Does unrecognised ADHD need to be brought into the Counselling Room?

© Jade Rita Taylor

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This is a critical analysis of the known literature that I was hoping to publish, but as we know, research moved on very quickly, and with the amount of work required for my research publication and PhD proposal, I haven’t got time for the 6+ months it takes to get published. But because the original started at one point and I concluded with a another very important point, I felt rather than wait any longer, I should at least get it out there to be read.

Please note, while it did get a high enough grade to publish, it has NOT been peer reviewed.

Can those with unrecognised Attention Hyperactive Deficit Disorder (ADHD) achieve Self-Actualisation in Counselling

Introduction

ADHD is defined as neurological learning, social and emotional differences (Chirombe et al., 2014). As a female with ADHD as well as a counsellor for over 18 years, in my experience, clients explain comorbid presentations while the all-to-well-known common ADHD symptoms go unrecognised. They attempt to unpick who they are from what they have learnt while navigating societal expectations that are designed for the masses. In some cases, counselling a person with unrecognised ADHD can be short-lived; without an immediate sense of relief, counselling becomes short where it needs to be long, in order to address the whole person and their presentations. I question whether self-actualisation is possible in an unrecognised ADHD client and if social, interpersonal, and symptom severity affects this therapeutic goal.

Despite the recent increase in ADHD diagnoses over the last twenty years (Gascon et al., 2022), the current rate of undiagnosed ADHD in women remains high, and only a small portion of those with ADHD are treated (Biederman et al., 2007b). This review will critically analyse literature relating to ADHD presentations in females only, linking it to self-actualising theory (McLeod, 2015). While it is widely acknowledged the long-term difficulties of undiagnosed ADHD females, such as mood disorders, depression, anxiety, disorganised eating, and relationship difficulties (Adamis et al., 2016; Ginsberg et al., 2014b; Goodman and Thase, 2009; Hallowell, 2016; Souza et al., 2008; Young and Cocallis, 2021). There is little research on ADHD and the person-centred model, especially concerning achieving self-actualisation (Harvard-Sweeting, 2019). I intend to explore the presentations of ADHD, looking into social expectations, education structure, trauma, and comorbid mental health difficulties, interlinking the literature to how these presentations can show up in the counselling room, and what support and guidance is advised.

I intend to explore the theory of self-actualisation, specifically focusing on Carl Rogers’ person-centred model and Abraham Maslow’s Hierarchy of Needs theory. I will evaluate the theory against the critical analysis of the published literature on ADHD. Exploring how ADHD presents psychologically and behaviourally and the destruction it can create if unsupported. I will investigate whether self-actualisation can be achieved when the other presenting difficulties are treated exclusively, without acknowledging and celebrating neurobehavioural differences. Using the literature, I will analyse if ADHD needs to be recognised for successful therapeutic change to occur, and evaluate the ethical dilemma of disclosing potential ADHD. Including the evaluation of whether therapists require minimum competencies to facilitate the recognition and support of unrecognised ADHD. This will conclude with a well-rounded exploration of all the difficulties resulting from unrecognised ADHD and an evaluation of whether they create a barrier to achieving self-actualisation.

Self-actualisation is the therapeutic goal of Carl Rogers's person-centred theory (Short and Thomas, 2015). Explained as a continuous way of being oneself, experiencing and reacting congruently at the moment. Our true self is at the core of all beings, which can become distorted and changed by the expectations of others as we adapt our behaviour to feel acceptance and belonging (McMillan, 2004). When we look at this concept that people learn to be someone they are not, against the understanding that ADHD individuals adapt their behaviour to fit in (masking), the achievement of a pure, unmodified self, free to be themselves, becomes problematic (Mash and Wolfe, 2015).

The more widely recognised self-actualising concept is the hierarchy of needs theory, coined by Abraham Maslow (1958), which states that to achieve a higher level, the previous must be fulfilled. His five-staged theory consists of ‘the appearance of one need usually rests on the prior satisfaction of another more prepotent need. the hierarchy of needs is arranged as follows: 1) The Physiological Needs, 2) The Safety Needs, 3) The Love Needs, 4) The Esteem Needs, 5) The Need for Self-Actualization’ (Maslow, 1958, p.26–47). The third stage is love, respect and belonging, which Maslow (1970) stated can only be obtained from other people. I commonly experience teenagers with suspected ADHD being told by external influences that they should not feel the way they do. They often express feelings of being ‘hated’ and experience emotions more intensely while also struggling to regulate them surrounded by shame, leading to a sense of loneliness and isolation, requiring long-term support to undo the internalised messages of being ‘less than’ (Herron, 2008). I argue that Rogers's non-judgemental (non-ablest?) approach goes a long way to helping ADHD individuals to be themselves. However, cultural and collective expectations are less likely to change, so without acknowledging their neurological differences: love, belonging, and self-esteem can be challenging to achieve. Through a collaboration of personal stories, women explore the damage done growing up with unrecognised ADHD and how, without self-identification or a diagnosis, a sense of self gets lost in a lifetime of negative messages constructed by the social belief system (ADDitude, 2016). 

The self-actualising theory has come under much scrutiny since its first development. It is argued that as a concept, it is inherently too positive and mythical, and its primary purpose is only to give conceptually understandable structures to aim for (Jones and Crandall, 1991; Geller, 1982; Daniels, 1988). Mearns and Thorne (2007) challenged the suggestion that self-actualisation is only positive by asserting that actualising is the drive a person experiences to make the best out of their situations and that this may mean that congruent behaviour may be seen as inappropriate by the masses. Behaviour that is deemed as socially unacceptable, such as some of the symptoms of ADHD, can cause social isolation, shame self-esteem difficulties (Cross, 2011).

