Lynne Malcolm: On RN, you're with All in the Mind, I'm Lynne Malcolm, and today; racing minds.

Jessica Morrison: One of my ex-boyfriends always used to say, 'I absolutely love you until first thing in the morning,' because I'd wake up and want to jump up and down on the bed and be, like, 'Wake up, wake up, wake up,' poking him, all energetic and ready to go for the day, and he'd just be lying there going, 'I really hate you.' 'Immature' is the word that gets thrown around a lot, but I don't think immaturity is the right way to describe it. It's an energy.

Lynne Malcolm: Jessica Morrison is 26 years old. She manages a bar, which suits her down to the ground, and she's excited about her future career in the wine industry. She was diagnosed with attention deficit disorder when she was in primary school and, along with three to five per cent of adults in Australia, still experiences ADHD symptoms as an adult.

Jessica Morrison: I was a pretty hyperactive, out-there child, which I think was a bit my personality, a bit the ADD. I was a very intelligent child that just could never understand school at all. Reading and writing, even to this day, are still a killer. And obviously you've got all the behavioural issues that come with ADHD. The older I got, the more I was aware that it was impossible for me to concentrate. No matter how hard I tried, no matter what alternatives we tried, no matter what medications we tried, I just couldn't pay attention to anything, it was just all gibberish. I always needed to be doing two things at once, whether it was doodling or playing on my laptop. I knew nothing would ever sink in.

It is definitely still there, it never goes away, but I do find as an adult people are a lot less sympathetic towards it. When you're a child it's, oh, it's okay, she can't do that, she's got ADD. As an adult people are, like, don't you get over that by now? It can be very frustrating and difficult because you are trying, you are doing your best. You probably work harder than anybody else at some of the simpler tasks, but no one is ever going to give you a pat on the back for it because they kind of just have this attitude of, 'Well, that's something you have when you're a kid, you should be over it by now,' not really grasping the understanding of, yes, it is something that's diagnosed in your childhood but it's something you've got for the rest of your life.

Lynne Malcolm: Unlike Jess, some people don't become aware that they have an ADHD condition until they reach adulthood.

Dr Caroline Stevenson is a clinical psychologist in private practice and specialises in ADHD across the lifespan.

Caroline Stevenson: ADHD in adults is slightly different from the experience of childhood. With children you expect to see them running around the room, not being able to sit still, very impulsive children. Or, conversely, you'll see children like little wallflowers at the back of the classroom who are zoned out. With adults it's very interesting because the presentation for adults is usually chronic disorganisation, problems with procrastination, or that they are actually in trouble with the law because of impulsive behaviour, like they come in with speeding offences or drug offences or just chaos.

Lynne Malcolm: Some people don't believe that this condition actually exists. What's the research that says that it does exist?

Caroline Stevenson: It's very interesting. The reason why we have got to the position that some people believe that ADHD doesn't exist is because research originally was inclined to show that you grew out of ADHD during adolescence, and the reason that idea persisted for a very long time was because hyperactivity dampens down. You do not see teenagers or adults running around the room and climbing over the furniture. The manifestation of that symptom in adults is very fidgety, restless, and that racing mind experience.

So because hyperactivity dampened down it led people to the belief that you grew out of ADHD. But research that started in the late 1970s and then spanned into the last few decades actually showed that if you followed people over time, yes, the hyperactivity dampened down, but the other symptoms don't, so that you would continue to be inattentive, you would continue to have poor organisational skills, you would have problems dealing with boredom, and you'd definitely have problems with procrastination.

So while the hyperactivity…it was that that actually changed in the way that it presented, that was what led to the idea that it disappeared. But in actual fact the research doesn't support that.

Lynne Malcolm: And it can't actually start in adulthood, can it.

Caroline Stevenson: By definition it's a childhood condition, it is a developmental condition that needs to start in childhood. But what we do know is that you can have symptoms that don't impair you until you reach adulthood, because as soon as you actually increase cognitive load on a person you may get a manifestation of the symptoms to a degree that it impairs them.

Lynne Malcolm: So that would explain why some people don't realise they've got a condition but their life seems to be out of control.

Caroline Stevenson: That's right. I mean, when I look at the presentation of adults, the first time that they come is their first year of university, for the reason that that cognitive load increases. They have suddenly got to organise themselves, get to classes, deal with the sustained attention, very independent in their learning, and they don't actually have the skill-set to do it. They become very stressed, they get overloaded, and that might be a time that they actually present for treatment.

