Attention Deficit-Hyperactivity Disorder (ADHD) is one of the most widely researched disorders in the Diagnostic and Statistical Manuel (DSM-5), yet still remains elusive to many that either struggle themselves or have a child struggling from this condition. Impacting school, work, relationships, injuries, and productivity, this neurodevelopmental disorder is estimated to impact 11% of children in the US, according to the CDC. Others, including clinical psychologist Vincent Monastra, estimate up to 29% of children present symptoms of ADHD. Of the 6.4 million children diagnosed with ADHD, boys (13.2%) were more likely than girls (5.6%) to be diagnosed with the average age being seven years old. Typically chronic in nature, ADHD is characterized by a pattern of behavior that is present in multiple settings.
The DSM-5 defines ADHD as a pattern of behavior that is present in multiple settings that results in performance issues in social, educational and work settings affecting both children and adults. A persistent, on going pattern of inattention and/or hyperactivity-impulsivity that impacts daily living and development creates difficulties around attention, executive function and working memory, present by age 12. Three presentations of ADHD are possible, including inattentive, hyperactive-impulsive, and combined inattentive & hyperactive-impulsive. Based on how many symptoms an individual has and how difficult these symptoms make daily living, ADHD is classified as mild, moderate or severe and several symptoms need to be present in more than one setting. When diagnosing children, six or more symptoms should be present. When diagnosing people over 17 years of age, only five symptoms need to be present. The criteria of symptoms include the following; Inattentive presentation: fails to give close attention to details or makes careless mistakes, has difficulty sustaining attention, does not appear to listen, struggles to follow through on instructions, has difficulty with organization, avoids or dislikes tasks requiring a lot of thinking, loses things, is easily distracted, is forgetful in daily activities. Hyperactive-impulsive presentation: Fidgets with hands or feet or squirms in chair, has difficulty remaining seated, runs about or climbs excessively in children; extreme restlessness in adults, difficulty engaging in activities quietly, acts as if driven by a motor (adults will often feel inside like they were driven by a motor), talks excessively, blurts out answers before questions have been completed, difficulty waiting or taking turns, interrupts or intrudes upon others.
Throughout history, signs and symptoms of ADHD have been present. Famous historical figures such as Beethoven, Virginia Woolf, Henry Ford, Leonardo Da Vinci and Henry Ford have all been reported to show signs and symptoms of ADHD. In current day, it has been reported that Michael Phelps, Ted Turner, Dustin Hoffman and Prince Charles all have ADHD. While core ADHD symptoms historically have been labeled “morally defective,” “minimum brain damage,” to “minimal brain dysfunction,” ADHD has been apart of psychiatric terminology since the inception of the DSM in 1952. From long ago to present, core signs and symptoms of ADHD have always existed, just labels have altered.
Signs and symptoms of ADHD include:
Existing over a prolonged period of time and present from an early age, these symptoms create difficulty for an individual in organizing their life. Nine domains can exhibit atypical behavior including alerting, concentration, behavioral inhibition, affective control, socialization, memory, language processing, word retrieval, and fine and gross motor development.
Having a short attention span or difficulty focusing is the hallmark of this disorder. What is often confusing to parents, teachers is that individuals with this disorder can focus and pay attention to things that are interesting, stimulating, new, novel or frightening. These specific set of circumstances help activate the brain. While a child may take hours to complete a simple homework assignment, they are often able to hyper focus on areas of interest.
Distractibility is different from having a short attention span. Distractibility expresses itself through a hypersensitivity to the environment. A child or adult experiencing distractibility will be unable to block out stimulation from the environment such as traffic sounds, the sound of a heating system turning on, smells, insects and often tags in clothing. Experiencing a hypersensitivity to senses, this distractibility has been linked to under activity in the prefrontal cortex of the brain.
Organizational problems are common and impact how one organizes their space and belongings, time, and goals in life. Bedrooms or offices look messy, backpacks are disastrous with papers everywhere, projects are left half done and there is often the sign of chronically being late. With a disorganized approach to projects, and taking a long time to complete them, people with ADHD often experience crisis after crisis waiting for attention.
Difficulty with follow through is hallmark in ADHD with people struggling with the ability to stick with a project to the end. Many items are procrastinated until the last minute where the pressure of the deadline finally forces them to finish. Many different interests can be present and many people with ADHD will complete 50 to 80 percent of their task until they move to a different project. This sign and symptom can be seen in failing to turn in homework, procrastinating chores, not turning in paperwork, not paying bills on time, not fulfilling promises in friendships and failing to follow through will diets, medications or lab work.
Poor internal supervision involves the capacity to generate goals and to achieve them. Forethought is an issue for individuals with ADHD and this can manifest in blurting out thoughts or actions. People are more likely to do or say something that can make a situation worse, and make the same mistake over and over again. Living in the moment, not understanding the consequences of five minutes from now, tomorrow or next year is how this is experienced. Living in crisis much of the time, these individuals lack planning and are constantly putting out fires.
