ADHD

Updated 23 September 2016

Could stress be mistaken for ADHD in SA?

ADHD medication is doled out at the drop of a hat in South Africa. With the symptoms of chronic stress and ADHD overlapping, could there be some misdiagnosis?

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A recent study published by Bloomberg has ranked South Africa as the second most stressed country in the world. Nigerians are the most stressed out and Norwegians the most laid-back.

These rankings are based on information from the United Nations Office on Drugs and Crime, International Monetary Fund, Central Intelligence Agency World Factbook, Transparency International and World Health Organisation.

Factors like GDP, corruption and unemployment were taken into account when determining the stress levels of individual countries.  

According to the South African Depression and Anxiety Group (SADAG) South Africans are under extreme amounts of stress and don’t know how to deal with it. We have faced a diversity of challenges, and the rapid changes that the country has undergone have been very stressful for all South Africans.

Factors like economic uncertainty, high levels of unemployment and high crime levels greatly contribute to our daily stress levels.  

Do I have ADHD, or am I stressed? Or both?

Not only are South Africans of the most stressed nations on Earth, Neuro linguistic practitioner and ADHD consultant at The Attention Deficit and Hyperactivity Support Group of South Africa (ADHASA) Heather Picton postulates that we also have one of the highest rates of prescribing medication for ADHD in the world – even higher than in the USA. 

In the United States, at least 9 percent of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In South Africa, it is estimated that eight to 10 percent of the population has the disorder while in France, the percentage of children diagnosed and medicated for ADHD is less than 0.5 percent. 

She says, in South Africa, we follow the US DSM5 (Diagnostic and Statistical Manual of Mental Disorders) and Connors Scale for assessing ADHD, as they do in the US, whereas countries like France take a more eco-systemic approach.

This involves examining the impact of the child/adult with ADHD on the environment; as well as the effect of the environment on them, and making adjustments to ensure a better fit.  

Psychology Today reports that French child psychiatrists view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioural problems with medication, French doctors prefer to look for the underlying issue that is causing the child distress – not in the child's brain but in the child's social context. 

This begs the question: are we being prescribed ADHD medication when we are in reality stressed-out and anxious?

Laken Folster, a counselling psychologist at Synergy Psychological Services in Johannesburg, and who has a special interest in ADHD, says both ADHD and stress induce symptoms that can disrupt a person’s life. She says there are many commonalities between the symptoms of stress and those of ADHD.

These include: 

  • Sleeping problems
  • Difficulty concentrating
  • Being easily distracted
  • Having racing thoughts
  • Forgetfulness
  • Disorganisation
  • Increased frustration
  • Low frustration tolerance
  • Reduced work efficiency and productivity
  • Decreased motivation
  • Restlessness
  • Impatience
  • Difficulty sitting still

According to Folster research has shown that there is, additionally, a close relationship between ADHD and stress. "It is possible that, as a result of ADHD symptoms, individuals who struggle with this disorder are more likely to experience stress than the average individual. Conversely, stress is likely to exacerbate the symptoms of ADHD.

Secondly, she says, in both conditions, on a neurochemical level, there is an imbalance in the level of the neurotransmitters, serotonin and dopamine in the brain. Serotonin is the neurotransmitter related to impulse control and aggression, whilst dopamine is the neurotransmitter responsible for reward and pleasure processing.

Lastly, on a neuroanatomical level, one of the main functional similarities between stress and ADHD is the below average level of the activity in the prefrontal cortex.

The prefrontal cortex is responsible for executive functioning (a set of mental skills that help you get things done, such as memory, reasoning and planning). Irregularities in executive functioning are demonstrated by both individuals struggling with ADHD and individuals struggling with stress.

Diagnosing ADHD: the process

To diagnose ADHD, doctors most often use guidelines established by the American Psychiatric Association. (Doctors diagnose ADHD in children after a child has shown six or more specific symptoms of inattention or hyperactivity on a regular basis for more than 6 months in at least two settings.)  

In South Africa, patients are often prescribed ADHD medication after a single visit to a psychiatrist or GP. 

East London pharmacist Ettien Grassi told Heraldlive.co.za that he had seen an increase in Ritalin prescriptions and suspected that in some cases children were put on the ADHD medication to counteract modern lifestyle issues such as poor discipline in homes. 

Fact of the matter is that, since ADHD and stress share many symptoms, you or your child may have some symptoms that seem to point to ADHD, but might in fact be something else. 

Dr Larry Silver wrote an article for US-based ADD and ADHD support organisation Additude where he stated: "Analysing symptoms of ADHD in children to make a correct diagnosis isn’t always easy."

"A child who seemingly has ADHD – with symptoms like hyperactivity, impulsiveness and inattention – may actually have an anxiety disorder. The opposite may also be true and children who display classic symptoms of anxiety disorder may have ADHD.

"Even professionals can misinterpret symptoms. If a child can’t sit still, doesn’t stay on task, calls out in class, or shouts out inappropriate comments, they think it must be ADHD. If a child has excessive fears or worries, it must be an anxiety disorder."

So is it ADHD or is it just stress?

Laken Folster says that, based on the above information, it is clear that there is a relationship between ADHD and stress and due to the overlap in symptomology, neurochemistry and neuroanatomy, diagnosis of either syndrome can be complicated.

From a pharmacological point of view, stimulant medication can be of assistance to an ADHD sufferer whereas in the case of an individual who is stressed, it may increase the level of anxiety. "I always advise that an individual is assessed by a skilled diagnostic practitioner, such as a psychologist, in order to ascertain an accurate possible diagnosis and treatment plan."

Test yourselfHow are my stress levels?

CyberShrink weighs in

Recently Health24 users asked our resident psychiatrist, Professor Michael Simpson (aka CyberShrink) if the ADHD medication she was prescribed after one visit to her physician was in fact the right treatment and diagnosis.

She describes herself as not being able to concentrate or complete tasks as well as anxiety and sleeplessness. She survived a hijacking 2 years ago, and has had to deal with financial and relationship problems. She says she is short tempered, forgetful, frustrated, and has little motivation.

CyberShrink advised: "I consider the diagnosis of ADHD in an adult still controversial, and not to be made lightly. Only internationally recognized criteria would be appropriate in making such a diagnosis. If someone came to the average really good psychiatrist with the symptoms you describe, adult ADHD is not the diagnosis most likely to be made, and ADHD medication would definitely not be the first choice of treatment. 

Especially as such medication would have a strong possibility of causing precise the symptoms you were complaining of. Anxiety can arise on its own, or can be caused by stresses in one's life, at home or at work. 

Whatever diagnosis the doc made, he had a duty to explain it to you, and explain why he made this diagnosis rather than more obvious ones, what it implied, and how the treatment would help. 

Though some of us recover well from a trauma such as the hijacking, some of us don't, so a variety of Post Traumatic Stress Disorder (PTSD) is a possibility that would need to be ruled out. It could also cause some of the symptoms you describe, and would need different treatment.

Frankly, I share your sensible doubts about the diagnosis and especially the treatment, and would be happier if you could arrange to get a fresh and independent second opinion from a different psychiatrist."

If you’d like to share your opinion or experience of ADHD with us, please give us your comments below.

Read more:

Causes of ADHD

Understanding ADHD

Treating ADHD

 

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ADHD Expert

Delia Strondl is a Registered Career Counsellor focusing on both school readiness and career counselling. She achieved her honours in Psychology and completed a career counselling internship. Since then, she has been working with children with a variety of learning difficulties including ADHD and Cerebral Palsy.

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