There is little current American or UK research on the achievability of Rogers's self-actualising theory. However, from an East Asian perspective, Kim (2018) concluded that self-actualisation is culturally biased because it empathises independence and autonomy. Research by Shaw (2021) found that individuals with ADHD discovered acceptance of self through socialisation with those of a similar neurotype. Questioning the need for interdependence in some groups and, in this case, ADHD individuals. It is reviewed that individuals with ADHD are drawn towards others of a similar neurotype and behaviour patterns, and those who have not found like-minded individuals experience feelings of isolation. Nonetheless, self-concept can develop through social integration and acceptance (Narayanamma, 2020).

Essay Scope

-          Literature included

It is recognised that most studies on ADHD are carried out on children (Maddux and Winstead, 2012), however, there is extensive literature on the effects of ADHD into adulthood. Due to the higher rates of adult ADHD females being missed or misdiagnosed (Mowlem et al., 2018), and the different presentations and comorbid difficulties in females with ADHD (Wright, 2022), I intend to focus on literature specific to females aged between 4-65 who are either diagnosed or explained as having ADHD traits.

Due to self-actualisation theory being coined by American Psychologists but widely used around the world and ADHD not being geographically restrictive, I will be using literature from around the world but attempting to focus on American and UK literature where available to remain culturally relevant to my practice.

-          Literature not included

I will not be using literature related to males due to the different social expectations, which alter presentations, and the higher rate of earlier diagnosis (Garcia-Delgar et al., 2021). 

-        Why is this topic important

It is essential to explore ADHD as it manifests through childhood into adulthood. How it interlaces with other mental health difficulties and can cause interpersonal fractures. Unrecognised ADHD can manifest into life-long difficulties, which individually are often brought into the counselling room. When weighing the achievement of self-actualisation as being our actual selves reacting organically in the moment, it is important to explore how ADHD, comorbid difficulties, and the practitioner’s knowledge and skills all impact this therapeutic growth.

-        How it relates to my practice

In the counselling room, ADHD can present as difficulties such as low self-esteem, overthinking, anxiety, depression, relationship breakdowns, OCD traits, rejection sensitivity, self-injury, disorganised eating, and emotional burnout. Depending on the severity of symptoms, without looking into the neurobehavioural differences, or without having specific knowledge on identifying ADHD, undoing all said difficulties will be long-term work (McMahon and Palmer, 2014).  Giving rise to the question of whether it is ethical to disclose such identifications of potential ADHD or refer to a more strategy-based therapist to treat the symptoms? The focus on the literature will provide a critical evaluation of such questions and offer an informed conclusion to assist in a decision when working with a client with unrecognised ADHD. 

As an integrative practitioner working with females with unrecognised ADHD, this is intended as a practice-friendly review. It is anticipated to answer not only the minimum competencies required of the counsellor but also whether potential ADHD needs to be identified in the counselling room in order to achieve self-actualisation or even therapeutic growth.

-         The assignment layout

Within this review, I intend to specifically focus on the presentations and effects of ADHD and how it may present in the counselling room. The assignment will be broken up into three sections with subheadings where necessary.

The presentations and experiences of those assigned female at birth with ADHD

This will include subheadings:

-          ADHD and the education system

‘Many schools have expectations for learning that are not realistic for a child with ADHD. For example: being a good listener, focusing on task, exhibiting appropriate behaviour, being able to work independently and quietly’ (Ledgerton-Cooper, 2012, p. 10). I intend to assess the educational expectations against the natural abilities of those with ADHD and the impact such differences can cause.

-          ADHD and trauma – Childhood and adulthood

This section will explore how children with ADHD can experience trauma, and how this can manifest into adult mental health difficulties. Without early identification and support, ADHD has also been linked to complex post-traumatic stress disorder (c-PTSD) (Cuffe, McCullough and Pumariega, 1994).

-          ADHD and comorbidity disorders

Due to more subtle presentations such as internalised thoughts and behaviours (Pountney and Liang, 2022), research has shown that ADHD is linked to behaviours such as self-harm (Ward and Curran, 2021), impulsivity, violence, and comorbid mental health difficulties in females such as depression, anxiety, (Hinshaw, 2022) and borderline personality disorder (Fox, 2022).

-          ADHD and societal clash

This section will explore how social and cultural expectations can contradict the ADHD neurobiological workings, resulting in problematic behaviours, internalised ableism, and trauma responses (Chandler, 2011). I will refer specifically to Britain’s culture and the social expectations of females.

The recommended treatment for ADHD

Cognitive behaviour therapy (CBT) is recommended alongside medication to support the management of ADHD (Fullen et al., 2020; Vidal-Estrada et al., 2012). To aid comparison, CBT will be evaluated alongside Rogers’ person-centred model.

The unspoken word and the ethical dilemma

The literature concerning whether ADHD needs to be recognised alongside treating the comorbid presentations will be analysed. It will be reviewed whether a counsellor should divulge suspicions of ADHD and what training should be obtained to do so safely. The discussion will also include whether, without the proper training, knowledge, and skills, a practitioner should refer ADHD clients to another modality or specialist.

