About ADHD

• ADHD is thought to affect 1 in 5 adults, although only 120,000 are diagnosed.
• Boys are three times more likely to be diagnosed than girls despite there being no evidence of gender bias in the condition.
• The current wait time for assessment via the NHS is between 18 months and seven years.
• A privately-obtained assessment can cost in excess of £1,000.
• Medication purchased privately costs an average of £100 per month.
• Adults with ADHD are at increased risk of anxiety, depression, self-harm and substance abuse.
• Adults with ADHD are more likely to face problems with debt, employment and relationship issues.

ADHD stands for attention deficit hyperactivity disorder.

ADHD is a neurodevelopmental condition which affects a person’s behaviour. Typically diagnosed in childhood, ADHD can last into adulthood and has recently gained a lot of traction as awareness grows, with recent years seeing a surge of adults seeking a diagnosis, as awareness of the condition has grown and stigma around mental health has decreased.

Men and women are equally likely to have ADHD, but women appear to be significantly less likely to be diagnosed. as a result, it is often suggested that ADHD is twice as common in males.

This can be due to a number of factors, but studies have suggested that natural fluctuations in hormones and oestrogen levels mean the external presentation of ADHD symptoms is less likely to be identified in women. Additionally, women are far more likely to be misdiagnosed, most commonly with anxiety, depression, personality disorders or bipolar disorder.

It is also common for women with ADHD to present with symptoms often associated with rejection-sensitive dysphoria (rsd), such as perfectionism, people-pleasing, co-dependency, body dysmorphia (a negative or inaccurate perception), low self-esteem, intense emotional reactions and overwhelm.

Currently, it is estimated that only 20% of those who would qualify for an ADHD diagnosis (male or female) have actually been diagnosed with the condition.

The effects of ADHD can vary from person to person but is divided into three main types:

• Inattentive type
• Hyperactive-impulsive type
• Combined type

These often present in the following ways:

The inattentive type

• May miss details and be easily distracted.
• May get bored easily.
• May have trouble focussing on a single task.
• May have difficulty organising thoughts and learning new information.
• May often lose or misplace things.
• May seem to not be listening.
• May process information with less accuracy or slower than others.
• May have trouble following or remembering directions.

Hyperactive-impulsive type

• May fidget, squirm or often feel restless.
• May struggle to sit still.
• May talk constantly.
• May touch or play with objects, even at inappropriate times.
• May struggle to engage in quiet activities.
• May seem constantly on the go, as if driven by a motor.
• May seem impatient.
• May act impulsively, or without considering the consequences.
• May interrupt or make inappropriate comments.

Combined type

• Whose presentation may contain elements of both inattentive and hyperactive-impulsive type.

The process of being diagnosed can be quite intimidating and overwhelming, and it is common to feel nervous or to ask the question, “what if I don’t have it?”

Psychiatrists and those assessing ADHD look for evidence of ADHD symptoms by asking questions during the assessment process, assessing ADHD-like behaviours in childhood through to the present day and determining whether the symptoms are associated with moderate to severe psychological, social, educational or occupational impairment and are not better explained by other psychiatric diagnoses.

Please note: the following advice and pathway relate to those in the UK only.

Step 1 – Complete an online test

In response to the under-diagnosis of ADHD, the World Health organisation (WHO) and the workgroup on adult ADHD generated a screener survey designed to be completed by individuals.

Surveys only give an indication of the likelihood of ADHD and do not constitute a formal diagnosis.

Step 2 – Speak to your GP

Inform your GP of your suspicion of ADHD (and any other co-morbid mental health conditions).

At this stage, you may mutually decide that you be referred for an NHS ADHD assessment.

Be sure to establish an approximate waiting list time. It is likely to be in the region of 12-24 months.

Step 3 – Assessment

3a – nhs assessment

NHS assessment covers overall mental health, an assessment of whether you have ADHD, and an assessment of any other mental health conditions.

