Written by: Dr Utpaul Bose, member of the Expert in Mind Expert Witness panel
In children, ADHD is conceptualised as being at one end of a normal distribution curve; that is children who are the least attentive and those who are the most hyperactive are considered to have ADHD. A lot of the detractors of childhood ADHD make an issue about the cut-off point at which the children will be diagnosed. Therefore, if the cut-off point is lowered, there will be a lot more children diagnosed with the condition. However, adult ADHD cannot be diagnosed in this way. If you asked most General Adult Psychiatrists about the most inattentive patients they have seen in their clinic, they would think of patients who are floridly psychotic and paying more attention to their inner world than your questions. In addition, if you ask the same question about who their most hyperactive patients were, they would think of patients who were in the middle of a manic episode.
In adults, as opposed to children, ADHD presents as a syndrome of extremes. In addition to inattention there is hyper-focusing, which is when an emotion is attached to a task at hand. There is both procrastination and impulsivity; hyperactivity and hypoactivity; disorganisation and perfectionism. The main feature of adults with ADHD is their variability.
Leading London Consultant Psychiatrist Dr Utpaul Bose explains how adult ADHD presents in both men and women and the negative effects that it can have on people’s behaviour if left untreated.
How does ADHD affect people’s behaviour?
Childhood ADHD had a 60 year head start over Adult ADHD (1935 vs 1995). Unfortunately, children to at least the age of 10 cannot give a good description of their mental state. Children do not usually refer themselves to child psychiatry clinics but are usually referred by other people e.g. parents and/or teachers and are more likely to be referred for externalising symptoms (behavioural problems) rather than internalising symptoms e.g. anxiety, mood and low self-esteem. However, children with ADHD actually suffer with both internalising and externalising symptoms. It is the ones with externalising symptoms that get noticed because the adults can see them and the ones with negative externalising symptoms, which impinge on others, that are likely to be referred the most. Thus, the sample of children with ADHD that are diagnosed with the condition is an extremely biased one. It misses a lot of children who predominately suffer with mood swings and emotional incontinence; that is, they burst out crying when their classmate says they don’t like them, or they run around the playground a hundred times after scoring a goal. It also misses out on all the space cadets (usually girls) who do not have any observable behavioural problems but daydream all day long.
However, Adult ADHD is not predominately a behavioural disorder - as opposed to childhood ADHD. Not all people with ADHD suffer from temper outbursts. In fact, some spend all of their mental energy trying to control their tempers, with the odd occasional leakage. When temper outbursts do occur, they are usually because of frustration due to impatience like missing a train or the person in front of them spending too long in a queue. The focus on negative behaviours because of the emphasis on childhood ADHD overlooks the fact that all emotions are uncontrolled. Therefore, those with ADHD can also suffer with poor regulation of positive emotions and many individuals who never lose their temper, but have an abnormally loud laugh, suffer with ADHD as well.
Does ADHD have a negative effect on people’s behaviour?
Individuals with ADHD are impulsive; that is, they prefer smaller immediate rewards rather than larger long-term benefits. Therefore, they have financial difficulties, problems organising themselves and with household tasks such as running a family. They are also particularly prone to compulsive behaviours, which can range from shopping, masturbating, knitting exercises and risk-taking behaviours such as gambling, extreme sports, risky sex, risky driving (speeding) and shop lifting. Some of them self-medicate with illegal drugs.
How can ADHD be managed?
This can be managed with ADHD medication, life coaching or cognitive behavioural therapy (CBT). The benefits of treatment for ADHD are often much more dramatic than other psychiatric disorders.
Does ADHD present differently in men and in women?
There is a trend amongst women for more internalising symptoms such as anxiety, depression and low self-esteem. However, these symptoms can be very prominent amongst men and there are also many women who are sensation seeking risk-takers.
How do you assess someone for adult ADHD?
As children cannot tell you how their brain works, childhood ADHD is diagnosed based on their behaviours. General adult psychiatrists, however, use the mental state examination to diagnose mental disorders. It is therefore appropriate not to use specialised checklists that were designed for children but to diagnose it primarily on the way the individual describes their mood, thinking, behaviours and sleep.