Everything You Need to Know About ADHD
ADHD is a complex neurological disorder described as a “developmental impairment of self-management functions linked to complex brain operations.” In other words, ADHD impacts the executive functions needed to assess, plan, and execute life. This means different things to different people; read on to learn about ADHD’s disparate symptoms, causes, and treatment options.
“Attention deficit” is, some experts assert, a misleading name. “Attention deregulation” might be a more accurate description since most people with ADHD have more than enough attention — they just can’t harness it in the right direction at the right time with any consistency. And so individuals with ADHD hyperfocus and lose track of time, or misplace their keys, or blurt out an unrelated thought when their focus breaks free from its chains.
ADHD may present in two very distinct ways, or a combination of both. People with hyperactive-impulsive subtype of ADHD act “as if driven by a motor” — moving, squirming, and talking at even the most inappropriate times. They are impulsive, impatient, and interrupt others.
People with the inattentive subtype of ADHD are easily distracted and forgetful. They may be daydreamers who lose track of homework, cell phones, and conversations with regularity.
Individuals with Combined-Type ADHD display a mixture of all the symptoms outlined above.
ADHD rarely looks the same in any two people. Though it is most commonly diagnosed in grade school — when a child’s lack of focus, forgotten homework, or behavior challenges draw teachers’ attention — adult women comprise the fastest growing population of ADHD diagnoses today. Symptoms once mistaken for mood disorders, anxiety, or ditziness are finally recognized as ADHD later in life — commonly when a mother recognizes herself in her child’s symptoms1.
What Is ADHD?
ADHD is a complex brain disorder that impacts approximately 11 percent of children and almost 5 percent of adults in the United States.2 It causes great difficulty in focusing and managing many aspects of daily life, though many adults and children with the condition are able to focus on other tasks well.
Findings from neuroscience, brain imaging, and clinical research challenge the old understanding of ADHD as essentially a behavior disorder, says Thomas E. Brown, Ph.D., associate director of the Yale Clinic for Attention and Related Disorders.3 We now understand that ADHD is a developmental impairment of the brain’s self-management system, its executive functions, he says.
“ADHD is not a breakdown of the brain in one spot. It’s a breakdown in the connectivity, the communication networks, and an immaturity in these networks,” says Joel Nigg, Ph.D., professor of psychiatry at Oregon Health & Science University. “These brain networks are interrelated around emotion, attention, behavior, and arousal. People with ADHD have trouble with global self-regulation, not just regulation of attention, which is why there are attentional and emotional issues.”4
What Causes ADHD?
ADHD has a number of likely causes — though the medical community still can’t pinpoint exactly which one explains the symptoms.
What we do know is that ADHD is not caused by bad parenting, too much sugar, or too many video games. It is a brain-based, biological disorder. Brain imaging studies and other research show many physiological differences in the brains of individuals with ADHD.5
Other studies reveal that a child with ADHD is four times as likely to have had a relative also diagnosed with the condition — clearly pointing to a genetic factor. Researchers in the U.S. and Europe are working now to determine which specific genes make an individual susceptible to ADHD. Scientists are investigating many different genes, especially ones linked to the neurotransmitter dopamine that may play a role in developing ADHD. They believe it likely involves at least two genes, since ADHD is such a complex disorder.6
In addition, scientific research suggests that exposure to dangerous chemicals — everyday toxins found in foods, carpeting and flooring, cleaning and lawn products, and personal-care products like toothpastes — may contribute substantially to disorders such as ADHD, autism, and learning disabilities.7,8,9 When toxins disrupt brain development, disabilities like ADHD can occur.
What are the Symptoms of ADHD?
Doctors diagnose ADHD using detailed criteria spelled out in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). In its entry on ADHD, the DSM-V lists nine symptoms that suggest ADHD–Primarily Inattentive and nine that suggest ADHD–Primarily Hyperactive-Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six of nine symptoms from one of the lists below, and if the symptoms have been noticeable for at least six months in two or more settings — for example, at home and at school. What’s more, the symptoms must interfere with the child’s functioning or development, and at least some of the symptoms must have been apparent before age 1210. Older teens and adults may need to consistently demonstrate just five of these symptoms in multiple settings.
ADHD – Primarily Inattentive Type
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
ADHD – Primarily Hyperactive-Impulsive Type
- Often fidgets with or taps hands or feet or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
- Often unable to play or engage in leisure activities quietly.
- Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
- Often has difficulty waiting his or her turn (e.g., while waiting in line).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).”10
How is ADHD Diagnosed?
No ADHD test alone can diagnose symptoms of attention deficit disorder. ADHD is a nuanced condition with three distinct sub-types, symptoms that appear along a spectrum of severity, and overlapping comorbid conditions that often complicate diagnosis and treatment.