Ethics

Chang (2016) describes how every piece of writing holds the author's essence and how personal stories can intertwine with scholarly, allowing self and cultural identity to be used as a reference for self and others to learn from. I bring my personal and professional ideology to the literature so that this review will include lived experienced components. Per the ethical framework of the National Counselling Society (2021), to maintain strict client confidentiality, all the client stories are interwoven and used so that no individual narrative will be identified.

Literature Review

The presentations of ADHD

-          ADHD and the education system

This section will explore how the education system, by design, does not complement the neurological and neurobehavioral differences of the ADHD brain and how this impacts the child’s social and psychological development.

Children are defined by the messages of adults and the broader society around them. Children will adapt their actions to reduce punishment and criticism (Rasmussen et al., 2023). However, as they progress to the second stage of moralisation, they question these demands and begin expressing their opinions (Garz, 2009). By age 12, children with ADHD are estimated to have received 20,000 more negative comments from adults than children without ADHD (Dodson, 2021).

The experiences we go through as children define our concept of self and our emotional adaptability as adults (Bybee, 1998). The current school system requires children to memorise facts for tests. Sit in silent test conditions. To listen directly to the teacher. To not fidget, talk or doodle in class. To not question adults or give an opposing opinion. To not get emotional or angry. To manage vocal volume and tone. To sit for long periods and manage independent study time. Have specific toileting and eating schedules. To navigate social expectations with maturity and logic. The ADHD individual, by nature, can struggle to recall information. Retain concentration long enough to read and digest information. Require movement or stimulation to listen and absorb information. Feel emotions more intensely and need space and time to regulate them. Get sensory overloaded with noise and distractions. Need time to process information. Need movement breaks to reengage. They are naturally impulsive and honest. They need help managing procrastination and structuring time and workloads. They can reach emotional and social burnout quicker and find it challenging to recognise bodily sensations, including hunger and toileting needs (Reid and Johnson, 2011; Wiersema and Godefroid, 2018).

ADHD is associated with poor grades, increased behavioural interventions and exclusions (Loe and Feldman, 2007). In a UK study with over 900 10-year-olds, it was discovered that 8% presented with ADHD, all with hyperactivity/impulsivity traits, with only half recognised and supported. Without empathetic support and reasonable adaptions, most girls with ADHD receive negative reinforcement, creating devastating long-term damage to self-esteem (Nadeau, Littman and Quinn, 2016). By age 12, these children had received clear messages that what they need, and who they are, is unacceptable within the education system. They learn they are failing, lazy, stupid, and poorly behaved (Skuse, 2003). I witnessed children become introverted, defensive, and even suicidal, all before the age of 16. I frequently hear ADHD students in my counselling room reflect that no matter how hard they try, they ‘fail’. This is echoed more intensely as my clients become older, and the damage continues into adulthood.

-          ADHD and trauma – Childhood and adulthood

Within this section, I intend to explore how ADHD can be linked with trauma in childhood and how this can lead to mental health and mood disorders in females.

Adverse Childhood Events (ACEs) and ADHD. ACEs are defined as traumatic events experienced by a child before the age of 18. Originally defined in 1998 as experiences of sexual abuse, physical abuse, and household dysfunction, including ‘household members with drugs or alcohol, depression or mental illness, suicide attempts and incarceration’ (Asmundson, 2019, p.17). When four or more of these events are experienced, the effects have been linked to neurological changes in children and long-term health difficulties in adults (Boullier and Blair, 2018). ACEs are viewed to follow intergenerational patterns, similar to the view that ADHD runs in families (genetic) (NHS, 2018). There is an ongoing debate about whether ACEs can initiate latent ADHD symptoms or whether ADHD children are more susceptible to ACEs (Boodoo et al., 2022; Brown et al., 2017; Lugo‐Candelas et al., 2020). In a study with over 1500 cross-cultural urban children, there was a direct link between the experiences of ACEs before the age of five and ADHD diagnoses by age nine (Jimenez et al., 2017). However, the household environments are argued to be symptoms of ADHD in adulthood, especially if left untreated (Chung et al., 2020; Young et al., 2015). Children experiencing such ACEs could be living with unsupported ADHD families, finding it difficult to function in a society not accommodating of them (Walker et al., 2021). 

Over the last three decades, literature has shown that poverty is the leading cause of ACE’s (Hughes and Tucker, 2018; Lacey et al., 2020; Lee et al., 2021; Walsh et al., 2019). While there is research on the effect of ACEs on developing ADHD and how children with ADHD are significantly more likely to experience ACEs (Brown et al., 2017), literature linking parent ADHD, poverty, and the development of ACEs is yet to be explored. Nevertheless, in a study with over 70,000 children, Miller et al. (2017) found that families significantly below the federal poverty line were more likely to have moderate to severe ADHD than no ADHD.

ACE’s and ADHD have been linked to the development of complex post-traumatic stress disorder (c-PTSD) (Zyromski et al., 2018). C-PTSD is described as multiple and prolonged exposures to developmentally adverse events, often interpersonal, that cause shame-based cognitive distortions, hypervigilance/psychological reactivity, and maladaptive behaviours (O'Shea Brown, 2021). Due to the emotional, interpersonal, learning and processing differences of ADHD and a less flexible nervous system (Arnsten, 2009), a sense of alienation within the family and larger social circles can be caused.

