Just days before her wedding in Chennai, Varshaa Narayanan was overcome by the need to see a therapist. The 30-year-old was convinced of “depressive” episodes in her adolescence and college days, even though there had been no such diagnosis. As she approached a major life event, Narayanan’s past—the constant bullying, the inability to do well in exams, and very low self-confidence—rose within to confront her yet again.
Narayanan—she lives in California now—did go to a therapist. During the conversation, she mentioned her experiences in school. The therapist zeroed in, suspecting Attention Deficit Hyperactivity Disorder, or ADHD, and investigating it till there could be no doubt. “I just brushed it off. I mean, what is this new thing? I did not want to come to terms with this,” says Narayanan, recalling her diagnosis of April 2021. It involved long interviews along with psychometric assessment. Such diagnoses are based on criteria detailed in the holy book of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is published by American Psychiatric Association.
The disorder is associated mostly with children, but increasingly adults are being diagnosed with, and “coming out”, as ADHD-ers. Often these are people like Narayanan who seek psychological care after experiencing distress, or come with other kinds of conditions such as depression, trauma, anxiety or even substance abuse issues. Some even seek diagnosis suspecting they have this condition, and to seek validation.
ADHD is a chronic condition characterised by symptoms of inattention and/or hyperactivity/impulsivity that impair many aspects of living. The disorder, which usually starts in childhood or early adolescence, and is more commonly diagnosed in boys than girls, affects 5.9 per cent young people and 2.8 per cent adults worldwide.
ADHD is a neuro-developmental disorder that results from the interaction of both genetic and environmental risk factors. Many studies, including a major one in 2019 with scientists all over the world that was published in Nature Genetics, identified biomarkers. The latest version of DSM published in 2022, however, states that there is no biological marker for ADHD and that meta-analyses of all neuroimaging studies do not show differences between individuals with ADHD and control subjects, a critique of the DSM-2022 in the Frontiers in Psychiatry has said.
“These conditions are multifactorial. Some children may have traits that are similar to those who have ADHD, but their environment may help them cope with it better,” says Porrselvi AP, a Chennai-based cognitive neuropsychologist, adding, “Besides, why are we looking at it as a disorder? You do not talk about why someone is short or tall for instance. These are individual differences we should accommodate as a society.”
Left out as children
Mental health professionals say that there are hardly any systems in place for systematic diagnosis of children with ADHD. Dr Nidhi Singhal, director for Research and Training at Action for Autism, Delhi says, “Children do not have the vocabulary to say they are not able to concentrate. We assume that they are being difficult; the responsibility is put on the individual. It is dismissed as bad behaviour or bad parenting.”
Psychologists say that it’s easier to diagnose ADHD in children. “It can be confused with personality disorders (such as bipolar disorder) or depression and anxiety, or trauma. Diagnostic criteria overlap with many conditions. There are many co-morbidities in adults because of the amount of emotional damage as children,” says Porrselvi.
For an accurate diagnosis, a mental health professional looks at patterns of behaviour that are pervasive in nature. “Your symptoms cannot occur only in the workplace, but also at home or in your relationships. We look at the whole picture,” she says.
“It is not like systems in the UK and US where teachers and nurses can refer children for an ADHD diagnosis,” says Porrselvi who was trained in the UK. She says that ideally at least paediatricians and teachers should be trained to look for red flags that can help early diagnosis of such ailments. “Parents here may ask a paediatrician, and possibly a diagnosis may happen. We have had clients who said that their parents were given some indication that the child may have ADHD, but that was not followed through.”
Porrselvi speaks of a recent case she had when they suspected a developmental condition in a two-year-old which was not followed up by the parents. “The parents stopped coming to us. They blamed us for everything. And they still have not taken any help from a mental health professional. Now the child is about four or five years old.”
Needless to say, there is a huge lack of awareness about neurodivergence among both parents and teachers. “My parents are staunch believers in astrology. When I was born an astrologer said that my moon star is weak. They accepted that I may not do well in studies. They did not stress on studies as a result,” says Narayanan.
In fact many studies, including a 2023 Canada-based study published in Research on Child and Adult Psychopathology, says that early diagnosis and intervention and involved parenting can help stabilise ADHD.
An expert consensus document, published in BMC Medicine, says that ADHD is often associated with co-occurring conditions, which can complicate diagnosis, such as Autism Spectrum Disorder. A meta-analysis done in the UK and published in BMC Medicine showed that among those diagnosed with ADHD, over a fifth reported coexisting conditions of autism. Apart from this, many who come for diagnosis as adults could also have depression, anxiety, personality disorders such as bipolar disorder, trauma, post-traumatic stress disorder as well as addictions, which complicate the diagnosis.