Understanding the etiology of ADHD is important to grow our knowledge of neuroanatomical, biochemical, and neurophysiological characteristics. Much has been learned about the physiology of ADHD through positron emission tomography (PET), single photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI), and quantitative electroencephalography (qEEG) brain imaging techniques. Strong evidence is present highlighting ADHD’s hereditary component with 75 to 91 percent of children estimated to have a family member with the disorder. Researchers show the symptoms of ADHD resemble those produced by damage to the prefrontal cortex, including distractibility, forgetfulness, impulsivity, poor planning, and hyperactivity. Playing an essential role in memory, the prefrontal cortex assists working memory to guide thoughts, behavior, attention, and monitor effects of actions while organizing plans for the future. When these neural circuits are damaged, ADHD symptomology is created. In addition, research exemplifies investigations that show abnormalities in a network of brain regions that involves the caudate nucleus and putamen with the prefrontal cortex. When there is decreased activation in the caudate nucleus or medial prefrontal cortex there are typically abnormalities in dopaminergic transmissions. The growth of the brains of children with ADHD follows that of the brains of unaffected children, but the rate of growth is slower.
Physiological explanations show an association for four genes and ADHD: DA D4 and D5 receptors, the DA transporter DAT1, and the 5-HT transporter (5-HTT). Also, the norepinephrine transporter gene and the DA D2 and 5-HT 2A receptors have been implicated in their association with ADHD and a reduction in grey matter volume in the cerebellum. Neuroimaging studies, utilizing MRI, fMRI, PET and SPECT scans reveal abnormalities in frontal lobes, the basal ganglia, corpus callosum, and cerebellum. It is these areas that regulate alertness, executive functions, and imaging that show ADHD present at a cellular and regional level. MRI and fMRI studies show significant differences in brain volume with patients with ADHD with a trend of a 5% reduction in ADHD patients. MRI’s show regions of the basal ganglia and cerebellum (control of movement), anterior cingulate gyrus (executive control), the right frontal region (alerting functions, and the left dorsolateral region of the frontal lobe (verbal working memory and fluency) to be 10% to 12% smaller in patients diagnosed with ADHD. Also shown in MRI studies is evidence of asymmetry of the caudate nucleus with the right caudate being smaller than the left. Also reduced is the size in the anterior region of the corpus callosum. QEEG studies show the activity of the brain measured by surface electrodes reveal excessive slow cortical activity (high ratios of theta versus beta frequencies) and excessive relative theta power over frontal regions of the brain.
Known as a disorder of cortical arousal and modulation, ADHD is postulated to have impairment of alerting and behavioral inhibition. While it is unlikely that ADHD is caused by an abnormality of a single brain region, identifying multiple polymorphisms show atypical development of neural pathways, incorporating networks involving posterior regions and thalamic and frontal regions. It is the atypical development of these brain regions that are responsible for alertness, sustained attention, executive functions, response inhibition, planning, working memory, cognitive flexibility, shifting and fluency. It is the frontal lobes, the corpus callosum, the basal ganglia, and the cerebellar vermis that are indicated in neuroanatomical studies showing a reduction ins size, abnormal rates of blood flow and glucose metabolism, and abnormalities in patterns of electrophysiological activation.
To fully understand the complexity of ADHD, it’s paramount to look beyond the neurophysiological components to gain clarity of psychological etiology. A child or adult with emotional trauma and emotional issues may create the intense feelings that show ADHD symptomology. While they do not qualify for a diagnosis of ADHD, it is important to understand that a child demonstrating Post Traumatic Stress Disorder (PTSD) or one that is emotionally traumatized taking a stimulant medication will not get better. There is no healing in ADHD stimulant drugs. Emotional causes of ADHD behavior can include a death in the family, life stresses such as parents divorcing or moving to a new town or country, low self-esteem, sexual abuse when young, emotional difficulties, neglect by parents, bullying at school, lack of rules at home, lack of discipline at home, lack of boundaries at school, and feelings of rejection. The cause of ADHD behavior should be determined as it drastically alters the intervention and treatment plan.
