Medical Doctor - Marmara University, Faculty of Medicine, Department of Mental Health and Diseases
"ADHD is not just a "trendy diagnosis" — it is based on scientific evidence, and when correctly diagnosed, treatment can lead to positive changes in all areas of a person's life."
What is ADHD?
ADHD (Attention-Deficit/Hyperactivity Disorder) is a neuropsychiatric condition characterized by persistent inattention, increased impulsivity, and hyperactivity, affecting individuals of all ages. Research has shown that it has a biological basis. It impairs academic performance and social functioning in children, adolescents, and adults. ADHD is frequently comorbid with other disorders such as anxiety, depression, eating disorders, substance use disorders, sleep disorders, and obesity.
Prevalence of ADHD
ADHD affects approximately 4-8% of school-aged children. Among those diagnosed in childhood, 60-85% continue to meet diagnostic criteria during adolescence, and nearly 60% continue to do so in adulthood.
Diagnostic criteria
To establish a common language in psychiatry globally, diagnostic criteria have been standardized. The most commonly used diagnostic tools are the latest versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11). According to DSM-5, for a diagnosis of ADHD, several symptoms related to inattention or hyperactivity/impulsivity must have been present before the age of 12. These symptoms must be observed in at least two different settings (e.g., at home, school, or work; with friends or relatives; or in other activities).
DSM-5 specifies that for inattention, at least 6 of the 9 symptoms must be present in individuals under 17, and at least 5 in those over 17. These symptoms include: 1. Failing to give close attention to details or making careless mistakes, 2. Difficulty sustaining attention in tasks or play activities, 3. Appearing not to listen when spoken to directly, 4. Not following through on instructions or failing to finish tasks, 5. Difficulty organizing tasks and activities (e.g., messy, poor time management), 6. Avoiding tasks requiring sustained mental effort, 7. Losing things necessary for tasks and activities, 8. Easily distracted by extraneous stimuli, 9. Being forgetful in daily activities (e.g., returning calls, paying bills, keeping appointments).
For hyperactivity/impulsivity, 9 symptoms are also defined, with the same age-based threshold. These include: 1. Fidgeting or squirming, 2. Leaving seat in situations where remaining seated is expected, 3. Running about or feeling restless in inappropriate situations (in adults, this may present as restlessness), 4. Inability to play or engage in activities quietly, 5. Often being “on the go” or acting as if “driven by a motor”, 6. Talking excessively, 7. Answering questions before they have been completed, 8. Difficulty waiting one’s turn, 9. Interrupting or intruding on others.
ADHD is categorized into three presentations: 1. Combined Presentation, 2. Predominantly Inattentive Presentation, 3. Predominantly Hyperactive/Impulsive Presentation.
Clinical features
Although ADHD can be observed during infancy, diagnosis is often delayed due to the difficulty of identification. Signs may include being overly active in the crib, sleeping little, or crying excessively.
In childhood, behaviors such as blurting out answers without waiting their turn or starting assignments/tests hastily but not completing them may be observed in school settings. At home, children may struggle to complete even simple tasks assigned by parents and may require repeated reminders. Impulsivity and an inability to delay gratification increase the risk of accidents. Many children with ADHD also display behavioral issues such as aggression and oppositionality. Since children often receive support from families and teachers during childhood, many intelligent children with ADHD only start showing clear symptoms once removed from these protective environments. When they become independent, difficulties in planning and foresight begin to cause problems.
Some recent studies suggest the possibility of a "late-onset ADHD" group, where symptoms begin after age 12. Although the symptoms, comorbidities, and impairments are similar to those with childhood-onset ADHD, cognitive and genetic profiles may differ.
Attention problems
The idea that "people with ADHD are completely unable to focus" is not accurate. Attention can be sustained for short periods, especially when the task or situation is new or interesting (e.g., hobbies, video games, engaging conversations). However, attention difficulties are more commonly observed in boring, routine tasks that require sustained focus (e.g., reading instructions or emails, filling out forms or official documents, organizing household chores).
Individuals with inattentive-type ADHD (without hyperactivity or impulsivity) may be slow in thinking and generating new ideas, hesitant when answering questions, or may get lost in unnecessary details.
Hyperfocus
ADHD can also involve a phenomenon called hyperfocus, where individuals become intensely focused on activities they find highly engaging (e.g., browsing the internet). They may remain focused for hours without taking a break. For this reason, ADHD can involve both inattention and periods of excessive attention. The problem is not a complete inability to pay attention, but rather an inability to control attention when it's needed. As a result, individuals with ADHD are often unfairly labeled as lazy or unmotivated. In reality, simply wanting to pay attention is not enough — it also requires the cognitive capacity to initiate and sustain focus.
