Professor Amanda Kirby, CEO of Do-IT Solutions., Campaigner for Neurodiversity, Medic, Knowledge Translator, researcher

Originally published as part of The Neurodiversity 101 LinkedIn Newsletter.

Neurodiversity- Are we all a ‘bit’ ADHD or is there a difference between you lacking focus and a diagnosis of ADHD?

A couple of weeks ago I was invited to share my thoughts on ‘Radio 5 Live’ about a book by Johan Hari book– Stolen focus which talks about us all becoming more and more inattentive. The book is an interesting read, is well researched, and proposes a number of changes in our lives that may contribute to changes in the way we behave.

Around the same time, I was reading another book by Peter Bregman, called 18 Minutes Find Your Focus, Master Distraction and Get the Right Things Done. ( *my ADHD brain means jumping from book to book with great enthusiasm !). This provides a series of tips on helping you to focus more.

The emphasis in the Hari book is that society is changing the way we attend and focus, and to some extent, ADHD is being over and wrongly diagnosed and treated. I thought long and hard about the writings in the book which gather information from many sources globally and talk about changes that have happened in our lifestyles in terms of working practices, use of social media, access to endless information on the internet, what we are eating, our physical and psychological wellbeing, as well as the impact of lack of sleep.

Each of these factors can certainly have an impact on our ability to focus.

Don't lose focus

**If you are losing focus at this point you can scroll to the bottom if you just want some tips to help you**

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"We are not all the same!"

This seems an over-simplistic statement but often headlines such as ‘we all have a bit of ADHD’ contract what are complex interactions of varying factors that impact people in very different ways.

We need to consider what has changed in each of our environments. There are qualitative differences and degrees in the way we function (or not) and the level of impact impairment has on ourselves and others. A lack of focus for one person may make them feel a little ‘stressed’ but it may not stop them from working or result in being excluded from school.

It is very true that the way we work, live, and engage with technology has resulted in us switching more from task to task. Every time we switch tasks, we have to remember what we were doing before, and we have to remember what we thought about it and where we were in the task. This makes us less efficient. This is called the ‘switch-cost’ amount.

One study cited in the Bregman book was undertaken at Carnegie Mellon University’s human-computer interaction lab. They took over 100 students and got them to sit a test. Some of the participants had to have their phones switched off, and others had their phones on and received intermittent text messages. The students who received messages performed, on average, 20% worse.

Social inattention has become a social problem. For example, it has become accepted behavior that we will check our phones all the time and respond to emails instantly. More than ten years ago, when I was on holiday in the US, I remember watching a family at a ‘posh’ restaurant sitting together. They all had their mobile phones out and were staring at them and we were not talking to one another at all (The food was great). I was appalled by this and can still remember the restaurant where it happened. Today this has become the norm. Children sit at the table mindlessly eating while watching some cartoon. We now endlessly ‘doom scroll’, and ping as if it is part of our being. It has changed the way we act, think, and behave and has certainly divided our attention. However, as far as I know, we are not robots and don’t have to continue this way if don’t want to and can make some serious choices. Habits can be hard for us to break from.

During Covid-19 we flipped to WFH and this has led to some gains but also losses. Have we become too used to bouncing from meeting to meeting, ( with no gaps between), with a stream of emails coming into our inbox and distracting us away from dedicated thinking time? Do real-time meetings allow time between meetings ( even if it is walking from one room to another) to provide some time to think or do we have distractions in the office setting that are equally distractible. May be interesting for us to consider this when we are being told now to return to the office. Our total vulnerabilities are a combination of both our genetics and the environment we live in, both now and in the past.

The bottom line, of course, is that if children and adults are having challenges with their attention we need to stop and consider why this is happening, what makes the situation worse, and potentially what can help. We need a systematic review otherwise we can reach wrong conclusions. A recent paper from John and colleagues highlighted the impact of having a label of SEN ( Special Educational Needs) for children with neurodevelopmental conditions in that being identified with ‘special’ needs had a protective effect on the risk of being excluded from school.

Anyway, I am losing the main focus of this article(ironic isn’t it)… So back to the difference between social inattention and ADHD.

 (** Remember…If you are getting bored you could cut to the chase and look at some practical tips at the end of this).

What is the difference between being ‘a bit’ inattentive and being diagnosed with ADHD?

ADHD is a cluster of behaviors relating to inattention, hyperactivity, and impulsivity. They impair the person across different settings and this means it has an impact at home /school/work. It is on a continuum and is dimensional. A recent review has shown that about 80% of children with ADHD continue to experience challenges that can impact day-to-day functioning.

Estimates for childhood rates of ADHD range between 3% and 7%. The pathway to adulthood does not appear to be different in males or females with ADHD but the way someone experiences the challenge may vary by gender. Many females also have been missed or misdiagnosed as we have not regularly considered ADHD in females.

