Relief of a midlife ADHD diagnosis
• The signs and symptoms of attention deficit hyperactivity disorder, which run from mild to severe, can be missed in childhood
AJohannesburg doctor relates how, when she delivered an attention deficit hyperactivity disorder (ADHD) diagnosis to a 60-year-old patient, the woman broke down in tears. After testing, the doctor found her patient had many of the symptoms, including difficulty in focusing on tasks and failing to complete projects she once started enthusiastically. She also felt a constant urge to chip in when someone was speaking and often impulsively booked airline tickets only to decide a few days later she didn’t need to get away.
Now at last in the doctor’s surgery the patient had an explanation for what she had always seen as her annoying sloth and generally being a “difficult” person.
The patient recalled some of the opportunities she felt she had missed out on in her life: like not having completed her degree at university and qualifying as an occupational therapist, as she had wanted to. Instead, she had worked for decades in the administration department of a big company, doing rote work.
It was recommended that she see a psychologist qualified in cognitive behavioural therapy (CBT) and a low dose of Ritalin
— 10mg — was prescribed. This was later adjusted to 5mg. This small amount of methylphenidate, she said, had changed her life. She could not change her career or undo the past, but the medication helped her to focus better on her work and hobbies. The small dose did not interfere with her sleep.
According to Lorian Phillips, a Johannesburg-based clinical psychologist who specialises in treating patients with ADHD, most people who are diagnosed with the condition later in life would have experienced symptoms as children.
“It is not that ADHD developed in adulthood only. It most likely was present all along but not diagnosed for various reasons, such as the child managing in school due to the structure and organisation of the school environment, the child having developed good compensatory mechanisms for dealing with ADHD issues or the child not having behavioural issues and therefore falling under the radar,” she says.
“Also, ADHD can present on a continuum from mild to severe and therefore if the child had it on a less severe scale, it could be managed without diagnosis.”
But the world of tertiary education and work presents more challenges and perhaps less support. “Often in adulthood, there are far more demands, deadlines, a lack of organisation and structure [compared with] school life so the adult starts to flounder in certain important areas of life and their functioning becomes compromised, leading to the seeking out of a diagnosis.
“When taking a history of the adult, there are usually many signs that were present during childhood.”
Dr Rushda Olivier, a GP with a diploma in psychiatry who is based in Johannesburg’s Fourways, says another reason for a late diagnosis could be that there was a lack of awareness or understanding of ADHD in the family or school during the person’s childhood.
Olivier says diagnosis of ADHD typically involves assessing symptoms such as inattention (for example, difficulty sustaining attention and being easily distracted); hyperactivity (restlessness and fidgeting); impulsivity (acting without thinking and difficulty waiting for a turn); and executive dysfunction (poor organisation and time management).
She says that before receiving a diagnosis, adults with undiagnosed ADHD may experience difficulties such as:
● Struggling with organisation and time management;
● Trouble maintaining focus and completing tasks;
● Impulsive decision-making, leading to problems in relationships or at work; and
● Feeling misunderstood or criticised for behaviours that are perceived as careless or irresponsible.
In addition, ADHD symptoms can sometimes be mistaken for other conditions or personality traits, such as:
● Anxiety disorders: Symptoms like restlessness and difficulty concentrating may overlap with symptoms of anxiety;
● Depression: Fatigue and difficulty concentrating are common symptoms of depression, which can overlap with ADHD symptoms; and
● Personality traits: Some ADHD symptoms, like impulsivity or distractibility, might be mistaken for personality traits rather than symptoms of a neurodevelopmental disorder.
There are three types of ADHD, according to Olivier:
● Predominantly inattentive presentation: Characterised by difficulties with attention, organisation and follow-through on tasks without significant hyperactivity-impulsivity symptoms;
● Predominantly hyperactiveimpulsive presentation: Individuals display symptoms of hyperactivity and impulsivity without significant issues with attention and focus; and
● Combined presentation: This type involves a combination of inattention, hyperactivity and impulsivity.
The medications that are prescribed will depend on the individual patient. “Factors such as side effects, effectiveness and personal preference play a role in determining the best medication.”
GENETIC
Medications include stimulants (such as methylphenidate and amphetamine-based medications); non-stimulants (such as atomoxetine, guanfacine and clonidine); and antidepressants (such as bupropion and venlafaxine).
“Finding the right medication often involves a process of trial and error, as individual responses can vary.”
