In the UK, ADHD is recognised by the NHS as a 'neurobehavioural' condition, meaning that the primary focus of the NHS is treating it as a neurodevelopmental condition with consequences on behaviour.
Despite being classified as a neurodevelopmental mental health condition, most experts and doctors are moving towards an understanding of ADHD as a strictly neurodevelopmental condition. Having ADHD does not automatically mean you have poor mental health. Additionally, poor mental health is usually thought of as something someone can permanently recover from, which is not particularly relevant for understanding ADHD. Whilst it is true that negative ADHD symptoms can become more or less impactful at different points in someone's lifetime, people born with ADHD cannot permanently 'recover' from ADHD - it is just the way the brain and nervous system develop.
ADHD also comes with strengths such as creativity, out-the-box thinking and periods of high energy that do not disappear as the more negative symptoms are treated and managed. Some people do lose an ADHD diagnosis over their lifetime, particularly between childhood and adulthood. However, this means that they are now 'sub-clinical', meaning they do not have enough negative traits to meet the diagnostic criteria - it does not mean that their brains and nervous systems have suddenly become neurotypical.
It's important to understand that mental health problems arising from untreated, unmanaged and, often, undiagnosed ADHD are often 'secondary' mental health problems and will abate when ADHD is treated - meaning focusing on ADHD is key. Secondary mental health conditions get worse when ADHD, the primary condition, is left untreated and get better when ADHD is treated. This is different from 'primary' mental health conditions, which require their own treatment, although it is possible to have both ADHD and a primary mental health condition.
Co-occuring primary mental health conditions
It is completely possible for someone with ADHD to have a co-occuring primary mental health condition that requires independent treatment. Having ADHD is itself a risk factor for going on to develop another primary mental health condition.
However, due to misunderstanding and a lack of knowledge, often ADHD is misdiagnosed as more well-known mental health conditions such as bipolar disorder, borderline personality disorder, OCD and/or schizophrenia, despite these conditions being 4 to 8 times rarer than ADHD. Additionally, it is highly common for adult ADHD to be interpreted simply as anxiety or depression, particularly when ADHD impacts mental health.
The rate of misdiagnosis is so high that in the UK it is thought that the average person with ADHD will experience 3 to 4 misdiagnoses before they are diagnosed with ADHD.
For this reason, it is very important that diagnosis of other mental health conditions is done very carefully by adult ADHD experts. Unfortunately, GPs, mental health nurses and even clinical psychologists are often not experts in ADHD, and it can take seeing one or more specialist psychiatrists who work with people with ADHD to get a reliable diagnosis.
What is a secondary mental health condition?
Secondary mental health conditions can arise from any primary health condition, although this is often misunderstood with ADHD. For example, someone who breaks their legs in an accident may become depressed because they are suddenly unable to walk or live the life they want. They undergo physical therapy and recovery and, when they are able to walk again, their depression lifts. In this case, the primary condition is a leg injury, and the 'secondary' condition is depression arising from the impact of the primary condition. In the same way, someone who is struggling with executive dysfunction, impulsivity, hyperactivity and inattention may be impaired and unable to live the life they want, and experience a secondary mental health issue like depression.
When they are given an ADHD diagnosis and education about their condition, alongside coping strategies, support, medication options and therapy options, core issues of ADHD can reduce. The person will be empowered to live the life they want and no longer experience their secondary mental health issues.
What secondary mental health conditions might somone with ADHD have?
The most common secondary mental health conditions experienced with ADHD are:
- depression, often due to executive dysfunction impairing key parts of work, education or home life
- generalised anxiety, often since excessive worry partially combats inattentiveness
- social anxiety, often when ADHD traits like impulsivity, inattention and different thinking styles impair social functioning
- OCD-like cycles, often since fixations and excessive checking partially combats inattentiveness and disorganisation
There are some ways people with ADHD can tell the difference between secondary mental health conditions and their primary counterparts:
- Secondary depression means that depressive episodes co-incide with someone's life being out of control, whereas someone with primary depression is likely to experience a depressive episode even if everything is going well.
- People with ADHD are particularly susceptible to 'post-success depression', where they experience a short depressive episode after finishing a long-term project or reaching a personal goal.
- Secondary generalised anxiety tends to become exacerbated when demands increase from work, education, social or family life or when disorganisation increases.
- Although the cause of anxiety or a panic attack may not be obvious moment-to-moment, periods of anxiety and increased frequency of panic attacks coincide with disorganisation, loss of structure or having racing thoughts and feelings without a productive outlet.
- Secondary social anxiety tends to orient around particular aspects of ADHD that can cause social challenges, such as worrying about seeing someone after having not structured a relationship for a long period of time as well as forgetting people's names or missing important social events.
- Secondary social anxiety with ADHD is often paired with 'scripting' which is where someone with ADHD rehearses conversations or phrases in their head, or plays past conversations over and over trying to remember details.
- Someone with secondary social anxiety may also get someone else to help 'script' them, meaning they ask them what to say or do in particular situations in order to help them fit in and appear typical.
- 'Scripting' is often found in people with autism.
- Secondary OCD usually does not involve a sense of guilt, which primary OCD does; someone with ADHD and secondary OCD is more likely to feel ashamed and embarrassed of their OCD-like cycles rather than guilty.
- Secondary OCD in people with ADHD typically revolves around particular challenges of executive function, working memory and organisation, and it can often take the form of checking and making lists obsessively.
- For example, worrying and checking that a house door is locked five times after locking it but only because someone with ADHD can forget more frequently to lock a door, meaning the OCD-like cycle compensates for past mistakes.
ADHD and trauma
Finally, it is worth noting that many people with ADHD go on to develop PTSD or other trauma-related conditions. There is thought to be a two-way relationship between ADHD and trauma, where the vulnerability of someone with ADHD predisposes them to traumatic incidents and likewise traumatic events exacerbate ADHD traits and influence development. In addition, since ADHD is heritable, parents and families with diagnosed or undiagnosed ADHD can create a challenging environment during someone's upbringing, which can mean the two-way relationship between trauma and ADHD is maintained between generations, something which is often referred to as 'transgenerational trauma'. Anyone affected by both ADHD and trauma should seek treatment and support for both.