We don’t know the specific causes of ADHD but we know it has a mix of gene and environmental interactions. ‘Genes don’t operate in a vacuum’ as Sroufe was quoted in the Hari book (p230). Professor Nigg, an international specialist in ADHD also explains that having some specific genes may make us more vulnerable to environmental experiences. We see evidence of greater risk adversity with underlying ADHD traits.

What else could it be if it is not ADHD?

Someone may be inattentive and distractible for different reasons.

External factors – someone talking too fast, in a noisy setting so it is harder to focus, someone talking about something you don’t understand… These may vary from place to place and time to time.

Internal factors – the presence of other conditions including Developmental Language Disorder (DLD) ( this also co-occurs with ADHD), hearing difficulties, fetal alcohol spectrum disorder (FASD), traumatic brain injury(TBI). The impact of these is likely to be consistently present.

Different reasons for inattention other than ADHD to consider

Being diagnosed with ADHD

A diagnosis is made by a professional with appropriate training and on the basis of collecting information (where possible from different sources) to consider the pattern of behaviors and see if they fit with a diagnosis of ADHD.

They take a history to consider when the challenges started.  Part of making a diagnosis also considers ‘the differential diagnoses’. This means the clinician considers the varying other reasons for these symptoms and signs including other developmental conditions that often co-occur.

Co-occurrence with ADHD is often present.

We talk about Autism SPECTRUM Conditions but we could really be talking about the Neurodivergent Spectra in reality. When making a diagnosis the clinician considers the degree of impairment but this is on a continuum.

Binocular

Which lens are you looking through?

Different professional lenses see different things and end up making different diagnoses.

The inattention described in the Hari book I think does not consider that those with ADHD often have a ‘spiky profile’ and importantly have higher rates of co-occurrence with Autism Spectrum Condition, Dyslexia, Developmental Language Disorder, Developmental Coordination Disorder (also known as Dyspraxia), and Tic Disorders such as Tourette’s syndrome as well.

People with ADHD also often have a heightened risk of having other mental health challenges such as anxiety, depression, eating disorders (and ARFID), obsessional compulsive disorder for example. In females, especially, we have focused a lot on these conditions and then not considered ADHD within the mix.

Do we diagnose ADHD too often or not enough in the UK?

In the UK we have stringent criteria for diagnosing ADHD. The UK also has NICE guidelines for ADHD which provide information from professional consensus on best practices for support and intervention in the UK.

Varying rates of diagnosis may be because of how data is recorded and how ADHD is assessed and defined. A 2009 study in the USA found that 6.3 percent of children aged 5-9 years were diagnosed with ADHD. In contrast, just 1.5 percent of parents in the UK reported a diagnosis of ADHD in children aged between 6-8 years. In 2003 there was a worldwide comparison published which showed some variability in diagnosis. A later study was published in 2014.

What we also see in the UK is wide variability in service delivery with big gaps altogether in some areas. This is especially true for adult provision. A study published in 2020 revealed that there’s a disparity in how services are labeled. “The https://link.springer.com/article/10.1186/1741-7015-10-99best provision appeared to be from services specifically labeled as ADHD or neurodevelopmental services – yet only 12 of these dedicated services provided the full range of treatment recommended by NICE for adults with ADHD. Only half of the dedicated services (55%) and a minority of other services (7%) were reported by all groups surveyed, highlighting a lack of awareness surrounding available support, both among healthcare workers and service users.” This map is from 2018.

Identification and intervention for ADHD make a long-term difference in educational and employment outcomes. There is a clear social return on investment.

What are the symptoms and signs of ADHD?

ADHD is not per se a deficit in focusing but it is often related to difficulties switching focus. Many people with ADHD can hyperfocus on the things that interest them and in doing so can reach flow states as described by psychologist Mihály Csíkszentmihályi .

People with ADHD often lose focus on the more boring process-orientated parts and also prevaricate when these tasks need to be completed. Some people with ADHD may have innovative ideas but find it hard to plan out the steps to make it happen without help. They may have difficulties prioritizing and are often not good at planning out how long a task will take as they can be ‘time blind’ as Professor Russel Barkley described.

Rather than being ‘mind-less’, people with ADHD are often ‘mind-full’ and have overactive and busy brains. The distractibility of thought makes it harder to gain and sustain focus and attention and this can result in lost productivity. A busy mind also impacts sleep and makes it harder to settle down to sleep.

It is not only about inattentiveness and for some, it includes symptoms of hyperactivity. This motor element has been mentioned from early descriptions of ADHD.

In children, we describe this as fidgetiness. This can be, for example, difficulty sitting still for long, a need to swing on a chair, or move around at the meal table.

In adults, it can be pinging a pen on and off, the constant need to doodle, finding it hard to sit still when watching something on the TV, or difficulty remaining quiet for long. It feels like ‘inner restlessness’. Girls may display less overt hyperactivity and so don’t often get noticed in class being inattentive as they are less disruptive to others.

