What’s ADHD and why are more adults being diagnosed with it?
Being unable to focus can feel like a normal symptom of modern life. But ADHD is more than being distracted
It was in a busy hospital office that newly qualified speech pathologist Charlotte Moore wondered if she had made a big mistake.
Sitting at her computer, typing her notes, the 28-year-old’s brain could not remain focused on the screen in front of her. She cared about the work – being a “speechie” was her dream job – but her mind simply could not stay in one spot. It jumped around the room, turning its attention to the conversations between the nurses behind her, tracking the rhythm of medical machines in the background, noting the movements of every person coming in and out the door.
Meanwhile, Tania Gricia, 53, had returned to study when she started to experience an overwhelming brain fog. At first, she put it down to perimenopause, only it felt different – and targeted to when she was doing her coursework.
“I would struggle with the readings, I wasn’t meeting deadlines – things that had happened to me in previous periods of life and I would dismiss them, thinking it was just a personality flaw,” she says. “But I knew that I wasn’t lazy. When I was working I could focus. So, why not now?”
Both Charlotte and Tania are among a growing number of adults, particularly women, being diagnosed with ADHD. For Tania, the diagnosis meant an overhaul of how she scheduled her time. For Charlotte, it triggered a move away from practising in a busy hospital and into community care, as well as relief that she had not completely misread her aptitude in the field. “It wasn’t that I was bad at my job, the job just wasn’t compatible with the way that my brain works – and that’s OK.”
ADHD is an acronym we hear a lot these days, but why? What is it? And how is it diagnosed?
What’s ADHD?
In a world where our phones feed us a constant stream of text and social media notifications, being unable to focus can feel like a normal symptom of modern life. But the experiences of people with Attention Deficit Hyperactivity Disorder are more debilitating and severe than just being easily distracted. “The key is functional impairment: it’s not enough to just have difficulty with your memory or with keeping attention, it has to be impacting areas of your life,” says Tamara Cavenett, president of the Australian Psychological Society.
ADHD is one of the most commonly diagnosed mental health conditions in children, impacting about one in 20 Australian kids. An early iteration of the condition called “hyperkinetic reaction of childhood” was first listed in the practitioners’ standard text, the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (the DSM) in 1968, but its definition has been tweaked several times since.
“The major feature of ADHD is the inability to hold attention when a person is not interested in what they are doing,” says the University of Sydney’s Professor Adam Guastella. This can manifest in forgetfulness, being unable to focus, or hyperactivity and acting out – even when a person knows they shouldn’t.
When someone with ADHD is forced to focus on something they do not want to for any period of time, it can become almost painful.
This makes ADHD different to autism, which centres on whether someone understands social situations. “But most kids with one neurodevelopment disorder will be diagnosed with another,” says Guastella, who is also chair in child and youth mental health at Sydney Children’s Hospital Westmead. He notes that 60 per cent of children with autism have ADHD. (Inversely, about 40 per cent of children with ADHD also have autism.)
You may remember the term “ADD” – once used to describe a non-hyperactive form of the disorder – but that is now obsolete. Since the most recent DSM edition – DSM-5, released in 2013 – ADHD has been an umbrella term for three different presentations: predominantly inattentive, which may have previously been diagnosed as ADD, predominantly hyperactive-impulsive, and combined (with elements of both).
Across all categories, ADHD impacts a person’s executive function: their ability to complete tasks through higher-level cognitive skills such as working memory and impulse control. When someone with ADHD is forced to focus on something they do not want to for any period of time, it can become almost painful.
While Tania could focus at work, her condition made committing to study impossible. She struggled to explain to family and friends why the tips they would give her for overcoming procrastination or refocusing were not enough.
For Charlotte, it was the loud work environment that shattered her concentration. As with many other people diagnosed as an adult, learning the symptoms of ADHD made some longstanding habits make more sense. “I’ve always been messy,” she says. “As a kid, my mum just wouldn’t understand how I could have such a messy room. And now, as an adult living by myself, it’s something I really need to watch because I never think to put something away.
“And when I was in uni, I would be terrible at exams because I just couldn’t remember things.”
CREDIT: ARTWORK: MONIQUE WESTERMANN
How is the disorder diagnosed?
Like other neurodevelopmental disorders, ADHD is more common in people with a family history. And UNSW child psychology researcher Professor Valsamma Eapen says there can be signs from early in development. “As babies, they have less need for sleep, want too many things to always keep them occupied,” she says.
Most diagnoses are in school children, when behaviours such as hyperactivity and inability to focus become apparent, although a growing number of people are being diagnosed as adults (more on that below). Not all children who have ADHD carry it to adulthood but somewhere between half and three-quarters will. Not enough is known about why, says Associate Professor Katherine Johnson, director of the University of Melbourne’s Attention Dynamics Lab. “Some [adults] will only have partial symptoms and some will no longer have the condition altogether.”
