ADHD: Essentials for Therapists 1/2 – Nature and Impact

ADHD is a neurobiological condition that interacts with a child’s and adult’s interpersonal environment to create a variety of difficult and painful experiences and profound effects on a person’s self-esteem. Most psychotherapists, clinical psychologists, or counsellors will have clients with ADHD, but perhaps without understanding the nature of this condition. Many people with ADHD do not realise this is a central part of their problems.

Vast amounts of time and money may be invested in fruitless explorations of psychodynamic explanations for the individual’s anxiety, procrastination, emotional upheavals, mood swings, episodes of rage, impulsiveness, failure to follow through on commitments, chronic lateness, and generally erratic behaviour. Years of difficulty, helped only minimally by mental health professionals, may leave an adult with ADHD deeply wounded in their feelings about self and life.

A person with ADHD may know they cannot manage many ordinary aspects of life, may know they tend to be disorganised and forgetful, may know they get bored easily and find this very aversive, may know they can be impulsive, and easily get into fights and arguments, may know they tend to experience life as tedious, painful, frustrating and unrewarding, may know they can feel depressed and anxious – but they may not know they have ADHD!

There are many variants of AD(H)D. Some tend more towards hyperactivity and some are more dreamy. It is a spectrum and a mixture, without neat categories. There is also much overlap with the autistic spectrum.
 

The name ‘Attention Deficit Disorder’ is misleading

Much misunderstanding arises from the name, with its emphasis on attentional problems. Whilst difficulties in sustaining attention can be a feature, this is not the key defining factor – and, in fact, people with ADHD are often capable of sustaining obsessive attention for long periods on a task that is of interest to them (a phenomenon called hyperfocus).

The core feature of ADHD is a difficulty in the brain’s management of itself. Although many complex brain functions may be involved, it is generally recognised that under-functioning frontal lobes are crucial. The frontal lobes are somewhat like the Freudian ego, managing the interface between inner needs or drives and the outer environment. It is the frontal lobes that apply the emotional brakes and inhibit impulses in order to achieve longer-term goals. With these functions in deficit, the person with ADHD is often overwhelmed and floundering.

A person with ADHD needs external assistance in managing their brain

We are all, throughout the lifespan, dependent on empathic and responsive others for our wellbeing, but particularly so during childhood. In the case of the person with ADHD, this need for the presence of a responsive other, who can function like an external ego, is more pronounced. The responsive other is needed as someone to talk things through with, to help motivate, to soothe and reassure, and to remind the person of priority tasks. When this responsive other is not available, or fails in some way, the person with ADHD may feel extremely anxious, may panic, or fly into a rage.

The brain of a person with ADHD will seek stimulation – as if trying to wake itself up. Unfortunately, this stimulation sometimes takes the form of fights and arguments with others, or the creation of drama. This can be addictive.

For some people, stimulant medication is helpful because it wakes the brain up and increases arousal in the frontal lobes. This has a paradoxical calming effect. The drug takes the place of the other person as an external ego.  
 

Deficits in reward and motivation

It can be very hard for a person with ADHD to engage in tasks that are not immediately of interest or rewarding. Procrastination can be a significant problem – a difficulty starting, and then sometimes a difficulty stopping. Their neurobiology is such that they are deficient in the processes mediating reward and motivation. As a result, they are inclined to experience life as dreary and to feel depressed. This may lead them to seek activities and substances that provide immediate reward and pleasure.

The deficit in reward neurobiology leads to negative emotional interpretations of events and other people’s motivations. This neurobiology also leads them to feel unloved, because their inner brain responses do not match the external expressions of love by others.