End of 2020 STP reflections: Why the chaos of COVID-19 and the STP might just be the best thing for my ADHD brain…

Having unfortunately spent the majority of December in self-isolation and spending just 6 days at work this entire month, I have had a LOT of time to reflect on my experiences of the STP so far and the highs and lows. Whilst these weeks spent in isolation have been extremely difficult and have no doubt seen me reach some very low lows, it has also allowed me to reflect on and appreciate some of the real highs I have experienced so far so here goes…

I feel this warm fuzzy feeling in my stomach as I write this. That mixture of adrenaline and dopamine that my ADHD brain often so desperately craves and this need is finally being met. I feel a genuine sense of excitement as I go into work, not knowing what’s in store for the day ahead. I don’t just sit there all day clock watching, counting down the hours until I can go home. I arrive home from work and collapse on my bed, often exhausted, but with a real feeling of contentment. I feel like my brain has been thoroughly fed and nourished. I will often feel mentally exhausted when I get home in the evening but I liken this to that ‘food coma’ you get after a huge meal. You may not be able to move now and will most likely spend the next few hours laying on your bed/sofa, but you feel so happy and content. My brain seems to experience a similar thing. I arrive home from work, and my brain goes into its own form of ‘food coma’, but the ‘food’ is the excitement and stimulation of the day it’s had. So satisfied and content but it may have possibly slightly overindulged and now needs some time to rest and digest.

I feel like my brain is and always has been hungry for knowledge but being sat in a classroom/lecture hall was not an effective way for my brain to absorb this knowledge. Being talked at for hours simply sent my brain to sleep and did not allow it to absorb the knowledge it wanted to in an effective way. I thought maybe I just wasn’t interested enough in the subject and that was why I found it so hard to sit and learn about these things? But at the same time I was so sure that I did find these topics interesting, hence why I had chosen to study the degree I did at uni. I was so confused as to how in theory I felt so interested in the subject but in reality I would sit there bored, with no apparent motivation, and struggling to even stay awake for an entire lecture/seminar…

I now realise that it wasn’t the content that was wrong for me, it was the method of delivery. Long lectures that involved me being sat down and talked at for hours on end were not an effective method too feed me the knowledge I was so hungry for. It’s kinda like someone trying to eat soup with a fork (please hear me out lol). To an outsider simply looking at the bowl of soup and seeing it still almost completely full it may look like the person just wasn’t hungry and was choosing not to eat it. However, it’s not that they don’t want to eat the soup, it is simply that most the soup has slipped through the fork before it reaches the person’s mouth because they have not been given the correct tools with which to eat. I feel like this is what has happened with me and my learning. It wasn’t that i didn’t want to learn, it was simply I wasn’t given the correct tools to learn, However, I feel like this has changed now I am on the STP, learning hands on in a hospital environment by seeing and doing, rather than being sat down and talked at for hours on end. I arrive at work everyday hungry for knowledge and excited to learn more. I have the opportunities to see how things work, to put my knowledge into practice and understand how what I am learning is relevant to the job and real world applications. I get to see and hear a range of different perspectives from colleagues and patients. I get the opportunity to move around, rather than endlessly fidgeting in a lecture hall chair, and my brain feels like it can actually remain focussed without getting tired and falling asleep. It really does seem like some sort of miracle! I feel like a completely different person. Rather than being the ‘lazy’, ‘unmotivated’ person that I, and many other people, have always seen myself as, I now realise that this is not the case. I was simply trying to eat my soup with a fork, rather than a spoon, and wasting a lot of energy in the process!

I won’t lie, the anxious part of my brain definitely had (and still does have) worries about the lack of ‘structure‘ and the high levels of uncertainty with what will happen with my training, due to the chaos of COVID, and the wheres, whens, whos and hows of it all, but the ADHD side of my brain is kinda loving the excitement of it all and the surges of dopamine and adrenaline it brings. For example, one week last month I started off in cardiology, as I had been for the previous 2 weeks. However come Tuesday, I was being sent home within 30 minutes of getting to work, due to a COVID-19 outbreak amongst some of the staff, and told that my cardiology training was being temporarily suspended. At this point I did have a slight sense of disappointment and worry that I was would be stuck at home bored for weeks to come. However by the end of the day I had received a negative COVID swab and been invited to spend the rest of the week back in the respiratory department. My brain was kinda loving the excitement and chaos of it all!

One of my favourite things about the STP and working in the hospital is that every day is different! Such a cliché but it really is. Even if you are doing the same sets of tests each day, every patient is different and the experience of doing the same tests can be differ greatly. Whilst in respiratory I have seen patients with severe COPD, who struggle to walk even a few metres, but also fit and active people with very few limitations, as well as patients experiencing the effects of ‘long COVID’ six or seven months on from being infected. In cardiology I have seen patients ranging from six months old to those in their late 90s. Every patient and every day is different and I LOVE it!

