What is ADHD?
ADHD (Attention Deficit Hyperactivity Disorder) is a neurodevelopmental disorder with global symptoms concerning attention deficits, hyperactivity and impulsivity, from which the name of ADHD stems. It can be detected both in children and adults, since it undoubtedly begins in childhood and continues to adulthood in at least 2/3 of cases (Adult ADHD).
During the last decades, an increased alertness for the identification of the disorder in adult population has been observed in global psychiatric community, as a continuum which begins in childhood and puberty. It has also been added as an official diagnosis to DSM-V. Despite the alertness mentioned above, ADHD in adults might be the less recognized disorder worldwide, while its prevalence reaches up to 5%, a particularly high rate, taking into account for example, that the different types of anxiety disorders separately have similar incidence rates. ADHD shows a clear preference for males at a ratio of at least 3>1.
ADHD in childhood and teenage years, can cause various problems in school and social functioning among children, due to difficulty concentrating, and often co-occurs with other entities such as anxiety disorders, mood, behavior (behavioral disorder, coping disorder) and substance use. In over 60% of cases the disorder persists even with a partial remission in adulthood. Risk factors for the onset of the disorder include family history, symptom severity, combined type (see below), comorbidity, and aggravating environmental factors.
The core symptoms of ADHD are attention deficit, hyperactivity and impulsivity.
Clinically there are 3 types in each of which inattention, hyperactivity / impulsivity or both (combined type) predominates. The disorder is chronic so it goes without saying that the symptoms should last for at least 6 months. The importance of the above lies in the fact that at times everyone can experience some of the symptoms of the disorder e.g. in times of intense stress or fatigue. In addition adult adhd symptoms should have started in childhood or adolescence regardless of whether they were recognized then or not.
- Attention Deficit Disorder
Attention is a higher mental function through which an active or passive focus is achieved on sensory data or other higher functions.
In ADHD, a core symptom is Attention Deficit, the existence of which results to the difficulty on various occupations and obligations of everyday life. Attention is easily distracted by external (or internal such as thoughts) stimuli.
The person characteristically experiences unwilled tuning-outs from the immediate reality.
He/she suffers from an obvious lack of order and organization, loses things, forgets things, finds it difficult to complete tasks that require repetitive mental effort such as a job at university or workplace and misses details.
Attention Deficit Symptoms may be one or all of the following
- Maintenance of attention
- Attention shift from one stimulus to another
- Prioritization of focused attention, that is, to select what is important to pay attention each time
Eventually the above can be interpreted as difficulty concentrating on various grades.
Usually, there is difficulty in multitasking, which refers to the ability of dealing simultaneously with more than one thing. Furthermore, a special feature appears in the fact that it often seems as if the person doesn’t hear and needs repetition in what has been said in a conversation.
Hyperactivity is manifested with continuous pointless movements, eg. fidgeting or walking back and forth, difficulty staying in the same position for sufficient time, a subjective feeling of inner anxiety and tension, and often excessive talking.
When there is no immediate focus stimulus, this innate lack of stillness takes hold, causing “static” in the mind. By extension this results to an incapacity of tolerating not having something to do or in other words a more than the average aversion to boredom.
“I always feel i should be doing something, but i do not know what”.
Sometimes motor co-ordination problems exist, resulting in clumsy behaviour (which can contribute to low self-esteem).
On the other hand, we can see that in a category of people with the disorder there is a special inclination towards manual or mechanical work, which often determines their professional orientation.
Impulsivity can be observed in acts of thoughtlessness, impatience, and might have unpleasant results in everyday life such as frequent quarrels, careless driving resulting to several fines and accidents, delinquent behavior, excessive spending of money, changing partners easily, inability to to maintain steady work and relationships. An important issue, as well, is the substance addiction, with alcohol abuse being more frequent, perplexing the therapeutic approach.
