Category: ADHD

High Functioning ADHD: What to Know

If you are someone with high functioning ADHD, you may not even know that you ‘have’ ADHD. Like other mental health diagnoses, ADHD exists on a dimensional continuum. At the highest level of this spectrum is high functioning ADHD.

What is it like to have high functioning ADHD? How do you treat it? In this article, we’ll review symptoms of high-functioning ADHD and treatment. If you want a precise diagnosis, consider psychological testing for ADHD in adults.

Symptoms of High-Functioning ADHD

First, let’s review a set of symptoms commonly experienced with adult ADHD, including adults with high functioning ADHD.

Disinhibtion

Attention deficit disorder in adults often does not involve hyperactivity, as it does with children. A more common experience is disinhibition, which is typically experienced as an internal sense of restlessness or excessive talkativeness (Barkley, 2022).

Impulsivity

Adults with ADHD also often experience impulsivity and difficulty with self-regulation. This could be cognitive, motivational, or emotional.

Cognitive impulsivity can involve shortcuts in the decision-making and reflective process.

Motivational impulsivity is typified by choosing short-term tasks over long-term ones. Dodson (2021) calls this “an interest-based nervous system”. If the task at hand is something you like, are curious about, or one that has an attractive reward, you will have no problem doing it.

Where the challenge exists is in maintaining that same level of enthusiasm and engagement when the task does not feel attractive or interesting. Emotional impulsivity involves being more emotional and faster to those emotions than someone without ADHD. It can be thought of as emotional hyperarousal.

Emotional dysregulation

As just covered, emotions are harder to manage for adults with ADHD. It’s not just impulsivity, but reactivity that is an issue emotionally. Emotions go from low to high very quickly, but also often recede just as quickly.

Beyond the fact that they are more rapidly elicited and intense in expression, these emotions aren’t that different from neurotypical people. But there can often be feelings of shame and poor self-esteem that have developed over time as a result of a history of family members and friends not understanding the characteristics of ADHD and reacting poorly and with judgement.

Executive dysfunction

Difficulty with executive functioning (EF) is one of the hallmark characteristics of adult ADHD. Executive functioning describes a person’s capacity to organize, structure, and prioritize tasks. It involves working memory and a meta-cognitive capacity to observe oneself across experiences.

By having this multi-faceted perspective, people with EF know when to engage tasks, e.g. what takes priority, how and why to delay gratification in order to accomplish the larger goal(s). People with ADHD have trouble with all of these areas.

High Achievers with ADHD

Now that you have a better understanding of the symptoms of adult ADHD, let’s go back to the definition of ‘high functioning ADHD’. What is it? The best way to think of this is that you are successful in spite of your ADHD. The question is why.

Here are some explanations:

You have mild symptoms.

Just because you qualify for a diagnosis, doesn’t mean that the symptoms have to be severe. You may not even have all of them. Naturally, the less impaired you are in these areas, the more opportunity you have for success.

You’re really smart in ways which compensate for or ‘mask’ your symptoms.

There are many types of intelligence. Some people have high emotional or interpersonal intelligence. They understand emotional cues and know how to ‘read the room.’ While this latter area can be impaired by ADHD, it doesn’t have to be. For example, you could have difficulties with impulsivity and containing yourself – and still understand the cues and what is called for in a moment interpersonally. Other people have ‘math smarts’, e.g. they have high levels of numerical, spatial, or reasoning intelligence. This type of intelligence can help them be successful in certain contexts. The same is true of other types of gifts, such as people with linguistic intelligence (‘word smart’, e.g. gifted in writing), musical intelligence, or kinesthetic intelligence (e.g. sports).

You have found a context or setting(s) which allows you to be your ‘best self’.

I’ve heard the argument – and agree with it – that ADHD is not a deficit, but rather an expression of a poor fit between a person’s neuro-diverse mind and the demands of the environment they are in. How can we change the environment to maximize success?

