Attention deficit

hyperactivity
disorder (ADHD)
The brain ain’t broke…it’s just glitchy
DSM-5-TR Diagnostic Criteria for ADHD

For children <17 years

● ≥6 symptoms of hyperactivity and impulsivity or

● ≥6 symptoms of inattention

For adolescents ≥17 years and adults:

● ≥5 symptoms of hyperactivity and impulsivity or

● ≥5 symptoms of inattention
ADHD according to DSM-5-TR

Symptoms of hyperactivity/impulsivity or inattention must:

● Occur often
● Persist for at least six months
● Interfere with academic, social, or occupational functioning
● Be excessive for the developmental level of the child
● Not be better explained by another mental disorder
● Several symptoms must be present in more than one setting
(eg, school and home)
● Several symptoms must be present before the age of 12 years
Inattention Hyperactivity/impulsivity
● Avoids/dislikes tasks requiring sustained ● Fidgets with or taps hands or feet, squirms in seat
mental effort ● Leaves seat in situations when remaining seated is
● Failing to follow through on tasks and expected

instructions ● Experiences feelings of restlessness

● Does not seem to listen when spoken to ● Has difficulty engaging in quiet, leisurely activities

directly ● Is “on-the-go” or acts as if “driven by a motor”

● Careless mistakes/lacking attention to detail ● Talks excessively

● Blurts out answers
● Easily distracted (including unrelated
● Has difficulty
thoughts)
waiting their turn
● Poor organisation
● Interrupts or
● Loses things
intrudes on others
● Forgetful in daily activities
● Difficulty sustaining attention
Implications - the obvious ones
Academic performance

Adolescents and adults with ADHD are:

Potential reasons for this include:
● less likely to have graduated from high school
● inability to handle large workloads
● less likely to have achieved a tertiary

qualification1 ● inattention

● disorganisation

● difficulty following instructions

● making careless errors1

1. Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the
community. J Clin Psychiatry 2006; 67: 524-540.
Implications - the obvious ones

Employment

● Decreased productivity in the workplace

(motivation, focus, concentration)
● Higher rates of absenteeism
● High job turnover
(emotional reactivity, impulsiveness, novelty seeking)
● Difficulty retaining a job
(poor time management and impaired social skills)
● Unemployment (sporadic and disorganised in their job searches)
● Poorer reputation as an employee (due to all issues listed above)13

13. Adamou M, Arif M, Asherson P, et al. Occupational issues of adults with ADHD. BMC Psychiatry 2013; 13: 59.
 Implications - the obvious ones
Family and relationships
Negative impacts on:
● relationship between children and adolescents with their
parents or carers1
● family quality of life (emotional impact and family activities)
● parental psychopathology (depression, anxiety and stress)
● parental warmth, consistency of parenting and parental hostility.2

Difficulty in maintaining relationships and higher rates of divorce3

● Irritability, inattention, impulsive talking and forgetfulness can contribute to misunderstandings in
social interactions.4
1. Caci H, Doepfner M, Asherson P, et al. Daily life impairments associated with self-reported childhood/adolescent attention-deficit/hyperactivity disorder and experiences of diagnosis and treatment: results from
the European Lifetime Impairment Survey. Eur Psychiatry 2014; 29: 316-323.
2. Cussen A, Sciberras E, Ukoumunne OC, et al. Relationship between symptoms of attention-deficit/hyperactivity disorder and family functioning: a community-based study. Eur J Pediatr 2012; 171: 271-280.
3. Fleischmann & Fleischmann, 2012
4. Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes 2012; 10: 47.
 Implications - the obvious ones
Personal finances

● Lower income (more frequent job turnover = less opportunities for promotion/progression) 1
● Loss of income from periods of unemployment
● Difficulty saving and managing finances
● Poor credit rating or debt
● Buying on impulse, wasteful spending,
compulsive shopping
● Difficulty remembering to pay bills and how much
money they had2

