With an estimated 800,000 people impacted by adult ADHD nationally, and a price tag of nearly $20 billion a year in social and economic costs, the proliferation of what is often considered a childhood condition has real consequences for society.
Eric Martin reports
Literature reviews show that adults with ADHD have a lower life expectancy, are 10 times more likely to visit the doctor and are three times more likely to present at an ED. They are also 42% less likely to be fully employed and on average earn significantly less than their peers.
Considering estimates that up to 75% of children diagnosed with ADHD experience symptoms into adulthood, Medical Forum spoke with Dr Roger Paterson, a psychiatrist with ADHD WA, and Dr Michele Toner, Australia’s first adult ADHD coach and a member of ADHD WA’s Professional Advisory Board, to discuss the latest in diagnosis and treatment.
Dr Paterson said that when he trained in child psychiatry in the late 1980s, he was taught that ADHD existed, but only in children and teenagers, and most, by their mid-teens, had grown out of it.
“Now we know that is not true. People thought that because hyperactive kids became less hyperactive, they appeared to calm down and the hyperactivity seemed to lessen, that their ADHD was gone.
“But no. If they had tested for inattention, that was still there and persisted. The fact the hyperactivity had gone away did not mean that the ADHD had gone. A lot of adults suffer from inattention that could be subtle and harder to pick up.”
Masked symptoms
Recent evidence supports the view that children with ADHD do not “outgrow” the disorder, rather, adult ADHD often has a more diverse clinical presentation that exceeds the typical motor symptoms described in children and includes a wider range of emotional dysregulation and functional impairment.
“Adults present for various reasons and some present quite late, but, essentially, adult ADHD is really just childhood ADHD that has been missed for various reasons, such as, for example, they were not the bouncy type,” Dr Paterson said.
“They were less hyperactive and more the inattentive type, which can often be the case in girls, who are normally better behaved than boys, and can mask their symptoms.
“Bright kids or those who have got a good, supportive family or school, can mask their ADHD and may slip through the net. They may start to struggle in Years 11 and 12, and really struggle if they go through to tertiary education.
“Many of them have also got some reading and maths problems and, by Years 11 and 12, start hitting the wall and that is where I start to specialise. I come in around the age of 15 or 16 seeing these kids.”
ADHD has long been associated with educational difficulties and students often require extra help, attend special classes, repeat grades, and have higher rates of academic suspension and drop-out. Similarly, university students with ADHD have lower grades on average and are less likely to graduate than their peers.
Coming unstuck
“The issue with university is that where they may have had good support at home and school to help get them through Year 12, at university they are left to fend for themselves. It is much better than it used to be with mentoring and support, but it is still very much up to them,” Dr Paterson said.
“They are told, ‘Here is the lecture theatre, this is when you are going to sit through your exams, and we will see you in six months,’ and they just fall apart.”
He said that while adults with ADHD could be quite impressive, engaging, charismatic and full of ideas, they could become frustrated over work careers that ‘could have been’.
Dr Michele Toner said people with ADHD did not get the same memo as neurotypicals: ‘You do not do this, you do it this way; this is how you get to places on time.
“They do not naturally absorb or learn those skills. The most mundane tasks are often the most challenging,” she said.
“Organisation, time management, prioritisation: they are the things that really interfere with someone with ADHD, and their ability to be successful and thrive, she said.
“There is a huge amount of misunderstanding because of assumptions that someone who is intelligent, and may hold an engineering or a medical degree, should be able to manage their time if they just tried harder.
“People can trivialise those challenges when in fact it is very easy for them to design a bridge or an oil and gas platform out in the ocean, but actually organising themselves to get to work on time is extremely difficult.”
Dr Paterson said people could struggle when they started in the workplace and needed to march to the beat of a boss’s drum rather than working at a pace or in a pattern that suited them.
“People with ADHD are notorious for working in bursts, such as doing nothing for a week and then pulling an all-nighter to get something done,” he said. “And you just cannot do that in the workplace.”
However, Dr Toner said people with ADHD could learn skills and turn their lives around when they found out the best way for them to do things.
