Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder. Individuals with ADHD display symptoms of inattentiveness, over-activity, impulsivity, or combination of both. These symptoms start before age seven, however, ADHD can continue through adolescence and adulthood.

In the following series of articles, we discuss distinct aspects of Attention Deficit Hyperactivity Disorder (ADHD), with special emphasis on the ADHD treatment at CHMC.

Content:

• ADHD in Adulthood
• Childhood ADHD
• ADHD life-course
• Emotional Instability in ADHD
• Causes of ADHD
• ADHD types
• Nervous system role in ADHD
• Treatment effectiveness of ADHD
• ADHD Overdiagnosis
• Attention Deficit Hyperactivity Disorder. Summary
• FAQ (Frequently Asked Questions) about ADHD

In the following series of articles, we discuss distinct aspects of Attention Deficit Hyperactivity Disorder (ADHD), with special emphasis on the ADHD treatment at CHMC.

ADHD in Adulhood

Initially, the ADHD diagnosis was restricted only to children and adolescents younger than eighteen. First in the past twenty years genetic, neuroimaging, and psychological studies have demonstrated that ADHD symptoms persist life-long. In addition to that, the researchers found that ADHD in adulthood impairs individual’s neurocognitive functions not less than in childhood, leading to professional and social difficulties.

Prevalence of ADHD (Proportion of affected individuals in 100 people of a particular population)

ADHD is a common mental disorder. The exact prevalence numbers vary depending on which criteria (according to ICD-10 or DSM-5) are used for diagnosis and how the diagnosis is obtained.

Globally, an average prevalence rate of around 4% to 6% is assumed for children and adolescents, using the less strict diagnostic criteria according to the American classification system DSM-5. When the very strict criteria of ICD-10 are used, the rate is estimated to be 1 to 3%.

In all studies, gender-specific differences in the prevalence of ADHD can be observed, with boys being significantly more affected than girls.

Despite the evidence that ADHD symptoms continue lifelong, until today very few adults receive adequate treatment. One study conducted in the United States estimated that only 10% of adults suffering from ADHD received treatment. This means that up to nine million adult Americans remain untreated.

Symptoms of ADHD in adults

Many untreated ADHD patients have histories of negative academic and professional performance often falsely attributed to their low intelligence. However, the scientific data proved that people with ADHD are smarter than average.

ADHD symptoms include difficulty staying focused and paying attention, difficulty controlling behaviour, hyperactivity (over-activity) and impulsivity. It is hard to draw the line between normal and hyperactive behaviour and to identify a clinically significant level requiring intervention. Because other mental health disorders cause symptoms similar to ADHD, it easy to misdiagnose such conditions as ADHD. Therefore, it’s important to secure the diagnosis by an experienced psychiatrist who identifies whether a patient has ADHD, or psychiatric disorder with similar symptoms.

ADHD diagnosis in adults 

ADHD is defined as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. In order to secure the ADHD diagnosis, we cooperate closely with the patient himself as well as his parents, caregivers or fiends. At our psychiatric clinic in Dubai we diagnose ADHD based on the DSM-5 guidelines.

ADHD diagnosis in adults has the following five or more symptoms of inattention and/or 5 or more symptoms of hyperactivity/impulsivity. They must have persisted for more than 6 months.

– Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.

– Several symptoms (inattentive or hyperactive/impulsive) must be present in 2 or more settings (eg, at home, school, or work; with friends or relatives; in other activities).

– Clear evidence that the symptoms reduce the quality of social, academic, or occupational functioning.

– Symptoms do not occur exclusively during other mental disorder.

– Several inattentive or hyperactive-impulsive symptoms present prior to age 12 years.

– Several inattentive or hyperactive-impulsive symptoms present in two or more settings (e.g. at home, in the school or with friends).

– Clear evidence that the symptoms reduce the quality of, social, academic or occupational functioning

– Symptoms do not occur exclusively during the course 

The diagnosis of ADHD includes the specification of its severity

Mild – few, if any, symptoms in excess of those required to make the diagnosis are present. The symptoms result in no more than minor impairments in social or occupational functioning.

Moderate – symptoms or functional impairment between ‘mild’ and ‘severe’ are present.

