounts of research over decades have shown the saftey of stimulant medications (they are more researched than any other psychotropic medication), and they are also the most effective of all treatments for ADHD, with higher clinical effect than almost any other psychiatric medications (and more than a lot of physical health medications). There are also behavioural treatments for managing ADHD which focus on teaching organisation and time management skills through external means (e.g. by utilising automated reminders and developing routines).
In summary, ADHD is a serious usually lifelong disorder which can have a number of negative and disabling consequences to the affected person, and consequences for their family and loved ones. A range of effective treatments are available, but the first step is assessment and diagnosis. If you are interested in pursuing assessment please see the
Adult ADHD Assessment page for information about the service I can provide.
ADULT ADHD ASSESSMENT
I offer assessment and diagnosis for adult ADHD (age 18+). A standard assessment includes:
1. A two-hour assessment which includes a semi-structured clinical interview for ADHD, discussing other significant life history events, and current symptoms of other mental health problems.
2. Completion of a self-report questionnaire about current ADHD symptoms, and completion of an observer report form by someone who knows the person well. Screening tests for mental health issues are also performed depending on the issues present. These are all completed online.
3. A review of symptoms present prior to age 12 by interviewing someone who knew the person as a child (such as a parent, caregiver, or sibling) and any available documentation such as school or other assessment reports. Evidence of childhood symptoms is a requirement for diagnosis.
4. A 30-minute feedback session.
Please note that for diagnosis there has to be evidence that the person had significant symptoms of ADHD in childhood and early adolescence.
If there is evidence that ADHD is present a report will be provided to the person's GP who can then send this to the adult psychiatric public health system to a psychiatrist who can prescribe medication (free!). Other behavioural options for treatment can also be discussed. See the Common Problems section for more information about the symptoms and consequences of adult ADHD.
The base fee for this service is
$1400 but may be higher if extra interviews or work is required, such as needing to perform additional assessment for co-occurring or complex mental health or social problems.
The full fee is payable two weeks in advance of the first assessment appointment. Turnaround of a report is approximately one month from the assessment appointment.
If you are from outside the Canterbury DHB area please note that you will need a pathway for obtaining medication, which is the most effective evidence-based treatment for ADHD. This will most likely mean an additional appointment with a private psychiatrist. It most cases it would be better to find a psychiatrist directly and forego a psychologist assessment.
Stimulant medications include methylphenidate and amphetamine preparations. They are the firstline and most effective treatment for ADHD for children, adolescents, and adults. They are also the most researched medications (because they are prescribed to children) and are safe and effective when used as prescribed. They have the largest effect on symptoms than any other psychotropic (brain-active) medication. They also work within minutes or hours, and also completely leave the body in a matter of hours.
Finding the right formulation and dose can take a bit of work but the results can be completely life changing. They are a controlled substance in New Zealand which requires a special authority number provided by a paediatrician or psychiatrist. They are prescribed on a monthly basis and urine tests are also required a few times a year to prove that the person prescribed the drug is actually taking it (the urine test measure metabolites of the medication that shows it was ingested by the patient). This is becuase these drugs can be sold and easily abused.
Formulations come in the fastest acting (4 hours) up to the longest acting which is 12 hours, with a number of preparations in-between. Slow and fast acting versions can be layered to smooth the effect of the medication. Side effects can include difficulties with sleep and appetite suppression.
Far from being a risky treatment, research with children over the last decade has shown that those with ADHD treated with stimulant meds have brain scans and fuctional tests that more closely resemble children without ADHD than those children with ADHD not treated the stimulant meds. The interpretation is that stimulant meds help the brain to develop in a more conventional manner. This is an astounding result that underlines the usefulness and importance of stimulant treatment. In adults, stimulant medication can reduce rates of drug and alcohol abuse from twice that of the general population to lower than the general population. Stimulant meds are an effective treatment that significantly reduce drug and alcohol abuse in adults with ADHD.
Psychotherapy and coaching
Even if a person uses stimulant medications there are always aspects of ADHD which remain. Stimulant meds will not make a person with ADHD an excellent organiser. Hopefully it will help the person move more towards the average range for a skilll compared to the general population. There are still weaknesses and difficulties that may require treatment. Seeing a psychologist or ADHD coach to see what's left and what can be done about it can be really useful.
But it's not just getting things done which is important. Having ADHD (especially if it is diagnosed in adulthood) can lead to a range of mental health and self-esteem issues, as well as embarrassment, guilt, and shame. These issues are not fixed with stimulant meds and may benefit from education about ADHD and psychotherapy aimed at acceptance and embracing of neurodiversity in order to live a rich and fulfilling life in spite of the difficulties caused by ADHD. Specific mental health issues may benefit from medication and / or evidence based psychotherapies as they would for someone without ADHD.
USEFUL EDUCATIONAL RESOURCES
I can recommend books by researcher and clinician Dr Russell Barkley. He has written several books for people with ADHD, parents, and other loved ones. I recommend his books:
Taking Charge of Adult ADHD
When an Adult You Love Has ADHD: Professional Advice for Parents, Partners, and Siblings.
Dr Barkley’s website lists his books. They are readily available online at places like Amazon.