High achievers with ADHD find environments that they can be successful in. Let’s look at some of these examples, as seen through the prism of career (Orlov, 2022):

Jobs that allow for adaptation and ‘going with the flow’. These are roles that allow for making decisions on the fly, and being responsive to the moment. Some of the great performers (e.g. athletes, comedians, actors) are successful because of their ability to improvise. Creative types, such as artists, writers, and musicians, also fall in the category.

Jobs that let you think big and be the ‘idea person’. A lot of people with high-functioning ADHD are drawn to entrepreneurship and the start-up world. They don’t want the tedium of implementing details, but they love the process of brainstorming the next innovative idea.

Jobs where you can respond to emergencies. These are settings that have a ready supply of dopamine. They don’t call for consistency over time, but rather responsivity to emergent stimuli. Examples include ER docs, day traders, and decision-makers.

Jobs that have ‘focus flexibility’. Having ADHD doesn’t mean you can’t focus. It just means you can be somewhat dysregulated in that level of focus. When people with ADHD get ‘in the zone’ they can achieve very high levels of hyper-focus and be highly productive. This is a superpower of these high achieving types. Environments that are flexible in allowing this to occur help bring out a person’s strengths. One great example could be the life of a writer – long amounts of time to write, 80% of which could feel wasted, and 20% of which could be incredibly productive.

As you can see, in the right context or setting, what might typically be a ‘problem’ or ‘symptom’ becomes necessary and positive.

Strengths of ADHD

Before we transition to talking about treatment of high functioning ADHD symptoms in adults, let’s review some of the strengths of having ADHD. As we’ve just seen, sometimes the best treatment is adapting the environment to your strengths. Another useful outlook has to do with the mirror perspective of some of the common negatives of ADHD.

As Hallowell and Jenson (2010) observe in their book ‘Superparenting for ADD‘, someone who seems:

Distractible is also invariably curious
Impulsive can also be creative
Hyperactive is also energetic
Intrusive is also eager
Disorganized is also spontaneous
Moody is sensitive
Stubborn is also persistent

A positive perspective can be an important part of having a healthy relationship with yourself (if you have ADHD) and your loved ones (if they do). Treatment can often also be an important part of self-care for someone with high functioning ADHD.

High Functioning ADHD Treatment

There are several pillars of a multi-faceted treatment for high functioning ADHD. Let’s now review these:

Medication

As Russell Barkley points out in his book ‘Taking Charge of Adult ADHD’, people with ADHD have certain structural differences in their brains that result in the neurotransmitters dopamine and norepinephrine not being available to the same degree that they are for neurotypical people. As a result, people with ADHD don’t respond to stimulation as they should – they are understimulated.

The right drug at the right dose can make a huge difference in helping to sustain focus consistently, regulate impulses and creating emotional stability. ADHD medications are divided into stimulant drugs (e.g. amphetamine, methylphenidate) and non-stimulant drugs. Additionally, the delivery systems of the stimulant medications can vary (pro-drug, pump, pellet), influencing how long and slowly they are absorbed into the bloodstream. The non-stimulants include certain anti-depressants, which also seem to impact ADHD symptoms. After being diagnosed with ADHD, consult with your psychiatrist or primary care physician about which drug might be right for you.

Therapy

Therapy for ADHD can be helpful in several areas. First, strategies can be taught to implement adaptive behaviors and manage problematic ones. Second, therapists can help their clients identify and better regulate difficult emotions and impulses. Lastly, therapy can be an important reflective process to help clients have less denial about their symptoms, and increase motivation to make impactful changes.

Executive Functioning Coaching

This is a category that can potentially be included in an ADHD-focused therapy. It can also be a stand-alone, as there are coaches who work with ADHD. The critical piece is learning how to organize yourself effectively, as well as properly prioritizing decision-making and task completion. Because EF dysregulation is an area of ADHD that is not impacted by medication, this is an important area to address through therapy and coaching.

Meditation or Hypnosis

Meditation is an important practice that can lead to greater self-awareness and emotional calm. Mindfulness meditation can be especially helpful in proactively inoculating yourself against impulsive behavior and emotional reactivity. In her book ‘The Mindfulness Prescription for Adult ADHD‘ psychiatrist Lidia Zylowska reviews the science of mindfulness and provides a number of mindfulness exercises for adults with ADHD.

