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The Dose Transcript for January 18, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Attention deficit hyperactivity disorder, or ADHD, is a common diagnosis in children. Very common. But more and more grownups are also being diagnosed with ADHD. And one clue that we have is that the prescribing of ADHD medications among adults has gone up significantly in the last few years. Still, if you weren't formally diagnosed as a child, you or someone you know and love may suspect that you have it. So this week, we're asking, how do I know if I have undiagnosed adult ADHD? Hi, Ainslie. Welcome to The Dose.

AINSLIE GRAY: Thank you very much, Brian. It's a pleasure to be here.

BRIAN GOLDMAN: It's a pleasure to be talking to you too. So just off the cuff, how do adults react when you tell them they have ADHD?

AINSLIE GRAY: Surprisingly, adults often feel tremendous relief because they gain an understanding of what areas of their life have been responsible for their impairment.

BRIAN GOLDMAN: I've certainly had that experience of giving that diagnosis or other diagnoses and having a sense of relief. Just seeing them, they just relax and say, oh, good, this has a name. And now we can do battle with the name, which is why we have come to you to tap into your expertise. But before we do that, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

AINSLIE GRAY: My name is Dr. Ainslie Gray. I'm a focus primary care physician who has worked in the mental health field since the late 90s. I have a special interest in working with the diagnosis of attention deficit hyperactivity disorder, and have created a resource in Toronto that supports the life span intervention for providing not only assessment, but ongoing treatment.

BRIAN GOLDMAN: Let's start by getting some clarification. What is ADHD exactly?

AINSLIE GRAY: ADHD is a mental health diagnosis. People often think that you have to have the hyperactivity and impulsivity as well as the inattentiveness, but it can often present as just being what's classically talked about as being ADD without the hyperactivity. But it is a usually generic presentation of individuals who are suffering from a combination of inattention, hyperactivity, restlessness. That inattention and hyperactivity can often be very subtle. And people say when they look for an adult diagnosis, what they're looking for hyperactivity rather than mental restlessness or hyperactivity. So it's a serious treatable mental health diagnosis that needs to be understood by all of us in a better way.

BRIAN GOLDMAN: So how does behaviour in adults compare to that of kids?

AINSLIE GRAY: Well, adults learn to mask their symptoms very effectively. For example, people say, well, you can't have ADHD. Or the individual can say, well, I don't have ADHD because I have accomplished all these career or education or social relationships successes. But what brings them to our clinic is usually impairment. And that impairment is most commonly a mental health presentation of anxiety and sadness. They realize that they are underachieving from their own self-perception and they are running into difficulties in their life.

BRIAN GOLDMAN: Is it actual underachievement? Because, you know, it seems to me that that's part of the root definition of ADHD in kids, that if there's this noticeable gap between where intellectually they should be in terms of academic achievement and school achievement and where they actually are, that that's often one of the harbingers or one of the prime indications of ADHD.

AINSLIE GRAY: Yes, it is. And another harbinger, to use your term, is the transition time. So as a child, the transition may be moving into different levels of education, whether it's school entry, high school, university, first job. Any time there's a major transition, the skill sets around ADHD being an impairment situation become accelerated. So for example, the majority of adults with ADHD report struggles with mood regulation. It can be misdiagnosed as depression or anxiety or even personality disorders. So when someone starts feeling that they are not achieving what they expect they are capable of, the resulting co-morbidities often get identified first. For example, there are many middle aged women particularly who may be being treated right now for anxiety or depression, but it's treatment resistant. In other words, people have tried many different medications, but it hasn't really solved the frustration that the patient may have. The important thing here is to think, okay, are we just treating comorbidities of something else? Because if they have ADHD, the treatment regimen is different. And many individuals will come off mood altering medication which they no longer need because their signs and symptoms have been treated.

BRIAN GOLDMAN: How much of a gender split is there in adults? You mentioned women. And, you know, my understanding is that this diagnosis in adults and children occurs more often in men.

AINSLIE GRAY: No. By adult, it is 50-50 between the two genders. However, that misconception may be because in children and adolescents, the male individual often presents with more overt emotional dysregulation or physical hyperactivity. We all know that characteristic impression of the little boy in the classroom who's falling out of the chair and waving a flag saying, I'm having trouble engaging here. But by adulthood, it's pretty much 50-50.

BRIAN GOLDMAN: What are some of the ways that adults may unknowingly cope with undiagnosed ADHD?