“ADHD coaching is a bit like being an anthropologist really, it is about finding what is inherent in that person: so, if someone is visually strong and they are able to see things and design them in their mind’s eye, you want to translate their tasks into a visual medium, something that they can see and do,” she said.
Adults with ADHD can also find relationships more challenging, both in the workplace and romantically, according to Dr Paterson.
A recent study showed that in a sample of about 1000 adults, those with ADHD were significantly more likely to have been divorced (28% compared with 15% in the wider population) and were significantly less satisfied with their personal, social, and professional lives.
“People with ADHD can be successful at starting relationships, but often do not have long-lasting relationships,” Dr Paterson said.
“They tend to partner with people who are steady, who remain fairly central, and they gravitate around their partner’s consistency.”
Dr Toner said a lot of relationship problems came down to communication and a misunderstanding of what was happening for the person with ADHD.
“I often have the person’s partner come in for one session. Together, they come to an understanding. By making an adjustment in their communication and their family systems, they can reduce misunderstandings such as forgetting to pay bills or being late for family functions.”
Family connection
Dr Paterson said that it was common for adults to realise that they may be impacted by the condition when they bring in a relative, often a child, for diagnosis.
“Family history is an extremely common risk for presentation and ADHD can occur at any age. Many of my presentations are from parents who come along and say, ‘my child has just been diagnosed and when I looked at the symptoms, I realised it was me’,” he said.
“My oldest patient is 91 and lives in a nursing home, but he was incredibly busy looking after his wife for many years and needed his wits about him. I was treating his son and grandson and he said, ‘it sounds like me’.”
Dr Toner’s interest in the condition was sparked because she had family who were diagnosed with ADHD. It became a personal quest to find out as much as she could to support them.
She said one of the greatest sources of contention around the diagnosis of adult ADHD was the high degree of associated co-morbidities that could influence the potential accuracy of assessment strategies, such as the fact that ADHD was often diagnosed later in people with anxiety, who may be less impulsive because of this condition.
Overall, the risk for anxiety disorders is nearly 50% higher for people with ADHD than the general population.
“It is rare to see someone with just straight ADHD. Most of our clients have some anxiety and we often find that we are addressing such issues by helping them to address their ADHD,” Dr Toner said.
“Much of the anxiety that accompanies ADHD is anxiety around everyday things: ‘Am I going to forget something or am I going to say something stupid? Am I going to miss a deadline? Am I going to be late?’
“Often there is this terrible underlying anxiety of waiting for something bad to happen, and as people get more control in their lives, it helps them to manage that anxiety as well.”
She said that while ADHD coaches were not qualified to treat associated psychological conditions, they often worked with other therapists.
Co-morbidities
Dr Paterson said ADHD was co-morbid “with just about everything to a certain degree.”
“If you wake up each day and you have trouble concentrating, well, straight away, you have trouble organising breakfast, getting dressed, or even thinking ‘where am I heading?’,” he said.
“If you can’t concentrate and get organised and productive, you are stressed, and once you are stressed, you are more likely to reveal all sorts of possible co-morbidities.
“Stress might push you down the path of substance abuse to calm your busy mind, or you have trouble getting on with people, develop a personality disorder, or you could have this low-grade anxiety through your life, impacting every aspect of your thinking.”
Another condition associated with ADHD has been increased criminality, or rates of incarceration at least, with researchers from the US reporting that 47% of patients with ADHD had at least one criminal sentence.
“A lot of young teenagers head down the path of leaving school and becoming delinquent – the prisons in Australia are about one third full of people with ADHD, which is why people are saying places like Banksia Hill should be improved – not nasty prisons, but really five stars in term of great rehabilitation.
“I say, ‘Look, you’re only 20 or 30 or 40, and you are only about a third of the way through life, you have many good years ahead. You have some life experiences, let’s use those and your knowledge now and we can start applying it.’
“I want to give them some hope for the future, and we have a gradual acceptance that this is the problem. A lot of people can be full of remorse and sometimes blame for parents not taking to them to see someone when they were a child – they are upset about what could have been.