The ADHD brain is typically overvigilant and busy. Phillips says this is on the whole more due to brain chemistry — to nature rather than nurture. “ADHD is primarily a genetic, inherited condition, not a psychological one. The neurological reasons for ADHD are well understood: lowered dopamine and norepinephrine transmission in the brain. The reasons for this, however, are unknown.”
However, she says, “I do believe that some of my clients show ADHD symptoms that have been triggered by trauma so that their brain is in an almost constant state of activation and arousal. Whether the ADHD was already present and the trauma exacerbated it, I do not know.”
Speaking on an SA Depression and Anxiety Group (Sadag) webinar recently, psychiatrist Dr GS Matsebula noted how people with ADHD will sometimes interrupt conversations and “be obnoxious”. They benefit from social skills training and CBT, which looks at how the person thinks and replaces their negative thoughts with healthier ways of thinking.”
Family therapy helps loved ones understand the condition better and provides a safe place for the patient, as well as others who are affected, to express their feelings and demystify some of the myths around ADHD.
“There is a lot of stigma that comes with ADHD, for example, people are perceived as lazy.” There is also a strong stigma about mental health, which encourages people to hide their condition and develop defensive attitudes.
Taswill Welcome was one such individual. Growing up in Mitchells Plain in Cape Town, he has seen much violence in his life and was experiencing headaches and not sleeping for three to five days. Sometimes he acted out violently. “I knew something wasn’t right.”
After consulting a professional, he was diagnosed with bipolar disorder and ADHD. He decided to go for training with Sadag so he could run a support group, and today runs a weekly support group for people suffering with depression, bipolar disorder and ADHD in Strandfontein.
“I took the responsibility to educate myself on mental health,” says Welcome, who, after studying chemistry in Bremen, Germany, founded a chemicals company in Cape Town. “I was hyper-focused when I did my course,” he says. People with ADHD quite often show a complete lack of interest or focus when something doesn’t interest them.
Welcome is a passionate advocate for mental health now, and has changed his lifestyle to help him deal with both his conditions.
“I go for regular medical check-ups; I go for walks and I keep a log of my triggers. You need to avoid your triggers and build resilience,” he says.
A trigger can lead the person to become agitated and act out in different ways. Welcome says for him this includes a feeling of rejection — “something I am working on with my psychologist ”— and a fear that someone is disrespecting him. “I know I have a need for external validation.”
As well as providing support to others in his group, he also gains support and inspiration by being there. An important aspect is reaching out and asking for support when you need it, and explaining your challenges to your friends and family, he says.
Welcome is regularly invited to speak on various public platforms and is writing his autobiography. Getting a diagnosis, he says, changed his life for the better.
Phillips says that lifestyle changes can make a big difference. “Some form of physical activity — exercise is one of the key factors in helping the ADHD person to regulate their brain. Intense exercise that gets the heart rate up helps the ADHD brain to concentrate and focus more optimally.
“A diet with more protein is also helpful in helping the ADHD brain to function more effectively as dopamine is produced by protein and dopamine is the key neurotransmitter for activating the ADHD brain.
“Using planners, lists, diaries ... as well as reminders, all help to deal with issues like procrastination, task paralysis and task completion. Setting up systems that create reward help to motivate the ADHD brain, for example: ‘I can go on my phone once I have worked for half an hour without interruption.’ Having said that, trying to reduce the use of phones, technology, devices and so on, and using them in a ‘clean’ way, as just described, also helps to keep the ADHD person more focused and alert.
“Mindfulness techniques like meditation and deep breathing are all very helpful in soothing the ADHD brain.”
In addition, psychological therapy helps in assisting clients to deal with their own unique ADHD issues, be it procrastination, problems with time management or lack of organisation.
“Together, therapist and client identify the prime issues causing problems and create a plan to deal with them.”
Phillips adds that people with ADHD also often battle with low self-esteem and emotional regulation issues, as well as some interpersonal problems. “Therapy works on these too to assist the client in developing healthy ways of coping and regulating themselves.”
FAMILY THERAPY HELPS LOVED ONES UNDERSTAND THE CONDITION BETTER AND PROVIDES A SAFE PLACE FOR THE PATIENT TO EXPRESS THEIR FEELINGS
THE ADHD BRAIN IS TYPICALLY OVERVIGILANT AND BUSY. THIS IS ON THE WHOLE MORE DUE TO BRAIN CHEMISTRY — TO NATURE RATHER THAN NURTURE
● For information about Sadag support groups, visit www.sadag.org and click on “support groups”.