Severe – many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe.

Diagnostic problems in ADHD

In adults ADHD the signs and symptoms may differ from those during childhood due to the adaptive processes and avoidance mechanisms learned during the process of socialization. Many adults with ADHD are even not aware that they have the condition. An in-depth clinical interview of such individuals will uncover history of failure at school, problems at work, failed relationships, or multiple traffic accidents.

Misdiagnosing ADHD with other conditions

Another barrier to the diagnosis of ADHD in adulthood is the blurring of the boundaries between ADHD and other psychiatric disorders. Mood and anxiety disorders are often misdiagnosed as ADHD.

Adults-ADHD and psychiatric co-morbidities

People with Attention Deficit Hyperactivity Disorder often have other overlapping mental conditions called “comorbidities”. That’s why, a thorough clinical examination is required to confirm the diagnosis of ADHD, differentiating it from other psychiatric disorders. This helps to exclude overlapping comorbidities, such as depression or anxiety, which also impairs the performance of ADHD individuals.

ADHD assessment in adults

Psychological testing for ADHD in adults is a comprehensive assessment involving various methods and tools. These assessments include clinical interviews, self-report measures, behaviour rating scales, and neuropsychological tests. They provide a complete evaluation of cognitive, emotional, and behavioral functioning.

Clinical interviews provide important understanding into an individual’s history, symptoms, and overall functioning. Self-report measures includes patients or their family members sharing information about ADHD symptoms.

Neuropsychological assessment measures several cognitive functions, including attention, memory, and executive functioning. They help identify specific deficits and their impact on daily life. Though psychological testing is crucial, it should be part of a complete evaluation that reflects medical, educational, and social factors.

This multi-layered approach confirms a precise diagnosis, rules out other conditions, and guides tailored treatment plans. Psychological testing in adults with ADHD aids not only in diagnosis but also in understanding the individual’s strengths and challenges.

A comprehensive psychological assessment is essential for those suspecting ADHD, ensuring proper treatment and support.

If you need assistance, CHMC Clinic offers expert evaluations, diagnoses, and treatment for ADHD and other emotional and behavioural health concerns.

Diagnosis of ADHD in adults based on testing alone is not sufficient. The clinical investigation can detect the causes restricting the person’s limitation. Is it a mental health disorder that impairs functioning, or is it ADHD, or a combination of both? ADHD test results in patients with depression, anxiety, bipolar disorder, will default to false-positive results for ADHD.

Psychometric tests for Adults-ADHD

Professional psychometric testing for ADHD is a useful tool to secure the diagnosis and to quantify the degree of disability. However, the psychometric testing makes sense first after ruling out other psychiatric disorders which affect the concentration. Neuropsychological tests show differences between groups of adults with and without ADHD. The tests measure the executive function, memory, processing speed, and concentration.

CHMC patients are offered the psychometric test, Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV). It is a professional, evidence-based, and practical test. The test measures not only general intelligence, but also intellectual deficiencies spotting the ADHD symptoms in adults.

Treatment of Adults ADHD

Patients usually come to us because they have difficulties completing tasks, missing deadlines, or underperforming professionally. A proper diagnosis of ADHD requires a detailed investigation that includes the patient’s medical history, mental health assessment, and level of functioning.

The entire process of ADHD treatment usually involves combination of medications, psychotherapy, behaviour modifications and lifestyle changes. Multiple studies proved that the best ADHD treatment results are achieved using combination of medication and psychotherapy.

After confirming the diagnosis, our psychiatrist prescribes medications tailored to the adult ADHD symptoms. In case of co-morbid psychiatric disorders, such as depression or anxiety treatment follows in the correct order. For instance, if a patient suffers of both depression and ADHD, depression should be treated before ADHD.

Adults ADHD treatment with medication

The medication is one of the main pillars for the ADHD treatment. Psychiatrists prescribe this medication under conditions of strict documentation and close patient monitoring. Medication called “stimulants” is the first-line pharmacological treatment for ADHD. In the UAE just like in other countries stimulants have the status of “narcotic medication”. The medication available for treatment of ADHD in Dubai is: Methylphenidate in fast and extended-release form, and Atomoxetine.

