The brain can be compared to a complex network of wires inside a box. Imagine each wire representing a neuron, and these neurons communicate with each other to pass messages. When one neuron becomes active, it sends electrical signals along its wire. These signals travel through the network until they reach the tiny gaps, or synapses, between neurons.

At the synapse, chemicals called neurotransmitters act like messengers. They are released by the active neuron and cross the gap to reach the next neuron. This triggers a response in the receiving neuron, allowing the electrical signal to continue its journey along the network.

Two important types of neurotransmitters in the brain are glutamate and GABA. Glutamate acts as an accelerator, exciting the next neuron and making it more likely to fire electrical signals. On the other hand, GABA acts as a brake, calming down the next neuron and reducing its activity. Simply put, too much glutamate in the brain makes the brain “convulse” and too much GABA puts the brain into “coma”.

Neuromodulators, such as dopamine, norepinephrine, and serotonin, are molecules that play an role in adjusting the activity of these neurons throughout the brain's wire network. In ADHD, for example, there may be lower levels of dopamine and norepinephrine in the frontal region of the brain, affecting the efficient processing of information by neurons.

Medications used for ADHD treatment, like Ritalin and dexamfetamine, help increase the availability of dopamine and norepinephrine. This assists in fine-tuning the activity of glutamatergic and GABAergic neurons, allowing individuals to better focus on important information and reduce distractions.

It is important to remember that the brain is a complex organ, and ADHD involves various factors. The medications used have broader effects beyond simply increasing dopamine and norepinephrine availability. Individual responses may also vary, so it is essential to consult with healthcare professionals for personalized information and guidance tailored to you unique needs.

Emotional dysregulation (commonly known as mood swings) can indeed be a sign of an underlying ADHD in adults.

A 2020 systematic review and meta-analysis published in BMC Psychiatry involved a comprehensive literature search and included randomized case-control studies. The study specifically focused on identifying and quantifying aspects of emotional dysregulation, such as emotional lability, negative emotional responses, and emotion recognition in adult ADHD patients compared to healthy controls. The authors concluded that their findings supported emotional dysregulation symptoms as a core feature of ADHD’s psychopathology.

However, it's important to recognize that ADHD is a complex neurodevelopmental disorder, and its presentation can vary significantly from one individual to another. In adulthood, some of the overt symptoms of ADHD like impulsivity, hyperactivity and even difficulty focusing, may diminish, but other issues such as mood fluctuations or mood swings (emotional dysregulation) might persist or become more apparent. This can sometimes make diagnosis and treatment more challenging, as the adult presentation of ADHD can be quite different from the childhood presentation.

Moreover, emotional dysregulation in adults can be influenced by a variety of factors, including but not limited to ADHD. It can be associated with other mental health conditions like anxiety disorders, mood disorders (such as bipolar disorder), personality disorders (like emotional unstable personality disorder, otherwise known as Borderline Personality Disorder, premenstrual mood disorder (PMDD) and other hormonal-related fluctuations in women of productive or perimenopausal ages or even the result of chronic stress or unresolved trauma.

Thus, when patients present with mood dysregulation and a history of ADHD symptoms in childhood, it's crucial to conduct a thorough assessment. This often includes exploring the childhood history, current symptomatology, collateral history from childhood informants and overall functioning. The aim is to understand the full scope of the mental health needs and to provide a comprehensive treatment plan that addresses both their historical symptoms and their current challenges. Treatment of mood dysregulation needs to take into account the biological, psychologoligical and social cause of the symptoms and a combination of biological (with close monitoring of effects and side-effects) ad well as psychological therapies is often needed.

Rejection sensitivity refers to an increased tendency to perceive and react intensely to rejection or perceived criticism. This can lead to difficulties in interpersonal relationships at home, work or friends and heightened emotional responses to social interactions.

Thus, when a patient with a chief complaint of rejection sensitivity presents with convincing history of ADHD sympotms in childhood, it's crucial for psychiatrists and psychologists to conduct a thorough assessment and take into account the developmental trajectory of the symptoms. As mentioned in the response to the previous question above mood swings, the assessment in these circumstances includes not only ADHD symptoms but also personality structure and other psychiatric disorders like atypical depression, etc.

In the 2014 study “Justice and rejection sensitivity in children and adolescents with ADHD symptoms” published in European Child and Adolescent Psychiatry, researchers found that individuals with ADHD symptoms exhibit a higher sensitivity to injustice and rejection, which may lead to more intense emotional responses.