(I know I often use the chat function in a meeting as I am fidgety and impulsive. It allows me to get my ideas out without interrupting too many people. I also recognize I often put my virtual hand up a lot!)

Alongside this is the third and key area which is impulsivity. An example of this may be a child who blurts out an answer to a question in class because they can’t wait, or someone acting without thinking first. Cutting into others’ conversations because of a need to tell you what you are thinking straight away may come across as rude because of this. Impulsive actions can result in poor decision-making. For some children, inattention and impulsivity can end in exclusion from school.

None of this is ‘just a bit’ of inattention.

ADHD has also been associated with circadian rhythm problems impacting sleep quality. We know that poor sleep has a major impact on daytime functioning and also our ability to focus.

Strengths associated with ADHD including creativity, hyperfocus. hard working

It also comes with many strengths too.

ADHD doesn’t come alone

30-40% of people with ADHD have DCD (Dyspraxia) too.

25-40% of people with Autism Spectrum Conditions (ASC) have ADHD too.

It also comes with others’ views of you which can be wearing and wounding and impact self-esteem.

"If only you tried harder"​ "If you could be more organised"​ "​ Juts put a plan together- it's easy"​.

What does intervention look like?

Good diagnosticians take a whole-person approach to assessment and will consider the home/school/work environments and the pattern of strengths and challenges. They will also consider a differential diagnosis before developing a formulation of actions with the family/child or adult.

Intervention for ADHD is never/should never be ‘just’ about using medication. However, sometimes headlines in newspapers can talk emotively about ‘drugging’ kids. I think this language is dangerous and brings shame to families who are trying to help their kids.

(Please see Prof Peter Hill’s book for parents about medication).

Parents need help and guidance early as there is evidence of the impact on the family too. Remember ( as in my family) that the apple doesn’t fall far from the tree and many children will also have parents with ADHD too.

My interest in ADHD…

There is a lot of ADHD in my family (alongside a lot of other neurodivergent traits). I am also Chair of the ADHD Foundation ( but I write this blog from a personal perspective).

Medication is not magical and doesn’t work for all but it can be a door opener for some. I know that in some of my family members medication has made a tangible difference to their day-to-day functioning.

I have also seen in other families radical change. Gains in the ability to focus longer can have educational, social, and emotional impacts. One child went from being a slow reader to coming top in their spelling tests in their class. The medication can help with impulsivity and allow a moment of reflection. Teacher’s change attitudes about a child when they can see their ability and no longer see them as a ‘naughty child’. Reduced meltdown episodes create less disruption and mean the child can focus on conversations with peers and engage socially. I have seen the damage a meltdown in front of others can have. Parents can move their children away from the child as if ADHD is catching!

Who is missing out on support?

If we took the stance that ‘we all have a bit of ADHD’ I  think we will do a disservice to some continuing underdiagnosed groups of children and adults. Take some time to read the excellent paper by Young and colleagues published in 2018(Identification and treatment of offenders with ADHD in the prison population: a practical approach based upon expert consensus). This extensively reviews the literature relating to ADHD and offending groups and shows that around 1 in 3 people in prison are likely to have ADHD (alongside other conditions), but most will not have been diagnosed.

Gender biases

Females have been missed with ADHD. In recent weeks we have seen Angela Barnes talking on the One show talk about her late diagnosis. Again an excellent extensive review about our understanding of ADHD in females was published in 2020.

There are social biases.

Children excluded from education, children in care, children on Free School Meals have high rates of undiagnosed neurodivergent conditions. As I said at the start of this blog the reasons are complex. We sometimes jump to a conclusion that challenges must be related to their adverse home lives and not consider that it challenges can be a messy intergenerational mix.

Adult gaps in services for ADHD abound across the UK. Take a read of the ADHD Foundation report on England.

Sorry for the long blog… but I take point in the book ‘Stolen Focus’ that we need to consider how society has changed but we mustn’t conflate this with thinking that we all have ‘a bit’ of ADHD.

Tips to aid attention

Alarm
  • Use alarms on your diary as a reminder for tasks to be completed rather than having to remember to check( another thing to think about). This disrupts your train of thought.
  • Create spaces in your day for thinking time so you are not trapped in an endless wall-to-wall scenario of meetings and value and encourage this behavior in others.
  • Go outside and take exercise rather than being glued to your desk all day (* don’t take your phone with you).
  • Block off focused time for specific tasks. It feels great when you can see you have achieved something.
  • Guardian tips for taking control of your smartphone.
  • Stand when working as it can help you focus –better for your posture too. Some evidence for this.
  • Create spaces between meetings to process what has happened and to give you time to prepare for the next one.
  • Have walking meetings with colleagues too rather than sitting still around a Zoom or table.

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