A mental health professional can diagnose the condition – usually a psychiatrist, who can prescribe medication as treatment, or a psychologist – following a GP referral. There is no single test. Assessments usually take place over several appointments, and may include interviews about past incidents and the person’s general history, as well as working through checklists of symptoms and situations a person has found themselves in – Do they often lose things? Do they often interrupt others? – and standardised behaviour rating scales. Because of the overlap with symptoms of other mental disorders such as anxiety it is important to receive a formal diagnosis.
“A huge part of it is differentiating their symptoms from anything else that could cause those symptoms,” says Cavenett. “It’s not uncommon in a child for the symptoms of ADHD to actually be anxiety or trauma.”
The condition is considered under-diagnosed in girls. “Boys can show more externalising behaviour, they are more impulsive and hyperactive, which makes them more likely to attract the attention of a teacher when they are at primary school,” Johnson says. “But, in girls, it more commonly presents as inattentiveness. They are sitting in a classroom, but their mind is not on what the teacher is saying. That may not always attract the same attention.”
“I would say a lot of things before my brain even processed what I was saying, as it’s always going a million miles an hour.”
Stephanie Quaglia, 30, is seeing a psychiatrist who has diagnosed her with ADHD following multiple appointments. She believes her condition was missed by teachers when she was a child.
“I looked through all of my school reports and every single one of them from kindergarten to year six says something like, ‘Stephanie is easily distracted, slow to complete tasks, talks too much’,” she says.
Stephanie also completed some cognitive assessments as a child – the WISC intelligence test and Neale literacy test – which said she was within the acceptable range of intelligence but easily distracted and needed encouragement to complete challenging tasks. “When I showed the psychiatrist he was pretty shocked nothing came from this, but I guess it just shows how it wasn’t really diagnosed in girls back then,” she says.
When Sarah, a pseudonym, was diagnosed with ADHD as a teenager, it came after years of being labelled as having “behavioural problems”. Her private high school in Sydney said she could continue to attend classes only if she took medication prescribed for her ADHD. “The main struggles for me were, and still are, hyperactivity and lack of concentration,” the 29-year-old says.
“Something that I did a lot of, that I now recognise was ADHD, was speaking without thinking. I would say a lot of things before my brain even processed what I was saying, as it’s always going a million miles an hour.”
Why are more adults being diagnosed with ADHD?
Although mental health professionals had been treating adults with ADHD-type symptoms for decades, adult ADHD was recognised by the DSM as a mental disorder only in 2013. Eapen says this change has likely led to an increase in awareness of adult ADHD among professionals assessing clients, although it does not fully explain the astronomical rise in adults – particularly women – seeking a diagnosis.
The mental health professionals interviewed for this story all agreed the popularity of content focused on ADHD on social media platforms such as TikTok and Instagram had played a role, with this content de-stigmatising a condition once associated with badly behaved children.
At the Royal Australian and New Zealand College of Psychiatrists, Dr Karuppiah Jagadheesan says there are significant numbers of adults being referred for ADHD assessment, many of whom only now have the confidence to seek out a diagnosis. “There is a lag period from the last 20 years or so because there was stigma for diagnosis and treatment – their parents may have avoided it and it is only now, as adults, they feel comfortable to try to get the help,” he says.
Psychologists have noted an increase in referrals for assessment too, says Cavenett. “We certainly know adult ADHD has been under-diagnosed.”
In his Melbourne practice, psychologist Dr Arthur Stabolidis has seen an increase in adults with ADHD symptoms. He attributes it to the lack of structure after the city’s lockdown. “Lockdown disrupts your routine and routine is important for all mental health challenges,” he says. After the turbulent past two years, his clients (a “relatively even” mix of men and women) have reported being easily distracted and forgetful, struggling with motivation to perform ho-hum daily activities – making breakfast in the morning, getting dressed before starting work – which they would once have done without thinking about it. Not all of them received an ADHD diagnosis, but Stabolidis says it’s “not a bad thing” that people are seeking help for behaviours they believe are impeding their life.
How is ADHD treated?
There is no recognised cure for ADHD, but the condition can be treated using pharmaceutical or behavioural therapy – and often a combination of the two.
Medication is more commonly prescribed to children and adolescents than adults. (It must be prescribed by an authorised health professional, usually a psychiatrist or specially accredited paediatrician.) The most common drugs are two psychostimulants: methylphenidate (Ritalin) and dexamphetamine. Scientists believe they work by impacting the level of two chemicals in the brain, dopamine and noradrenaline, which control attention and concentration. A 2018 review published in Lancet Psychiatry found methylphenidate should be the preferred drug for children with ADHD, while dexamphetamine is better suited to adults (although children responded better to drug therapy overall). Prescriptions for these two drugs in Australia have doubled in the past decade, from 514,000 in 2013 to 1,074,860 in 2021.
While psychologists don’t prescribe drugs, they (and psychiatrists) can help people with ADHD to develop strategies for managing ADHD symptoms. “We use mindfulness-type strategies, sensory strategies to manage hyperactivity, impulse management and cognitive behavioural therapy,” says Cavenett. “We want people to know what their triggers are.” When a child has ADHD, the psychologist will also work with their parent, she adds, so they can better see the world from their point of view.