It may seem unusual to treat hyperactivity with stimulating medication. However, this medication has actually a calming effect on ADHD patients.

In order to reduce the risk of habit-forming behaviour the medication of choice in treatment of adults ADHD are slow-release stimulants. Patients with ADHD and symptoms of depression also can be treated with Bupropion, a dopaminerg antidepressant.

The use of stimulating medication such as Methylphenidate requires meticulous documentation of the prescribed dosage. ADHD patients respond “paradoxically” to stimulating medication, which in their case has calming and focus increasing effect. That’s why the risk of dependency in accurately diagnosed ADHD patient using the stimulants is negligible.

A careful titration of the medication used for ADHD treatment, regular laboratory and ECG controls help to exclude potential side effects. If these criteria are met, the benefits of treatment far outweigh the possible risks.

Adults ADHD treatment with psychotherapy

ADHD can be treated by various forms of psychotherapy. The most effective evidenced based method is behavioral therapy. It focuses on patient’s behaviour to improve concentration and to reduce the hyperactivity.

Behavioural therapy includes practical help by organizing tasks or dealing with emotionally challenging events working through positive reinforcement for desired behaviours. It helps to control the anger trough thinking before acting. It helps the patient and his family to understand and to gain control of the stressful feelings related to ADHD.

Our psychologists are using customer focused, evidence-based therapeutic methods, including the mentioned CBT as well as mindfulness and Life-Skills training.

ADHD in childhood

Attention Deficit Hyperactivity Disorder (ADHD) and refers to a behavioral disorder in children, adolescents, or adults, characterized by abnormalities in the following three core areas:

• attention and concentration problems

• strong impulsivity

• marked physical restlessness (hyperactivity)

An exclusively deficit-oriented perspective does not do justice to these children. Many children with ADHD also have special resources due to their condition. For example, impulsivity can manifest as spontaneity, flexibility, and even creativity.

A subtype of ADHD is Attention Deficit Disorder (ADD), primarily characterized by pronounced inattention rather than hyperactivity or impulsivity.

Core symptoms of ADHD

Children with ADHD exhibit abnormalities in the areas of inattention, hyperactivity, and impulsivity. Other children may sometimes be inattentive, and younger children are generally more active than older children. However, the problems that ADHD children experience in these areas are significantly more pronounced than their peers.

ADHD can affect their academic performance, as well as their relationships with parents, teachers, and friends. The severity of these problems can vary greatly, and the transition from normal to atypical behaviour is fluid. This is similar to other psychiatric disorders or physical illnesses that can range from mild to severe. Nevertheless, professionals can reliably determine whether your child has ADHD or not.

Inattention

Individuals, including children, adolescents, and adults, who struggle with attention problems find it extremely difficult to finish tasks they start. They can only focus on one thing for a short period of time getting easily distracted from a task at hand, resulting in frequent careless mistakes.

These difficulties are often more pronounced in activities that are less interesting and externally imposed by others (e.g., homework, school/work tasks). Some children also experience these problems in activities they choose for themselves, for example by quickly interrupting and not completing self-selected games.

Hyperactivity

Children and adolescents affected by hyperactivity (excessive physical restlessness), particularly in kindergarten and elementary school, stand out due to their constant restlessness and fidgeting. The restlessness can also appear by constantly getting up during class or meals. Children with ADHD often find it challenging to play calmly, as they are constantly active, continuously running or climbing. When asked to be still or sit down, they can only comply for a very short time.

In adolescence, the physical restlessness is usually less pronounced, but there may still be a strong inner restlessness and tension.

Impulsivity

Children with pronounced impulsivity tend to act thoughtlessly and hastily. They follow their initial ideas and impulses without considering the consequences of their actions. Impulsivity manifests in situations such as starting homework without reading the assignment carefully. Sometimes they blurt out answers before questions are fully asked, frequently interrupting others, and having difficulty waiting for their turn.

School performance

Many children with ADHD exhibit developmental delays and performance issues in school. However, for most children, these setbacks are specific, meaning they cannot be attributed to their intellectual disability. In contrary, the ADHD individuals have a higher IQ compared to their not affected peers. They poorer performance in reading, spelling, and arithmetic are solely the effect of inattentiveness and hyperactivity. Clumsiness and coordination difficulties also occur, leading to poor handwriting. Even in preschool and kindergarten, many children exhibit developmental delays, particularly in language, drawing, and movement coordination.