Hypnosis has received less attention in ADHD treatment, but the principles of a hypnotic state suggest it’s utility. Hypnosis involves a state of focused attention (zoning in) and dissociation (zoning out). Whether in formal hypnosis with a hypnotherapist or informal self-hypnosis practice, clients have the opportunity to learn techniques for eliciting, shifting, and deepening focus.

This can be useful for creating additional focus, or learning prompts to recognize and ‘get out of’ hyperfocused states. Additionally, specific hypnosis suggestions and techniques can also be helpful for ADHD. For example, age progression is a hypnotic technique that helps clients imagine specific experiences in the future. This can be helpful in creating alternate motivation for delayed gratification of immediate impulses or rewards.

ADHD classes/webinars/podcasts

There are fantastic educational resources on the internet available for adults with ADHD, and, as necessary, their spouses and families. ADDitude magazine has a robust archive of webinars and podcasts on different relevant subjects. On the subject of ADHD and marriage, Melissa Orlov offers a fantastic seminar series for couples (where at least one partner has ADHD). Parents who have ADHD can benefit from the courses offered by ADHD Dude.

Exercise

Exercise has been shown to have clinically significant effects in improving focus, energy, and mood issues associated with ADHD. Consistent exercise can have an important impact on managing ADHD symptoms. Exercise can have the same effect as medication on ADHD, although it only lasts for a few hours. Exercise works by increasing serotonin, dopamine, and norepinephrine production. Good vigorous exercise feels like ‘clearing your head’ and can serve as a release for restlessness.

Sleep

Sleep might just be THE most important ‘treatment’ for high functioning ADHD (and all ADHD). A good night sleep addresses virtually every pertinent symptom of ADHD. It’s not going to cure you, but it will help you be your best self. On the contrary, sleep deprivation will negatively impact focus, memory, executive functioning, and emotion regulation, amongst other areas.

Not surprisingly, people with ADHD have more difficulty falling asleep and sleeping restfully than others. The good news is that consistent exercise and good sleep hygiene behaviors can make a big difference.

The key is to develop a consistent sleep schedule. Pick a set bedtime and pre-bedtime routine and do your best to stick to it…. no matter what. Since many people with ADHD will get into hyperfocus mode in the evening, particularly with engrossing or pleasurable activities, make sure to set an alarm if you need to and hold yourself to that boundary no matter how much you might want to keep doing what you’re doing.

Stay off of screens for at least a half hour before bed, unless you’re reading a non-blue light e-reader. Do any reading, stretching, or relaxing in a low light environment. All these strategies can help improve the quality and quantity of your sleep.

Organizational Apps

There are a number of helpful smartphone apps which help people with ADHD manage and prioritize organizational aspects of their lives, such as unfinished task and to-do lists. One app that I like is Todist, for the range of categorical functions that it has. People who are more visual types like SimpleMind, for its ‘mind mapping’ visual layout. Explore what works best for you.

Additionally, when working to organize yourself, try to take advantage of your strengths. For example, in their book ‘ADD-Friendly Ways to Organize Your Life‘ authors Judith Kolberg and Kathleen Nadeau recommend turning tasks into fun, imaginative games, and involving others in these games as necessary. They also suggest ‘catching the wave’, that is trying to ‘ride’ your rhythms rather than over-control them. If you’re in a hyperfocused state, recognize this, and use that moment in time to get stuff done.

If you are someone who was diagnosed in adulthood with ADHD…

If you have utilized your intelligence to maximize your potential in spite of this condition…

If you have found ways to creatively cope with the symptoms of high functioning ADHD before even having a formal diagnosis…

The good news is that you are smart and resourceful. The better news is now you are more self-aware and even more informed than you were before. With these added tools in your tool kit, you can seek out the type of treatment for high functioning ADHD that is right for you, whether formally through therapy, coaching, medication, and classes, or informally through self-care like exercise, sleep, meditation, and apps.