Dr Ned Hallowell also has several user-friendly books on adult ADHD. He is a well-respected psychiatrist who has ADHD and dyslexia himself. His website lists his available books and again his books are available on places like Amazon. He and fellow psychiatrist John Ratey (also with ADHD himself) have just released a new book to update their popular title Driven to Distraction. The new book is written for people with ADHD and is highly readable and gives a good overview of ADHD:
I recommend the website
ADDitude which is a long-standing US ADHD support and information page. There are many articles about ADHD as well as book and other resource recommendations. I strongly recommend their webinar series called
ADHD Experts Podcast, which has been running for many years now with over 350 episodes. The webinars invite experts in the field to discuss a range of ADHD related material for people in all age ranges. I particularly endorse the very first episode by Dr Russell Barkley and the second episode (which has a more positive focus) by Dr Ned Hallowell. Episodes are clearly marked with a title to allow people to choose which ones they are most interested in listening to.
ADHD 2.0: New science and essential strategies for thriving with distraction – from childhood through adulthood
ADHD often presents differently in girls and women than it does for boys and men. I recommend the following book for addressing feelings of guilt and shame about ADHD, and how to accept and even embrace differences to have a better life:
I highly recommend the recent ADHD Experts podcast episode (no
ADHD is different for women: gender-specific symptoms and treatments presented by clinical psychologist Dr Ellen Littman who has over 30 years’ experience in working with people with ADHD and who has a special interest in women and girls with ADHD. This podcast discusses recent research into the differences in female presentations of ADHD, including the crucial role of sex hormones (specifically estrogen) in the exacerbation of symptoms at puberty, menopause, and as part of the menstrual cycle.
- A Radical Guide for Women with ADHD: Embrace Neurodiversity, Live Boldly, and Break Through Barriers, by psychologists Sari Solden and Michelle frank (both with ADHD themselves) - Amazon
PSYCHOLOGIST OR PSYCHIATRIST?
Both clincial psychologists and psychiatrists can diagnose adult ADHD. Only psychiatrists can prescribe stimulant medication. Stimulant medications are controlled substances and must receive a special authority code from a psychiatrist. A GP can not obtain this code. In the Cantebury District Health Board area psychologists can perform an assessment and provide a report that can be used to provide evidence for prescription by a psychiatrist withinthe public health service.
So how might an assessment differ between professions?
With a psychiatrist: a psychiatrist will likely peform a briefer assessment than a psychologist. The report will likely also be briefer. A psychiatrist may be less likely to talk to other family members about a client's current of childhood symptoms. A psychiatrist may feel comfortable prescribing a medicaiton at the end of an assessment appointment. A psychiatrist may manage a person's prescribing or may pass this on to the person's GP and work in a consultant fasion. A psychiatrist is unlikely to offer threrapy for ADHD. A psychiatrist is likely to charge a lower fee for the assessment than a psychologist.
With a psychologist: a psychologist is likely to perform a longer assessment that includes psychometrics and talking to other people in a client's life to ask about symptoms. The report is likely to be longer. The psychologists's report will need to be reviewed and agreed on by a psychiatrist to prescribe a stimluant medication. A psychiatrist or GP will then manage prescribing of medications. A psychologist may offer therapy for ADHD management. A psychologist is likely to charge a higher fee for the assessment than a psychiatrist.
PSYCHOLOGICAL CONSEQUENCES OF UNDIAGNOSED ADHD
By the time an adult comes for an ADHD assessment, whether they are 19, 35, or 49, they have usually spent years feeling different and not knowing why. There are multiple experiences of failure across multiple domains: primary and high schooling, tertiary study, social relationships, problems with intimate relationships, tensions between family members, problems at work, or limitations in how far they can progress in the workplace.
Understandably these experiences lead to issues with self-confidence, self-efficacy (the belief that a person can face challenges with the skills they have), and self-esteem. It also leads to increased difficulties with anxiety and depression symptoms. Addictions are also more common in people with ADHD.
When I diagnose and treat people with ADHD I often see education as the first step to self-knowledge, which is a step closer to self-acceptance. Learning the symptoms of ADHD and the common pitfalls and shared experiences can lift a weight from the shoulders. This isn't your fault. Your brain works differently, and it doesn't fit in well with modern environments. It's no wonder you have difficutlies, it's a shame it wasn't picked up earlier, but it has been now and it's time to learn and move forward with effective treatment.
EMOTIONAL DYSREGULATION AND SOCIAL PROBLEMS
While not a formal diagnositc criterion, many people with ADHD have issues with strong or sometimes overwhelming negative emotions of anger, rage, shame, and a sense of rejection. This can even lead to physical aggression and violence. The brain's frontal lobes which are affected in ADHD also help regulate emotional experience and expression and social behaviour. It is not uncommon for people with ADHD to have problems with social relationships due to impulsive verbal behaviour, offending others, feeling criticised or rejected, and in turn rejecting others. Anxiety about social situations is quite common.
In recent years the concept of rejection sensitivity dysphoria (RSD) has become discussed as a way to explain the intense sense of rejection and distress that some people with ADHD can feel in relation to perceived or real rejection by others. For more information about RSD I recommend the following resources:
How ADHD Ignites Rejection Sensitive Dysphoria
New Insights Into Rejection Sensitive Dysphoria
How Does RSD Really, Actually Feel?