By the time they turn up as adults seeking care, they come with emotional baggage, says Porrselvi, adding, “These adults would have lived a life full of shame, often wondering what’s wrong with them and why they are not able to do what others are able to.” Take 26-year-old Preethi Srinivasan, for whom life before diagnosis of ADHD and autism in 2021 is “like a blur”. “I hardly remember anything that happened in school and college... But I can say it was not pleasant. As an undiagnosed neurodivergent girl, life was hell for me throughout school and college, as I was seen as an outcast or just a laughing stock for my classmates,” says the Chennai resident, now training to be a mental health counsellor. Inattention and sensitivity Adults with ADHD seek help during transition phases of their lives. For example, when they move from school to college, or had just had a baby, or got married: when their life moves from structured to unstructured, when there is a need to multitask or make decisions on their own.
“Some people come in mid-adulthood on their own. They have been high-functioning all their lives, but believe that they can do more and are not able to. They feel a holistic achievement is not there. They are either not able to manage their family or work,” says Dr Arun Kandaswamy, Professor of Psychiatry at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
The presentation of symptoms of ADHD among adults is not most visible. “Among children with ADHD, hyperactivity is more common. They are not able to sit in one place. However, among adults with ADHD what we see more is ‘inattention’. This is unfortunately often subsumed under laziness, or perceived as the child not interested in studies,” says Dr Kandaswamy.
He clarifies that inattention sometimes does not completely explain what ADHD-ers experience. “When something is interesting to them, even if it is not important or immediate, they will be hyper-focused on that. They are not able to give attention to something that may be essential (like an impending exam). We could call it differential attention,” he says, adding that they may take up tasks that may interest them, but drop them before the task is complete “That’s because their mind is moving faster, and there is an expectation that the plan should work out faster. But when it comes to implementing anything in the real world, persistence matters,” he says.
Among ADHD-ers, executive function could be impaired. Executive functions are mental processes that are needed to help us plan, focus attention, remember and juggle multiple tasks. While communicating with many of the persons with ADHD, some said that they had “too few spoons” to spare, often choosing the route of writing answers to chatting on the phone. People living with disability often use the spoon analogy to explain finite energy levels.
Feel ‘stupid’
Often ADHD-ers describe themselves as “stupid” or “dumb” when they look back at their childhood. “I felt stupid compared to other kids in school. I could read, but could not understand what I was reading. I functioned well by listening. My mother used to read my textbooks. Later, during my college days, I started watching videos to clear my exams,” says 33-year-old Atheeth Rathish, who grew up in Dubai and now lives in India.
Aditi Gangrade, a late-discovered autistic and ADHD woman echoes the same sentiment. “I felt that I’m not equal to my peers. Like I’m dumb in some way,” the 25-year-old says, adding that she found it harder to process things in class, and would ask many questions to her classmates and teachers, which were seen as disruptive. Gangrade is the co-founder of Much Much Media, which is a disability-led story-telling studio.
Another characteristic that is common to adult ADHD is emotional dysregulation. “Their moods are often up and down. They are very sensitive to rejections particularly,” says Dr Kandaswamy, adding, “While all these symptoms may appear commonplace, it is important to understand that it is heightened in persons with ADHD.”
Narayanan says that comments that can be ignored by neurotypical people would hurt a lot. For example, it could be as benign as someone saying that the person has not cleaned the room. “Such comments can feel like a knife has been stabbed in my heart. Not only that, it keeps replaying. I may forget it after some time, but something like a movie can remind me again and it would flash before my eyes,” says Narayanan.
Gender bias
ADHD is diagnosed more often in boys than girls. “The portrayal of ADHD in films and shows such as Unbreakable Kimmy Schmidt shows a white boy jumping up and down. It is portrayed as being very visible,” says Gangrade.
A 2014 review of several academic articles on ADHD in women showed that women and those assigned female at birth with ADHD have more internalising symptoms, that is inattentiveness, being more prominent than the externalising symptoms such as impulsiveness and hyperactivity. These symptoms are likely to be overlooked, and therefore, such people are less likely to be referred for diagnosis.
“Gender plays a huge role in diagnosis. So many people who are female assigned at birth do not receive a diagnosis for their neurodivergence even as adults. They often also get misdiagnosed with anxiety disorders or borderline personality disorder,” says Anindita Kundu, an ADHD and autistic patient, and psychotherapist based in Bengaluru.
Kundu says that the diagnostic criteria does not include the experiences and presentations of those assigned female at birth. “We are also culturalised to not express what we are struggling with. We are culturalised to be quiet, to sit a certain way, to not be hyperactive, to be sensitive, etc. All of which leads to heavy masking and missed diagnosis,” she says.