Likely include forms of questions before the assessment. There will likely be one for you and one for someone who has known you during childhood, usually a parent.

3b – private option

The same as an NHS assessment, but at private expense.

The approximate cost is £1,000, including assessment, follow-up, and initial prescription of medication.

Step 4 – shared or GP care

Following diagnosis, a referral is made back to the GP, who is responsible for the ongoing prescription of medication.

Depending on the outcome of your assessment, it may be that you are either discharged solely to your gp, or that ongoing treatment or care is required by more specialist services.

For those assessed privately, shared care usually means that the GP continues to be responsible for the prescription of medication, but that your private psychiatrist will need to be consulted for changes in medication, with the associated costs.

Right to choose

Those based in England under the NHS have a legal right to choose their healthcare provider.

If you feel your waiting time for NHS ADHD assessment is too long, you are able to make alternative arrangements with an alternative provider, which will likely dramatically reduce your waiting time.

Providers such as Psychiatry UK, ADHD 360, clinical partners and Evolve provide services under the right to choose and are available to guide you through the process.

More information can be found on the NHS website: https://www.nhs.uk/using-the-nhs/about-the-nhs/your-choices-in-the-nhs/

Private assessments

ADHD Counselling UK is unable to provide recommendations for private ADHD assessment providers, but it is highly recommended that before committing to an assessment, checks are made to ensure the clinician you are seeing is a member of the general medical council.

You can check their register here.

The costs of private assessment can vary wildly, and the following guide is provided only as an approximation:

Initial assessment: approx. £800

Follow-up consultation: approx. £150

Medication: approx. £90 for a month’s supply, should you wish to begin before entering into a shared care agreement.

Unqualified practitioners – including qualified, registered counsellors and psychotherapists – are unable to provide a formal diagnosis for the purposes of prescription of medication or to access workplace protections.

Psychologists are able to provide assessments of ADHD but are unable to prescribe medication.

Standard treatments for ADHD in adults typically involve a combination of medication, education, training, adjustments in the home and the workplace, and psychological support.

There is no cure for ADHD. For those diagnosed in adulthood, the past is suddenly re-framed, and it is not uncommon for those diagnosed to experience something akin to bereavement – grief for a past that could have been and feelings of sadness, anger and loss.

Medication

There are five types of medication prescribed for ADHD:

• Methylphenidate, more commonly known as Ritalin, Concerta, Medikinet, Delmosart, or Equasym.
• Lisdexamfetamine, known as Elvanse or Vyvanse.
• Dexamfetamine is known as Adderal in the United States but is without a brand name in the UK.
• Atomoxetine, known as Strattera in the UK.
• Guanfacine, known as Intuniv in the UK.

These medications are available only by prescription in the UK and have potential side effects which need to be carefully considered and monitored.

Education

ADHD diagnosis does not come with a manual, but psycho-education represents an essential stage in management of the condition, empowering the diagnosed and those around them with necessary skills.

Irrespective of use of medication, the aim of psycho-education is to encourage recognition of symptoms and behaviours and to maximise the effectiveness of whatever treatment options are being utilised.

Books, podcasts, and videos on sites like youtube can provide essential resources.

The below video features ADHD counselling UK founder David Levy on the ‘Conversations with Nick Conn’ podcast, talking about ADHD.

Counselling/therapy

A lifetime undiagnosed will undoubtedly have had a psychological effect, and it is extremely common (more than half) for adults with ADHD to also suffer with a co-morbid condition such as depression, anxiety disorder, or personality disorder, and people with ADHD are at increased risk of self-harm or substance abuse (link to study).

‘Reasonable adjustments’

Those diagnosed with ADHD are unlikely to be diagnosed with a disability under the 2010 Equality Act, but this does not preclude employers from making ‘reasonable adjustments’ – minor alterations and accommodations – to ensure their best performance and insulation from discrimination or harassment.