Learn more in the special article on impulsivity
Emotions in ADHD
Emotion regulation is defined as an individual’s ability to modify an emotional state to promote adaptive goal-directed behaviors. It has long before been discovered that deregulated emotional function is extremely common in people with neurodevelopmental disorders, including ADHD, reaching a percentage of 70%. Related manifestations might be an intense emotional variability, aggression and anger outbursts.
Adult ADHD is a condition in which motivation is lacking. In terms of lack of motivation there is a seeming resemblance to depression. A psychiatrist specialized in ADHD can efficiently tell the difference. It is a common symptom among people with the disorder not to be able to do things even if they want to. Mobilization does not come with low-intensity stimuli, but usually with an escalation of stress or due to learning behaviors that subjectively give a more immediate reward.
Indecisiveness and procrastination often occurs even on matters of minor importance.
In a few words motivation can be fueled most of the times by high interest or high stress/anxiety.
During the child development (often even after the age of 18), the property called delayed gratification is consolidated. The term implies the ability to make an effort and to act without expecting an immediate, but a longer-term reward for it. Relevant research shows that people with depression have varying degrees of deficiency in developing this ability.
After all, anything that does not come with an immediate satisfaction/ pleasure is not a sufficient stimulus to activate attention. Focusing on stimuli of a more neutral/indifferent /negative interest, is especially difficult in people with ADHD regardless of whether these stimuli may be of great importance in the long run.
This does not happen exclusively in people with ADHD, but it is more intense with them. In fact, on average, people tend to concentrate more on tasks they like doing. Basically, it has to do with the immediate reward system of the brain. Since we receive immediate reward (pleasure) for doing tasks we like, we choose to do it more often and dedicate ourselves to it.
Hyperforcus – Extreme concentration
A topic that needs clarification is the fact that both children and adults with ADHD symptoms, have the ability to concentrate even at a high level, on things they enjoy. The above is related to the term “hyperfocus”, that is, the “over-concentration” on a task. It is considered to be a kind of compensatory mechanism in distraction.
This raises confusion over the perception of the disorder in different ways. Either, if there is a possibility of concentration, there is no ADHD, or that the person is spoiled or has no will to try, and concentrates exclusively on what he wants.
In general, ADHD is not considered a problem of will / willpower but a malfunction at the execution and reward system level.
The diagnosis of ADHD is conducted through psychiatric clinical examination by a psychiatrist. Questionnaires can be used additionally as well. There is not any biological or blood tests diagnosing ADHD.
No feature of it is so unique that it cannot be found to various degrees to most non-ADHD population. Problems of attention, concentration and hyperactivity are features that situationally or more frequently can be located to people with other or without diagnosed disorders. This is one of the reasons that fules dispute about the specific diagnosis.
So, the diagnosis may not be so obvious in the adult population and it might escape due to the co-existence in high rates, with anxiety disorders, mood disorders and substance use. In fact, comorbid manifestations are more common than just a attention deficit feature. For example, adhd and anxiety are closely related.
ADHD has common features with bipolar disorder and borderline personality disorder.
It is essential to point that in pure ADHD, there is no mental retardation.
Sometimes there are cases in which symptoms of ADHD manifest secondarily in the context of autism spectrum and mental retardation syndromes.
Disorders that may co-exist
To be specific: without a diagnosis and treatment, ADHD can affect the person’s functionality. It can also bring serious consequences to the individual’s life, and other disorders such as depression and addictions, aggravating the problem.
Myths about ADHD
Both symptoms and causes of ADHD are often misinterpreted. After all, there are some who mistakenly question it as a disorder in general. Nevertheless, the quantity and validity of scientific research on ADHD, leave no room for doubt.
In general it is a fact, from a neurobiological perspective, that the brain of people with ADHD is slightly different. Some myths referring to this increasingly recognized condition are:
- ADHD is not the result of insufficient / poor parental care.
- It is not a mistake in character (eg. Laziness or Disobience) of the child
- It doesn’t imply lack in understanding or intelligence, although it may seem so to the unfamiliar observer.