Most researchers in the field of ADHD point to heredity and a neurophysiological etiology. However, some sociological evidence points to different causes, at a minimum, contributing the distracted, fast paced lives of American children and adults. Dr. Michael Ruff, M.D., a clinical associate professor of pediatrics at Indiana University, believes some of the cases of ADHD are a byproduct of the cultural environment impacting the developing brain. With research by Dr. Doreen Magee showing average screen time for Americans being 12.5 hours a day, today’s children are immersed in a world of video games, texting, smart phones, computers, instant messaging and a world of rapid fire technology. Dr. Ruff’s theory shows that when children transfer the sense of urgency they’ve experienced with technology to their academics, their highly malleable brains cannot adjust. Arborizing is a process known as brain cells making new connections and pruning what is not used, back. Arborizing and pruning determine how circuitry is wired in the prefrontal cortex. He theorizes that the extent to which these environmental factors influence these processes is unknown. Dr. Doreen Magee in her research also finds that we do not fully understand the implications of the digital age we live in and how that impacts not just our brains, but also our development of biological systems and how we create relationships. Supporting Dr. Ruff’s theory, the University of Washington researchers found that toddlers that watch a lot of TV were more likely to develop attention problems. Dr. Ruff’s practice cares for over 800 Amish families that forbid TV and video games. There is not one single case of ADHD (or obesity). Conversely, when Amish families leave the community and adopt a modern lifestyle, the prevalence of ADHD (and obesity) occurs. The genes are the same, the lifestyle is different. Dr. Ruff counsels patients to limit TV, read to their kid’s daily, play board games and activities that promote reflection and patience. He also urges parents to participate in more slow paced, step-by-step activities with their children.
The most common treatment for ADHD is pharmacologic treatment with stimulant medication. Dr. Carlson states, “A moderate dose of methylphenidate increased the responsiveness of neurons in the prefrontal cortex.” Methylphenidate is a dopamine agonist and alleviates the symptoms of ADHD. This supports the theory that this disorder is caused by an under activity of dopaminergic transmission. Releasing dopamine and norepinephrine increases levels of these neurotransmitters in the prefrontal cortex. Side effects of stimulant medication can include insomnia, and in very rare cases of arrhythmias, sudden cardiac death has been reported (12 cases).
Methylphenidate, dextromethylphenidate, dextroamphetamine, and mixed amphetamine salts are the four primary types of stimulant medications prescribed for treating ADHD. In general, stimulant medications exert their beneficial effects by increasing the availability of the catecholamines in the synaptic cleft. The neuronal structures affected vary depending on the type of medication used. Stimulant medication has been demonstrated to improve symptoms of hyperactivity, impulsivity, and measures of vigilance, fine motor coordination, reaction times and academic productivity. However, it has been shown that stimulant medication in unable to enhance functioning of intelligence and academic ability. Scientific literature reveals that many patients will exhibit at least one side effect including appetite suppression, weight loss, headaches, abdominal pain, sleep-onset, insomnia, sleep discontinuity disturbance, nervousness, and irritability. Controversial side effects include cancer (toxicology of stimulant medications including the risk of chromosomal aberrations), sudden death (12 cases in clinical trials due to heart defects and toxic overdose.)
Alternative to medication treatment includes EEG biofeedback also known as neurofeedback. Neurofeedback utilizes operant and classical conditioning techniques to train the underlying physiology in the surface electrical activity of the brain. Training amplitude also known as power, ratios, and the communication of networks known as multivariate coherence training, neurofeedback can be powerful in the reduction of ADHD symptomology. Published in Pediatrics, the official journal of the American Academy of Pediatrics is a randomized controlled trial that included a large sample of elementary school students with ADHD who received in-school computer attention training with neurofeedback or cognitive training. Students who received neurofeedback were reported to have fewer ADHD symptoms six months after the intervention. The American Academy of Pediatrics also published a report to practitioners, educators, youth and families called Evidence-Based Child and Adolescent Psychosocial Interventions reporting biofeedback as level 1-Best Support for ADHD, equal to medication combined with behavioral therapy. Research continues to be published supporting this therapy. Frank H. Duffy, MD, professor (Harvard Medical School) and pediatric neurologist is quoted “Neurofeedback should play a major therapeutic role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used. It is a field to be taken seriously by all.” (Smith, 2014)
Counseling is often sought after to assist families in learning how to best support their child. Psychoeducational classes that include education on the causes of ADHD, establishing education support plans for children and teens with ADHD, teaching new skills including healthy sleep, diet, exercise and supplementation, motivational strategies, attaining emotional control, teaching about impulse control, teaching organization and responsibility, and problem solving skills all are helpful. Other strategies taught are helping your child succeed with peers and promoting self-care. Social skills training through applied behavioral analysis can also be beneficial.
In conclusion, ADHD is a well-researched disorder that many families still struggle with understanding the causes and best treatment choices for their child. Dysregulation in the neurophysiology is the most agreed upon answer, yet other views contribute to our fast paced modern society contributing to symptomology of inattention. As a neurodevelopmental disorder that has different presentations, many times the best options are not clear for treatment. While the most common treatment is medication, other treatment modalities exist that have proven beneficial. As a medical model society, these alternatives have not always been embraced, or covered by insurance reimbursement creating an environment of controversy around different options. We approach treating ADHD with a multimodal holistic approach including biofeedback, nutrition, exercise, supplementation, neurotransmitter testing, and counseling. By changing the underlying physiology creating the symptoms presented, we can not only treat symptoms but transform the lives and journeys our children take.