Examples of these might include:

• Offering a desk facing away from busy or loud areas in the office.
• Providing written information to support tasks.
• Opportunities to work flexibly, especially in regard to time-keeping.
• Offering regular breaks.
• Structuring work with defined deadlines and offering clear, structured steps for the completion of projects or tasks.
• The use of technology such as screen readers, blockers and scheduling and/or to-do programmes.
• In the UK, the NHS ‘Access to Work’ programme offers grants to help those with difficulties, including ADHD, make adjustments to their workplaces, funding things special adaptive equipment or additional administrative support.

Further information can be found at www.gov.uk/access-to-work

Adult ADHD presentation can be complex and varied, affected by a number of different factors, life experiences and co-morbidities.

Undiagnosed, ADHD can have a corrosive effect on the person with the condition, often resulting in poor self-esteem, anxiety, depression, issues in relationships or in jobs, and commonly with impulsive behaviours or addiction.

Below is an approximate list of presentations in adults with the different types of ADHD.

Inattention

• May become easily distracted by low-priority activities, chores or tasks that tend to otherwise be ignored.
• May have numerous thoughts or tasks to do at one time, making it hard to focus on just one.
• May have difficulty focussing on a single task, such as when reading or watching television.
• May ‘zone out’ or become distracted, even in the middle of a conversation. may forget simple instructions or when asked to complete a task.
• May overlook detail, leading to errors or incomplete work.
• May often seek new stimulating experiences, or frequently seek new hobbies.
• May ‘hyper-focus’, so completely lose themselves in a task that something else is entirely forgotten.
• Disorganisation and forgetfulness
• May have poor organisational skills, or be frequently seeking new systems of organisation.
• May have a tendency to procrastinate.
• May have trouble starting or completing tasks.
• May struggle with timekeeping.
• May often forget appointments or deadlines.
• May often lose or misplace items.
• May often underestimate the time tasks will take to complete.

Disorganisation and forgetfulness

• May have poor organisational skills, or be frequently seeking new systems of organisation.
• May have a tendency to procrastinate.
• May have trouble starting or completing tasks.
• May struggle with timekeeping.
• May often forget appointments or deadlines.
• May often lose or misplace items.
• May often underestimate the time tasks will take to complete.

Impulsivity

• May interrupt or talk over others.
• May have poor self or impulse control, addictive tendencies.
• May act without thought or consideration of consequence.
• May struggle socially or act appropriately in social situations.

Emotional difficulty

• May be easily stressed or overwhelmed.
• May be easily irritated or have short or explosive temper outbursts.
• May have low self-esteem, sense of insecurity, or underachievement.
• May have issues staying motivated.
• May be extremely sensitive to criticism.

Hyperactivity and restlessness

• May have feelings of agitation, restlessness or racing thoughts.
• May get bored or distracted easily, have a tendency to take risks.
• May seems as though they are doing multiple things at once.
• May have trouble sitting still or constantly fidgeting.

Despite evidence that men and women are both equally likely to have ADHD, men are three times more likely to receive a diagnosis.

The reasons for this are complicated but include:

• Historical ADHD studies only focus on young boys.
• In earlier life, girls are more likely to present with inattentive type ADHD, and because of the increased risk of self-harm and suicidal ideation, are far more likely to be treated for anxiety and/or depression rather than have underlying ADHD symptoms recognised.
• Stereotypes and fluctuating hormones. Beginning at puberty, monthly hormonal fluctuations bring high levels of oestrogen and progesterone, which improve cognitive functioning following menstruation. However, when premenstrual hormone levels drop, ADHD symptoms are far more likely to express but be dismissed. There is evidence that ADHD symptoms similarly increase during menopause as oestrogen levels drop.
• Being diagnosed with other conditions, such as PMDD.
• Despite historically lower levels of diagnosis, treatment for ADHD is the same and carries the same levels of efficacy regardless of gender.