Are you a high achiever with ADHD who also experiences anxiety?

In my experience as a psychologist, effective therapeutic questions don’t come from a prepared list. Both therapist and client should enter their first session of therapy with an open mind.

Good therapy process dictates that getting a feel for one another will emerge spontaneously, without a script. In fact, following a rigid list of questions too closely might interfere with this process.

Can you go into a first session with a plan? Sure! A therapist might enter the first therapy session with a list of important questions to address. Similarly, a client might be prepared with some ideas of what they want to discuss.

That’s great. But the most effective therapy questions are open-ended, come from careful listening, and flow from the natural unfolding interaction. This means that both parties might be surprised by session’s end about what they discuss and how they discuss it.

Additionally, questions about specific mental health symptoms are necessary, but can often be lacking in their ability to reveal meaningful information about a person you are meeting for the first time. Yes, it is important as a therapist to ask mental health questions that hone in on possible diagnoses while ruling out others.

For example, you want to ask questions which help you understand whether your client experiences symptoms of anxiety, depression, mania (or hypomania), or psychosis. You want to inquire about suicidal thinking and behavior. It is also important to get a sense of whether someone shows signs of an ‘Axis II’ (DSM-V) personality disorder.

However, in this article I try to help the reader understand the kinds of therapy questions that get clients reflecting on underlying thoughts, feelings, and experiences. In my experience, curiosity and reflection are the qualities that drive a strong therapeutic process.

Sometimes, clients enter therapy already possessing these abilities. When that is the case, they often volunteer such information without even being asked. But oftentimes, effective therapy questions help stimulate greater reflection that leads to insight and growth.

Therapeutic questions in a first therapy session should be open-ended. We are looking to learn, not coming in with with the assumptions that we already have the answers. Although there can be times in a first session that a closed question (yes/no) can be useful in narrowing down possibilities, this is the exception rather than the norm.

So, after telling you to avoid prepared lists, here are 5 questions that every therapist should ask you in the first session. But its not the questions themselves that are significant. It’s why we ask them that matters.

Let’s dive in…

5 Therapeutic Questions Every Therapist Should Ask

1. What brings you here today?

This sounds like such an obvious therapy question. And it is. But this question is as important for what it doesn’t say as what it does. Notice there is no use of the word “problem.” Why assume that it is a problem(s) that brings a client to therapy?

My point is that although this is often the case, we don’t want to make assumptions about why someone is here. We want to let our clients tell it it us in their own way without predisposing them to be problem-focused. I also think of the response to this question as the first in a Wordle game. What they include and what they leave out provides clues about where we might go next in our session.

2. How do you imagine therapy might be of help to you?

This is a therapy question that assesses clients’ perceptions of how the process of therapy will benefit them. I ask this type of therapy question because I want to understand how a client imagines therapy will help them.

Are they focused on learning skills, techniques, and solutions? Or are they more interested in the curative effects of an empathic, attuned therapeutic relationship? Do they perceive the process of therapy (how they and their therapist interact) to be most important? Or are they more focused on outcomes? The language a client uses to answer this question will tell me a lot about their personality and the kind of therapy experience and approach that would be the best fit.

3. What concerns do you have about starting therapy?

When new clients imagine the pros and cons of therapy, some unfortunately focus more on negative fears or concerns. For example, they may be afraid about feeling exposed, vulnerable, or judged by their therapist. I find that these concerns are often what is referred to as projections. This means that what they fear others will think and feel about them is what they actually think and feel about themselves. Answers that have this type of theme may be indicative of issues with shame, which are a difficult but important emotion to address in therapy.

4. Tell me about any previous experience with therapy. Why are you interested in working with me now?

Previous therapy experience can be very revealing. If a client has previously seen a therapist(s), I’m always curious to learn what the experience was like for them. What did they like and dislike? How did they fit with their therapist? Where was the relationship a poor fit? How did this past therapeutic relationship influence what they are looking for in a therapist now? I find in particular that how a client talks about their previous therapist can tell me a lot about how they relate (or wish to relate) with others.

