ADHD

 What actually IS ADHD? Do I have it if I struggle to stay seated? Do I have it if I can’t remember why I walked into a room? Do I have it if I did really well in school as a child but now I am struggling to juggle my adult responsibilities? 

ADHD stands for Attention-Deficit/Hyperactivity Disorder. Is is a neurodevelopmental (based in the brain and how it developed in utero) difference that impacts someone during childhood and, often, into adulthood. It can have an impact on someone's ability to use the "brake and gas pedals in their brain." For some people, they can't hit the breaks and act impulsively. For other people, they struggle to use gas pedal and don't follow through on tasks or complete responsibilities. 

Someone with ADHD had difficulties before the age of 12. The difficulties could have occurred in keeping their room clean, sitting still, or waiting their turn. When the original criteria for ADHD was written, psychologists thought symptoms had to show up even earlier than age 12 but they now know this isn’t true. Also, psychologists learned adults are pretty terrible at accurately remembering what life was like before they were 7 years old.1 

Symptoms of ADHD can vary for each individual. In fact, there are 116,220 combinations of symptoms within a diagnosis of ADHD.2 Someone with ADHD may look like the stereotypical child with ADHD - can’t sit still in a classroom, climbing on the furniture, and interrupting teachers and parents. But here is a really important update on how we understand ADHD… girls with ADHD don’t always present in the classic way (i.e., the way boys present). Someone can have ADHD without hyperactivity and impulsivity. A girl with ADHD may look like a daydreamer who spends time staring out the window or who doesn’t seem to listen when adults are talking to her. She may create plans for herself and then have trouble following through, showing emotions like sadness or anxiety about her behavior. She may seem forgetful but it can be played off as being “busy,” “flighty,” or “a worrier.” 

The title “Attention-Deficit/Hyperactivity Disorder” can be confusing because it is used even when the person doesn’t have symptoms of hyperactivity. When you hear the term “ADD,” someone may be trying to capture the presentation of ADHD without hyperactivity. However, the actual diagnosis is “ADHD” and it is broken into three types. 

1. ADHD predominantly inattentive presentation (as described above)
2. ADHD predominantly hyperactive-impulsive presentation
3. ADHD combined presentation (a combination of both inattentive and hyperactive-impulsive symptoms)

When a psychologist is determining what type of ADHD someone has, they will ask many questions about symptoms. A symptom is simply an emotion, thought pattern, behavior, interaction pattern with others, or physical sensation. For a diagnosis of ADHD, someone needs to have a particular number of these symptoms. So for example, if an individual struggles to follow through with instructions but doesn’t have any of the other symptoms of inattention, they would not receive a diagnosis of ADHD that includes inattention. Or if someone has trouble sitting still during a boring meeting but does not have other symptoms of hyperactivity, they would not receive a diagnosis of ADHD that includes hyperactivity/impulsivity. 

There are 9 symptoms of inattention in ADHD.

1. Fails to give close attention to details or makes careless mistakes
2. Has difficulty sustaining attention
3. Does not appear to listen
4. Struggles to follow through with instructions
5. Has difficulty with organization
6. Avoids or dislikes tasks requiring sustained mental effort
7. Loses things
8. Is easily distracted
9. Is forgetful in daily activities

There are 9 symptoms of hyperactivity and impulsivity in ADHD. 

1. Fidgets with hands or feet or squirms in chair
2. Has difficulty remaining seated
3. Runs about or climbs excessively in children; extreme restlessness in adults
4. Difficulty engaging in activities quietly
5. Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
6. Talks excessively
7. Blurts out answers before questions have been completed
8. Difficulty waiting or taking turns
9. Interrupts or intrudes upon others

Once the symptoms of ADHD are determined and the ADHD type (or “presentation”), then the severity is also determined. ADHD can be mild, moderate, or severe. When a diagnosis is made, the severity helps communicate how much the symptoms of the diagnosis impact the individual’s life and how many of the possible symptoms are actually present. For example, if the individual has just enough symptoms for a diagnosis of ADHD and if they are only being impacted in a small way, they may be diagnosed with mild ADHD. However, if someone has pretty much every possible symptom and their college academics or job, relationships, and ability to take care of their own needs (e.g., self-care activities, paying bills, etc.) is highly impacted, they may be diagnosed with severe ADHD. 