Admittedly this post is a bit messy and all over the place (an accurate representation of the inside of my brain…) and is a bit of a stream of consciousness rather than a coherent, logical post. But hopefully you’ll at least partly understand what I am trying to get across and why the STP may be the perfect scheme for a person like me and why am I so grateful to have been given this opportunity.

ADHD? Isn’t that just a fancy word for naughty/ hyperactive little boys?

No.

This assumption highlights several of the common misconceptions surrounding ADHD:

  1. that it only occurs in boys,
  2. that you have to be ‘hyperactive’ to have ADHD
  3. that people with ADHD are just badly behaved/lazy and simply need to try harder to behave/get stuff done
  4. that it is only present in childhood

These assumptions and the lack of awareness about ADHD can be very detrimental to those who have it and can lead to them being made to feel worthless and a failure. In this post I am to delve a little deeper and provide information and evidence to dispel these myths.

MYTH 1: Only boys have ADHD

Both boys and can girls can have ADHD. It had previously been reported that males are much more likely to have ADHD, with population studies reporting male to female ratios of around 3:1, whilst clinical samples suggested ratios of between 5:1 and 9:1 [1,2]. However it is thought these findings may not be completely accurate, owing to factors such as referral bias, differences in symptom presentation and symptoms being attributed to other co-morbid conditions, such as anxiety or depression. This is already highlighted by the differences seen between clinical and population based studies, supporting that females are much less likely to be referred for clinical diagnosis. More recent reviews have suggested a much closer gender split, with ratios of around 1.6:1 in adults (Figure 1) [3]. However it is likely that split could potentially be even closer than that as ADHD still tends to be diagnosed much more often in boys. This is likely due to the fact that hyperactivity appears to be more prevalent in boys than girls, and girls tend to be less disruptive and are more likely to present as ‘daydreaming’ or being generally distracted, indicative of the inattentive form of ADHD [3]. Females are also more likely to be diagnosed later in life compared to their male counterparts as they are often misdiagnosed, with their symptoms often being attributed to other conditions, such as depression and/or anxiety [4]. Additionally, it is thought that females may be better at developing coping strategies that mask their symptoms [4].

Figure 1: Male:female ratio of adults with ADHD, developed using data from Willcutt EG. Neurotherapeutics 2012; 9: 490-499. Taken from “Gender in ADHD Epidemiology | ADHD Institute” (2020) [5].

MYTH 2: People with ADHD are always hyperactive and full of energy

Hyperactivity is one symptom of ADHD, however not everyone with ADHD will experience it. As mentioned above, for example, hyperactivity tends to be less common in girls than boys.

There are actually 3 different types of ADHD; hyperactive-impulsive type, inattentive type, and combined type (see previous post on ‘What is ADHD?’).What is ADHD?August 11, 2020IntroductionJuly 11, 2020Why I started this blog…and how it relates to baths!?July 14, 2020

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https://bestwoldofknowledge.blogspot.com/2015/03/adult-add-symptoms.html

MYTH 3: People with ADHD are simply ‘lazy’, ‘unmotivated’ and ‘need to try harder’

A common experience for those with ADHD is being labelled as ‘lazy’ throughout school and their school reports being filled with phrases such as ‘needs to focus more’, ‘needs to stay on task’, ‘easily distracted’, ‘needs to apply his/herself more’, ‘not reaching his/her potential’, ‘must try harder’, ‘bad attitude’ etc. However, people with ADHD are not intentionally being lazy , in fact a lot of the time they are trying as hard (if not harder!!) than their neurotypical peers to pay attention. But they find this extremely difficult, not because of problems with their attitude, but rather due to how their brains work. ADHD brains tend to have lowers levels of the neurotransmitters dopamine and norepinephrine, which are associated with the pleasure and reward systems in the brain and with executive functions such as attention, planning and working memory[6]. This explains why ADHDers may have difficulties with tasks they find boring or repetitive, such as those common in classroom environments and office jobs.

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https://www.additudemag.com/adhd-is-not-fake/

MYTH 4: ADHD is only present in children

Similar to the boys vs girls myth, many people don’t believe that adults can have ADHD. Whilst it is thought to be true that you can’t develop ADHD in adulthood, and DSM-5 guidelines state that symptoms must have been present before the age of 12, many people (again particularly women) do not get diagnosed until well into adulthood[7]. This can be due to managing to ‘mask’ symptoms well or succeeding at school despite their difficulties due to ‘natural talent’, however it is likely the symptoms were in fact present from childhood. Symptoms in childhood can also often be attributed to other causes and many girls in particular are diagnosed with anxiety and/or depression during their teens, when in fact these symptoms may be, at least in part, caused by difficulties linked to their undiagnosed ADHD and the struggles associated with this. For example constantly being told they are not trying hard enough or are underachieving, despite putting in a lot of effort, which can severely impact self-esteem and contribute to mental health problems (e.g. depression and anxiety).