Regardless of whether one has past therapy experience, their interest in working with me can also be quite illuminating. Clients do varying degrees of preparation before choosing a therapist to meet with. Perhaps they read my profile or a piece of content that I wrote. Maybe they watched an informational video that I was in. What was it that engaged them? Was it something about my specialties or approach to treatment? Was there something in my tone or non-verbals that they felt comfortable with?

These same questions apply after a client has made initial contact, but prior to the first session. There is always some degree of interaction before a first session, whether it is by phone or email. This process can have a meaningful degree of impact in a client’s decision to work with me. Understanding these important and sometimes subtle influences and reactions can tell me a lot about the person I am meeting with.

5. What are your strengths? Where do you get stuck?

The psychoanalyst and attachment researcher Jeremy Holmes describes mentalizing (e.g. holding mind in mind) as “seeing yourself from the outside and others from the inside” (Allen, Fonagy & Bateman, 2008). Let me be clear. I view such a competency as a therapeutic mastery more typically associated with experienced therapy clients rather than ones just getting started. But when I ask clients about their strengths and growth edges, I’m curious about their ability to step outside of themselves and look at themselves from the outside in.

What is their ability to do this? How do they describe their strengths? How do they describe their growth edges or challenges? What they share can tell me a lot about the degree of self-awareness that they possess. Or, in the same vein, their answers can inform me about where they have room to grow.

You’ve had a chance to sample five therapeutic questions often asked in a first therapy session. The most effective therapy questions tend to be open-ended ones. More importantly, I’ve shared with you my underlying rationales for asking these questions. Keep in mind that the easiest part is always the initial question. The greater challenge is listening carefully and asking good follow-up questions based on the always unique and subjective responses that you get.

Now that you’ve learned more about the role of the first session in therapy process, read more about related therapeutic issues.

Read More: Pros and Cons of Therapy
Read More: Do Therapists Have Therapists?

High Functioning ADHD in Adults: Symptoms & Treatments

High Functioning ADHD: What to Know

Symptoms of High-Functioning ADHD

Disinhibtion

Impulsivity

Emotional dysregulation

Executive dysfunction

High Achievers with ADHD

You have mild symptoms.

You’re really smart in ways which compensate for or ‘mask’ your symptoms.

You have found a context or setting(s) which allows you to be your ‘best self’.

Strengths of ADHD

High Functioning ADHD Treatment

Medication

Therapy

Executive Functioning Coaching

Meditation or Hypnosis

ADHD classes/webinars/podcasts

Exercise

Sleep

Organizational Apps

Published by:

Eric
Spiegel Ph.D.

5 Therapeutic Questions Every Therapist Should Ask You in the First Session

5 Therapeutic Questions Every Therapist Should Ask

1. What brings you here today?

2. How do you imagine therapy might be of help to you?

3. What concerns do you have about starting therapy?

4. Tell me about any previous experience with therapy. Why are you interested in working with me now?

5. What are your strengths? Where do you get stuck?

High Functioning ADHD: What to Know

Symptoms of High-Functioning ADHD

Disinhibtion

Impulsivity

Emotional dysregulation

Executive dysfunction

High Achievers with ADHD

You have mild symptoms.

You’re really smart in ways which compensate for or ‘mask’ your symptoms.

You have found a context or setting(s) which allows you to be your ‘best self’.

Strengths of ADHD

High Functioning ADHD Treatment

Medication

Therapy

Executive Functioning Coaching

Meditation or Hypnosis

ADHD classes/webinars/podcasts

Exercise

Sleep

Organizational Apps

Published by:

EricSpiegel Ph.D.

5 Therapeutic Questions Every Therapist Should Ask

1. What brings you here today?

2. How do you imagine therapy might be of help to you?

3. What concerns do you have about starting therapy?

4. Tell me about any previous experience with therapy. Why are you interested in working with me now?

5. What are your strengths? Where do you get stuck?

Eric
Spiegel Ph.D.