A second time that you get adults presenting for treatment is when their child has just been diagnosed, and as a result of their child being diagnosed with ADHD they have the a-ha moment; oh my goodness, I have had all these symptoms myself and nobody actually recognised them. And when they look back historically they exactly can tell you that they couldn't concentrate in the classroom, that they were chronically disorganised and they've had major difficulties as an adult.

Lynne Malcolm: Caroline Stevenson.

There's no one cause of ADHD. It's been linked to a number of factors including prematurity, high lead levels in the blood stream, and smoking during pregnancy. Any mild neurological impairment may also lead to the disorder, and it has a strong genetic component, so it tends to run in families.

Dr Craig Surman is a neuropsychiatrist and scientific co-ordinator of the Adult ADHD Research program at Massachusetts General Hospital and Harvard Medical School. He's recently co-authored a book called Fast Minds with Tim Bilkey and Karen Weintraub. His concern is that adult ADHD is quite common, but the challenges are not well understood or managed.

Craig Surman: We find that a lot of professionals are ill-equipped to help people understand whether they have the condition. So I think many adults have come to an understanding by their own research.

Lynne Malcolm: And it's not necessarily about the inability to pay attention but of maintaining consistent engagement.

Craig Surman: Right, said very well. I think of attention deficit disorder as the most common self-regulatory problem, meaning are people in control of what they do and when they do it. So things like getting around to assignments or paying the bills or putting paperwork in that place you managed to plan the paperwork but, gee, it's not there right now. There's organisational challenges that come as a result of these traits. And so this mix of impulsive, hyperactive, focus challenges, it's a real gemisch of individually different kinds of problems. But we think of it all as what I call self-regulatory issues.

Lynne Malcolm: You talk about an engagement system in the brain. Could you explain this and how it's different for people with ADHD?

Craig Surman: So a lot of what makes us humans different from other animals is our prefrontal cortex, and our prefrontal cortex helps us with things like selecting what we're going to put our effort into in a conscious way, and also unconsciously it helps us keep long-range goals in mind. And we think about this area in particular in attention deficit I think because it's what we can tweak with medicines, like stimulants often. It's not the only culprit though, and it's connected to other regions that have a lot to do with ability to pay attention, for example to the sound of my voice versus thinking about something else you have to do later. This is a selection of thought that I'm speaking of, but there's also selection of sounds. There are also many competing motor activities in any given moment.

So there is some system that allows us to govern and stick with particular planned action, and this is something that I call the engagement system. And what tends to happen is that things that are very easily engaged, things that are fascinating, I call them shiny or interesting, or even things that people are just naturally good at tend to be very easy to engage in. Anything that is boring is harder for someone to engage in. But this kind of boredom factor is even worse for folks with attention deficit disorder. Their engagement system is a little bit loose. And there are multiple regions involved in this system, and some of them are really critical, and what we understand now is that there are other regions which are less critical but still very important for fine tuned attention, but they all work together in harmony to allow control and engagement. It's kind of like, to use a sailing metaphor, a keel of a boat, you know, you've selected a course and are you going to be able to hold the course or are you going to drift with the wind or drift with the current?

Lynne Malcolm: And it certainly wasn't smooth sailing for Jess Morrison through her adolescence.

Jessica Morrison: I was a very angry teenager, and most people I know with ADD were angry teenagers. One of the best and worst things my parents ever did was ship me off to boarding school, which was hell, I hated every second of it. I hated feeling like a captive, especially because, as my sister likes to say, ADD kids are wild-childs, it was like being a caged wild animal. But it gave me an outlet to focus on one thing, and through that I found that I was growing as a person and I was finding other ways to not be so frustrated about not fitting in and not being so frustrated about not being able to express myself. So I found all these other ways to deal with that.

But then when you become an adult and you're left to fend for yourself, it's like another battle all again. You don't have these teachers backing you up, you don't have these sports that you need to do. No matter what job interview I go to, I'm very upfront and honest about it. I'll always say, 'I've got ADD, mildly dyslexic.'

And my boss, who is an awesome guy, love him to bits, he's so sympathetic about so many things but it's little things here and there that I know he gets so frustrated and he tries to be sympathetic and tries not to let it bother him. Things as simple as emails, when I have to email a customer back saying, yadda yadda yadda, something about a booking or something about a lost purse, he'll be, like, 'Arg, you didn't capitalise the name and you didn't put a comma here,' and I'm like, 'I know, I'm sorry, I'm sorry, I'm sorry.'

