What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder of attention, impulsivity, and hyperactivity. ADHD is one of the most heritable psychiatric disorders and the most common behavioral disorder in children. ADHD is NOT a disorder of intelligence.
Adults may also suffer with ADHD symptoms. Approximately two-thirds of children diagnosed with ADHD experience symptoms in adulthood.
In school-aged children/adolescents, the prevalence of ADHD is about 5-7%.
There are different types of ADHD depending on whether the predominant symptom is inattentiveness, hyperactivity, or a combination of both. The combined type is the most common type in children and adolescents.
Males are more likely diagnosed in childhood and adolescence, likely because males display more hyperactive symptoms than females and therefore are more likely to be referred for evaluation. Females usually experience more inattentive symptoms and aren’t diagnosed until later in life.
As children age, there is a decrease in the hyperactive-impulsive symptoms due to the maturation of brain circuits in an area of the brain called the cerebral cortex.
In adults, the prevalence of ADHD is equal in males and females. The inattentive type is the most prevalent type in adults (about 47% of cases).

Core Symptoms

The core symptoms of ADHD are inattention, impulsivity, and hyperactivity. These symptoms interfere with relationships, work, schooling, or other important areas of functioning.

Inattention problems include any of the following

  • Difficulty with attention to detail
  • Often makes careless mistakes
  • Difficulty listening when spoken to directly (e.g., mind seems to wander elsewhere).
  • Difficulty following directions
  • Difficulty organizing tasks and activities
  • Often avoids tasks requiring sustained mental effort
  • Often loses things/personal items
  • Often is easily distracted
  • Often forgetful about daily activities
  • Often has difficulty sustaining attention
  • Often bored or loses interest quickly

Impulsivity includes any of the following

  • Often finishes sentences or blurts out answers
  • Often has difficulty waiting his or her turn
  • Often interrupts others
  • Often impatient

Hyperactivity includes any of the following

  • Often fidgets or shifts in seat (example: meditation can be very difficult for those with ADHD)
  • Often leaves seat in situations when remaining seated is required
  • In children, often runs about or climbs in situations where it is inappropriate
  • Often unable to play or engage in leisure activities quietly
  • Internal restlessness or feeling constantly on the go
  • May talk excessively

What is Attention?

Attention describes the process of determining the importance of various stimuli and selecting the one that’s most relevant to the task at hand. Attention is an important component of our consciousness.

Which Brain Areas are Involved in Attention?

Although neural networks throughout the entire brain contribute to most brain functions, there are some areas of the brain that may play a greater role in attentiveness. These areas include the prefrontal cortex (which is part of the frontal lobe) and the regions “underneath” or “embedded” in the frontal lobe such as the cingulate cortex and its connections with the parietal lobe.
 

Reward and Impulse Control

Controlling the impulse to take an immediate, smaller reward rather than waiting for the larger, delayed reward is essential for completing long term goals. People who cannot control their impulses often fall behind. In the famous Stanford Marshmallow Experiments of the 1970s, Dr. Walter Mischel, a psychologist, conducted a very interesting experiment:
Four-year-old children were given one marshmallow. These children were told that they could either eat the marshmallow now or wait and receive TWO marshmallows later (oh my!). Some children couldn’t wait and ate the marshmallow immediately. Some waited it out a bit longer but eventually ate the marshmallow. The rest waited until they were rewarded the TWO marshmallows (what a reward!). These children were then followed into adolescence and adulthood.
It turned out that the children who waited were, in general, more resilient, confident, and dependable as adolescents. They also scored higher on standardized tests such as the SAT. While a controversial study with some methodological problems, the results were interesting, nonetheless.

Dopamine and Norepinephrine Regulate Impulsivity

Dopamine and norepinephrine are two very important brain chemicals involved in attention, movement, and impulse control.
These two chemicals work together to “filter out” irrelevant stimuli while enhancing the relevant stimuli. In individuals with ADHD, these two chemicals appear to be imbalanced or “out of tune.” By enhancing these brain chemicals with medications and therapy we can improve symptoms dramatically.

Brain Changes in ADHD

Changes in the prefrontal cortex (PFC) and an area called the striatum are the most common abnormal brain findings reported for ADHD.
Judith Rapoport’s National Institute of Mental Health (NIMH) neuroimaging studies have revealed interesting findings in children with ADHD.
Children with ADHD, on average, have smaller brain volumes by about 5% and also have smaller cerebellums (the little brain in the back of the brain). Importantly, the trajectory of brain volumes did not change as the children aged, nor was it affected by the use of stimulant medication.
When comparing brain activity in children with and without ADHD, there was significantly greater activity in the parietal and frontal lobes of children without ADHD during an attention task. This tells us that decreased activity in the frontal and parietal lobes may partially explain inattentiveness. That is, these brain areas aren’t activated enough during attention-requiring tasks.
 