‘Masking’ is a term that has been introduced by neurodivergent persons. It is a coping strategy in which neurodivergent persons act in socially acceptable ways to fit in. “I have to mask in order to ‘be normal’, and not be perceived as an outcast or a weirdo, or bullied, yet I have only been labelled all of that all my life. Masking is tiring. In fact, masking is the utmost reason why us neurodivergent folks are in burn out (mode) most of our lives,” says Srinivasan.
Narayanan says she was a ‘people pleaser’. “I would agree with everything anyone said. Making people happy was my only way to cope,” she says.
Vulnerable to addiction, trauma
One of the dangers of not being diagnosed, and not having the awareness and coping mechanisms to deal with ADHD is the vulnerability to trauma and other kinds of disorders. The constant seeking of novel activities can lead to risky behaviours.
“Non-diagnosis can affect development. It can result in early onset of substance use. We have seen adolescents with ADHD use tobacco as early as eight years old. They may be more irritable and get more aggressive that can lead to criminal acts. We have also seen cases of persons with ADHD with petty crimes,” says Dr Vivek Agarwal, professor and head of Psychiatry, King George Medical University, Lucknow.
In 2017, psychiatrists from NIMHANS, Bengaluru published a study in the Indian Journal of Psychological Medicine exploring ADHD among people with substance use disorder. Among 240 patients from their OPDs, 56.25 per cent, or almost three-fifths, screened positive for “likely ADHD”.
“We are seeing ADHD among a fourth of our patients. Even if we treat the addiction, there is a chance of lapsing and relapsing unless we address ADHD,” says Dr Kandaswamy, adding, “We have to understand this as high-risk behaviour rather than addiction itself.” Persons with ADHD are also very prone to abuse. “When you have a lower self-esteem and the support system is contributing to it, it makes you vulnerable to abuse. This is one of the reasons why we need to diagnose them as children,” says Porrselvi.
Managing ADHD
Persons with ADHD pointed out that there are some fundamental problems in the approach of mental health professionals. It starts with the diagnosis itself. Srinivasan says, “Even the assessment questionnaire I was given was not ADHD-friendly. It had a bunch of questions that I found extremely hard due to the lack of challenge in the task, and due to the large number of questions that wasn’t helping me maintain my already tiny attention span.”
Kundu points to the pathologisation of neurodivergence in the training of mental health professionals. “In our entire training to be mental health professionals, we are not taught about neurodiversity from an affirmative lens at all. We are taught about a set of traits from the DSM and not about actual lives and what are the access needs for neurodiverse folks in therapy,” she says.
Doctors offer treatment by way of medicines. Two classes of medicines are prescribed usually: stimulants and non-stimulants. “These medicines primarily work on releasing dopamine or norepinephrine and trying to improve upon non-function. Stimulants are more effective than non stimulants,” says Dr Agarwal, adding that while the drugs are safe, they screen persons with heart conditions and offer non-stimulants instead of a stimulant.
It’s agreed on that medicine alone is not effective without therapy.
Kundu explains that historically therapy has been used to “fix” neurotypes to make the person “fit’ into a neurotypical world. “When we view something as a disorder, it prohibits us from developing a relationship and understanding its presence in our lives. It is a reductive way of looking at something that’s just us. Therapists need to learn and include a neuro-affirmative approach with their clients.”
A neuro-affirmative approach to therapy starts with believing that ADHD experiences are different for different people. The use of deficit-based medical language in the diagnostic manuals is now only contrasted with the increasing number of blogs, vlogs and social media posts by neurodivergent persons. The activism of adult ADHD-ers and other neurodivergent persons has changed the narrative around these conditions, earlier dominated by parents.
“The literature in social media describing neurodivergence in words that can be understood is an eye-opener. They are talking about their personal experiences, and how the condition has impacted their lives. They are also saying that we are great at many things, while significantly being challenged by others. Many parents have also told me that they feel they can now relate to their neurodivergent kids after reading these accounts,” says Singhal.
Neurofeedback is one therapeutic approach that’s working. Chetna Punia, Neurofeedback and Biofeedback Trainer, Maatram Center of Mental Health Development and Support, Puducherry, explains: “We map the brain’s electrical signals with an EEG-based device, and zero in on the frequencies that can point out various markers. With ADHD, it helps to manage mood regulation, tension span, sleep pattern, etc.” Punia emphasises that this is a way of training the brain, not curing it. “In a typical neurofeedback session, the client comes in and after we have zeroed in on the areas or issues and brain functions we want to work on, we can feed all that into the system. The person wears the EEG cap, and the brain activity is recorded. Each time the brain activity is in the optimal range, s/he gets a reward, in an audiovisual format. Once the brain is wired to the reward mechanisation, it wants to repeat the activity. The brain starts to rewire and the change begins to settle in.”