And every time we do a review or anything he's like, 'And this needs to improve,' and I've just got to turn around and say, 'I'm really sorry, I'll work as hard as I can for you but I can't fix that.' It's a very small part of my job, but apart from that I personally think I kill what I do, but it is something that's always going to be there.

At school they give you a bit of leeway, you've always got special allowances, things like that. Uni, you do a bit but they're a lot less sympathetic. I sympathise with anyone with ADD at university. Universities need to pick up their game and realise that this doesn't go away, and start making it a little bit easier for people like me to actually get through a university degree.

Craig Surman: Things that are challenging or mentally effortful require a lot more, and that's often what people say to me coming in, 'You know, I just think I have to try harder.' And I tend to ask them, 'Well, how long have you been trying?' And they may say 55 years. So a good portion of people have organisational challenges. We're talking about last-minute pressured deadline scrambles, and it's been that way their whole life, and it's only the effort that it takes that's a burden. They're not getting fired, they're not having people complain.

And so to understand if someone has attention deficit you really want to walk in their shoes and ask is there any other explanation. What I tend to find is that there is usually some period of time in a person's life where those explanations, those alternatives just weren't in play, yet the traits are still there.

Lynne Malcolm: There's a gender gap too, isn't there, more men than women experience it?

Craig Surman: Well, it's actually unclear to some extent whether clinicians in society are doing a really bad job by girls or if what you said is true, because the rates of diagnosis are four or more times as high in boys than girls, but when it comes to adults having recognised that they have a concern and they're coming in to a clinic, in my experience and my colleagues' experience it's about 50/50. The fact of the matter is that there's a lot of women who will tell me, 'I wasn't disrupting class. My brother with ADHD did. I was quietly passing notes in the back of the class, and I got passed, but I've maxed out now and I really find that I just can't keep on top of things the way I feel like I should. And I think I'm being reasonable about this, it's not just that I'm a workaholic and trying to be perfect.'

Lynne Malcolm: Neuropsychiatrist Dr Craig Surman.

You're with All in the Mind on RN, Radio Australia and online. I'm Lynne Malcolm, and today we're looking at fast minds and the experience of ADHD as an adult.

Over her lifetime living with attention and hyperactivity symptoms, Jess Morrison has been prescribed a range of treatments and medications.

Jessica Morrison: I was on a cocktail of everything. They kept switching it to try and find the right medication throughout my life. I was mainly on dexamphetamine, and then in older age I went to Ritalin, and then once it was introduced I went to the slow release Ritalin. The medication did make a difference but the side-effects killed me. Even though they did help level out my hyperactivity, what they were doing to me in the long run I still feel the effects of even today. Still to this day I have sleeping issues. The depression side-effect never went away. Even just little things like nausea, nausea is a massive side-effect of a lot of the ADHD drugs, and to this day the second I'm feeling anxious or the second my hyperactivity levels get up I'm nauseous for the entire day.

Lynne Malcolm: Are you medicated at the moment?

Jessica Morrison: No. I did go back on medication as an adult for about a year or so when I was 23 and just went I can't do this any more and I've sworn to myself I'll never do it again.

Lynne Malcolm: Medication obviously doesn't suit Jess, but clinical psychologist Caroline Stevenson, who specialises in treating adults with ADHD symptoms, believes it can have an important role for many.

Caroline Stevenson: I always have the view that the best treatment of ADHD is multimodal, which means that most people will actually require some medication. And then I say it's a lot of hard work, which is putting strategies in place which actually help manage difficult behaviour.

Lynne Malcolm: And is it sometimes difficult to define? It mustn't always be clear that it's not depression or it's not anxiety, that it is ADHD.

Caroline Stevenson: I think one of the reasons that ADHD is so controversial is the difficulties in unpacking it for an adult presentation; they are rarely walking in the room with a clear ADHD. What might appear on the surface as a substance abuse problem, when you look in a bit it looks like they were anxious, and then you look in a bit more, they had poor self-esteem issues, and then you look in a little bit more, they just couldn't cope in the classroom ever because they had ADHD and they couldn't concentrate. Really underneath the core was ADHD itself. But it's tricky, and one of the difficulties we have in Australia is really good education about ADHD across psychiatry and psychology and social work.

Lynne Malcolm: That's the challenge.

Caroline Stevenson: That's the challenge, yes. And I would also say GPs recognising it because in my experience one of the major issues is that an adult might go to their GP and say, 'Look, I really think that I've got the symptoms of ADHD,' and the GP will say, 'Well, that's a load of rubbish.' And so here we're looking at trying to educate the professionals about what ADHD is.

