Introduction
If you have landed on this page, there is a good chance you are somewhere in the middle of a long question.
Perhaps your child’s school has raised the same concern for the third term running. Perhaps your teenager is bright, articulate, and quietly falling apart. Perhaps you are forty-two, successful on paper, and privately worn down by how much effort it takes to do things that appear to cost other people nothing at all.
ADHD is one of the most common reasons people come to see me, and it is also one of the most misunderstood. In my rooms in Claremont I meet parents who have been told to be stricter, teenagers who have been told to try harder, and adults who have spent decades believing they were simply not as capable as everyone else. Almost none of that is true, and almost all of it is fixable with the right understanding and the right support.
So I have gathered here everything I would want a parent, a teenager or an adult to know before booking a first session: what ADHD actually is, how it looks at different ages, what the South African picture really is, and what counselling can and cannot do to help. Take whatever is useful and leave the rest.
What ADHD Actually Is, and What It Is Not
Attention deficit hyperactivity disorder is a neurodevelopmental condition, and that word matters more than it might seem. It means ADHD is a difference in how the brain develops and regulates itself, present from early childhood, and not something a person picks up through bad habits, poor discipline or too much screen time.
The name is also slightly misleading. ADHD is rarely a deficit of attention. It is a difficulty with regulating attention. People with ADHD can focus with extraordinary intensity on something that interests them, and find it almost physically impossible to focus on something that does not. The problem is not the amount of attention available. It is the switch that decides where the attention goes.
Underneath the familiar symptoms sits a set of skills psychologists call executive function: planning, sequencing, starting tasks, holding information in mind, managing time, and regulating emotion. When those skills develop unevenly, everything downstream becomes harder.
The Three Presentations
ADHD is diagnosed in three forms, and they look very different from the outside.
- Predominantly inattentive. Drifting, forgetting, losing things, appearing dreamy or disorganised. This presentation is quiet, which is exactly why it is missed so often, particularly in girls.
- Predominantly hyperactive and impulsive. Restlessness, interrupting, acting before thinking, an engine that will not idle. This is the version most people picture, and it is the one that gets noticed.
- Combined. Features of both, and the most commonly diagnosed presentation overall.
It is worth saying plainly: ADHD is not a character flaw, a parenting failure, or a modern invention. It was described in the medical literature well over two centuries ago.
How Common Is ADHD in South Africa?
I know statistics are not usually why people come looking. But these ones are worth a minute of your time, because the story they tell is mostly about who gets found and who quietly does not.
- Internationally, meta-analysis places ADHD in roughly 5.9% of school-aged children, making it the most common neurodevelopmental condition of childhood.
- A pooled analysis of African studies found a prevalence of about 7.5% in children and adolescents, with boys identified at roughly twice the rate of girls.
- Closer to home, research by Professor Renata Schoeman and colleagues reported a prevalence of around 2.5% in a community sample of children in the Western Cape.
- Symptoms persist into adulthood in as many as 60% of cases, and around 2.8% of adults meet full diagnostic criteria.
- The first South African study of adult ADHD estimated community prevalence at just over 1%, yet found rates of up to 52.5% among adults already in clinical psychiatric settings.
That last figure is the one I would ask you to sit with. The gap between how many adults are identified in the community and how many turn up in psychiatric care is not a story about ADHD being rare. It is a story about ADHD being found late, usually only after anxiety, depression or burnout have brought someone through a door they did not want to walk through.
Access compounds the problem. South Africa’s treatment gap for mental health conditions in the private healthcare sector has been estimated at around 75%, meaning most medical scheme members have no meaningful mental health benefit to draw on. Diagnosis is expensive, waiting lists are long, and many families simply give up somewhere in the middle of the process.
How ADHD Shows Up at Different Ages
ADHD in Children
In primary school, ADHD usually announces itself through friction: homework that takes three hours and produces one paragraph, mornings that end in shouting, instructions that evaporate somewhere between the kitchen and the bedroom.
Parents are often told the child is capable but lazy, or bright but not applying themselves. If you have heard either of those, I am sorry. Both descriptions miss the point entirely. A child with ADHD is not choosing chaos. Their brain has not yet built the scaffolding that makes ordering, sequencing and self-starting feel automatic. Much of my work with families at this stage is practical strategies for helping a child manage homework, mornings, routines and self-esteem, alongside repairing the child’s sense of themselves as a good and capable person.