Life with ADHD
Narayanan used to do poorly in her school and college exams. She recalls that about 10 years ago, she was casually sitting with her father when he asked her a question about what she was studying. “When I explained, I started to develop some confidence. I understood how to study and started clearing my papers finally. After my diagnosis (in 2021), I read up that this is called ‘body doubling’ where touching someone helps get the stimulation to remain motivated,” she says.
Narayanan enrolled in an online ADHD coaching class in the US, and found camaraderie among the adults who were late diagnosed ADHD persons. She started an Instagram and Youtube channel about ADHD for Indians.
As a child, Gangrade flitted from one interest to another. “Parents feel that their children should focus on one thing. I loved writing, drawing and colouring, shooting from my father’s phone, all of which apply in my current job as a filmmaker,” she explains in a vlog.
This feeling has some validation in evolutionary studies done abroad. A US-based study by neuroscientists published in Proceedings of Royal Society B: Biological Sciences showed that traits common to ADHD such as impulsivity may have been an evolutionary advantage for our ancestors.
Rathish was 22 when he was diagnosed with ADHD. The 33-year-old had struggled with reading all his life, his mother used to read out his textbooks to him. “The diagnosis gave me validation that I am not dumb. What happened over time is that I got the confidence to do whatever I wanted,” he says.
After finishing his Bachelors in Business Administration, he worked in nine different professions including insurance, filmmaking, chef, advertising, landscape procurement and design. He is now focusing on children’s education. Rathish says that the label of ADHD comes with the word “disorder”, which makes him uncomfortable. He says, “Though the label helped me recognising the condition, I do not focus on it. I want to instead build on my way of looking at the world.”
What is ADHD?
ADHD is a chronic condition characterised by symptoms of inattention and/or hyperactivity/impulsivity that lead to impairments in many aspects of living.
The disorder, which starts in childhood or early adolescence, and is more commonly diagnosed in boys than girls.
People diagnosed with ADHD have an elevated risk for school failure, antisocial behavior, other psychiatric problems, somatic disorders, drug and alcohol abuse, accidental injuries, and premature death, including attempted and completed suicide.
5.9% of youth worldwide are affected by ADHD, which starts in childhood or early adolescence
2.8 % of adults worldwide have ADHD
56.25% of people with substance use disorder screened positive for “likely ADHD” in a 2017 study of outpatients at NIMHANS, Bengaluru
When to Seek Diagnosis in Adults
● Underachieving at work or in education
● Driving dangerously
● Difficulty making or keeping friends
● Difficulty in relationships with partners
Symptoms in adults
● Carelessness and lack of attention to detail
● Continually starting new tasks before finishing old ones
● Poor organisational skills
● Inability to focus or prioritise
● Continually losing or misplacing things
● Forgetfulness
● Restlessness and edginess
● Difficulty keeping quiet, and speaking out of turn
● Blurting out responses and often interrupting others
● Mood swings, irritability and a quick temper
● Inability to deal with stress
● Extreme impatience
● Taking risks in activities, often with little or no regard for personal or others' safety
Symptoms in Kids and Teens
Inattentiveness
● Short attention span; easily distracted
● Making careless mistakes
● Appearing forgetful or losing things
● Being unable to stick to tasks that are tedious or time-consuming
● Unable to listen to or carry out instructions
● Constantly changing activity or task
● Having difficulty organising tasks
Hyperactivity and Impulsiveness
● Unable to sit still, especially in calm or quiet surroundings
● Constantly fidgeting
● Being unable to concentrate on tasks
● Excessive physical movement
● Excessive talking
● Being unable to wait their turn
● Acting without thinking
● Interrupting conversations
● Little or no sense of danger
When to Seek Diagnosis in Kids
● Been displaying symptoms continuously for at least 6 months
● Started to show symptoms before the age of 12
● Been showing symptoms in at least 2 different settings – for example, at home and at school
● Symptoms that make their lives considerably more difficult on a social, academic or occupational level
● Symptoms that are not just part of a developmental disorder or difficult phase, and are not better accounted for by another condition
Common Medication
● Methylphenidate
● Lisdexamfetamine
● Dexamfetamine
● Atomoxetine
● Guanfacine
Therapy
● Psychoeducation
● Behaviour therapy
● Parent training and education programmes
● Social skills training
● Cognitive behavioural therapy