ADHD & Gender Differences

The symptoms of ADHD present slightly differently in males and females. A list of differences is provided in the table below.
 

Consequences of Untreated ADHD

A World Health Organization survey estimated that 3.5% of all workers suffer from ADHD yet only a minority of these workers received treatment.
Young adults diagnosed with ADHD, but not treated
  • are less likely to enroll in college or graduate from college
  • are more likely to be on academic probation,
  • are more likely to have a lower grade point average
Adults with untreated ADHD experience difficulties in all aspects related to employment, are at significantly higher risk for developing substance use disorders and are more likely to engage in risky behaviors resulting in traffic tickets, motor vehicle accidents, and other injuries.

Core ADHD Symptoms in Adults

Hyperactivity, impulsivity, and inattentiveness present a bit differently than in children.

Hyperactivity in Adults

  • Inner restlessness, talkativeness
  • Excessive fidgeting
  • High-risk activities

Impulsivity in Adults

  • General impatience
  • Talking without thinking
  • Problems maintaining employment
  • Difficulty maintaining relationships
  • Attention seeking behavior
  • High risk behaviors
  • Self-medicating with drugs and alcohol

Inattentiveness in adults

  • Chronic boredom
  • Indecisiveness
  • Procrastination
  • Disorganization
  • Distractibility
Common complaints in adults with ADHD include rapid mood swings, difficulties dealing with stressful situations, frequent irritability and frustration, emotional excitability (e.g., anger over minor things), relationship problems (e.g., short-lived, divorce), and low frustration tolerance.

ADHD vs Bipolar Disorder

Differentiating ADHD from Bipolar Disorder can be difficult because many symptoms overlap and both disorders often co-occur (that is, many patients have both ADHD and Bipolar Disorder). Below is a table that helps differentiate the two.

Treatment Options For ADHD

Psychostimulant medications such as amphetamines (Adderall, Dexedrine, Vyvanse) and methylphenidates (Ritalin, Concerta, Focalin) are first line treatments for attention deficit hyperactivity disorder. Nonstimulants such as Bupropion (Wellbutrin), Atomoxetine (Strattera), clonidine, and guanfacine are also used for ADHD.
These medications primarily target inattention, hyperactivity, impulsivity, mood reactivity, restlessness, scattered thinking, boredom, procrastination, and tendency toward substance abuse.
Studies suggest that amphetamines may be more effective for adult ADHD symptoms than methylphenidates. However, amphetamines are more likely to worsen or induce tics. Therefore, amphetamines are usually tried first unless there is a history of tics in which case methylphenidates are a better option.
Educating patients about ADHD and offering behavioral tips (such as time management strategies) are very important and should be provided and incorporated in therapy.
Neuro-modulatory modalities such as biofeedback/neurofeedback should be considered if medication and behavioral strategies are not effective (or only partially effective).

For more information about ADHD, visit the NAMI Website.

What ADHD Might Look Like

As a psychiatrist who advocates for the appropriate diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults, I am frustrated by the many misconceptions of ADHD. If you or someone you know have suffered from this disorder, perhaps the story below will be familiar. 
At some point in your life, you came to the realization that something just wasn’t adding up. Throughout early schooling you struggled to stay organized and motivated. But on the rare occasion that you found the energy and courage to sit down on a Saturday (rather than Sunday near midnight) and attempt your weekend homework you were probably discouraged as your internal dialogue became louder and louder…

“How many times do I have to read this sentence before I understand what it means?”

“How did I just read 20 pages of this book but can’t tell you one meaningful thing about it?”

“Why is this so difficult?”

This pattern gets old, so you begin telling yourself that you’re just not smart enough, not good enough, not savvy enough to juggle life like everyone else. And of course, the most encouraging and reassuring remarks you received were statements like

“You just need to work harder”

“Stop being lazy”

“Do you even care about your future?” 