ADHD in Teenagers
Adolescence raises the demands sharply. Suddenly a teenager needs to manage seven subjects, multiple teachers, long-term projects, a social life and a phone, all with the executive function skills that are precisely what ADHD makes difficult.
This is also the age at which self-esteem takes the heaviest damage. By fifteen, most teenagers with undiagnosed ADHD have absorbed thousands of small corrections and concluded something unkind about themselves. They are not usually worried about attention. They are worried that they are stupid, or lazy, or broken.
ADHD in Adults
Adult ADHD looks less like hyperactivity and more like a life that costs too much to run. Chronic lateness, unfinished projects, impulsive decisions, a house that is either immaculate or unmanageable, and a persistent, low hum of underachievement relative to what you know you are capable of.
Many adults only arrive at the question in their thirties or forties, after years of quietly holding it all together. The effort of appearing fine is itself exhausting, and it has a cost that builds slowly and then arrives all at once. Often it is a child’s assessment that opens the door, or a job that finally demands more organisation than compensatory strategies can supply. If you are exploring this for yourself, international adult ADHD organisations offer excellent self-education material while you decide on next steps.
ADHD in Women and Girls
Girls are identified at roughly half the rate of boys, and it is not because they have ADHD half as often. It is because the inattentive presentation is quiet, and because girls are socialised early and hard to compensate: to be organised, agreeable, and to manage their own difficulty without making it anyone else’s problem.
The effort of appearing fine is itself exhausting, and it has a cost that builds slowly and then arrives all at once. Many of the women I work with were never disruptive. They were anxious, perfectionistic and privately overwhelmed, and they were diagnosed with anxiety or depression a decade before anyone asked about attention.
The Parts Nobody Warns You About
Emotional Regulation
The diagnostic criteria focus on attention and impulsivity, but ask anyone living with ADHD what is hardest and they will usually describe feelings. Emotions arrive fast, at full volume, with very little buffer between the stimulus and the response.
Criticism, correction or perceived rejection can land with a force that seems out of proportion to the moment. This is not fragility or drama. It is a regulation difficulty, and it responds well to being named, understood and worked with.
Task Initiation
One of the cruellest features of ADHD is the gap between intention and action. You know exactly what needs doing, you want to do it, and you cannot make yourself begin. From the outside this looks identical to not caring. From the inside it feels like standing at the edge of a cold pool for two hours.
ADHD Rarely Travels Alone
A clinical audit of children and adolescents diagnosed with ADHD in the Eastern Cape found that 83% presented with at least one co-existing condition. That figure matches what I see in my rooms. I mention it now, because it shouldn’t be a nasty surprise you find out at the end.
The conditions that most often accompany ADHD include:
- Anxiety disorders, frequently developed as a response to years of unpredictability and correction.
- Depression, particularly in adolescents and adults with a long history of undiagnosed ADHD.
- Specific learning difficulties such as dyslexia and dyscalculia.
- Sleep difficulties, which then worsen every other symptom.
- Oppositional and defiant behaviour, usually a downstream consequence rather than a separate problem.
- Autism, which co-occurs with ADHD far more often than was once believed.
This matters practically. Treating the anxiety while ignoring the ADHD tends to produce slow, frustrating progress, because the anxiety is being continuously refuelled by an unmanaged underlying difficulty. If you are in immediate distress while working through any of this, the South African Depression and Anxiety Group offers free telephonic counselling and referral support nationally.
Is It ADHD, or Something Else?
Several conditions share ADHD’s surface features, and telling them apart is genuinely difficult. Anxiety fragments concentration. Depression flattens motivation. Trauma produces hypervigilance that looks a great deal like distractibility. Sleep deprivation mimics almost everything. Giftedness can produce boredom, restlessness and daydreaming in a classroom pitched well below a child’s capacity.
The distinguishing questions are usually about pattern and history rather than symptoms alone. Has this been present since early childhood, or did it begin after a specific event? Does it appear across settings, or only at school? Does it fluctuate with mood, or is it steady?