Hyperactivity
Hyperactivity presents differently in children and adults. In adults, it may not look like constant physical restlessness as it does in children. Examples of adult hyperactivity include fidgeting in a chair, frequently getting up, pacing, talking non-stop, difficulty tolerating office work, throwing or tapping objects, and non-restorative sleep. Many individuals cope with hyperactivity by engaging in intense physical exercise, which can sometimes result in injuries due to overexertion.
Impulsivity
While hyperactivity and impulsivity often co-occur, they do not always appear together. Impulsive behavior can be described as "acting without thinking." This may manifest as blurting out comments, excessive spending, jumping into new projects suddenly, quitting jobs abruptly, starting new relationships quickly, or being unable to delay gratification. These behaviors can lead to problems in close relationships, work, and financial matters.
Impulsive eating episodes may arise as a way of coping with distress or due to the inability to delay satisfaction. Similarly, novelty-seeking is closely associated with impulsivity and can result in behaviors such as accident proneness, speeding, risky driving, risky sexual behaviors, starting fights, or frequently changing jobs or partners.
Subtypes
- Combined Presentation: This is the most common clinical presentation and includes symptoms of inattention, hyperactivity, and impulsivity. Among these, hyperactivity tends to change the most over time — it is common in childhood but may diminish or become easier to manage with age. Even if individuals no longer appear hyperactive externally, they may still experience internal restlessness and discomfort.
- Predominantly Inattentive Presentation: These individuals may appear dreamy, introverted, slow, suspicious, or rigid. Sometimes they show perfectionistic tendencies. They may fear failure and panic when they lose control. This subtype is more common in girls and women and is less likely to be diagnosed in childhood. Particularly intelligent individuals may compensate for their attention issues for many years, masking the underlying ADHD. As life challenges increase — for example, during university or when living independently — symptoms may become more visible.
- Predominantly Hyperactive/Impulsive Presentation: This is the least common clinical subtype and has less scientific data supporting its validity. It is characterized by individuals who are busy and impulsive but without significant attention problems. Epidemiological studies suggest it is more frequently observed in adults.
ADHD Treatment
First and foremost, individuals who are diagnosed should be educated about the condition. It is important to understand that ADHD is not just a “trendy diagnosis” but is based on scientific evidence. Patients and their families should be informed about the potential consequences of untreated ADHD, such as underperformance in school and work, frequent job and partner changes, traffic accidents, substance abuse, low self-esteem, chronic fatigue, and sleep issues.
Medication
Stimulant medications are the first-line treatment. Among them, short- or long-acting methylphenidate preparations are the most commonly used agents. Non-stimulant FDA-approved options include atomoxetine and α-agonists (clonidine, guanfacine). Although not FDA-approved for ADHD, other medications used in treatment include certain antidepressants (particularly bupropion, venlafaxine, reboxetine) and modafinil.
Some patients may question whether stimulant medications carry a risk of addiction. However, it is well-established that patients, especially those using long-acting methylphenidate, do not find the medication habit-forming. When used at the prescribed dose and under medical supervision, these medications do not carry a risk of abuse.
If the individual diagnosed with ADHD also has comorbid conditions like anxiety disorders, depression, or substance use disorder, it is usually recommended to treat the most severe and disruptive condition first. Symptoms from these disorders can obscure the benefits of ADHD medications.
Psychotherapy
There is scientific evidence supporting the effectiveness of Cognitive Behavioral Therapy (CBT) for ADHD. According to the CBT model, while the core symptoms of ADHD are neurobiological, additional cognitive styles and behaviors can influence symptom severity. Medication helps treat the core symptoms, but it may not address certain underdeveloped skills (e.g., planning). Thus, CBT can be used alongside medication to improve practical skills, address avoidance behaviors, and shift negative self-perceptions.
Coaching
ADHD coaching is a psychosocial intervention that helps individuals develop strategies and behaviors to cope with symptoms and build skills. Most coaching programs are based on CBT principles and focus on areas like planning, time management, goal setting, and problem-solving.
While coaching and CBT share similarities, they differ in approach. Coaching assumes biological impairments in executive functioning and aims to correct these through skill-based interventions. CBT, on the other hand, acknowledges that growing up with ADHD often leads to dysfunctional beliefs about oneself, the world, and the future — and works to change those beliefs.
Coaching is more pragmatic, behavioral, and goal-oriented, whereas CBT is more introspective and cognitive. Scientific evidence for coaching has started to emerge in recent years. According to researchers, those providing coaching should be familiar with CBT principles and have experience in mental health care.
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