Now that your self-esteem was sinking like the Titanic, your contagious positive spirit began drowning too. If not already feeling like a failure, you sensed actual failure was imminent.
As time went on, you probably took one of the following routes: Either you said “f**k it” and started drinking, partying, and rebelling out of anger and frustration OR you continued to suffer in silence pretending you were okay only to feel more drained and guilty about not telling the truth. Or maybe you developed coping skills and compensated by being overly obsessive and overly worried about everything because you’ve been told repeatedly that in order to achieve your goals you just needed to work harder. 
Then one day you heard someone talk about attention deficit hyperactivity disorder and you immediately felt something awaken inside you. You were so relieved to hear you weren’t the only one who relied on Spark notes to pass English class–not because you were lazy but because there wasn’t enough time in the day to read the same page more than 3 times. After all, 20 pages of reading meant 60 pages for you. 
So, you debated whether to go to the doctor and be evaluated. You felt vulnerable and worried about opening up to someone you’ve never met. You started to worry that you might sound like a “drug seeker” or a “cheater.” Once you finally built the courage to share your story you were met with your worst nightmare–immediate invalidation. 
“We don’t prescribe those drugs in this clinic.” 
This is followed by urine drug testing and a referral for a $1,500 Neuropsychological test that only worsens your preexisting anxiety and obsessive thinking.
So, you go to the testing center and sit there in a quiet room clicking buttons and solving puzzles for hours as if that accurately captures the work-life of someone struggling with ADHD symptoms. 

Human beings are really complicated

There are many points to this story. Humans are complex and the brain is by far the most complicated system in our universe. Neuropsychological tests for ADHD are NOT something I routinely order, and the reasoning is simple: How does sitting at a computer in a quiet exam room solving boring puzzles for hours confirm that my patient really is experiencing distress and dysfunction? How does a neuropsychology test with inconsistent validity help my patient who can clearly articulate how they are feeling and what they are experiencing?

Science Speaks

Despite numerous attempts by the uninformed to delegitimize the diagnosis of ADHD, the science speaks loud and clear: attention deficit hyperactivity disorder (ADHD) is a real disorder that can occur in children and adults. It isn’t uncommon to hear people offer opinions such as “ADHD is an excuse to medicate misbehaving children to appease parents” or “everyone has ADHD and would benefit from psychostimulants.” When I hear these things, I take a deep breath and remind myself that these opinions are just what they are…opinions.
The belief that ADHD is an excuse to medicate misbehaving children, or the notion that adults seek an ADHD diagnosis to obtain stimulants to “cheat the system”, are not supported by any legitimate scientific evidence.
Do people abuse prescription stimulants? Yes, they do.
Are some children misdiagnosed with ADHD? Yes, some are.
Do some adults “fake” the diagnosis to obtain stimulants? Yes, some do.
But let’s leave the blanket statements and unsubstantiated beliefs in the box labeled “99% of political arguments” (the label included). If anything, ADHD is not recognized nearly enough in adults. The possible reasons for this are beyond the scope of this post.
If you’re the one spreading rumors that street methamphetamine is just like Adderall, then you’re also the one who believes that illicit methamphetamine purchased on the street has the same pharmacokinetic and pharmacodynamic effects as prescription stimulants simply because both are amphetamines. In which case I’ll go ahead and whip up some methanol martinis for you. Don’t worry, ethanol and methanol are both alcohols. If you go blind, you’ll understand my point.

References

  1. Young, Joel. ADHD Grown Up: A Guide to Adolescent and Adult ADHD .(2007)
  2. Gil Zalsman & Tal Shilton (2016) Adult ADHD: A new disease?, International Journal of Psychiatry in Clinical Practice, 20:2, 70-76, DOI: 10.3109/13651501.2016.1149197
  3. Stewart, T. D., & Reed, M. B. (2015). Lifetime nonmedical use of prescription medications and socioeconomic status among young adults in the United States. The American journal of drug and alcohol abuse, 41(5), 458–464. doi:10.3109/00952990.2015.1060242
  4. Psychiatric Times. 7 Evidence-Based Insights About ADHD. https://www.psychiatrictimes.com/adhd/7-evidence-based-insights-about-adhd
  5. Higgins, E.S. & George, M.S. The Neuroscience of Clinical Psychiatry: The Pathophysiology of Behavior and Mental Illness. 3rd Edition. 2018.
  6. Blumenfeld, Hal., MD, PhD. Neuroanatomy Through Clinical Cases. 2nd Edition. 2010.
  7. Sadock, Benjamin J., and Harold I. Kaplan. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/clinical Psychiatry. 10th ed. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins, 2007. Print.
  8. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.
  9. Stahl’s Essential Psychopharmacology, 4th Edition. Cambridge University Press. 2013
  10. Schatzberg & Nemeroff. The American Psychiatric Association Publishing Textbook of Psychopharmacology. 5th Edition. 2017.

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