Diagnosing ADHD in adults requires close examination of symptoms in Adulthood as well as childhood. ADHD is a neurodevelopmental disorder which means it has its onset in childhood. Therefore, when the diagnosis of ADHD is made in adulthood for the first time, the diagnosis is in fact being made retrospectively. To make a retrospective diagnosis, while patients’ recollection of their symptoms and struggles in childhood is helpful and necessary, often collateral information from other childhood informants like parents, older siblings or school reports is required to arrive at as clear a picture as possible.

There is an explicit requirement by the Medicare that states that for patients to be able to access subsidised stimulant medications, there has to be an in-depth consultations with parents, teachers, siblings or third parties (possibly like second opinions from a psychologist, another psychiatrists or ex-partners, or reliable childhood friends), records of which to be present in the patients’ files to corroborate patient’s accounts.

However, there are genuine circumstances that collateral information form parents, siblings or school reports are not readily available to substantiate patients’ accounts of their childhood experiences (for instance, in the case of refugees and immigrants; the patient being estranged from family members; fear of rejection of and disbelief in ADHD symptoms in Adulthood by the family, etc.) In these circumstances the doctor and the patient need to be patient and work collaboratively to rule out other aetiologies and cautiously make a retrospective diagnosis of ADHD on the balance of probabilities. In these cases, we may have to try non-stimulant treatments first. Non-pharmacological interventions that assist with habit formation, emotional dysregulation management, time management, organisational skills, etc) are also an integral part of treatment. These are possible if patients are committed and patient to work with their psychiatrists to develop a trusting relationship and to assist in understanding the longitudinal history further to minimise any harm with making an incorrect diagnosis and recommending an inappropriate and potentially harmful treatments.

Comorbidities (co-occurring conditions) are a rule rather than an exception in ADHD (like any other psychiatric diagnosis). These include anxiety, depression, substance use, low self-esteem, psychological trauma, rejection sensitivity, mood fluctuations, personality vulnerabilities, sleep disturbances, allergies, etc.

The comorbidities have a significant bearing on treatment hierarchy (which conditions need to be addressed first) as well as on understanding their impact on the ADHD core features. While treatment of core ADHD symptoms can help with some secondary complications, stimulant medications may worsen other comorbidities. There are other specific evidence-based biopsychosocial interventions for each comorbidity that are often required to implement concurrently or sequentially based on the patient’s presentation.

While stimulants are often the first line of treatment for most patients with ADHD, every patient is different as are their specific biological, and psychological needs and vulnerabilities, strengths, and risks. There are circumstances (like concurrent substance use) that may elevate the risks with stimulant medication as first-line treatment. Therefore, treatment approaches vary from patient to patient and may involve stimulant medications, non-stimulant medications, non-pharmacological interventions, or a combination of these -in varying orders- throughout the treatment and recovery journey of each individual.

A very important distinction between management of ADHD and other psychiatric diagnoses is that in other diagnoses (like depression, anxiety, etc.) the aim of the treatment is the resolution of all symptoms, otherwise there will be a high risk of relapse. However, it is different in the case of ADHD. In pharmacological management of ADHD, the goal is arriving at a “good enough” control of symptoms. The reason is that some symptoms of ADHD (i.e. executive dysfunction) do not respond fully to medications. There will be a point beyond which any increase in the dose of a stimulant, will increase the likelihood of side-effects and development of tolerance. Non-pharmacological therapies that address core and associated symptoms of ADHD will help the patient overcome the residual symptoms and develop new habits.

No. Diagnosing and managing ADHD and its comorbidities usually take more than one session to systematically work through history, collect corroborative history from other informants, discuss different treatment strategies, applying for permits (if required), implementing the agreed treatments, monitoring response and side-effects to the treatment of core features, complications and comorbidities. Once reasonably stable, patients can follow up with their GPs and come back for less frequent reviews. The frequency of reviews varies between patients based on different factors but mainly the complexity of management.

No. However, it is often recommended to have private health insurance if you were to be admitted to the hospital or if you were to attend the day program. Take a look at The Melbourne Clinic Adult ADHD Day Program.

Yes and no. For the first appointment, I encourage patients to attend face-to-face. I currently see patients at Suite 31, 140 Church Street, Richmond, Victoria 3121. For subsequent sessions, if agreed by all parties, telehealth appointments over Zoom can be arranged.