AINSLIE GRAY: One way might be they acknowledge the fact that they need extra time to do something. For example, an employee might say, you know, I'm staying late every night at work. But I find that as soon as the office is empty, I can do my day's work in two or three hours if I'm alone. That's a perfect example of someone whose distractibility and lack of focus is challenged by their working environment in a regular shift. But once they can actually tune in and hyper focus, quote unquote, they can achieve almost more success in a shorter period of time as a compensation. Often, people will say, not only am I taking more time, but when I actually get down to do the job, I've been avoiding it or I've been procrastinating. And once I just take that first step and get going, I'm away to the races. So that's a very common presentation. Often, people are thinking they're coping by saying, well, I guess I'm not very good at studying math or science or whatever, so I'm going to change courses or I'm going to change universities, change my learning environment, and they realize that their lack of ability to engage and focus follows them along. So it's that frustrating impairment piece of not meeting their own expectations when they realize they are capable of it. They just aren't able to get going the way they'd like to.

BRIAN GOLDMAN: So they may drop subjects. They may need extra time. They work at times perhaps where there are fewer distractions and they can hyper focus. Are there any other coping mechanisms that undiagnosed adults with ADHD may use?

AINSLIE GRAY: Yes. And I alluded to this earlier in that many people try to slow down that restless brain by, well, doing exercise, which is great, by organizing time management skills. But more seriously, when people make attempts to use mood altering drugs like cannabis or even regular cocaine use in the back yard kind of thing just slow down what they feel. Alcohol is another that people can begin to use in appropriately. So when they are diagnosed and successfully treated, some of these substance abuse situations improve dramatically because the individuals understand why they are having the difficulties they are. There's also real concrete stat saying that there's compromised socioeconomic status. There's lower annual incomes. There's higher divorce rates. There's less workplace satisfaction and less job security. Many people will crash their cars and experience other traumas or die by trauma because of their inability to stay engaged. The biggest thing is persistent and deteriorating self-esteem. People see me as being lazy, incompetent and incapable. And those are huge concerns. It's costing society a great deal financially as well as academic outcome and performance when individuals are not identified and ultimately treated appropriately.

BRIAN GOLDMAN: You're painting a picture of people at the extreme of undiagnosed ADHD. Is there something to be said for people who may have milder forms of ADHD and basically are able to cope, but they find that the cognitive load in keeping them at the top of their game is exhausting?

AINSLIE GRAY: Yes. And I think, you know, there's a lot of joking around when somebody doesn't stay focussed or engaged. Oh, you must have ADHD. And it's trivialized in many social situations. But the impact of ADHD is tremendous, and understanding when it's present and when it's not present gives an individual very clear Guideposts on how to move forward. For example, in our own medical community, there is a tremendous number of people in the paramedic or emergency room, for example, that will have ADHD. That doesn't mean they're being compromised by it, but they've chosen a career where they can hyper focus when they have to. They don't have to take homework home with them at the end of the shift. They are on the moment. They are at 100% capacity for a short period of time and then they can settle down again. So we see that career choice, for example, often being an individual who works more successfully with change, with the silver tinsel of an exciting new opportunity, not enjoying a routine, predictable, repetitive type of career situation.

BRIAN GOLDMAN: Ainslie, you've painted a picture of me and you've painted a picture of a lot of my colleagues. And I'm not joking here. And, you know, there is a cliche about people on the frontlines of emergency medicine who have undiagnosed ADHD. But you're talking about me. You know, most of the time, I'm fine. But when I'm a little bit tired, sleep deprived, and of course, there's a lot of that in emergency medicine. There is a particular intercom alarm that distracts me in the emergency department, particularly when I'm tired. I just can't put it out of my mind. I hear it and it seizes my attention. So I suspect for a lot of people who are listening to this conversation right now, bells are going off right now. And I don't just… I mean alarm bells, internal alarm bells, not the ones I just described.

AINSLIE GRAY: Yes. It's important, though, Brian, to remember that ADHD manifests itself differently in different people. As physicians, you know, we need to welcome learning from our patients and create a safe space for them to unpack some of those feelings. And ask the question, what is it that you've noticed about yourself that makes you think you might have ADHD? And looking for signs and symptoms of that impairment. I think that there are areas of medicine, may I suggest, that you may not have thrived in. Certainly, I can tell you there are some in my life, but I think there are certainly career choices where people are going to excel when they have that variability. That quick response sounds to me like you want your emergency physician to be someone who can engage and can be focussed on the task, and you don't really care if you can't have that level of commitment for your whole shift, for example.

BRIAN GOLDMAN: Now, you know, a lot of people listening to us are guessing that they have adult ADHD. How do you actually make the diagnosis? Tell us about the assessment.

AINSLIE GRAY: The assessment, in my opinion, requires a series of questionnaires from not only the individual, but third party informants. Many adults will be able to bring in their report cards, surprisingly enough, even though they're in their 30s or 40s. And often, there are signs, usually by the age of 11. You know, if Susie could just not fall out of her chair, if Johnny could remember to bring his books, there are early signs of just lack of focus. But when this trend is seen repetitively, that early identification of signs and symptoms is an important thing to document. At our clinic, with our adult assessments, not only is a psychiatrist interviewing the individual, but so is a clinical psychologist and so is a coach therapist. So when those three interviews get together along with created questionnaires, it's pretty clear when someone has ADHD and when they don't. And there are many people who come in for assessment that don't have ADHD, and they may have an undiagnosed learning disability, for example. There may be some other medical condition that is complicating their ability to perform the way they want to. So having an assessment does not necessarily mean you're going to have a diagnosis. But I think the important thing is to have confidence in the assessment process so that the recommended treatment is not only understood by the individual, but validated by very thorough investigations.