It can take several hours of talking, test taking, and analysis to diagnose someone with ADHD. An evaluation for ADHD may start with a routine visit to a primary-care physician, but chances are it won’t end it there. As a rule, most general practitioners are not trained in the idiosyncrasies of ADHD and its overlapping conditions. Few are equipped to perform the in-depth evaluation needed.
Any good ADHD diagnosis is based on the criteria defined in the DSM-V. A clinical interview is performed to gather the patient’s medical history, and is often supplemented with neuropsychological testing, which offers greater insight into strengths and weaknesses, and helps identify comorbid (or co-existing) conditions.
Not all doctors subscribe to these criteria. Many professionals point out that some patients’ ADHD symptoms aren’t recognized until later in life — this is particularly true for twice-exceptional individuals, women and girls, or those who have the inattentive form of ADHD.
Diagnosing an adult is trickier than diagnosing a child. The DSM-V symptom guide is really invalid for adults; almost all of its criteria is geared toward diagnosing children. An ADHD diagnosis in adulthood emerges only from a careful clinical interview conducted by a specialist in ADHD who takes his or her time with the evaluation.
“The DSM-V criteria are based only on research with children four to 17 years old,” says Brown, assistant clinical professor of psychiatry at Yale University School of Medicine. “As a result, most clinicians bend the criteria when it comes to the age of onset — recent research has shown that, in some people, symptoms don’t appear until adolescence, when there are greater challenges in self-management. Clinicians also may diagnose adults who have just four or five symptoms, not seven or eight, if they show significant impairment.”
How is ADHD Treated?
Stimulant medication is the most recommended form of ADHD treatment for one simple reason: studies show it to be most effective. “When adults ask me questions about why they should try medication to manage their ADHD, my answer always comes down to two words: Medication works,” says Russell A. Barkley, Ph.D., a clinical professor of psychiatry and pediatrics at the Medical University of South Carolina. “When you find the right medicine, you can experience substantial improvements in your ADHD symptoms.”
The clinical practice guidelines developed by the American Academy of Child and Adolescent Psychiatry (AACAP) recommend medication as the first-line treatment for ADHD in school-age children, citing a formal review of 78 studies on the treatment of ADHD, which “consistently supported the superiority of stimulant over the non-drug treatment.”
Even the widely-cited Multi-Modal MTA Cooperative Group Study, which concluded that medication combined with behavior therapy is the optimal treatment of ADHD in children, conceded that “a pharmacological intervention for ADHD is more effective than a behavioral treatment alone.”
Stimulant medication might be the most recommended treatment for ADHD, but it certainly isn’t the only option to consider.
While medication works on a neurological level to regulate the brain, behavior therapy addresses specific problem behaviors by structuring time at home, establishing predictability and routines, and increasing positive attention. Behavior therapy operates on a simple premise: Parents and other adults in a child’s life set clear expectations for their child’s behavior — they praise and reward positive behavior and discourage negative behavior. Behavior therapy requires participation from parents and teachers.
Cognitive behavioral therapy is a short-term, goal-oriented form of psychotherapy that aims to change negative patterns of thinking and change the way a patient feels about herself, her abilities, and her future.
Originally a treatment for mood disorders, CBT is based on the recognition that cognitions, or automatic thoughts, lead to emotional difficulties. Automatic thoughts are spontaneous interpretations of events. These impressions are susceptible to distortion, such as unfounded assumptions about yourself (or others), a situation, or the future. An unhealthy internal dialog could prevent an individual from working toward an aggressive goal, working to develop productive new habits, or generally take calculated risks.
CBT aims to change irrational thought patterns that prevent individuals from staying on task or getting things done. For an individual with ADHD who thinks “This has to be perfect or it’s no good” or “I never do anything right,” CBT challenges the truth of those cognitions. Changing distorted thoughts, and the resulting change in behavior patterns, is effective in treating mood disorders, anxiety, and other emotional problems, as well.
Poor nutrition and eating habits do not cause ADHD. However, adults and parents of children with ADHD are finding that, while whole foods may not be a cure-all, nutritional changes can make a big difference for some patients with ADHD.
Research shows that what you feed your body has a direct correlation to how your brain functions. Nutritions impact cognition, attention, sleep, and mood. According to the Harvard Health Blog, studies show that people who eat “clean” or “whole” foods like vegetables, fruits, unprocessed grains, and lean meats, are more likely to experience better emotional health and 25 to 35 percent less likely to experience mood disorders.11
Studies by Massachusetts Institute of Technology neuroscientist Richard Wurtman Ph.D., and others have shown that protein triggers alertness-inducing neurotransmitters, while carbohydrates trigger drowsiness. These findings support the popular belief that people with ADHD do better after eating a protein-rich breakfast and lunch. The better you want your brain to perform, the more unprocessed foods, complex carbohydrates, proteins, vegetables, and fruits you should eat. That will mean you or your child are not eating artificial colors and flavors, chemical preservatives, and over-processed foods — all shown to exacerbate ADHD symptoms in some individuals.
