ADHD and Personality; What Personality Assessment Can Add to the Diagnosis and Treatment of ADHD
Throughout my experiences diagnosing and treating individuals with ADHD I have often been struck by the significant differences between individuals. Traditionally, ADHD is broken down into three diagnostic categories consisting of a inattentive type, a hyperactive/impulsive type, and a combined type. However, even this breakdown barely scratches the surface of the significant variability observed in individuals with ADHD. One interesting area of research that offers some unique contributions to better understanding this diversity is that of personality assessment. I would like to briefly outline some of the available personality measures that can be used to accomplish this as well as some of the research findings from studies of personality types in individuals with ADHD.
There is a wide array of avenues that can lead to a diagnosis of ADHD. Perhaps most frequently children that are displaying some type of disruptive behaviors and difficulties with self-regulation and sustained attention are identified by parents and/or teachers and referred for evaluation. These evaluations can range in their degree of comprehensiveness from simple clinical interviews to some checklist type surveys all the way up to formal neuropsychological evaluations. As part of a comprehensive neuropsychological evaluation, personality assessment measures are traditionally included. These typically serve two main functions in the process of diagnosis. The first is to rule out whether the symptoms of concern may better be accounted for by another disorder such as anxiety, depression, or bipolar disorder. The second is to determine whether those types of conditions may be co-occurring, that is the individual may, in addition to ADHD, be experiencing another psychiatric illness. As one might imagine it is important to accurately diagnose ADHD for obvious reasons and it is also equally critical to assess for any co-occurring conditions when making decisions about recommended medications and therapies.
There are also a number of personality assessment measures available that assess various aspects of personality style, temperament, and character traits. While there is some research examining how these various aspects of personality interrelate with ADHD, it is less common to see them used clinically as part of an ADHD evaluation. However, many of these instruments can offer valuable insights which can help guide treatment. One such instrument is the MIllon Index of Personality Styles (MIPS), which is used to provide an evaluation of “normal personality.” This instrument addresses three key dimensions consisting of motivating styles, thinking styles, and behaving styles. This instrument can help better understand individuals who may be experiencing difficulties in work, family, or social relationships and can also be helpful in career counseling and employment settings. Unlike other measures focused on identifying psychiatric symptoms, the MIPS can help identify various personality traits associated with ADHD, which can be precursors to success or potentially problematic pathways that are both lacking on other personality measures. For example, adults with ADHD are nearly 4 times as likely to be entrepreneurs as their counterparts without the disorder, which is linked with a number of unique underlying personality traits. Understanding an individual’s unique emotional style, modes of cognitive processing, and typical ways of relating with others can all be valuable sources of information when providing therapy to individuals with ADHD.
The Big Five Model, also known as the Five-Factor Model is another personality model that is among the most widely accepted personality theories held by psychologists today. This theory states that personality can be broken down into five core factors consisting of conscientiousness, agreeableness, neuroticism, openness to experience, and extroversion. Conscientiousness describes the person’s ability to regulate their own impulse control to engage in goal-directed behaviors. Individuals high in this trait tend to be organized, disciplined, detail oriented, thoughtful, and careful, whereas individuals low in conscientiousness may struggle with impulse control, task completion, and disorganization. Agreeableness refers broadly to how people tend to treat other people in relationships. Individuals high in this trait tend to be sensitive to the needs of others, helpful, and cooperative whereas people low in this trait tend to be perceived as uncooperative, manipulative, or antagonistic, which can make them less likely to be trusted and liked by others. Neuroticism refers to the overall emotional stability of an individual as well as how they might interpret events. Individuals high on this trait are prone to feeling anxious and insecure and can be perceived by others as being moody or irritable. They can also be prone to depression and low self-esteem. By contrast, those low in neuroticism are more likely to be calm, self-assured, and resilient. Openness to experience refers to a willingness to try new things and to engage in imaginative and intellectual activities. Individuals high on this trait are often perceived as creative and artistic. They typically enjoy variety and value independence. Individuals low on this trait tend to be practical people that find it difficult to think more creatively or abstractly. Finally, extroversion refers to one’s tendency to want to interact with their environment especially socially with those high in the trait generally being outgoing and thriving in social situations, whereas introverts tend to find social events to be more tiresome. These individuals also tend to be more reserved and thoughtful.
Regarding the research literature on how all these traits and measures interact with ADHD, the Five-Factor model has linked the inattentive type of ADHD to low conscientiousness and to a lesser extent neuroticism, whereas the hyperactive/impulsive type has been associated with low agreeableness. Low conscientiousness has been associated with attention problems including the ability to direct and regulate one’s attention. Low agreeableness has been related to aggression and delinquent behavior and relates to the frequent overlap with more oppositional and antisocial traits that can sometimes be seen in individuals with ADHD. Regarding the trait of neuroticism, it is not uncommon that the more inattentive sub-type more frequently experiences negative emotions, including anxiety, unpleasant mood, and anger. In a cluster analysis (Robin, L. et al, 2008) using the Millon Index of Personality Styles the participants were classified into two personality “clusters.” Cluster 1 participants tended to have a more negative outlook on life and feeling out of control, whereas Cluster 2 participants tended to believe that they could actively shape their world to produce positive outcomes. Cluster 1 participants also tended to look inward and rely upon their feelings to solve problems, whereas cluster 2 participants looked to external sources of reason to solve problems. Finally, the clusters also differed dramatically on interpersonal characteristics with cluster 1 being introverted, unassertive, and more prone to complaints, and cluster 2 being extroverted, assertive, and agreeable. The authors note that potential clinical indications of these findings include the fact that for individuals with Cluster 2 personality styles, medication, and some therapy targeting time management organizational skills etc. may be sufficient whereas for individual’s with Cluster 1 personality styles more extensive therapy or other psychotherapeutic interventions may be more appropriate.
Overall, both personality and ADHD are quite complex and the ways in which the two interact are not entirely understood. Good diagnostic and treatment work require both an understanding of the individual as well as an understanding of the disorder that an individual is diagnosed with. This is important because no two individuals experience the same disorder the same way. Personality assessment can offer a number of contributions in this process including better understanding an individual’s unique strengths and weaknesses. This can allow for more targeted therapeutic interventions that addresses issues such as risk factors for emotional difficulties, behavioral problems, or interpersonal difficulties. The links between ADHD and various personality traits can also be helpful in differential diagnosis between subtypes of ADHD. Finally, while it remains difficult to neatly cleave apart those parts of an individual associated with the disorder versus those parts of an individual attributable to personality traits, this type of assessment and conceptualization approach to ADHD can provide both patient and therapist with greater insight and understanding about how the patient thinks, feels, and behaves. This in turn opens more avenues for creative and adaptive solutions to coping with ADHD and its symptoms.