Emotional problems

Children with ADHD exhibit emotional problems which often go unnoticed initially because other issues, such as hyperactive and impulsive or oppositional and aggressive behaviour, are more prominent.

Such problems can manifest as insecurity and lack of self-confidence. Over time, many children with ADHD develop anxiety and uncertainties. They feel less capable than other children, especially in situations related to school performance. Therefore, children with ADHD tend to repeat grades more frequently.

However, they also often experience a lack of self-confidence in other situations. Due to frequent rejection from peers, parents, caregivers, and teachers, many, although not all, children feel insecure and display low self-confidence in social situations.

For some children and adolescents, these emotional issues can escalate into depression and/or anxiety which affects even more their school achievements and social interactions.

Rejection by peers

Children with ADHD are often marginalized by their peers. This can happen either because they constantly disrupt shared play or because their impulsive or aggressive behaviours are perceived as troublemakers or bullies.

Many children with these behavioral problems attempt to dominate and control others as a result of this rejection, in order to maintain relationships with their peers. However, this behaviour can amplify the rejection from their peers.

Strained relationships with parents and teachers

The hyperactive and inattentive behaviour combined with problems to follow roles leads often to conflicts with parents making the relationship between parents and their ADHD child frequently highly strained.

Parents often feel desperate because they can hardly or not at all reach their child with parenting measures (repeated talking and explaining). Parents frequently feel like they have failed in parenting. On the other hand, the child often feels rejected by their parents and believes that he can never do anything right in his parents’ eyes.

The relationships between the child and the kindergarten teacher or the school teacher are often similarly tense.

Diagnostic procedure in child ADHD

Assessments for children ADHD are primarily based on information provided by third parties (parents, teachers), whereas ratings for adults are primarily based on patient self-reports.

DSM 5 diagnostic criteria for child ADHD

The diagnosis for ADHD is based on the DSM-5 defining the disorder as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

In general, the ADHD symptoms usually appear early in life, often between the ages of 3 and 6. The major diagnostic problem is that children mature at different rates and have different personalities, temperaments, and energy levels. 

Children get often distracted, act impulsively, and struggle to concentrate at one time or another. We have to be careful not to mistake these normal factors for ADHD. For securing the ADHD diagnosis the symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.

Six or more of the below symptoms must persist for at least 6 months:

– fails to give close attention to details or makes careless mistakes in schoolwork

– has trouble holding attention on tasks or play activities

– does not seem to listen when spoken to directly

– does not follow through on instructions and fails to finish schoolwork

– has trouble organizing tasks and activities.

– avoids, dislikes, or is reluctant to do tasks that require mental effort

– loses things necessary for tasks and activities (e.g. school materials, pencils, books)

– Is easily distracted

– Is forgetful in daily activities

Clinical interview and psychometric testing

We use several methods to diagnose ADHD. The most important of them is a thorough clinical interview followed by psychometric assessment. The physical examination, neuroimaging, and laboratory tests help to rule out physical causes of the attentiveness and hyperactivity. The interview of the parents helps to identify the first signs of ADHD in the early child’s development. The parents describe the child’s behaviour as: “having been all over the place”, “daydreaming”, and not being able to ply consistently.

No single test can diagnose a child as having ADHD. A licensed health professional specialized in ADHD should secure the diagnosis by gathering information about the child’s behaviour and environment. The diagnostic process should include the school and medical records. It’s also important to identify unusually stressful child`s home or school settings. The child`s parents and teachers complete the clinical picture providing the necessary information about child’s past behaviour in the home setting and at the school.

ADHD therapy in children

The question of the right treatment arises immediately for parents after the ADHD diagnosis. As ADHD is a not curable condition, the therapy focuses on the symptoms.

Above all, the goal is to normalize the hyperactive, inattentive, and impulsive behaviours of the child as much as possible. This is important for the affected children to develop appropriately for their age and integrate into their environment (family, school, leisure activities).