1. Moffitt et al., 2015

2. Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes 2012; 10:
47.
 Implications - the obvious ones

Problematic and risk taking behaviours

Symptoms of ADHD in adults associated with a higher incidence of:

● Accidental physical injuries1
● Criminality and arrests2
● Substance use3
● Aggressive/reckless driving3
● Traffic violations and risk of motor vehicle accidents2
● Suspension of driving licence2
● Suicide4

1. Ruiz-Goikoetxea et al., 2018

2. Barkley RA, Murphy KR, Dupaul GI, et al. Driving in young adults with attention deficit hyperactivity disorder: knowledge,
performance, adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc 2002; 8: 655-672.
3. Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a
qualitative study. Health Qual Life Outcomes 2012; 10: 47.
4. Septier et al., 2019
 The not-so obvious implications
Self esteem
Individuals with ADHD frequently experience:

● being blamed for their symptoms

● being told they need to “just try harder”
● criticism for not having enough willpower to force “normalcy”
● invalidation, being told that ADHD is “something we all have to a degree,” “not that serious”
or “not a real thing”

Why?
Because symptoms of ADHD are often misunderstood and seen to be evidence of a character
flaw rather than a neurological disorder.

https://www.healthline.com/health/adhd/adhd-and-self-esteem
 The not-so obvious implications

Quality of life
a subjective measure of an individuals’ perceived well-being across multiple life domains

For men, impacted by:

➔ Income
➔ Social functioning

Delayed diagnosis Poorer quality of life

For women, impacted by:
➔ Symptom severity
1. Joseph et al., 2019 ➔ Emotional control
 The not-so obvious implications
Stigma

A highly esteemed group of researchers conducted a study in 2021 looking at stereotypes, prejudice and
discrimination related to adults with ADHD in Australia and found:

● the community were willing to have friends, neighbours, and colleagues with ADHD, but were far
less welcoming of them as housemates, babysitters, or to risk their reputation by recommending
them for a job
● only 25% of respondents were willing to acknowledge that ADHD symptoms exist on a spectrum,
and that we all experience them to some extent
● when presented with a vignette depicting an adult exhibiting ADHD symptoms, 58% of those
surveyed responded with irritation, and reported feeling annoyed by the person 1
1. Sorensen, Knorre, & Bell, 2021
 The not-so obvious implications

Stigma
● approximately one third of all respondents reported believing that ADHD was caused by
factors such as the pressure to perform, work-related stress, and stressful life events

● 43% of respondents were unsure about stimulant medications as an appropriate

recommendation for treatment of ADHD

● 10% of the community sample were directly opposed to the use of stimulant medications as
a treatment for ADHD symptoms

1. Sorensen, Knorre, & Bell, 2021

Barriers to diagnosis
Stigma

● The stigma surrounding mental health issues, and the

associated shame, presents a major barrier to seeking
treatment and help for many sufferers (Godfrey et al., 2021).

Being female

● The female presentation of ADHD is more often

associated with less obvious internalised characteristics
(mind racing and restlessness) that are often missed in
childhood (Jeavons et al., 2018).
Barriers to diagnosis

ADHD in Girls ADHD in Women

Barriers to diagnosis
Having higher than average intelligence
● Adults with ADHD and higher than average IQ show less evidence
of executive functioning deficits compared with those with ADHD
and standard IQ, suggesting that a higher degree of intellectual
efficiency may compensate for deficits in executive functions,
leading to problems in establishing a precise clinical diagnosis1

Difficulty finding a specialist

● Many psychiatrists refuse to treat adults with ADHD due to perceived
issues about illegitimate drug-seeking

1. Milioni, A. L., Chaim, T. M., Cavallet, M., de Oliveira, N. M., Annes, M., Dos Santos, B., Louzã, M., da Silva, M. A., Miguel, C. S., Serpa, M. H., Zanetti, M.
V., Busatto, G., & Cunha, P. J. (2017). High IQ May "Mask" the Diagnosis of ADHD by Compensating for Deficits in Executive Functions in Treatment-
Naïve Adults With ADHD. Journal of attention disorders, 21(6), 455–464. https://doi.org/10.1177/1087054714554933
Barriers to diagnosis
Cost