This image has an empty alt attribute; its file name is adult-adhd.png
https://www.verywellmind.com/adhd-symptoms-4157281

I know I for one held some similar beliefs to these for many years. Often wondering if I may have ADHD due to my inability to stay focused and constantly being distracted, but also thinking I could not have ADHD as I so often felt completely exhausted and seemed to spend a large amount of time napping, including at school…, the apparent complete opposite to being hyperactive.

I have obviously experienced first hand the damage these stereotypes can cause in terms of preventing diagnosis and the detrimental and long lasting effects this can have on an individual’s self-esteem and mental health. As such, I am very eager to try and help raise awareness of and bust these myths and increase knowledge of the truth about ADHD and how it can present. Particularly the contribution of such myths to the low levels of diagnosis in young girls. More needs to be done to ensure schools and higher education institutes, as well as parents, are more aware of the potential signs of ADHD, particularly in girls, so that early identification and intervention can occur. This would allow more support to be put in place to help them at an earlier stage in their life, which would help minimise the detrimental impacts this can have on emotional wellbeing, academic achievement, relationships and employment prospects.

[1] Gaub, M., & Carlson, C. L. (1997). Gender differences in ADHD: a meta-analysis and critical review. Journal of the American Academy of Child & Adolescent Psychiatry36(8), 1036-1045.

[2] Skogli, E. W., Teicher, M. H., Andersen, P. N., Hovik, K. T., & Øie, M. (2013). ADHD in girls and boys–gender differences in co-existing symptoms and executive function measures. BMC psychiatry13(1), 298.

[3] Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics9(3), 490-499.

[4] Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders16(3).

[5] Gender in ADHD Epidemiology | ADHD Institute. (2020). Retrieved 8 August 2020, from https://adhd-institute.com/burden-of-adhd/epidemiology/gender/#:~:text=ADHD%20is%20more%20commonly%20diagnosed,years%20and%20over%20(Figure).

[6] Logue, S. F., & Gould, T. J. (2014). The neural and genetic basis of executive function: attention, cognitive flexibility, and response inhibition. Pharmacology Biochemistry and Behavior123, 45-54.

[7] https://chadd.org/about-adhd/overview/

What is ADHD?

So what is ADHD? Most people have heard of it but much fewer have a good understanding of what it is. When the term ADHD is mentioned I’m sure many people’s minds immediately picture the classic stereotype of hyperactive, naughty little boys who are constantly full of energy and get distracted by anything and everything. Whilst it can sometimes present in this way, this does not describe the large majority of people with ADHD and someone does not need to be hyperactive to have ADHD. In fact ADHD can lead to many different symptoms and difficulties that differ greatly between individuals. In particular symptoms can present very differently between sexes and between adults and children. This post aims to outline the different forms of ADHD and highlight some common symptoms, beyond the typical ones that everyone has heard of.

There are 3 types of ADHD:

  • Hyperactive-impulsive type
  • Inattentive Type (formerly known as ADD/Attention Deficit Disorder)
  • Combined type
https://bestwoldofknowledge.blogspot.com/2015/03/adult-add-symptoms.html

Symptoms of inattentive type include (DSM-5 criteria)1:

  • becoming easily distracted
  • trouble holding attention on tasks or play activities (i.e. getting bored quickly)
  • poor attention to detail or making careless mistakes in schoolwork, at work, or with other activities.
  • avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
  • difficulty organising thoughts, tasks and activities
  • losing things, e.g. keys, phone, pen, homework etc
  • often appear not to be listening when directly spoken to
  • forgetful in daily activities
  • often does not follow through on instructions or fails to finish tasks

People who are impulsive or hyperactive often (DSM-5 criteria)1:

  • fidget, fiddle with things or feel restless
  • struggle to sit still or often leave seat when remaining seated is expected
  • talk too much and/or too quickly
  • have trouble engaging in quiet activities
  • are constantly “on the go”
  • are impatient and have difficulty waiting their turn
  • act impulsively without thinking about consequences of actions, e.g. doing something dangerous without thinking about potential for injury
  • blurt out answers and inappropriate comments
  • interrupt people when talking

May also (not included in DSM-5 guidelines):

  • struggle to process and remember new information or large amounts of information at once
  • have difficulty focusing on a single task, often switching between many different tasks
  • be overly sensitive and/or have exaggerated emotional responses
  • often appear to be ‘zoned out’ or daydreaming

People with combination type experience many symptoms from both lists.

To meet diagnostic criteria you must experience at least six of the nine key symptoms for a specific type of ADHD (or five or more if aged over 16 years)1. To be diagnosed with combination ADHD, you must show at least six (or five if 17+) symptoms from each group (inattention and hyperactive-impulsive behaviour). Additionally, symptoms should have been present before the age of 12, occur in more than one setting (e.g. home, school, work, or with friends), and significantly impact everyday functioning, e.g. work or school performance or socially. Finally, the symptoms cannot be better explained by another mental disorder.

Hopefully this post has helped deepen your understanding of ADHD slightly and highlighted that not everyone that has ADHD is hyperactive and that there are many other everyday difficulties associated with ADHD, such as memory, processing and organisational issues.

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.