What is Adhd?
Attention Deficit Hyperactivity Disorder is a complex neurodevelopmental disorder that is characterized by low production of dopamine in the prefrontal cortex. The prefrontal cortex is in charge of what we call executive functions; planning, organizing, decision-making–all of the directing parts of the brain. Emotional regulation and reward pathways in the brain are also affected by individuals with ADHD. The diagnosis is further broken down into three different presentations: primarily inattentive, primarily hyperactive, or the combined type. Here’s a list of some of the symptoms to look for:
The inattentive symptoms (previously referred to as ADD) in the Diagnostic and Statistical Manual 5th edition (DSM-5) are:
- Often fails to pay close attention to details or makes careless mistakes in schoolwork, at work, etc.
- Often has trouble holding attention on tasks or activities (e.g., easily distracted)
- Often does not seem to listen when spoken to directly
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, gets side-tracked)
- Often has trouble organizing tasks and activities; has trouble finishing tasks
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
- Often loses things necessary for tasks and activities (e.g., school materials, wallet, phone, keys).
- Often forgetful in daily activities
- Often distracted by stimuli (e.g., sounds, movement)
The hyperactive/impulsive symptoms in the DSM-5 are:
- Often fidgets with or taps hands/feet or squirms in seat
- Often leaves seat in situations when remaining seated is expected (e.g., leaves place in the classroom, in meetings, etc.).
- Often runs about or climbs in situations where it is inappropriate. In adolescents or adults, this may manifest as 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 remain still for any extended time without significant discomfort; others may say that the person is restless, fidgety, or difficult to keep up with).
- Often talks excessively
- Often completes other people’s sentences or blurts out an answer before a question has been completed
- Often has difficulty waiting for their turn (e.g., while waiting in line, while speaking in conversations).
- Often interrupts or intrudes on others. For adolescents and adults, may intrude into or take over what others are doing (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission)
The combined type is diagnosed by the presence of an even mix of the symptoms. There are other criteria for this diagnosis which include symptoms lasting for a specific duration and having an impact on various domains of an individual’s life.
What are the Statistics
Approximately 5% of children and adolescents are affected by ADHD globally. In the U.S. 6.1 million children (9.4%) between the ages of 2 and 17 are estimated to be diagnosed with ADHD, with boys more likely to be diagnosed than girls (11.7% compared to 5.7%). The difference in the diagnosis of girls and boys is often due to the presenting symptoms and socialization of children. Girls are more often diagnosed with the inattentive presentation which is often missed in a classroom setting where most referrals for ADHD testing occur.
While ADHD is considered a childhood disorder, 139.84 million adults have persistent ADHD with childhood onset (2.58% of the global population) and 366.33 million adults have symptomatic ADHD regardless of onset (6.76% of the global population) as of 2020. Because ADHD affects brain development, it manifests in all aspects of life and can significantly impair educational achievement, relationships (romantic, familial, friendships), employment, finances, etc. There are many common symptoms of ADHD (inattention, inability to focus, poor time management, weak impulse control, exaggerated emotions, hyperfocus) which are often seen as character flaws or bad parenting when the underlying cause is due to an individual’s specific brain functioning. This is also seen in difficulty with emotional processing.
One aspect of ADHD that has been recognized as a symptom for diagnosis in Europe and noted in research for at least two decades but is still not considered in the Diagnostic and Statistical Manual version 5, has been the emotional component of ADHD. About 70% of adults with ADHD report emotional dysregulation (ED), which has led to the term, DESR, or deficient emotional self-regulation, popping up in ADHD research, and other mental health conditions in which emotional dysfunction is a major component. This refers to a deficiency in the four components of self-regulation. These four components are the ability to inhibit behavior triggered by strong emotions, the ability to self-soothe and regulate strong emotions, the ability to refocus from events that cause strong emotion, and the ability to organize emotional responses. This emotional dysregulation greatly impacts a person’s ability to recognize and control the emotions that they are feeling which can lead to issues connecting with others, putting feelings aside to focus on something, and processing a difficult situation. This can be seen in rejection sensitive dysphoria.
Rejection sensitive dysphoria (RSD) is a common manifestation of emotional dysregulation that is defined by an extreme emotional sensitivity and pain that is triggered by the idea that someone is being rejected or criticized by important people in their life or by the idea of failing to meet an expectation. While RSD is not caused by a trauma, the pain from it can be felt as a traumatic experience. When these feelings are internalized, they can imitate a mood disorder, and often leads to misdiagnosis of a major mood disorder. When these feelings are externalized, they can be like a sudden rage at the person or situation causing the pain. This can be a devastating ordeal that can lead to feelings of alienation.
Comorbidities with adhd
People with ADHD often have other co-occurring mental health conditions. According to the CDC almost 64% of children with ADHD have at least one other mental health condition: 52% have behavioral health or conduct problems, 33% have anxiety disorders, 17% have depression, 14% have been diagnosed with autism spectrum disorder, and 1% have Tourette syndrome.
In adults as many as 80% of people with ADHD have at least one co-occurring mental health condition. It is estimated that rates of comorbid bipolar disorder in adults with ADHD are between 5.1% and 47.1%, about one-fifth to one-half of adults with ADHD have major depressive disorder/dysthymia, about 50% of individuals with ADHD have some type of anxiety disorder, personality disorders are present in more than 50% of adults with ADHD, and research shows that 25% to 40% of adults with substance use disorder also have ADHD. Having multiple mental health conditions can make it harder to identify the source of a condition and the best way to approach treatment. When talking about ADHD, we expect it to present as primarily hyperactive/impulsive and this can also lead to issues in beginning treatment. Women and girls are often misdiagnosed or underdiagnosed in ADHD because they primarily present in the inattentive type. The classroom setting is most often where ADHD is first noticed, but with the inattentive type it is often less disruptive to the classroom so is less likely to get someone referred for treatment. Also in female students the behaviors that would often get male students categorized as ADHD get labeled as “airheaded” or a “chatterbox” or “flighty.” They also are socialized to behave in ways that more easily mask their symptoms, such as spending more time on school work, which can lead to other problems when they are unable to manage emotionally or socially in the ways they are expected to. This can be stigmatizing when they are unable to perform the way they are expected to and can lead to perfectionism, social withdrawal, low self-esteem, and negative self-talk.
The future of adhd
In current ADHD research there is looking into changing the name to better reflect the complex of the condition. One proposed future name is variable attention stimulus trait (VAST). This name comes from Edward Hallowell, M.D., John Ratey, M.D. who are leading researchers and wrote the book ADHD 2.0. Other areas of research are looking into better understanding the emotional aspects of the condition.
Treatment for adhd
When approaching treatment for ADHD, medication is the most well known and most stigmatized. It is an important treatment approach, because when people are on the right dosage of medication it greatly improves their lives. RSD can be greatly improved by medication management.
Another treatment approach is ADHD/executive functioning coaching. This is a behavioral training that focuses on finding ways to deal with/externalize the executive functioning skills that are lacking.
Therapy is another approach that helps build coping strategies, builds greater understanding of the areas in which a person is struggling, and can help a person learn ways of dealing with the emotional issues of ADHD.
Neurofeedback is another treatment that has been proven effective for ADHD. Neurofeedback, or EEG Biofeedback, is a technique that uses operant conditioning to train the brain to be more efficient (and is a service that we provide).
As we continue to learn more about ADHD and how to improve the quality of life of people who have the condition, we will continue to approach it by looking at the strengths that can be found in it. Here at TriWellness we can help.
This month’s blog post was written Jessie Duncan, MA, LPC, a specialist in Chronic Illness and Neurological Treatment modalities.