Lynne Malcolm: In her practice Caroline Stevenson incorporates the use of medication, along with self-help techniques, to treat adults whose lives have become chaotic due to their attention and hyperactivity symptoms. Her approach is the result of a research program she conducted for her PhD.

Caroline Stevenson: So the idea here was to not use medication but to look at can I teach life skills like time management, use of a diary, putting your keys in the same place, managing your stress better, impulse control, all these type of strategies, and seeing if it improves quality of life. My research has shown that if you can put in strategies that you can get a third drop in your ADHD symptoms. And I have looked at this both in terms of an intensive intervention program and more like a self-help type program where people would have a manual and try to implement the strategies at home with a coach. And both approaches are actually fairly effective, but the more intensive intervention is actually better. And in some cases, for very motivated people you can get as good improvements in symptoms as medication.

I have also looked at are those people who are on medication, could they do even better if they have the strategies in place. This one has been difficult for me to unpack in terms of research because people coming to the research study were already prescribed medication, and so it's really hard for me to say whether I got a group of people whose medication wasn't working particularly well and therefore they were wanting strategies. But what I have shown is that it really doesn't make any difference. You can get a third drop in your symptoms whether you're on medication or not.

Lynne Malcolm: And the medication has also been controversial. It has been thought in some circles that there has been over-prescription of medication for this condition. What are your thoughts on that?

Caroline Stevenson: Yes, I think this is a very interesting question because when you look at the number of people that we would predict to have ADHD, I think it's about 5% of the population, the number that are actually on stimulants is something like 0.1%. You know, it's a really low number of people who potentially have ADHD that are actually on stimulant medication.

Lynne Malcolm: Is this just in the adult group or…?

Caroline Stevenson: That's just in the adult group, yes. But the fear that we have—a wide range of people taking stimulant medication for treating adult ADHD—is not true. In fact we have more people out there with ADHD that would actually benefit from being on medication than are treated at this point in time. I mean, one of the things I can very clearly say is from my experience of 15 years working in adult ADHD is people benefit from medication, and it significantly improves their quality of life.

Lynne Malcolm: Neuropsychiatrist Craig Surman from Harvard Medical School agrees that medication can be very helpful, but he's also a strong believer in assisting people to develop their own personal coping skills. His book Fast Minds: How to thrive if you have ADHD outlines the program he and his colleagues have developed.

Craig Surman: There's so much that individuals end up doing on their own. People can empower themselves to change their environments. In a workplace it could be getting the cubicle that is the furthest from the lunchroom or some place that's noisy. Develop skills that help them thrive, and these are things that don't necessarily require a pill. A pill might help if they have a lot of trouble following through on self-improvement, but sometimes it's really just as simple as finding the right strategies for them.

One thing I harp on a lot is that our modern society tends to value jobs that require a lot of mind effort as opposed to hands-on work, and the lack of vocational training is astounding to me. You're asking square pegs to fit into round holes, and of course you get tuning out and daydreaming because you're taking people who are hands-on people and you're asking them to do more mental work. And I think what really matters is that an individual understands themselves, understands how these traits apply, and can really have a thoughtful conversation with someone who's going to try to walk in their shoes and entertain alternatives.

Jessica Morrison: The hyperactivity, when I was in other industries, was a pain because I'd get really, really happy and really, really high and go like crazy, and then all of a sudden I'd be dead, whereas working in hospitality it's actually a bit of a bonus. You're always on the go, so the ADD if anything is actually a benefit.

Lynne Malcolm: Are there other areas that you think it helps you thrive as a human being?

Jessica Morrison: Well, the multitasking. There's no one I know that can multitask the way somebody with ADD does because we need to multitask or we can never concentrate on anything. So if you are in an industry…really anything that you have to be multitasking on a high level, it does become a benefit because you can concentrate on six things at once, you can give it your full attention.

Lynne Malcolm: And do you think you're more creative than you would be if you didn't have this condition?

Jessica Morrison: Definitely, because it's what you have to rely on to get through school. You know you're never going to be the bookworm, that's never going to happen, so you actually need to find different outlets to express that you do have a brain. Because the most frustrating thing about ADHD is…and it is I think the reason a lot of kids with ADD have a very high level of anger issues, is that you are an intelligent person but you can't express it in the way that we conceive as conventional intelligence. You have to find other ways to prove to people that you're not dumb. For me now it's a lot about wine and cocktails. I come up with very unusual ingredients for my cocktails, unusual flavours, and they work, and I love doing that. So you've got the multitasking there and you've got the creativity.