“Especially after they start the medication and suddenly their brains are switched on, they go, ‘Oh, if only my brain had been like this through school and relationships and work, I could have done such and such’.”
Dr Paterson said treating adults was often easier than working with children, because adults had a greater self-awareness and could give good feedback.
“However, with adults, I also make a point of always asking a relative or friend to come along and give some background, and sometimes to keep coming, because some people are not all that aware of how they are going and the impact of the medication,” he said.
“I have even had some patients say, ‘I see absolutely no difference at all,’ but in the background, the spouse or the mother is saying, ‘No, they are fantastic – it is a big change’.”
Dr Paterson said the rate of ADHD was about 5% in children and half that in adults, whereas the rates of taking medication in WA was around 2% in children and close to 1% in adults.
Treatment options
While there was now a range of new, slow-release tablets, the medication had changed little since they were first introduced back in the 1940s and ’50s.
“Dexamphetamine and Ritalin are still exceptionally good drugs and are still being used, though they have now developed long-acting versions of both, which has been the major change,” he said.
“They are what we call clean pills: they are good with few side effects; they are not addictive; they are not dangerous, and you can take them forever. Of all the medications prescribed in psychiatry, they are by far the best.”
Psycho-stimulants such as dexamphetamine sulphate are classified as schedule 8 controlled drugs due to their euphoric effect and ‘likeability’, yet there is limited evidence of psycho-stimulant abuse among ADHD patients.
“Because they are stimulants, they can be abused,” Dr Paterson explained, “but it is low-grade abuse: the bikies are not interested, there is no great street trade in them, but there is a little bit at universities with students that are buying and selling them around exam time.
“Mostly, folk will take them, and they are a bit like a cup of tea or coffee, they have a bit of a lift, but not an enormous difference, whereas someone with ADHD will go, ‘Wow, these are fantastic!’ And some of them will then get accurately diagnosed and treated, and it makes a real difference to them.
“We are only scratching the surface of how the brain works, but as far as we can understand ADHD, it seems to be that parts of the brain are underactive.”
One possible explanation is that ADHD and mood disorders stem from similar neurobiology, with neuroimaging studies revealing differences in volume and activity in the frontal lobe, responsible for attention, behaviour selection and emotion in adults with ADHD and psychiatric disorders.
Studies of neurotransmitters have also pointed to abnormalities in dopamine and norepinephrine signalling, which has been used to support the use of psychostimulants to treat individuals with ADHD due to the dopamine increases.
“When we stimulate with dexamphetamine or Ritalin, the underactive parts of the brain come to life and their executive function works better,” Dr Paterson said.
“The analogy we often use is the underactive parts of the brain are like the conductor and the rest of the brain is the orchestra: ADHD people have their orchestra playing, but no conductor; everybody is off doing their own thing.
“As they take the tablets each day, they wake up the brain, and at the end of the day, the tablets stop working and you go to sleep. They wear off and each day you start again. You get instant effect and instant wear off at the end of the day.”
GPs’ role
In Australia, GPs can investigate but cannot initiate ADHD treatment.
“It is still the province of specialists and probably will remain so for a while yet. We have to be careful about who starts on the medication, how it is controlled and then, once it is stabilised, GPs can get involved with code prescribing,” Dr Paterson said.
“And that is going to increase with the new regulations that are coming in WA to allow more GP involvement with less bureaucratic regulations attached to them, which is a good thing.”
Dr Toner said people with ADHD could also benefit from seeing a coach, particularly if there was a long waitlist to see a specialist. As there was no medical rebate for coaching, people did not need a referral.
“Awareness of ADHD coaching has grown among medical professionals, certainly among the psychiatrists and paediatricians who treat ADHD,” Dr Toner said.
Dr Paterson said GPs should have their antenna up for anyone who had mental health problems, to ask more about what their concentration was like in primary school.
“Particularly if they have that low-grade chronic anxiety or depression and frustration with life, and they have not had much success in relationships or work, you might think, ‘Hang on, what is going on here?’
“Sometimes they are obviously overactive, restless and fidgety and you can tell at the interview that they are a bit all over the shop, but not always – they could be masking their ADHD, especially the inattentive types.”