Some techniques popular among adults with ADHD that they may work on by themselves or with a psychologist include:
- Body doubling: Arranging for someone else to be with you while you complete a task, to keep you on track. This has become particularly popular online, with businesses popping up that offer paid-for body doubling through video calls.
- Time blocking: Dividing tasks into smaller tasks of varying intensity. This technique can help people who struggle with procrastination to make it through their work, by offering multiple options to progress with a task.
- Habit stacking: Associating some tasks with other tasks – so, if a person struggles to remember to drink water, turning this into a habit when they brush their teeth or make breakfast.
“I watched one of the videos about not being able to maintain a fitness routine and it was, honestly, exactly how I had struggled to keep routines going.”
Cavenett says most of the techniques popular on TikTok are grounded in strategies a psychologist would use but people should really be seeking professional mental health support to determine if the techniques they see online are right for them – particularly if products cost money. “Whether an aid is effective depends on what it is and what it is doing for you, but the first step should be making sure the person actually has ADHD,” she says. “When TikTok is being used for professional help it could just result in people profiteering off a condition which the person may not even have.”
Charlotte says she found a YouTuber recommended by her psychiatrist to be helpful, not necessarily for the techniques provided, but the validation of her experience. “I watched one of the videos about not being able to maintain a fitness routine and it was, honestly, exactly how I had struggled to keep routines going,” she says.
In consultation with her psychiatrist, Charlotte has opted not to go on specific ADHD medication and instead uses techniques such as making detailed notes because she knows she can forget things, and leaving her items for the next day – keys, wallet – at the door so she doesn’t forget them on her way out.
Is ADHD being over-diagnosed?
The surge in adult ADHD diagnoses, and the popularity of “ADHD influencers” online, raises a question: is the condition now being over-diagnosed?
“Confirmation bias is a problem we all have a tendency for,” says Dr Brad Ridout, co-founder of the University of Sydney’s cyberpsychology research group. “Social media algorithms throw fuel on that fire because they funnel information to us based on what we have been looking at.”
And while concerns about “Dr Google” have been around for years, Ridout says “Dr TikTok” presents unique challenges: Google attempts to select for credibility but TikTok’s algorithm is solely based on popularity.
Jagadheesan says there is “a risk” ADHD is being over-diagnosed, but believes Australia is playing catch-up with people who were not diagnosed as adults.
In his clinic, Stabolidis says while adult patients are much more interested in receiving a diagnosis now than they were five years ago, the quality control in the mental health system is sufficient that people are not being unnecessarily diagnosed. “People come to me asking for an ADHD diagnosis,” he says. “They don’t really do that for depression or anxiety.”
“If anything, it is massively under-diagnosed and under-treated. Kids don’t get the right treatments early enough.”
Tania did not find her diagnosis through a social media revelation but she has experienced stigma about her neurodivergence all the same. “It’s an unfortunate time to be diagnosed because people who are sceptical think, oh, another one.”
As for whether the condition is being over-diagnosed in children, Guastella says this doesn’t align what is being seen in clinics. “If anything, it is massively under-diagnosed and under-treated,” he says. “Kids don’t get the right treatments early enough.”
Acknowledging there’s “a lot of public controversy” about kids getting stimulant medication, Guastella says the medications are, ultimately, what helps many children overcome their symptoms, particularly in the classroom. “The evidence is clear that kids’ lives change with the right treatment and there are too many stories of kids not getting that. It is well established that kids who don’t get the right support end up with collateral problems: lack of confidence, feelings of inadequacy, falling behind in education.”
As a speech pathologist, Charlotte works with several children who have an ADHD diagnosis. She says the stigma is changing for both adults and children. “More girls are being picked up when they are younger. There’s a recognition that ADHD isn’t just what hyperactive boys have.”
In recent years, high-profile people ranging from US Olympic champion Simone Biles and reality TV star Paris Hilton to Queensland LNP MP Andrew Laming and media personality Mia Freedman have all publicly revealed they have an ADHD diagnosis.
What’s next in the field?
Australia is approaching a shift in the way it manages ADHD. In October, the first Australian Evidence-Based Clinical Guideline for ADHD will be published by the Australian ADHD Professionals Association. The guideline, the first endorsed by the federal government’s National Health and Medical Research Council, will contain 132 recommendations for the diagnosis, treatment and support of people with ADHD across their lifespan – including referring to people “having” rather than “being” ADHD – designed to provide a consistent standard of care for mental health practitioners beyond the diagnostic definition in the DSM.
“There’s a huge gap in the medical profession’s knowledge about ADHD; [diagnosis and treatment] is mainly supported by private psychiatrists,” says Jagadheesan. “As a college, we are advocating for more professionals to be trained.”
The new wave of adults seeking a diagnosis are facing months-long waiting times as mental health services strain to help the community come to terms with the impact of the pandemic. Tania waited six months to see a psychiatrist, Charlotte one. Upfront fees can be high, too.
“There’s a huge waiting period, and sometimes that puts people off seeking a diagnosis at all,” says Jagadheesan. “Until the resources are better, that is something is going to be difficult to improve.”
Republished with permission from the Sydney Morning Herald.