The multimodal therapy approaches

Treatment options for ADHD have significantly improved in recent years. The multimodal therapy combines various treatment components such as:

• Education and counselling (“psychoeducation”)

• Behavioral therapy

• Parent and teacher training for educational purposes

• Medication treatment

The multimodal therapy approach aims to normalize the main symptoms of hyperactivity, attention deficits, and impulsivity. It also aims to improve academic performance and behaviour in school. Additionally, the child’s personal development and social relationships with friends and family are important measures of therapy success.

ADHD life-course

ADHD symptoms can manifest before school age, typically becoming recognizable by the age of five to six. However, these children often stand out even in early childhood, and ADHD-related problems intensify during the preschool years. The elementary school years are typically the most challenging. During adolescence, some core ADHD issues may diminish. However, in many cases, impairing problems may persist into adulthood. In the following article, we present the ADHD course in different life stages.

ADHD course in early childhood

In infancy and early childhood, some children who later develop ADHD exhibit a very high level of activity. They constantly appear restless and struggle to find calmness. Some children experience regulatory disorders, such as difficulties with feeding, digestion, and sleep. They often seem irritable and cry a lot. These behaviours can significantly burden parents.

The development of ADHD is more likely when these regulatory disorders in the child coincide with significant parental stress. In some children who later develop ADHD, early developmental delays may already be noticeable, such as delayed walking or speaking.

ADHD in preschool age

Motor restlessness and extreme hyperactivity are typically pronounced during the preschool years. Children find it challenging to play calmly and persistently. Sometimes, these behaviours are more noticeable in the kindergarten setting due to the increased stimulation compared to the home environment. Additionally, many children exhibit extreme tantrums and disregard for boundaries and instructions. Parents often experience significant strain due to their child’s uncontrolled behaviour, which requires a high level of supervision and patience that may not always be sustainable. The high impulsivity of children with ADHD significantly increases the risk of accidents at home and in traffic.

Some children may also experience developmental delays. For example, they may exhibit motor clumsiness or have difficulty speaking compared to their peers. Motor problems can manifest, for instance, in a dislike of colouring, particularly staying within the lines, or struggles with using pens and scissors compared to same-age children.

ADHD course during elementary school

With the start of elementary school, affected children often experience a significant increase in difficulties. The onset of typical symptoms or additional problems frequently occurs at this time because the children are suddenly confronted with demands for calmness, endurance, and concentration that overwhelm them.

Homework completion often becomes a core problem within the family. Poor academic performance, particularly difficulties in reading and writing, commonly occur but not always. Due to these challenges, many children quickly lose interest in learning. Aggressive behaviours and self-esteem issues may escalate. School difficulties can become so severe that grade repetition or changing schools becomes necessary.

Furthermore, during this time, affected children frequently encounter rejection from their peers, which can amplify the development of low self-esteem and the expansion of aggressive behaviours.

ADHD course in secondary school

Transitioning to secondary schools usually brings significant changes to the educational environment. Academic requirements increase, and teachers change in nearly every subject. Consequently, establishing a stable teacher-student relationship, which is particularly crucial for these children, is often challenging. As a result of these changes, symptoms often worsen in many cases.

ADHD in adolescence

With the onset of adolescence, physical restlessness generally diminishes, while attention problems and impulsive actions often persist.

Children with a favorable progression of the condition may no longer exhibit differences compared to their peers, although they are still considered highly energetic. Adolescents who displayed aggressive behaviours as children are prone to developing antisocial behavioral problems. These problems mainly manifest as truancy, significant lying, and stealing. Frequently, these teenagers tend to associate with peers facing similar issues, which often leads to alcohol and drug abuse.

If significant impulsivity and inattention persist during adolescence, the risk of traffic accidents increases. Heightened sexual curiosity and risky behaviours are more likely to result in infectious diseases and early pregnancies.

For children who have experienced school as highly negative over many years, extreme aversion to anything related to academic performance (“zero motivation”) develops, and their self-esteem suffers as a result. Those who experience numerous failures in school, within the family, and among peers during childhood and adolescence are at an increased risk of depressive moods.