While it is possible, please bear in mind that every Australian State and Territories has its own regulations with regard to the prescription and dispensation of controlled drugs (like Stimulant drugs used for the treatment of ADHD). Therefore, I always encourage patients to seek help from a psychiatrist in the same State or Territory as where they usually reside. In circumstances where this is hard to arrange, please speak to our reception and we will try to help you as much as possible.

While psychologists provide invaluable assistance in ADHD assessments, ultimately it is the responsibility of the psychiatrist to confirm the diagnosis. Having already been assessed by a psychologist greatly assist in checking for the presence of core features of ADHD but in a psychiatric assessment we will also look at other medical (including organic), psychiatric, social, and cultural factors at play as well as all the other collateral corroborative history. We will also do a risk-benefit analysis in relation to the various treatment modalities/ options and treatment hierarchy to choose the most effective, evidence-based, and safest treatment tailored to each individual’s circumstances.

We encourage all patients to bring with them to the first appointment any school reports, previous psychologist’s or psychiatrist’s reports, or any discharge summaries from previous inpatient admissions and - as much as possible - to come to the first appointment with a reliable support person. In the case of ADHD assessments, coming along with a parent or an older sibling or a childhood friend or a current/ past partner or friend greatly help with the assessment process.

For those patients who have not a formal structured assessment by a trained psychologist before seeing me, in the first session, we go over a general psychiatric history (to rule out or rule in comorbidities, camouflages, and complications as well as associated features of ADHD, physical and more personal history). In a second (and in extreme cases, a third session) we will cover the ADHD core features in a structured interview.

If we suspect there is another comorbid neurodevelopmental disorder like ASD, we will need a separate long structured assessment for ASD assessment to diagnose and come up -collaboratively with patients or other childhood informants (parents, older siblings, other childhood informants)- with a management plan based on the vulnerabilities and strengths of the patient.

As a rule of thumb, about 20 to 25 percent of adult patients with a bipolar disorder have ADHD. This means roughly 1 in 5 bipolar patients. While ADHD completes the diagnosis and management of the bipolar disorder, both conditions need to be treated. The important caveat is if we prescribe stimulants or, for that matter, non-stimulant ADHD medications like atomoxetine there is a chance of worsening of the bipolar illness or its trajectory. It is more of a problem when a patient is still effectively unstable or is still on an inpatient unit. Once the mood reaches a level of stability for a period of time, this will be time to sit with the family and other support persons to come up with a management plan that is safe and effective for ADHD in the presence of bipolar disorder.

These are the symptoms that are often present in ADHD - as well as other psychiatric diagnoses - that do not appear as the main criteria on DSM-5 or ICD-11. These need to be assessed in every “ADHD assessment” as well. As these “associated symptoms “are present in other psychiatric disorders, we will have to evaluate for them and after considering the whole picture and ruling in/ out the comorbidities (life soft bipolar, prominent personality vulnerabilities, specific relational difficulties) utilise them in understanding the patient’s struggle with ADHD.

As a matter of fact, these “associated features) are a major source/ burden of distress and interpersonal difficulties for adults who suffer from ADHD and its complications.

These “associated features” include, but are not limited to; low frustration tolerance, bursts of anger, irritability, mood lability (mood swings), rejection sensitivity, and cognitive problems in tests of executive function or memory.

Again, please bear in mind that there might be other causes of these “associated symptoms” and that is why a thorough psychiatric assessment with the help of other informants - as much as possible- is required.

In these circumstances and other medical conditions, we will work closely with your specialists to ensure prescription of ADHD medications is safe. There is no clear right or wrong and it depends on the severity of AF, current rate and rhythm, previous cardioversion treatments, or being on the waitlist for electrical cardioversion, other heart medications, etc. The short answer is prescribing stimulants to someone with active AF without consultation with the treating cardiologist is inappropriate.

The short answer is, for as long as you need them. Neurodevelopmental disorders like ADHD and ASD should be seen as lifelong disorders with a “waxing and waning” course. However, there is a slight difference between ADHD and ASD. The prevalence of ADHD in childhood is around 5 % and in adulthood, it’s about 2.5 %. What it means is that, in around 50 percent of children when they reach adulthood their symptoms fall below the diagnostic threshold and in those who continue to struggle in adulthood, it’s mainly the inattentive symptoms that cause the most problems. However, in the high functioning ASD patients as the child grows up - if undiagnosed- with the increase in social demands they may show more symptoms, and struggle more in relationships with others. They may have to “work out” other’s emotions or jokes or sarcasm rather than understanding them intuitively and this may cause difficulties when they eventually get into a job that involves a lot of employees with a lot of noise. Some children through the help of school and especially their parents, or self-determination through necessities of life (parent of a migrant who always had to interpret for his parents) “develop new skills” to deal with their underlying vulnerabilities in social reciprocity or communication (verbal or non—verbal through eye contact or appropriate use of body language, etc), their symptoms may not be as apparent as they grow older but without assistance, the opposite trajectory is what is often seen in clinical practice.