Those with a neurobehavioural difference, such as ADHD, are more closely linked to developing trauma due to victimisation and their adaptive differences Larkin and Morrison, 2007; Martin and Preedy, 2016). In a study on bullying consisting of 195 children with ADHD aged between 8-10, it was found that there was a direct link between males having bullying tendencies and females being victimised (Czamara et al., 2013). Victimisation can be seen cross-culturally, between peers, siblings and colleagues and the effects on emotions and self-esteem are widely acknowledged globally (Rodríguez-Hidalgo, Ortega-Ruiz and Monks, 2015; Bain and Lunde, 2021; Stickley et al., 2013; Roy, 2015; van der Ploeg, Steglich and Veenstra, 2016). Singh and Bussey (2007) studied 2167 two secondary school students and concluded that victimisation caused the most significant maladjustment, requiring specific coping strategies to help manage the psychological damage. Due to some individuals being more prone to victimisation (Armitage et al., 2022), such as those with ADHD, without acknowledgement and support of said differences, long-lasting damage can be caused (Schonwald, 2020).

The depth of literature linking PTSD and ADHD is significant, and it is argued that they are hard to differentiate between because they commonly occur together (Spencer et al., 2015; Antshel et al., 2013; Adler et al., 2004; Biederman et al., 2012; Jabour, 2015). Philipsen et al. (2008) concluded that because childhood ADHD can be associated with childhood abuse, this can lead to personality disorders as adults, including borderline symptoms. However, an older study argued that ADHD children could experience psychological trauma but not develop PTSD (Ford and Connor, 2009).

Over the last decade, there has been increasing literature on the link between ADHD and Borderline Personality Disorder (BPD) in adults (Matthies and Philipsen, 2014; Philipsen, 2006; Storebø and Simonsen, 2013; Weiner et al., 2019). BPD is an adult diagnosis defined as a difficulty in interpersonal and emotional regulation in response to childhood trauma (c-PTSD), and is sectioned into four categories: including unstable yet intense relationships, emotional dysregulation, distorted patterns of thinking and impulsive behaviour (NHS, 2019a). Compared to the 5% occurrence of BPD in the general population, in those with ADHD, it is 33% (Bernardi et al., 2011) and Fossati et al. (2002) summarised that 60% of BPD individuals have childhood ADHD. A study with over 2 million Swedes found that those with ADHD were over 19% more likely to be diagnosed with BPD. Females with ADHD combined type (includes hyperactivity), are more likely to be diagnosed with BPD than men, who were predominately diagnosed with antisocial personality disorder (Cumyn, French and Hechtman, 2009). It is argued that ADHD can go unrecognised, shadowed by the louder symptoms that are seen first, specifically the BPD symptoms (Fossati et al., 2002).

Due to the nature of the BPD traits, the diagnosis has often been stigmatised by society and mental health professionals, leading to isolation and a sense of rejection (Aviram, Brodsky and Stanley, 2006). Luckily, this analysis was done over 16 years ago, and modern mindsets are starting to recognise its sexist origins of essentially disapproving of behaviours that were seen to be undesirable in women (Potter, 2009; Nicki, 2016). The social stigma of BPD often originates from the family, perpetuating the belief that BPD responses are unacceptable, linking to victimisation and trauma (Columbus et al., 2021). Connecting ACEs, ADHD, c-PTSD and adult BPD, I feel it is essential to recognise this is literature based on known ADHD.

This section has established that ADHD children are more likely to experience ACEs, and ACEs have been linked to the development of c-PTSD. C-PTSD and ADHD have been linked to BPD and mood disorders in adults. Concluding that from childhood, children with ADHD are likely to be managing not only neurobiological and behavioural differences but also trauma responses and social exclusion, potentially leading to adult comorbid mental health difficulties.

-          ADHD and comorbid presentations

Within this section, I will explore the mental health conditions that can exist alongside ADHD, how they can be diagnosed and treated and the long-term effects this can create, including lifestyle difficulties.

It is well-documented that ADHD can hide behind the more known and treatable mental health difficulties (Quinn and Wigal, 2004; Huntley et al., 2012; Turgay et al., 2012; Kooij, 2013; Waite and Ramsay, 2010; Barkley and Brown, 2008). While ADHD is the most common diagnosis in childhood, it is the comorbid symptoms that are diagnosed more frequently in adulthood (Ginsberg et al., 2014a). 85% of adults with ADHD are known to have comorbid mental health difficulties (Björk et al., 2020). As a practitioner, I have seen unrecognised ADHD take the form of eating disorders, self-blame and guilt, extreme stress, intense feelings of rejection, vulnerability including sexual exploitation, breakdown of relationships, self-injury, obsessive-compulsive tendencies, intrusive thoughts, sleep difficulties, substance misuse and suicidal ideation or attempts. One of a limited number of studies explicitly looking into the effect of undiagnosed ADHD and psychiatric conditions, a Czech study on patients being treated for comorbid psychiatric symptoms found that undiagnosed ADHD significantly increased suicide rates and depression, substance misuse, anxiety, and stress symptoms. They also reviewed that the severity of ADHD correlated to psychiatric difficulties, concluding that assessing and diagnosing ADHD needs to be more prevalent (Bitter et al., 2019). In a 41-article review, Quinn and Madhoo (2014) concluded that because females with ADHD adapt their beliefs and behaviour to fit expectations, they get higher rates of depression and anxiety than males. In an eighteen cross-study review involving 1997 participants, Tung et al. (2016) found a significant increase in oppositional defiance behaviour, conduct disorder, anxiety, and depression in females with ADHD. The known literature on the comorbid presentations of ADHD is well documented (Gnanavel et al., 2019; De la Barra et al., 2012; Katzman et al., 2017; Waite, 2010), but without the recognition and acceptance of neurological differences and the challenging of learned messages, then the comorbid symptoms continue to exist as symptoms.