A word about my own role, because I would far rather be upfront than have you discover it halfway through. As a registered specialist wellness counsellor I do not diagnose ADHD and I do not prescribe medication. Formal diagnosis sits with a psychiatrist, paediatrician, neurologist or clinical psychologist. What I can do is help you think clearly about what you are seeing, prepare properly for an assessment, and refer you to a practitioner who can carry out that assessment when it is the right next step.
What ADHD Counselling Actually Involves
What the Evidence Says
Cognitive behavioural approaches have the strongest evidence base for ADHD in adults. Meta-analyses report meaningful reductions in core ADHD symptoms, with additional benefits for depressed mood, anxiety and executive functioning. The most robust and consistent finding across studies is improvement in occupational functioning, which is to say the practical business of holding down and succeeding at work.
Where therapy is combined with medication, the evidence points to added benefit for quality of life and anxiety specifically. The UK’s National Institute for Health and Care Excellence recommends combining non-pharmacological support with medication for adult ADHD rather than relying on medication alone.
That is a lot of research language for something that is, in the end, deeply personal, so here is the simple version. Medication generally does the best job on core symptoms. Therapy generally does the best job on the life built around those symptoms: the systems, the relationships, the self-concept, and the accumulated belief that you are the problem.
What a First Session Looks Like
A first session is a conversation, not a test. I will want to understand your history, what is currently hardest, what you have already tried, and what you are hoping will be different in six months. There is no homework, no questionnaire to fail, and no requirement to arrive with a diagnosis already in hand. Coming in with nothing more than a hunch is completely fine, and it happens more often than not.
From there the work usually moves along three lines: building external structures that do the job internal executive function struggles with, developing emotional regulation strategies that fit how your brain actually works rather than how it is supposed to, and undoing the story that years of being misunderstood has written about you.
ADHD in Families and Relationships
ADHD does not stay politely inside one person. It shapes how couples argue, plan, divide labour and repair. A partner who is chronically forgetful and a partner who has become the household’s memory will eventually find themselves in a resentment loop that neither of them chose.
ADHD is also strongly heritable, which produces one of the most common moments in my practice: it is very common for a parent to recognise themselves while sitting in a session about their child. That recognition can be painful, and it often comes with a fair amount of grief for the child you once were. It is also, almost always, the beginning of something much better for both of you.
Family and couples work in these situations is less about fixing a person and more about redesigning a system so that it stops running on willpower alone.
What I Offer as a Therapist
From my rooms in Claremont, and online across South Africa, I offer:
- Individual counselling for adults navigating ADHD, whether recently diagnosed, long diagnosed, or still working out whether the question applies to them.
- Counselling for teenagers and tweens, with a particular focus on self-esteem, school pressure and emotional regulation.
- Parent guidance and support, including practical strategies for homework, routines, mornings and sibling dynamics.
- Couples counselling where ADHD is affecting communication, division of labour or intimacy.
- Support for twice-exceptional children and teenagers who are both gifted and neurodiverse.
- Preparation for and support through the formal assessment process, including referral to assessing practitioners.
- Ongoing support alongside medication, working in coordination with your prescribing doctor.
Conclusion
If there is one thing I would want you to take from this guide, it is that ADHD is not a verdict. It is an explanation. And an explanation, arriving at any age, changes what becomes possible.
I have watched adults in their fifties reorganise a working life around how their brain actually functions and describe the following year as the easiest they have had. I have watched teenagers stop apologising for existing. None of that required becoming a different person. It required understanding the person who was already there.
You do not need a diagnosis to begin. You do not need to have it worked out. You only need to be willing to start the conversation.
I see clients in person in Claremont, and online across Cape Town and the rest of South Africa. Online sessions are just as effective as sitting in the room together, and for many people with ADHD they remove exactly the logistical friction that would otherwise make consistent attendance difficult.
About Me
I am Paula Marais, a registered specialist wellness counsellor based in Claremont, Cape Town. I hold an Honours in Psychology (Unisa) and a Master’s in Creative Writing (UCT), and I am registered with the Association for Supportive Counsellors and Holistic Practitioners (ASCHP).
I offer individual and couples counselling, both in person and online. Online sessions are equally as effective as in-person sessions.
You can reach me at info@paulamaraistherapy.com or on WhatsApp at 072 633 7661.
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