It’s true that not everyone eats the right foods to achieve beneficial levels of certain nutrients. But it’s also true that our bodies don’t always produce the nutrients we need, so we have to get some of them from supplements. There are many vitamins, herbs, and supplements that may diminish ADHD symptoms in some individuals: Omega-3s, Zinc, Iron, Magnesium, Vitamin C, Valerian, Melatonin, Ginkgo, and Ginseng.
However, “all natural” is not synonymous with “safe.” Many herbs and supplements have side effects, may cause or worsen health problems, or interfere with prescription medications. Talk with your doctor before taking any supplements. When your doctor asks if you are taking any medications, be sure to tell him about all vitamins and supplements you take on a daily basis.
“Think of exercise as medication,” says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School. “For a very small handful of people with ADHD, it may actually be a replacement for stimulant medication, but, for most, it’s complementary — something they should absolutely do, along with taking meds, to help increase attention and improve mood.”
Routine physical activity firms up the brain — making it a simple, alternative ADHD treatment. “Exercise turns on the attention system, the so-called executive functions — sequencing, working memory, prioritizing, inhibiting, and sustaining attention,” says Ratey, author of Spark: The Revolutionary New Science of Exercise and the Brain. “On a practical level, it causes kids to be less impulsive, which makes them more primed to learn.”
Exercise causes the brain to release several important chemicals. Endorphins, for one, hormone-like compounds that regulate mood, pleasure, and pain. That same burst of activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels. These brain chemicals affect focus and attention, which are in short supply in those with ADHD. “When you increase dopamine levels, you increase the attention system’s ability to be regular and consistent, which has many good effects,” explains Ratey, like reducing the craving for new stimuli and increasing alertness.
A 2015 study published in the Journal of Abnormal Psychology found that 30 minutes of exercise before school can help kids with ADHD focus and manage moods. It can even eliminate or decrease the need for stimulant medications used to treat symptoms.12
Exercise boosts the brain’s neurotransmitters — chemicals that many individuals with ADHD run short on. It primes the brain for learning, and environmental enrichment helps to make the important connections happen.
“Working memory is the ability to hold information in your mind for several seconds, manipulate it, and use it in your thinking,” says Ari Tuckman, Psy.D., a clinical psychologist in West Chester, Pennsylvania. “It is central to concentration, problem solving, and impulse control.”
People with ADHD can’t always hold on to information because their attention gets hijacked. Improving working memory capacity with brain training enables an individual to pay attention, resist distractions, manage emotions better, and learn.
Neurofeedback is a form of brain training that uses brain exercises to reduce impulsivity and increase attentiveness. The brain emits different types of waves, depending on whether we are in a focused state or daydreaming. The goal of neurofeedback is to teach a person to produce brain-wave patterns that reflect focus. The result: Some ADHD symptoms — namely, impulsivity and distractibility — diminish.
Mindfulness & Meditation
For many adults and children with ADHD, two persistent daily challenges are paying attention and maintaining self-regulation. So it stands to reason that some kind of attention training that also hones self-control would be invaluable — and incredibly powerful.
Mindful awareness, or mindfulness, involves paying close attention to your thoughts, feelings, and bodily sensations; in other words, developing a greater awareness of what’s going on with you from moment to moment. It can be used as a tool to foster wellness, especially psychological well-being. Similar techniques have been used to lower blood pressure and to manage chronic pain, anxiety, and mood disorders.
A 2005 study at Arizona State University found that children who participated in mindfulness exercises had lower test anxiety and ADHD symptoms, and greater attention than kids who did not participate in the exercises.14
Up to 90 percent of individuals with ADHD are diagnosed with at least one other psychiatric, developmental, emotional, and/or neurological disorder sometime during their lifetime.15
Doctors used to view ADHD as a stand-alone disorder. But research now suggests that the majority of individuals who have ADHD also suffer from a mood disorder, anxiety, obsessive-compulsive disorder (OCD), oppositional defiance disorder (ODD), a learning disorder, autism, or some other psychological or neurological problem.
In some cases, these problems are “secondary” to ADHD — that is, they are triggered by the frustration of coping with symptoms of ADHD. For example, a girl’s chronic lack of focus may cause her to experience anxiety in school. Years of disapproval and negative feedback from friends, family members, and teachers may cause a boy to become sad or to develop a mood disorder. Most of the time, secondary problems fade once ADHD symptoms are under control.
When other problems don’t resolve with effective ADHD treatment, it’s time to consider another possibility: Some problems are not secondary to ADHD, but distinct entities known as “comorbid” conditions. Like ADHD, comorbid conditions occur along what doctors call a “continuum of neurologically based disorders.”
Comorbid disorders may be caused by the same factors that trigger ADHD (heredity, exposure to environmental toxins, prenatal trauma, and so on). But unlike secondary problems, comorbid conditions do not go away on their own once ADHD has been treated. They require their own specific treatment in addition to any treatment given for ADHD itself.
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