BRIAN GOLDMAN: And when you diagnose an adult with ADHD, what are the treatment options that are available that are evidence based and effective?

AINSLIE GRAY: You need a combination of pharmaceutical support often, but more importantly, you have to have coaching or behavioural interventions for the individual to deal with their signs and symptoms or their impairment. And ideally, the combination of both is the optimal treatment. I think it's very important to have an understanding of why you think you have it. If it's confirmed, what are you going to do about it? So from a treatment perspective, I think a pharmaceutical called a stimulant is a medication that has been around for decades. And all the time, they're being improved upon long acting preparations. And there are excellent choices covered by our Ontario health care plan or whatever province you're in that will allow an individual to feel more engaged and more a part of their daily routine. I personally think that ADHD is a result of a shortage of available neurotransmitters to the individual. So when you take a medication, you're not stimulating, quote unquote, that individual's behaviour. You're actually providing neurotransmitters to stabilize and have them be more normally engaged with the world around them. So the dosage of medication is important. These medications are often misused or dare I say, abused. But when they are correctly diagnosed, individuals with ADHD will often feel, oh my goodness, I feel like myself rather than an engine on overdrive.

BRIAN GOLDMAN: But it is possible to misuse these medications, and maybe people are passing along tips to one another on the internet on how to do it.

AINSLIE GRAY: Yes. And I think that's why there's only a very few long acting stimulants that I personally prescribe, because the ones that I think should be used are the ones that primary care physicians need to be informed about. And because many family doctors are apprehensive, they will try a low dose of an immediate release alternative. And those are the ones that can be misused, crushed, sniffed, snorted. The long acting ones, without getting brand specific, are much more difficult and don't have the same interest. So prescribing immediate release stimulants, in my opinion, should never happen. And that's why the fact that OHIP is covering long acting stimulants is just a wonderful success story.

BRIAN GOLDMAN: And finally, what are some of the ways that we need to destigmatize ADHD to ensure that more people receive the care that they need?

AINSLIE GRAY: Destigmatization is always a big challenge. There are still a lot of issues. For example, I think the occupational community may think that if a person is on ADHD medication, that they are going to be a second class employee. My quick response to that would be, oh no. Find out who in your job base has ADHD treatment and you'll get a much better employee. But there are many adults who do not want their employers to know, for example, that they are being treated for this diagnosis. So I think that has to change. I think that there is more awareness of mental health in the last decade. I think the world is becoming more ready to see that mental health diagnoses need to be supported. And opportunities like this to share our conversation, Brian, with individuals who may be suffering from a misdiagnosis or no diagnosis is very important.

BRIAN GOLDMAN: Doctor Ainslie Gray, thank you so much for speaking with us.

AINSLIE GRAY: It's been a pleasure. Thank you.

BRIAN GOLDMAN: Dr. Ainslie Gray is the founder and medical director of the Springboard Clinic in Toronto. Here's your dose of smart advice. About a third of children with ADHD meet the criteria for a diagnosis in adulthood. More grownups live with ADHD than many other mental health conditions, and yet, ADHD gets less attention from the health care system. In childhood, more boys than girls are diagnosed, in part because boys are more likely to exhibit hyperactivity. Girls are more likely to have inattentiveness, which is easier to disguise. By adulthood, the ratio of men to women with ADHD is closer to 50-50. Adults with ADHD often cope with difficulties at work and in their personal and family lives. Problems at work can affect their careers and their relationships. These can lead to chronic feelings of frustration. Some adults have difficulty focusing on tasks but remain undiagnosed because they use coping skills to compensate, things like taking extra time to complete tasks, working at times when there are fewer distractions, and getting regular exercise. ADHD is more serious when it interferes with work and relationships, life skills such as driving, and when alcohol and drugs are used to cope with the symptoms. The diagnosis of ADHD requires a comprehensive assessment of academic, social and emotional functioning by a qualified health care professional. ADHD is treated through a combination of long acting stimulant medication, skills training, counselling, behaviour therapy, as well as supports and accommodations at school and at work. Because there may be prenatal effects, you should tell your health care provider if you're pregnant or are planning a pregnancy and are on ADHD medications. With greater awareness, a diagnosis of adult ADHD will ideally be less stigmatizing over time. In general, the most effective way to get support at work is to tell your employer that you have ADHD. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How do I know if I have undiagnosed adult ADHD? - Transcript

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