- The symptoms of Attention Deficit Hyperactivity Disorder have no significant ups and downs. They are constant.
- The severity of symptoms is not the same for everyone but range from mild, moderate to severe.
- The hyperactivity can be diminished, mainly in adulthood, during the development of the disorder.
- People with ADHD can be normally functional in everyday life. Not only that, but it is possible for distracted people to be very charismatic and very successful in their field.
- Distraction in ADHD is not a conscious (when it happens) or intentional behavior.
- It is impossible to force people with ADHD to engage and focus on an activity in a similar way that it is not possible to force a person with myopia to see far!
What is the treatment for ADHD
The basic treatment for ADHD is medication. Psychotherapeutic approaches like CBT, psychoeducation, counceling (eg. Time management), have been proved to be beneficial to the end result. In the special clinic structure for ADHD, the medical and / or psychotherapeutic treatment of the common comorbid conditions (see previous image) also consolidates the best possible therapeutic result.
Medicine for ADHD
Treating ADHD with medicine has in most cases a positive effect. Drugs act primarily on distraction & concentration. Furthermore, they have a remarkable effect on the “chaos of thoughts”, referring to the problem of the existence of many thoughts without sufficient organization and hierarchy in the mind, which many people face with the disorder.
Pharmaceutical care includes methylphenidate/Ritalin, a substance acting as a central nervous system stimulant. Its action is manifested by inhibition of the reuptake pump of the biogenic monoamines dopamine & noradrenaline, accumulating those substances in the synaptic cleft between neurons. It is available in two forms in Greece:
- Immediate release & shorter duration of action (Ritalin)
- Prolonged release & longer duration of action (Concerta)
Due to significant dopaminergic and noradrenergic innervation of the prefrontal cortex (region of the brain primarily regulating attention, motor activity and impulsivity, thus other functions such as decision making and problem solving), the therapeutic effect of methylphenidate is undisputable.
Similarly, but with the difference that it affects only the noradrenergic neurotransmission, is atomoxetine (Strattera), a drug with an official indication for attention deficit hyperactivity disorder.
These two drugs must be administered strictly under the supervision of a psychiatrist regarding the addiction risk of methylphenidate due to reckless use on one hand and possible side effects and interactions with other drugs on the other. Additionally, they can have side effects in comorbid conditions such as depression and emotional instability. Irrespective of the above, comorbidity should be treated to an extent according to which clinical condition predominates.
For instance, in cases of alcohol abuse, it is mandatory to firstly complete the procedure of detoxification then to proceed to the phase of treatment of ADHD.
Other drugs which can be used as 2nd line treatment are modafinil (modiodal/aspendos) and stimulants such as bupropion (wellbutrin) & venlafaxine (effexor).
Physical Exercise and ADHD
The benefits of frequent physical exercise are well-known for a wide range of mental and non-mental disorders. Research depicts that exercising has a positive effect in attention improvement thanks to the release of endorphins and the indirect reinforcement of dopamine and noradrenaline levels. In addition, exercises help to reduce the intensity and the tendency for hyperactivity. Exercise is a complementary approach to reducing the symptoms of attention deficit disorder, while for a small percentage it has sufficient results and as a main treatment.
rTMS for ADHD
RTMS therapy has been studied and is being used gradually with encouraging results in the treatment of attention deficit disorder.
Online community for ADHD http://www.adhdforum.gr/ is a very interesting website (extremely useful for the Greek data) for people with the disorder and more. The forum discusses a number of specialized issues related to the disorder (eg. The difficulties the pandemic has caused to people with ADHD), thus self-help groups have been formed.
Highly recommended is an excellent reading on ADHD called “Scattered Minds” by Gabor Maté, offering multidimensional aspects and insights on the condition.
Attention deficit hyperactivity disorder awareness
Recognizing ADHD in people, adult, teenagers or kids should be a way of better understanding and supporting them, not a judgment that there is something irretrievably wrong or a label that characterizes their whole being.
Spiros Kalimeris Psychiatrist