A New Approach to ADHD
How many people have ADHD?
Estimates vary, but the rate of incidence of ADHD in the general population is somewhere between 4-10%. Rates of incidence in the professional research literature point to boys and men being slightly more than twice as likely to have ADHD than women, but that statistic might be misleading. It might be misleading, because it might turn out—and this is the opinion of the practitioners at Nightingale Counselling—that girls and women have better coping strategies at a younger age to mask the effects of ADHD than do their male counterparts.
This is compounded by what we call the “standard model” of ADHD presentation: hyperactive adolescent males. For those of you who have some familiarity with a 9 year old boy with ADHD, you know what that standard model looks like: inability to remain in his seat, an internal motor that never seems to stop, an inability to modulate the loudness of his voice, and the regular interruptions of others.
The Name of the Disorder
And though hyperactivity is right in the name of ADHD (Attention Deficit Hyperactivity Disorder), hyperactivity is only one aspect of ADHD. In fact, there are presentations of ADHD in which hyperactivity is not at all a prominent feature—which suggests that the name of the disorder is not a particularly good match for the experience of many who struggle with the condition, and this is true not simply for the hyperactivity aspect but for the attention deficit aspect, which we will discuss below.
The 3 subtypes of ADHD:
Do people with Attention Deficit Hyperactivity Disorder suffer from a deficit of attention?
On the face of it, this seems like an odd question. After all… it’s right in the title of the disorder. But as noted above, there is an entire subtype of ADHD whose main feature isn’t hyperactivity, so perhaps there are other difficulties attendant to the name. And this turns out to be exactly the case: people who struggle with ADHD don’t suffer from a deficit of attention but with a dysregulation of attention.
If people with ADHD suffered from a deficit of attention, then it would follow that deficit would be global. But we know that is not the case, because people with ADHD also regularly experience what is often called hyperfocus. Hyperfocus is the experience of being singularly fixated on something to the exclusion of all else. When a person with ADHD hyperfocuses on something, they become globally engrossed in that thing and often have the experience of losing track of hours or large chunks of the day. That seems incongruent with the idea of a deficit.
This doesn’t mean attention is a critical site of difficulty for people with ADHD, but it does mean that the name—now for a second time—doesn’t do a good job of describing the condition.
Who gets diagnosed and when?
We tend to think of ADHD as something that children—and, in particular, male children—struggle with. There are many people—physicians included—who claim that ADHD is something people grow out of. If we accept that people grow out of ADHD, then only children require support. But that is surely not the case. There is much we still do not understand about ADHD, but we do know that there is no growing out of it. It is true that as people mature, they find strategies to deal with the difficulties they face. But the difficulties remain.
And this is why it is typically during childhood when ADHD is diagnosed: because a 7 year old has no strategies to deal with the cognitive, emotional, and bodily difficulties that people with which ADHD struggle. But ADHD varies in severity, and, as noted above, it also varies in its presentation. As a result it is often missed.
Adult ADHD Counselling
It has been the experience of the clinicians at Nightingale Counselling that there is an overrepresentation of adults with undiagnosed ADHD—and, in particular, women—in our clientele. And this is true for two reasons: first, adults with undiagnosed ADHD have spent a lifetime struggling, without support, with the difficulties all people with ADHD struggle with: impaired working memory, difficulties with decision making, impaired executive functioning, difficulties around procrastination, and difficulties getting started (activation) to name just a few.
This often results in a distorted self-conception: for example, feeling that one is lazy or unintelligent or unreliable. And second, people with ADHD are significantly more likely to have other mental health diagnoses, for example depression, anxiety, and bipolar disorder.
ADHD and Diagnosis
Counselling is a type of health intervention that doesn’t spend a lot of time on diagnoses. Our scope of practice, generally, does not include a diagnostic component, and our way of interacting with clients is not typically dependent on the labels clients enter counselling with. But ADHD is different, because a diagnosis is important for accessing medications and accommodations when at school and even being eligible for a disability tax credit from the Canadian Revenue Agency (CRA).
Nightingale practitioners can help clients navigate the diagnostic process, accessing accommodations where available, and working closely with clients as they begin the process of finding the right medication at the right dosage.
We highly recommend a joint approach emphasizing counselling before and after any possible diagnoses. For those seeking urgent assessment, we recommend the Adult ADHD Center
What is the standard definition of ADHD?
The standard definition(s) of ADHD are typically in the realm of the cognitive and the behavioral. Symptoms include the following:
● Makes careless mistakes/lacks attention to detail
● Difficulty sustaining attention
● Does not seem to listen when spoken to directly
● Fails to follow through on tasks and instructions
● Exhibits poor organization
● Avoids/dislikes tasks requiring sustained mental effort
● Loses things necessary for tasks/activities
● Easily distracted (including unrelated thoughts)
● Is forgetful in daily activities
● Fidgets with or taps hands or feet, squirms in seat
● Leaves seat in situations when remaining seated is expected
● Experiences feelings of restlessness
● Has difficulty engaging in quiet, leisurely activities
● Is “on-the-go” or acts as if “driven by a motor”
● Talks excessively
● Blurts out answers
● Has difficulty waiting their turn
● Interrupts or intrudes on others
What’s missing from the standard definition?
The standard definitions and the standard model of who struggles with ADHD are generally well known. And though the cognitive and behavioral aspects of the condition are important to diagnosis and treatment, they do not tell the whole story. For instance, one of the critical features of ADHD that does not show up in the DSM is rejection sensitive dysphoria (RSD). In the experience of Nightingale Counsellors, everyone who has ADHD experiences some degree of RSD, which is the experience of feeling particular difficult emotions—rejection, criticism, or the feeling of being slighted—in disproportionate and particularly physical ways. For instance, clients report the experience of these feelings like “an elephant standing on my chest,” or feeling like they’ve been stabbed with a knife, or feeling like “my skin is on fire.” It is important to note that these reports are not metaphorical but sustained and common feelings clients experience in their bodies.
How does ADHD therapy help?
Therapy can help in a number of ways. First, Nightingale Counsellors are expert in spotting adult clients whose ADHD was not picked up as children and helping them to gain access to the appropriate diagnostic and then medical/ pharmaceutical services. Second, Nightingale Counsellors can provide critical psychoeducational resources to clients. And third, Nightingale Counsellors can work with clients around the subtle but critically important theme of acceptance. So many clients who receive diagnoses later in life have spent a lifetime hearing from others and thinking of themselves as unreliable, lazy, overly sensitive, and unintelligent. There can often be substantial feelings of grief and loss over “what might have been if only I had be properly diagnosed at 7.”
Is ADHD therapy enough?
ADHD is a persistent structural/neurological condition. Therapy is a powerful modality and can be critically important for clients with ADHD. For some, working around the theme of acceptance can allow an enormous amount of the daily cognitive and emotional loads to be lessened, which can be profound. However, for most clients finding the right medication at the proper dose can be life altering.
Our experience at Nightingale Counselling is that the gold standard for the treatment of adult ADHD is a combination of psychotherapy and medication. Medication can help with the deficits and difficulties in the cognitive and behavioural realm, while therapy can help clients come to a place of acceptance with the persistent struggles of ADHD, work with clients to come to a more representative sense of self concept, and work through the feelings of grief and loss that often accompany a diagnosis later in life.
If you are in a partnership where one or both people may be living with neurodiversity, have a look at our couples counselling opportunities
If you are organizing a family around a child or parent with ADHD, many families will benefit from family therapy services