ADHD in adulthood

The behavioral problems of adolescence can continue into adulthood for some individuals, while others see a reduction in problems as they enter adulthood. The least favorable outcome occurs for those who developed antisocial behavioral issues during adolescence and completed school with poor academic performance.

Motor restlessness becomes less prominent in adulthood and is replaced by a sense of inner restlessness. Impulsivity may persist and manifest, for example, in an inability to wait in line or frequently interrupting conversations. However, adults primarily struggle with attention and concentration problems. These difficulties are most pronounced in the workplace, but also affect family life and leisure activities. Organizing tasks becomes challenging, forgetfulness is common, and they often act without a plan.

ADHD in boys and girls

According to most studies ADHD is much more common in boys than in girls, occurring two to four times more frequently in boys.

The causes for the gender difference are still unknown. It is believed that genetic factors play the dominant role. However, it is possible that differences in the upbringing of boys and girls still play a – albeit subordinate – role.

Among children with ADHD boys are presented for diagnosis and therapy more frequent than girls. This is probably because boys tend to be “noisier” than girls. They show also more frequent hyperactivity and impulsivity than girls.

Moreover, when it comes to additional problems, boys more commonly exhibit disruptive symptoms such as aggressive and oppositional behaviour. In contrast, girls tend to show slightly higher rates of inattentiveness and emotional problems such as daydreaming, insecurity, or sadness.

Emotional Instability in ADHD

Despite not being part of the official diagnostic criteria, one third of adolescents and adults with ADHD report about their emotional instability as their main impairment. The emotional instability includes flash tempers, low frustration tolerance, and feeling easily overwhelmed by emotions. Individuals with ADHD also struggle with empathy. They may appear cold and aloof while being very sensitive to rejection and criticism.

Assessing emotional instability in ADHD

The absence of emotions in ADHD diagnostic criteria is attributed to the difficulty of measuring them objectively. As the research focuses on observable behaviours the symptoms should be visible and countable. However, emotions are not always present and not easy to be quantified.

Major types of emotional instability in ADHD

There are three major types of emotional problems associated with ADHD. This includes over-reaction, shame/guilt and emotional regulation issues sensititve to rejection. The first two are commonly associated with a number of other psychiatric conditions. However, the rejection sensitivity seems to be associated exclusively with ADHD.

Over-reaction

People with ADHD live intense, passionate lives. If they are not interested in something, it is not on their radar screen. They only engage deeply with subjects that genuinely interest them. People with ADHD tend to over-react to things that others may consider minor. This hyperarousal can lead to constant mental agitation, making it hard for ADHD individuals to experience inner peace.

Shame and Guilt

Children with ADHD often receive a significant number of critical or corrective messages during their upbringing, affecting their self-esteem and emotional well-being. This can result in feelings of inadequacy and incompetence, ultimately impacting their self-esteem.

Rejection Sensitive Dysphoria (RSD)

The RSD appears to be the emotional condition found only with ADHD. Rejection Sensitive Dysphoria (RSD) involves extreme emotional sensitivity and pain triggered by perceived rejection, teasing, criticism, or disappointments. The emotional pain is described as unbearable and can lead to depression or externalized rage. RSD is often misdiagnosed as social phobia but is distinct in its nature.

ADHD individuals may become people-pleasers, or withdraw from chalanges to avoid potential rejection or failure. These coping mechanisms comes at a high personal cost preventing them from higher achivements and leading to disatisfaction.

RSD Treatment of adults with ADHD

Treatment for RSD and emotional difficulties associated with ADHD is challenging due to its genetic and neurological nature. Since RSD is genetic and neurological, psychotherapies have been found to have little benefit.

RSD Treatment with Alpha-Agonists

Psychotherapies have limited benefits, but certain medications like alpha-agonists (Guanfacine and Clonidine) can provide relief for some individuals. Guanfacine and Clonidine are FDA-approved for the treatment of ADHD, especially for the treatment of hyperactivity. Unfortunately, only one out of three people treted with Guanfacine get a robust benefit; the rest just get mild sedation. But for the lucky ones, the change is nothing short of life changing and freeing. Most report that the benefits to their quality of life are much greater with an alpha-agonist than they experienced with stimulant medication. Side effects are dry mouth, mild sedation, and more frequent dizziness if the person stands up too quickly.