A central belief of oneself is created from experiences with others; this is known as self-concept. In people with ADHD, because of the separation between society’s expectations and the natural ADHD processing and behaviours, this self-concept can be damaged (Dash, 2021). It is widely acknowledged that children with ADHD transitioning to adulthood need additional support and guidance to develop a healthy sense of self (Jones and Hesse, 2014: Krueger and Kendall, 2001; Cueli et al., 2020). In individuals with unrecognised ADHD who do not get this acceptance, there is more likely to be a split from their true self (incongruence) (Jones and Butman, 2012). Recognising a gap in the research on self-concept, Houck et al., 2011 conducted a culturally diverse study involving 145 children, concluding that adolescents with internalising symptoms struggled with self-concept. When we cross-reference with the literature agreeing that ADHD females are more likely to have internalising difficulties (Hinshaw and Scheffler, 2014), this study concurs that self-concept could be impaired in females with ADHD. Difficulties in self-concept were shown as diminished self-esteem, and the long-term effects of self-esteem difficulties are anxiety and depression, leading to alcohol and substance misuse (Park and Yang, 2017). linking ADHD to weakened self-concept and comorbid challenges.

Due to damaged self-concept, comorbid psychiatric difficulties and behaviour changes, ADHD can have long-term health and lifestyle struggles. Comorbid mental health difficulties have been discussed, but long-term life difficulties can also include car accidents, criminality, gambling problems, infidelity, and addictions (Romo et al., 2019). ADHD has recently been linked to diseases such as basal ganglia and cerebellum, including Parkinson's disease (Baumeister, 2021). However, it has questioned the impact of ADHD stimulant mediation on the results of such studies. There is significant literature on the link between ADHD and obesity and the comorbid health risks (Stanford and Tannock, 2012; Cortese and Castellanos, 2014; Martínez de Velasco et al., 2015; Cortese and Peñalver, 2010; Levy, Fleming and Klar, 2009; Cortese et al., 2016).

This section has explored how ADHD can manifest as various mental health conditions and how a loss of self-concept can damage self-esteem and confidence. This is important to note in relation to Rogers’s self-actualisation theory, which aims to support clients in becoming their ideal selves and reconnecting the divide in self-concept that gets created through wanting to feel a sense of belonging. This is especially true when we assess ADHD behaviour and neurological working against society’s expectations.

-          ADHD and the societal clash

This section will explore how societal rules, explicitly relating to British culture and women, differ from the needs and natural expression of those with ADHD, and how the clash can create emotional, social and behavioural fractures, creating a barrier to self-actualising tendencies.  

Society's expectations do not harmonise with the ADHD brain. Depending on culture, religion, class and location, social expectations are a set of rules deemed acceptable by the greater empire. There are cultural expectations in the UK, such as being punctual, overly polite, patient, adhering to spatial etiquette, valuing privacy, and not being too animated when speaking (Study in the UK, 2018). This is contradictory to the animated, impulsive, honest and detached characteristics of those with ADHD (Rief, 2012). Describing the impact of culture, community, and family on achieving self-actualisation, Brown (2014) states, 'fixed social constructs can heavily impact on an individual's perceptions which, in turn then affect the individual's self-belief and ability to employ the actualising tendency in ways that lead to the individual's unique actualisation' (p.43). 275 students with ADHD reported feeling rejected within academic and work settings due to negative bias towards them not having qualities such as thoughtfulness and amicability, which were valued as communitive (Canu et al., 2007). In conclusion, some ADHD organic ways of being are not welcomed or valued within a larger commutative structure, creating a barrier to ‘employ the actualising tendency’.  

Self-actualisation aims to marry the ideal self with the actual self, however as the literature concludes, society's expectations of girls and women conflict with them being their ADHD self (Doyle, 2007; Hinshaw, 2022; Scholtens et al., 2011; Pardini et al., 2006). The complex and extensive literature on gender roles throughout history is a more considerable argument than here. However, I wish to discuss the basic social rules towards females compared to the natural workings of the ADHD brain. Different expectations of female identity depend on culture; however, it is commonly felt worldwide that women are the fairer sex, nurturing, sensitive, caregivers, listeners, and mothers (Tabassum and Nayak, 2021). Christov-Moore et al. (2014) argue that empathy is more biological than cultural, with females naturally being the caregivers. Controversially, studies have linked ADHD, with a lack of empathy in children (Braaten and Rosén, 2000; Waller et al., 2014; Demirci et al., 2016). However, arguably, most of the research has been on male children, and Marton et al. (2008) found girls with ADHD to be more empathetic than boys with ADHD. Nevertheless, there is a lack of research on the correlation between adult ADHD and empathy, especially focusing on females.  

In general, women are expected to be more polite and not show aggression or react excessively. As discussed previously, ADHD individuals with hyperactivity tend to be more impulsive, aggressive and angry (Carlson and Kaur Singh, 2021). More commonly victimised, individuals with ADHD can be quicker to anger and find it hard to regulate. This can be more widely seen with meltdowns occurring when the individual feels safe, mostly at home, which can cause shame and rejection from family, partners, and friends (Alexander-Roberts, 2006). ADHD individuals also find it more natural to talk about more profound, more emotionally sensitive topics, finding small talk unsustainable (Kelly and Ramundo, 2006); this can cause discomfort in the different minded, causing retroactive shame for the ADHD individual (Liang, 2022).