Often in ADHD patients, at crossroads in life like going from kinder to school, school to high school, high school to uni, uni to the workplace, promotions at work, and entering relationships, the symptoms of ADHD and their associated dysfunction may flare up due to increased cognitive, emotional and social demands with progressively reduced external structures (like family support and “scaffolding” during primary school)

Regular reviews with your medical practitioners and psychiatrist can help you find a reasonably appropriate time for you to trial without medications.

Some patients are able to skip the weekends if their ADHD symptoms do not affect their relationship at home.

Also, we need to bear in mind that flares up of other associated symptoms or comorbidities affect the progress and intensity of the symptoms.

As mentioned about the trajectory of ADHD is overall towards improvement as stated by the prevalence mentioned above., to the degree that not so long-ago people thought children with ADHD “grow out” of ADHD when they reach adulthood. Now the evidence is clear. 50 percent continue to struggle into adulthood.

There are hypotheses that need to be teased out in collateral from parents or other childhood informants as to why symptoms were not ostentatiously evident in childhood. The factors that modify the expression could be cultural, family scaffolding, the school supports and structure, and performance (social anxiety)- which leads to the child “hide” their symptoms or push through with extra-effort for fear of failing at school, or trouble with authorities, etc- and other personality structure like obsessive (perfectionistic) traits among others. More evidently increased cognitive responsibilities and demands with no appropriate support, leads to feelings of being overwhelmed and causing subsequent depression, anxiety, or alcohol and drug use that need treatment in their own rights.

Unfortunately, not. While treatment of ADHD (with medications and psychotherapy) might help with reducing the symptoms of depression, in most patients, depression needs to be treated with medication and appropriate psychotherapy as well as ADHD.

In those patients with comorbid mental health (not all) who we decide that treatment with stimulants is warranted, an application to department of health needs to be made. This is called Schedule 8 Permit. As a requirement of this permit, the prescriber

(i.e., the psychiatrist) MUST ensure that Supervised Random Drug Screen (often done in a pathology) is conducted from time to time. The aim of this Random Urine Drug Screen (UDS) is that with the introduction of the stimulant treatments, patients need to show that they have been able to abstain from any other recreational use to minimise harm associated with concomitant use of stimulant medications and recreational drugs. Please not all patients with active drug use will be suitable for stimulant medication prescription. We will only know this after consultation with the patient and after receiving follow-collateral from other family and collateral informants. If the clinical decision is that the risk of stimulant drugs prescriptions outweighs the benefits (it is the same for some medical conditions or old age), there are other non-stimulant medications that can be tried first until such time that the recreational drug use or the concomitant drug use (or collateral from other medical specialists like cardiologists in case of heart problems points towards stability) reaches a stable level of abstinence. The whole process requires ongoing trusting relationship with the psychiatrist to ensure that safe and personalised treatment is suggested and implemented.

Absolutely. Once we arrive at the dose that is effective to give us a “good enough” control of symptoms, the psychiatrist will authorise the GP to apply for a permit and prescribe the stimulant. The patients in Victoria need to be seen at the very least every 24 months to make sure the treatment with stimulants is still warranted, necessary and safe. A lot can happen in 24 months. Therefore, it is advisable for patients to see their psychiatrist at least every 12 months.

In cases where there is limited or unavailable evidence from childhood, or when the symptoms during childhood were at a sub-threshold level and not readily noticeable to parents, teachers or other informants, especially when the symptoms did not include overt hyperactivity or impulsivity, psychometric assessments can indeed shed more light on the diagnosis of ADHD in adults. These assessments may include tests that evaluate attention, working memory, impulse control, and executive functions. These assessments can provide valuable insights into the presence and severity of ADHD symptoms, as well as their impact on various domains such as work, relationships, and overall functioning

It is important to note that clinical assessment and psychiatric interviews with patients and childhood informants, serve as the principal mode of diagnosis in ADHD. Psychometric assessments may be recommended on a case-by-case basis during the diagnostic process, if they are believed to add more clinical insight into the differential diagnoses and ruling out other conditions that may mimic ADHD.