For a long time ADHD was thought of as simply hyperactivity, but in recent years there has been an increase in diagnoses and a greater understanding of the symptoms and required treatments for ADHD.

Although the ‘ADHD Iceberg’ is not a concept mentioned in the DSM-5 (the official guidelines for diagnosing certain conditions), it is quickly becoming known in the ADHD community, so we are breaking down what it means and why it’s so important.

At Augmentive, we aim to provide holistic, tailored mental health support to everyone so they can live their life to the fullest, so if you have questions about ADHD or its symptoms, we’re here to help.

What is ADHD?

ADHD stands for attention-deficit hyperactivity disorder, which is a type of neurodivergence. This means there is a difference in how the brain is hard-wired in comparison to neurotypical individuals.

In adults, symptoms can include trouble focusing, impulsiveness and inattention, so naturally some people with ADHD find it affects their everyday activities such as learning, studying, working, organising, remembering, managing time or getting things done.

Children with ADHD may struggle to play quietly, take instructions without becoming distracted, and can be hyperactive. It is important to also keep in mind that ADHD can present differently in girls than in boys, as girls often present less features of hyperactivity and more of inattentiveness.

What is the ‘ADHD Iceberg’?

You may be familiar with the idea of something being compared to an iceberg. It is well documented that in nature, an iceberg can look much smaller on the surface of the water than it actually is. The ice you see floating on the top of the water may in fact be many times larger underneath, hence the saying “only the tip of the iceberg”.

This essentially means that what we can visibly see or notice in some situations is actually much worse below the surface. In the case of the ‘ADHD Iceberg’, this refers to the fact that the problem can sometimes run much deeper than simply the physical symptoms we perceive in a person with attention-deficit hyperactivity disorder.

This analogy helps to better represent the real-life experience of living with ADHD, to demonstrate that just because you may notice symptoms such as hyperactivity, there can be a lot more going on with regards to the person’s mental health and internal struggles. Sometimes these symptoms can even feel debilitating for the person.

Understanding the ADHD Iceberg is important as it can help in all aspects of a person’s care; from the signs that finally lead to a diagnosis, to their healthcare professional understanding their symptoms, to the treatment they receive, to the people around them that can help and support them in day-to-day life.

"The iceberg theory shows how ADHD can be misleading because behaviour doesn’t always reflect internal experience. If you think a loved one may be struggling with this, rather than suggesting it is ADHD, it may be better to generally approach them and say something like, "things may be appearing ok on the surface but I get a sense that you are struggling underneath it, might it be time to talk to someone?" Encourage them to talk to someone rather than jumping to conclusions about what the cause could be or what the diagnosis could be."
- Dr Chetna Kang, Consultant Psychiatrist

What are the external symptoms of ADHD?

At the tip of the iceberg, or what is visible for others to see, are the external symptoms of ADHD. These may include mostly inattention and hyperactivity symptoms.

Signs of inattention could be:

• Regularly making what seem to be careless mistakes
• Often losing items such as keys or phones
• Forgetting important things, such as paying household bills or attending appointments

Signs of hyperactivity could be:

• Prolonged restlessness and difficulty sitting still for long periods of time
• Fidgeting or squirming a lot
• Being unable to engage in fun activities in a quiet manner
• Excessive talking, interrupting, or answering questions before they are finished
• Difficulty waiting, such as in a line or for their turn to speak

Typically the hyperactive symptoms of ADHD are easier to spot in someone, however keep in mind that these symptoms are less common in girls and women with ADHD, so it can be more difficult to diagnose them.

What are the hidden symptoms of ADHD?

Underneath the iceberg is where many of the real issues lie, and the more internal symptoms of ADHD include mostly inattention symptoms such as:

• Trouble paying close attention to details
• Trouble maintaining attention during long tasks
• Trouble organising tasks and activities
• Trouble managing time
• Being easily distracted by unrelated thoughts or external stimuli

Hyperactivity symptoms are more external and therefore more obvious to those around the person with ADHD, but it is the internal ones mentioned here that can pose the most problems when it comes to their mental health in daily life.

How to support those with ADHD in daily life

It is important to note that advice and support for those with ADHD should always be bespoke and individualised, because what works for one person may not work for another, however if you know someone with ADHD, it can be helpful for them if their family and friends learn about the different symptoms of ADHD and understand how these might affect them in daily life.

Although you may never completely understand how the brain of a person with ADHD works, you can aim to have more patience and curiosity when spending time with them.

Some general things you can do to best support someone with ADHD might include:

• Bringing up the idea of the ‘ADHD Iceberg’ with them and ask what they feel are the biggest challenges in their daily life
• Trying to understand their internal experiences, while keeping in mind that they may not be able to explain exactly how they feel
• If you are working with a child with ADHD, aim to treat the condition in its entirety rather than focusing treatment on only the characteristics of ADHD that may be inconvenient for parents or teachers
• Always be kind and patient when interacting with someone who has ADHD, and try not to become frustrated at symptoms that they may not be able to help
• Encourage them to seek proper treatment from a healthcare professional

How to treat ADHD

As above, we believe advice and support for those with ADHD should be bespoke and individualised, so that each person receives the care and support that will work best for their specific circumstances. Therefore, if you believe you may have ADHD it is best to speak to a healthcare professional who can listen to your unique experience and symptoms, and recommend the best ways for you to work through the hidden symptoms that cause you the most distress.

In general, studies have found that due to symptoms underneath the iceberg that may not be visible to others, it is important to address any issues as soon as possible by improving doctor-patient communication, and ensuring patient satisfaction throughout treatment.

Treatments for ADHD can include medication. There are 5 types licensed for ADHD treatment in the UK, which are methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine and guanfacine. While these medicines do not cure ADHD, they can help those with the condition to focus more, be less impulsive, feel less anxious, and pay attention more in order to learn. You can read more in our article: Your Guide to ADHD Medication in the UK.

Different therapies can be useful in treating ADHD in people of all ages, as well as treating comorbid conditions like anxiety disorders. These might include:

• Psychoeducation: A therapy where the patient is encouraged to discuss ADHD and its effects with the aim of making sense of their condition and coping better.
• Behavioural therapy: A therapy which includes the whole support unit such as carers and teachers of those with the condition, and where rewards are used to encourage children to control their symptoms.
• Cognitive behavioural therapy (CBT): A talking therapy that can help people with ADHD manage the issues they face by changing the way they think and behave.

Often, a combination of medication and therapy is recommended by healthcare professionals, but if you are unsure which type of therapy may be best for you, our free 15 minute consultation could help you figure out the most relevant therapist to help you manage your ADHD in daily life.

Whether you’re feeling off-kilter or want to shake up your routine, our state-of-the-art mental wellbeing platform gives you quick and seamless access to world-class support on your terms, from a private ADHD assessment or review, to broader mental health care: join us today.

DISCLAIMER: The content published by Augmentive is not designed to treat, diagnose, cure, or prevent any disease or condition. Always consult your GP or a qualified healthcare provider with any questions regarding a medical condition and before starting any therapy, diet, exercise, or any other health-related programme.