Social media portrays girls as thin, beautiful, sexualised, and successful.

Disorganised eating, such as binge eating, emotional eating, boredom eating and eating disorders, especially bulimia nervosa and obesity in adults, has been widely associated with ADHD in females (Cortese, Bernardina and Mouren, 2008; Kaisari, Dourish and Higgs, 2017; Fernández-Aranda et al., 2013; Biederman et al., 2007a; Seymour et al., 2015). However, Tong, Shi and Li (2017) argued that while abnormal eating was associated with ADHD, binge eating and obesity were linked to the depression symptoms rather than ADHD. With the higher academic failure rate, unemployment, and divorce (Barkley, Murphy and Fischer, 2010), the social media representation of females can be even more unattainable by those with ADHD.

Socially, it is also expected that females should have female friends. However, females with ADHD report feeling more comfortable having male friends because males are more energetic, honest, and impulsive (Paul, 2018). However, as hormones and social constructs change, friendships with males can become sexualised and lead to rejection. Mixed with victimisation and exclusion, this can lead to sexual exploitation (Brown, 2005), which is more prevalent in females with ADHD (Hogg et al., 2022).

This section has concluded that there are additional expectations on females regarding how to behave, look, and think. This can cause females to become more vulnerable in friendships, hide their emotions, and impact their sense of social inclusion. In relation to self-actualisation, this can impact a sense of cultural and community belonging and cause a significant divide in being able to be their true ADHD self.   

The recommended treatment for ADHD

This section will explore the recommended medicalised treatment of ADHD and the comorbid conditions, such as depression and anxiety. While also exploring the person-centred model and the known recommended psychological support needs of an ADHD individual.

While it is known that there is no cure for ADHD because it is a neurological difference, not a disorder (as its name suggests) (Ophir, 2022), there is medication to manage the symptoms. While traditional and most current literature and research focus on ADHD through a deficit lens, mindsets around neurological diversities have changed over the last ten years, with many autistic and ADHD individuals advocating for their differences and defining ADHD as strength-based (Low, 2021). In my experience, I have found that this mindset is experienced by individuals who are aware of having ADHD and so can advocate and assert their needs—not those who are trying to manage the symptoms against social expectations and the lack of inclusion and accommodations.

For the unaware, unsupported, or negatively affected ADHD individuals, there are suggested therapeutic strategies to help function in a world not designed for them. The primary suggested treatment for ADHD is medication; however, I wish to focus on the recommended psychological treatment.

Along with medication, the primary recommended psychological treatments for ADHD are psychoeducation and cognitive behaviour therapy (CBT) (NHS, 2019b; Young et al., 2020). Psychoeducation aims to give individual guidance and information on a condition to help manage the symptoms. The cognitive aspect of CBT aims to undo the learnt negative thought patterns, while the behavioural aspect aims to change the (ADHD) behaviour that is seen as undesirable (Bloom, 2022). Changing to fit external expectations and promoting conformity is argued as the opposite of self-actualising and being one’s actual self (Bhui, 2012).

There is extensive literature recommending CBT, with or without medication, as the primary therapeutic approach to supporting both children and adults with ADHD (Barkley, 2018; Emilsson et al. 2011; Jensen et al., 2016; Knouse and Fleming, 2016; Sprich et al., 2016; Young and Bramham, 2012). There is little research on the effect of other approaches, especially on adults and there is limited analysis comparing the effectiveness of CBT, psychoanalysis, and person-centred therapies. However, one study consisting of 5613 NHS clients concluded that all modalities, when used as a treatment in primary care, all wielded similar results (Stiles et al., 2007). Also, a study with over 33,000 IAPT clients that compared person-centred and CBT again concluded they both had similar results (Pybis et al., 2017). However, in both of these studies, the clients were not reported to have ADHD, and these studies are outnumbered by evidence of the effectiveness of CBT due to being measurable (Bowers, 2013), unlike the person-centred model (Louw et al., 2020; McArthur et al., 2013). There is little research on non-directive play and the person-centred approach on children and adolescents with ADHD (Baggerly, Ray and Bratton, 2010; Martel et al., 2010) and there is a significant gap when researching ADHD adults (Young and Myanthi Amarasinghe, 2010).

A study with over 40,000 ADHD individuals argued that females have more comorbid mental health difficulties, such as depression and anxiety, and males have more substance misuse and criminality (Solberg et al., 2017; Fuller-Thomson et al., 2016). Again, CBT is the primary recommended treatment for anxiety, depression, and trauma/c-PTSD. The argument for CBT's effectiveness against its ability to be critically measured, its shorter session frequency and cost-effectiveness, is widely debated. I also argue from my practice that adults and adolescents with ADHD who have had CBT state that due to its reliability on measured goals, they felt a need to please the therapist, and so told them what they wanted to hear for fear of rejection or disappointment (Dodson, 2022)—or feeling as though their experiences and feelings were not listened to and they felt the goal was for them to be 'fixed'.