RSD Treatment with MAOIs

Additionally, Monoamine Oxidase Inhibitors (MAOIs), particularly tranylcypromine, have been found to be effective for both the attention/impulsivity component of ADHD and RSD. However, these medications require dietary restrictions and caution when combined with other drugs, making them only suitable for specific cases under professional guidance.

Causes of ADHD

The scientists were not able to pinpoint the root cause of ADHD. Multiple studies suggest a combination of genetic, environmental, and social factors trigger the disorder.

Genetics as the root-cause for ADHD

Inherited from our parents, genes are the “blueprints” for who we are. Results from several international twin studies show that ADHD often runs in families. Children with ADHD have thinner brain tissue in the brain areas (prefrontal cortex) associated with attention. Those children carry a version of a certain gene which seems to be the underlying cause for developing ADHD.

Environmental factors versus genetics

Scientific twin studies suggest that 9 to 20 % of hyperactive and inattentive behaviour attributes to non-shared environmental (non-genetic) factors. This means that in reverse 80 to 90 % identical twins will develop the condition. Such ratio proves that genetics is the main factor in developing ADHD.

Other studies showed that infections during pregnancy and in early childhood, and premature births increased the risk of developing ADHD.

ADHD predisposition is inherited, however not every individual with such predisposition will develop the condition. Parents can reduce the likelihood of ADHD genes being expressed as the child grows older by decreasing their child’s electronic time while increasing interpersonal time. Science-based recommendations from experts can help them take practical measures towards minimizing the risk. One of such measures is limiting the amount of television watched and computer games and putting down mobiles. Studies have shown that infants and toddlers who watch television or play with mobiles more than two hours a day are more likely to develop ADHD.

On the other hand, parents should encourage reflection and patience-promoting activities such as reading, social interactions, having family meals, reading together, playing board games, going outside and playing sports. They should engage their children in slow-paced, step-by-step activities by avoiding multitasking.

Expectant mothers should take care to avoid alcohol, cigarettes, illicit drugs, or mistreatment of themselves. A poor health care during pregnancy can increase the risk of developing ADHD. Thus, a proper medical care during delivery is particularly important.

Brain abnormalities, pathophysiology, and ADHD

The pathophysiology of ADHD is still unclear and there are several competing theories. Imaging studies using MRI and PET-scan on the brain of children with ADHD showed reduction in the volume of the prefrontal cortex.

A review of published studies involving neuroimaging, neuropsychological genetics, and neurochemistry suggest that four connected front striatal regions (the lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen) play a role in the pathophysiology causing ADHD.

Evolutionary theories and ADHD

The hunter vs. farmer theory suggests that hyperactivity may be an adaptive behaviour in pre-modern humans. The individuals with ADHD retain some of the older “hunter” characteristics associated with early pre-agricultural human society. According to this theory, individuals with ADHD may be more adept at searching and seeking. On the other hand, they are less adept at staying and managing complex tasks over time.

Hyperactivity as a leading symptom of today’s ADHD may be explained trough the adaptive evolution of ancient societies. In these societies, those with hyperactivity might have been more proficient in tasks involving risk or competition (i.e. hunting, mating rituals, etc.).

Researchers found a genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele), is more frequent in more nomadic populations. Consistent with this, another group of researchers observed that the health status of nomadic men was higher if they had the ADHD associated genetic variant (7R alleles).

Social influence as the root cause of ADHD

Researchers believe that disturbed relationships between the baby and the caregiver is one of the root causes for ADHD. Emotional detachment of the caregiver has a profound effect on child’s attentional and self-regulatory abilities. Behaviour typical for ADHD has been found in children who have suffered violence and emotional abuse.

ADHD types

The core symptoms of ADHD – inattention, hyperactivity, and impulsivity – rarely occur alone. Often, affected children and adolescents with ADHD have other problems that can change as they age.

Although most children and adolescents with ADHD do not differ in their intellectual abilities from others, many struggle with academic performance problems. They have difficulties in reading, spelling, or arithmetic and, as a result, often repeat a grade.

The symptoms vary in different individuals with two predominant ADHD presentations: inattentive and hyperactive-impulsive as well as the mixture of both: combined presentation.