● Significant costs associated with private psychiatrist

appointments are often out of reach for adults with
ADHD who have financial difficulties associated with
impaired academic, employment and financial performance

Sourcing historical information

● Significant amount of historical information required for retroactive diagnosis

○ school reports - may have been misplaced, discarded
○ corroboration - family members may not “believe” in ADHD or agree with pursuing a diagnosis
and thus be reluctant to cooperate and/or may not have noticed that symptoms, recognised their
significance or remembered them
Barriers to diagnosis

Executive function

● Getting a referral, finding a specialist,

booking an appointment, collating the
required information, and getting
yourself to an appointment requires
executive function skills (ironic!)
Treatment
Stimulant medication

● has the highest efficacy (up to 90%

effective in reducing symptoms)
● methylphenidate (Ritalin, Concerta)
● amphetamines (dexamphetamine, Vyvanse)

Non-stimulant medication
● 40-60% effective in reducing symptoms
● atomoxetine (Strattera)
● guanfacine
● venlafaxine

Most medications are available in immediate

and extended-release formulations
ADHD Paradoxes
● Easily Distracted and Hyperfocused
● Fixated and Creative
● Lacking Inhibition and Showing Courage
● Disorganised and Very Organised
● Procrastinating and Being Impatient
● Procrastinating and Being Super Productive
● Having Lots of Energy and No Energy
● Forgetful and Having an Extraordinary
Memory
● Passionate Interests and No Interests
● Irritable and Tender-hearted
● Worried and Not Worried Enough
● Rejecting Help and Giving Help
 Myths about ADHD

● Everyone has ADHD now

○ A systematic review of epidemiological studies
revealed no increase in ADHD prevalence over
the past 30 years1

● ADHD is an attention problem

○ ADHD is an attention regulation and allocation
problem

1. Polanczyk et al., 2014

Myths about ADHD

Stimulant medications

● Cause aggression
○ They can reduce aggressive and antisocial behaviour
● Cause seizures
○ You’d have to swallow the whole bottle
○ Can be taken safely by those with seizure disorders
● Cause tics
○ They may worsen tics if the person was already prone but only in 30% of cases
○ Worsening is temporary - disappears within 7 days of ceasing medication
Myths about ADHD
Stimulant medications

● Over-prescribed
○ Prevalence of ADHD in children is 7.5%,
only 4-5% are medicated - this means one
third of all children are not medicated
○ 90% of all adults with ADHD are not treated

● Increasing rates of stimulant prescriptions indicates a problem

○ A lot of adults missed being diagnosed as children
○ Girls and women are both still under-diagnosed
○ As our understanding of ADHD increases, we are better able to recognise and diagnose it
○ Greater public awareness of ADHD = increased numbers of people seeking diagnosis
In the therapy room
Experience of an ADHD late diagnosis often triggers a grief response

1. Euphoria: It might last minutes, or days. Finally, there is an explanation for why you are
the way you are. You aren’t crazy (well…it’s still possible), there is a name for your
struggles.
2. Disbelief: Finding out you have ADHD gives you a greater understanding of yourself.
But, it also shakes your self–identity to the core. You have to rebuild your sense of self
with this new knowledge. You might question if the person who tested you was
accurate.
3. Anger: The anger can be at yourself, at other people or at ADHD for existing. Why didn’t
I find this out sooner? Why didn’t my teachers, parents or wife / husband notice?
4. Depression: Sadness. A sense of loss of what could have been. You might find yourself
thinking that your life would have been easier, happier, more successful, richer, etc. if
you had known years ago.
5. Acceptance and hope: This is where you embrace the new part of you. You realise that
some of the strengths you have are related to ADHD; that without ADHD, you wouldn’t
be the person you are today.