Lynne Malcolm: What's your best cocktail, according to you?

Jessica Morrison: That's a tough one. We've recently put a new one on the list that I absolutely love which is Goodbye Rhubarb Tuesday which is our first ever desert cocktail, so it's a cocktail that's designed to be had as a desert. It's a rhubarb and vanilla purée with gin, a few different flavoured liqueurs in there, a little bit of strawberry, a little bit of raspberry, and we've got grated white chocolate on top, so it actually looks like a rhubarb crumble and it tastes like one as well. Oh, it's the naughtiest cocktail, but it's so good. I don't normally like chocolate and stuff in cocktails, I think it's a bit '80s, but somehow we made this one work.

Lynne Malcolm: I must say it sounds like a lot of fun working at the bar with Jess Morrison, but no doubt there are challenges to being close to someone who seems chaotic, impulsive, and can easily fly off the handle. And sometimes people with these symptoms don't even recognise that they have a condition. So what are the best ways for family and friends to help?

Craig Surman: I think that if an individual is very interested in support, then there is a lot that a family member can do. And to some extent this can put a loved one or a significant other, a friend, co-worker, whoever, in an awkward position. It can be a burden. There are some folks who, for example, will find themselves leaning on caretaker types and putting real strain on relationships. So I think it should be ideally 'I want to be available to help you adapt but I want to know that you're going to meet me partway on this'. But I really hesitate to overburden. I think that it should be a collaboration.

Lynne Malcolm: Dr Craig Surman, neuropsychiatrist from Massachusetts General Hospital and Harvard Medical School, and he's co-author of Fast Minds: How to thrive if you have ADHD.

So tell me more about some of the strategies that you've developed for yourself, because you've decided not to be on medication. What are some of the things, the tools that you use to keep your life in control?

Jessica Morrison: Diet and exercise is incredibly important, and allowing yourself a lot of personal time. I find it's really important for me to analyse my day at the end of the day. I go home and I sit in bed and I'm, like, was I happy with how I was today? All right Jess, so what are you going to do next time? And one thing that every shrink and every pathologist my parents ever set me to is 'before you get angry, before you get upset, just walk away'. I have actually learned that's the worst advice anyone could ever give you. It doesn't work. Now I've actually learnt you can actually turn around and walk away without moving a step and looking like you're listening. You just mentally switch off and go, 'I agree.' I can sit there calm as anything and literally have no idea what they're saying and I am not listening in the slightest. It's probably really rude but no one has ever caught me out, although after this I think they might!

Lynne Malcolm: You mentioned you've had therapy. How has that helped?

Jessica Morrison: I was lucky to have a great psychiatrist, and I think it's important to have a psychiatrist that does understand what your wants are. If you want to stay on medication, no judgement at all, I think for some people it's the right decision. For me I knew it wasn't. He was fantastic, I was very lucky, but I do think it is important for people with any form of learning disability to have that professional person to talk to. But I think it's best for your sanity to not let them be a yes person, because all you're going to do then is coast through life thinking poor me, I've got ADHD or I've got dyslexia or I've got Asperger's and my life's so hard and everyone's out to get me, whereas if you've got someone who is being straight with you and logical with you and saying, no, your life's not that hard. Somebody dying of cancer's life hard, your life's not that hard.

Lynne Malcolm: And you seem to have a really good understanding of yourself now.

Jessica Morrison: Yes, I think actually more than most people I understand myself. I think it's also given me the ability to understand other people better. I'm not good with people who are sick or who have hurt themselves because I'm very much, like, 'Eh, suck it up and walk it off Princess.'

Lynne Malcolm: Because you've had to do that for yourself really, haven't you.

Jessica Morrison: Yes, exactly, especially, like, I was constantly sick as a child, and so you get a bit unsympathetic towards that. But when it comes to actual proper emotional issues, you can pick it a lot easier. You can normally read someone very quickly and understand someone very quickly. It does help in your dating life because you can weed out the jerks very, very quickly.

Lynne Malcolm: Thanks to Jessica Morrison for sharing her story with us today, and to sound engineer Luke Purse. I'm Lynne Malcolm.

That was the final program in this season of All in the Mind. To catch up on previous episodes you've missed, go to our website at abc.net.au/radionational where you can also leave comments, and I'd love to hear from you. I look forward to being with you again on All in the Mind in early October. In the meantime though stay in touch with All in the Mind on Facebook and Twitter. Next week at this time tune in to a brand new season of The Body Sphere with Amanda Smith. Bye for now.