When treating women with ADHD and their health issues, a nurse-led health program found that a sense of belonging, namely the relationship, was the foundation of supporting adults with ADHD long term (Björk et al., 2020). Cooper (2019) summarised that what clients find most helpful from therapy is the therapists' interpersonal qualities, such as kind-heartedness and compassion. Based on Rogers's theory, self-actualisation is achieved through the therapeutic relationship. Belsher et al. (2019) found that the dropout rate for trauma-focused person-centred was less than tf-CBT; however, arguably, these did not include ADHD individuals who are known to have difficulty sustaining relationships due to a difference in communication and social connectedness. In the first study of its kind looking into attachment and ADHD, Kissgen et al. (2021) questioned the interlink between disorganised attachment and ADHD difficulties, defined as feeling both love and fear when in relationships. However, if a therapist is aware of the ADHD individuals' interpersonal difficulties and attachment style, they can ensure acceptance and warmth, which could help develop a trusting relationship. Concurring with Shaw (2021), I found through my practice that individuals without support and understanding of their differences discovered acceptance of self through socialisation with other like-minded people. Arguing that an ADHD therapist may be able to develop a relationship with an ADHD client more successfully due to lived experience and awareness.

The person-centred model is recognised as a longer-term process, especially if it does not focus on a specific area of difficulty. Some individuals with ADHD, mainly unrecognised, can want quicker relief and management of their struggles (Barkley, 2018). Arguing that CBT's strategy-based model would better fit some who want a goal-oriented approach. However, it is reasoned that cognitive and behaviour therapies can fall guiltily into treating the symptoms and can slip into advocating masking and ableist behaviour, making lasting recovery unlikely (Prasher, Davidson and Santos, 2021). Also, conclusively, psychoeducation relies on the individual knowing they have ADHD.

This section has established that ADHD females respond to a relationship founded on understanding and nurture. CBT is the primary suggested treatment for the comorbid mental health symptoms of ADHD and behaviour. However, it is established that CBT is measurable and has obtained evidence of its effectiveness, but it can create another set of conditions around achieving therapeutic goals, creating client pacification. Person-centred would be able to explore the person as they are at their core, to look to undo the internalised ableism, and empower a sense of self, which is suggested would improve mood and ADHD symptoms.

The unspoken word and the ethical dilemma

In this section, I will explore the dangers of both disclosing and not disclosing potential ADHD, along with the minimum competencies needed to ensure careful assessment and delivery, and whether it should be done at all.

When ADHD is unrecognised in the counselling room, support becomes about managing the symptoms and not the cause. Heated ethical debates continue within counselling communities on whether ADHD traits should be addressed with clients and the minimum counsellor competencies to do so. Ford and Connor (2009) concluded that trauma was associated with ADHD, and to treat the trauma, ADHD needed to be recognised and managed together. Undeniably, there is very little research on how effective treatment is for ADHD’s comorbid conditions without the recognition of ADHD. The known literature explores the treatment and the neurological difference as one. To look at the success rates of the treatment for depression, anxiety, disorganised eating, and c-PTSD without studies on the misdiagnosis or missed diagnosis of ADHD, these numbers would be void. Evidencing a gap in the research. Cortese and Castellanos (2014) determined that ADHD prohibited the treatment of obesity unless it is recognised as coexisting, and Reale et al. (2017) studied over 2000 children and adolescents and concluded that individuals with combined ADHD had higher rates of comorbid mental health difficulties, and the success rate for treatment was to have a multi-tooled approach working with all conditions.

Arguably, getting a diagnosis later in life has proven to give a better quality of life, a better understanding of self and a sense of relief (Fleischmann and Miller, 2012; Ginsberg et al., 2014b; Hansson Halleröd et al., 2015; Pawaskar et al., 2019). However, Hitchcock (2022) from the BACP ethics committee examines the potential psychological consequences of discussing such observations with the client. These include being incorrect in such observations, a possible misinterpretation that the observation was an absolute, distress caused by the cultural or social stigma of having what is described as a disorder, and the extensive waiting time to get a diagnosis.

Even though no law stipulates a minimum training requirement to support someone with ADHD, it is argued that counsellors must work within their competencies, especially concerning cultural and neurological differences (BACP, 2020; Center for Substance Abuse Treatment, 2014). It is acknowledged that only specific professionals with high levels of specialist training can diagnose ADHD (NICE, 2018), and some argued that over the last few years, ADHD has been over and inaccurately diagnosed (Paris, Bhat and Thombs, 2015). Undeniably, counsellors who divulge to clients their belief about possible unrecognised ADHD need to justify appropriate training and knowledge in this area in order to offer the required specialist support (National Institute for Health and Care Excellence, 2013). Waite et al. (2012) implored the importance of nurse practitioners having training in recognising and assessing unrecognised adult ADHD patients to ensure appropriate care and support. Concluding that disclosure of suspicions could cause psychological distress to the client without correct knowledge and training.

This section has analysed the necessity of counsellor competencies to safely reveal potential ADHD to clients and the dangers of disclosing inaccurate or uninformed information. The literature to date has stated that to treat comorbid symptoms, ADHD needs to be acknowledged and supported alongside. Concerning self-actualisation, acknowledging differences that cannot be changed would develop acceptance and awareness of self (Baumeister and Bushman, 2020).

Discussion

It is important to note that there is no cure for ADHD (Ophir, 2022), so managing one symptom or the emotional consequences of systematic ableism and trauma, does not focus on the central origin of such difficulties. It is highly evidenced that CBT does provide effective results; however, from my experience working with ADHD individuals, the effectiveness can come from appeasement or continued behaviour modification, potentially eliciting more masking behaviours and conformity. (Dodson, 2022). Even though it is argued that there will be relief from the targeted symptoms, there is no self-acceptance, self-awareness, or growth into a self-actualised person who welcomes and understands ADHD is part of who they are. Interestingly, recently, one CAMHS therapist acknowledged that CBT does not work for those who are Autistic or have ADHD.