Difficulties with attention, activity level, and impulsivity rise to the level of an ADHD diagnosis when they are actually impairing someone’s life. Many people experience symptoms of ADHD in their life that do not occur in multiple settings or create difficulties for them. For example, someone might “talk excessively” when they are with a close friend they have not seen in some time. Or someone might have a hard time focusing during a boring lecture when they have something exciting planned for the weekend or when they did not sleep well. However, these occurrences are not consistent, do not change the course of academics, relationships, or jobs, and do not create significant mental of physical health issues. It may be helpful to think of this impairment piece in terms of depth and breadth in the life domains that can be impacted. 

• Self-Care: Someone without ADHD may skip brushing their teeth on a night they are really tired. Someone with ADHD may have such difficulty maintaining a brushing routine and finding the motivation to regularly see their dentist that it impacts their oral health. In fact, people with ADHD are at an increased risk of cavities, periodontal disease, bruxism (e.g., teeth grinding and clenching), and impulsivity in eating sugary foods.3 

• Academics: Someone without ADHD may have a tough or boring class in college where they do not pay attention, scoring lower than is typical and slightly impacting their GPA but not resulting in significant academic consequences. However, someone with ADHD may feel the impact of inattention even when they find subject matter interesting and they value doing well in school. In fact, people with ADHD consistently have lower GPAs and higher dropout rates.4 On the flip side, people with ADHD can have great academic success but they may require significantly more support and effort than their classmates who don’t have ADHD. ADHD may not be identified in these individuals until later in life. 

• Friendships: Someone with ADHD may feel the desire to have close friendships but they may struggle due to communication and follow-through difficulties. When an individual with ADHD frequently interrupts conversations, has trouble staying on topics, and struggles to listen to full conversations, they can have difficulties making and keeping friends. In addition, difficulties with regulating emotions (especially avoidance in relationships) is associated with poorer friendship quality and romantic relationship problems among individuals with ADHD.5 

• Finances: Financial management in adulthood can be challenging for anyone. For individuals with ADHD, they often make decisions that have long-term consequences on finances and financial decision making. Individuals in their late 20s and early 30s with ADHD typically have significantly lower monthly income and less control of financial dependence (e.g., still living with their parents) than same-age peers who do not have a diagnosis of ADHD. The findings in this study remain true even when the adult no longer reports symptoms of ADHD.6 Other studies have show significant credit score decline among individuals with ADHD in middle age.7

• Work: Someone without ADHD may change jobs when they are feeling unfulfilled or when a good opportunity presents itself. However, someone with ADHD may jump quickly from job to job due to impulsive decision-making and restlessness. Frequent job jumps can lead to less support within the workplace and reduced wages over time. Individuals with and without ADHD may have overlapping reasons why they change jobs but differences occur in the timelines, planning, patterns, and impact on job satisfaction and growth. 

If you are an adult wondering if you have ADHD, an assessment may be something to consider. ADHD assessments are completed with a licensed mental health professional who is trained in how to ask the right questions and collect the right information to help you better understand your mental health and if you do or don’t have ADHD. 

Not all ADHD assessments are created equal. Some ask way too few questions and some way too many. For example, if someone just reads off the symptoms of ADHD and then says you do or don’t have ADHD, you are not getting a thorough enough assessment. Also, if someone says it is going to take them 10 hours of face to face time with you and they are assessing for things that are not at all relevant to you, you are getting too thorough of an assessment. It is always a good idea to find out what all goes into an assessment and why! 

Partnering with a mental health provider who uses science-based (also called evidence-based or standardized) assessment strategies is very important. A good adult ADHD assessment will have these components at a minimum:

• Standardized questionnaires about ADHD symptoms 
• A clinical interview where you are asked questions about childhood, adulthood, and symptoms. The questions are not “yes or no” questions but allow space for you to elaborate. A good clinician will spend time talking to you and understanding your symptoms. They will put your childhood and adulthood functioning into context and this is critical for a good assessment. 
• Screening questionnaires about depression and anxiety symptoms. 

OF NOTE: It is important to note that assessment of ADHD often means discussing many of the negatives. Individuals with ADHD have many strengths but the current accepted process of diagnosing ADHD is based on symptoms and impairment. If the mental health person doing the assessment keeps asking questions like “how do your symptoms get in the way of your life” or if they ask you questions that highlight things you don’t love about yourself (e.g., wishing you had more consistent self-care behaviors like brushing your teeth), please remember you are way more than any symptoms or diagnosis.