The research has shown the impact ADHD has on health, social inclusion, self-worth, and relationships. It has been argued that without proper support and acknowledgement of ADHD, significant difficulties can be caused, including personality disorders, academic limitations, eating disorders, dangerous behaviour, sexual vulnerability, substance misuse, criminality, and family and community breakdowns- all symptoms that can individually be brought into the counselling room for treatment. The impact for practitioners treating comorbid difficulties, such as depression, anxiety, OCD, BPD, c-PTSD, and eating disorders without recognising and treating ADHD could be different depending on their modality. CBT practitioners use goal-orientated, strategy-based interventions that can support the individual to adapt their behaviour, change their thoughts and manage some difficulties (Bloom, 2022). However, for the ADHD individual, it is argued that multiple difficulties originate from one cause and without recognition of this, long-lasting change can be difficult (Ford and Connor, 2009; Reale et al., 2017). It is strongly evidenced that CBT is the recommended treatment for ADHD and the main comorbid difficulties, such as depression and anxiety (Barkley, 2018; Emilsson et al. 2011; Jensen et al., 2016; Knouse and Fleming, 2016; NHS, 2019b; Sprich et al., 2016; Young and Bramham, 2012; Young et al., 2020).), and it is recommended due to its measured, time-limited, cost-effective methods (Bowers, 2013); however, more research is needed to compare other models against it.

For the person-centred practitioner supporting unrecognised ADHD in the counselling room, the treatment could become trickier due to the non-directive approach. This approach aims to support the client in gaining insight into the self and removing any learnt socially constructed conditions (Jones and Butman, 2012). Person-centred practitioners support growth alongside clients, allowing them to progress at their own pace. Arguably, the client would organically bring the content into the room without any counsellor's influence and agenda. However, this requires time and the development of a relationship (Timulák and Lietaer, 2001), which can be a challenge for the ADHD individual. It is also argued that depending on the client's support network, some of their natural ADHD behaviour may not be accepted into the wider family and social constructs, causing continued isolation and rejection.

The research showed the importance of disclosing ADHD symptoms to treat the person as a whole and how being part of a community and being understood by like-minded individuals was essential for those with ADHD to develop self-acceptance (Shaw, 2021). The positive impact of having a later diagnosis than none at all has been analysed and evidenced (Fleischmann and Miller, 2012; Ginsberg et al., 2014b; Hansson Halleröd et al., 2015; Pawaskar et al., 2019), and where the research does exist, it states that the supporting of the acceptance of having ADHD along with the treatment of the comorbid difficulties should be done together (Cortese and Castellanos, (2014; Ford and Connor, 2009; Reale et al., 2017). However, the necessity of a well-informed, trained therapist who can competently identify traits and assess risk, to be able to explore potential neurological differences sensitively and carefully is essential to minimise any risk of harm (Hitchcock, 2022). It was reasoned that an integrated, ADHD affirmative practice is essential to supporting ADHD individuals. One that is founded on a trusting relationship, acceptance, and empowerment and that offers tailored strategies and psychoeducation to help the client learn about their differences.

Due to the highly debated and unanswered question on whether practitioners should mention their observations, I suggest more research should be conducted into the effect of therapists, both revealing, and not revealing their suspicions of ADHD. This would support the development of clear guidance on managing such situations, including assessment and referring to specialist support if necessary (NICE, 2018). The literature established that disclosure needs to account for a client's support network, the severity of traits (Bitter et al., 2019), any prejudices about ADHD (Hitchcock, 2022), their therapeutic aim, and their commitment to the potential longer-term process (McMahon and Palmer, 2014).

Concluding that if ADHD is unrecognised in the counselling room and symptoms are severe, then self-acceptance will not be achieved without social support and acknowledgement of neurological differences. However, minimum practitioner competency and skills are needed to manage such complexity. This means that for some individuals with unrecognised ADHD in the counselling room, self-actualisation would not be possible without recognition of their differences.

The literature lacks evidence on the impact of counsellors not being trained in ADHD, so the consequences of missed diagnoses are overlooked, including therapy dropouts, criminality, and suicide. The analysis of this research identifies the high levels of misdiagnosis in female adults with ADHD and the positive outcomes of receiving an ADHD diagnosis. It highlights the potential high frequency that ADHD is brought into the counselling room as comorbid symptoms. So I argue that more research should be conducted into whether ADHD training should be mandatory for a counsellor working with known comorbid mental health conditions that are related to potentially unrecognised ADHD.

As identified, there is a gap in research on the therapeutic support needs of unrecognised ADHD. Importantly, it is suggested that counsellors working with ADHD should have some form of regulation or minimum training standard. SCoPed is in the process of regulating the counselling profession, but focusing on specific groups is not in the immediate future.

Where the research is lacking is the literature on the person-centred model and the treatment of ADHD. Mick Cooper has begun introducing measurements on person-centred therapy, hoping to revolutionise measuring effectiveness against goal-originated giants such as CBT (McArthur, Cooper and Berdondini, 2013). Nevertheless, for now, there is a considerable disparity. There is no literature on the achievement of self-actualisation for ADHD individuals, even with a diagnosis. Therefore, there is a huge gap in research that could support counsellors in determining treatment plans or a necessary referral process for such individuals. 

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