Children with ADHD often do not respond to normal disciplinary measures in the same way as other children. Consequently, parents, caregivers, and teachers often find themselves in challenging situations. Positive experiences become overshadowed by these negative events, both within the family and in kindergarten or school.

ADHD diagnosis and its subtypes

The diagnosis of attention disorders is based on WHO’s internationally defined criteria set forth in the ICD 10 (International Classification of Diseases) and the DSM-5 classification system (Diagnostic and Statistical Manual of Mental Disorders), developed by the American Psychiatric Association. You will find the criteria in our other article about diagnosing ADHD.

As with all mental disorders, nowadays the term “illness” is avoided when referring to ADHD to emphasize the distinction from physical diseases. Therefore, the more neutral term “mental disorder” is preferred internationally.

The characteristics of attention deficit disorder, hyperactivity, and impulsivity may not be equally present in all cases. Therefore, DSM 5 differentiate further ADHD in subtypes distinguishing between inattentive, hyperactive-impulsive and combined presentations.

In cases of lower severity, not all three areas are equally apparent, and the problems may not occur to the same extent in all aspects of their lives. It is also possible for ADHD to manifest in different forms as a child develops:

In the preschool years, symptoms of hyperactivity and impulsivity often dominate, while in later development, especially during adolescence, inattention takes the forefront and hyperactivity diminishes.

In the American classification system (DSM-5), the following three presentations (subtypes) of ADHD are distinguished from one another.

Predominantly inattentive ADHD presentation

In ADHD with predominantly inattentive presentation, individuals often fail to give close attention to details or make careless mistakes. They struggle to sustain attention, do not appear to listen, and have difficulty following instructions. Additionally, they face challenges with organization, avoid or dislike tasks requiring sustained mental effort, and tend to lose things easily. Moreover, they are easily distracted and forgetful in daily activities.

ADHD with predominantly hyperactive-impulsive presentation

ADHD individuals with hyperactive-impulsive presentation, frequently fidget with hands or feet, squirm in chairs, and have difficulty remaining seated. They engage in excessive running or climbing, which manifests as extreme restlessness in adults. Moreover, they struggle to engage in activities quietly and act as if automatically driven. Adults with this presentation often feel internally “driven by a motor”. They also tend to talk excessively, blurt out answers, and have difficulty waiting or taking turns. Additionally, they may interrupt or intrude upon others.

ADHD with combined type

The Combined presentation involves meeting the criteria for both inattention and hyperactive-impulsive presentations.

Children and adolescents with this form of ADHD exhibit characteristics in all three areas, including pronounced hyperactivity, strong impulsivity, and marked inattention. To receive a diagnosis, these symptoms must start before age 12, be present in multiple settings, and interfere with functioning at home, school or work, and social settings. Moreover, they cannot be better explained by another disorder.

ADHD in partial remission

If symptoms decrease in adolescence or adulthood to the point where they are no longer sufficiently present for a diagnosis, according to DSM-5, it is possible to add the term “in partial remission” for adolescents and adults.

Residual type of ADHD

In the residual type of ADHD, not all symptoms that were present during childhood, are fully expressed but they still persist. However, in adolescence, hyperactivity and partly impulsivity often decrease, while attention deficits (inattention) remain.

Additional problems in ADHD

The core symptoms of ADHD – inattention, hyperactivity, and impulsivity – rarely occur alone. Often, affected children and adolescents with ADHD have other problems that can change as they age. Unpleasant experiences and negative interactions occur more frequently between parents, teachers and the child or adolescent.

Most commonly, children and adolescents with ADHD also exhibit oppositional and aggressive behaviours.

Conflicts with parents, teachers and peers

A variety of children and adolescents with ADHD are often rejected by their peers. This can happen because they constantly disrupt play due to their ADHD symptoms or because their aggressive behaviours are perceived as bullying.

Due to the frequently socially inappropriate behaviours of children and adolescents with ADHD, parents often have increased conflicts with their child, and the relationships between parents and child are often highly strained.

Oppositional and aggressive behaviour

Most commonly, children and adolescents with ADHD also exhibit oppositional and aggressive behaviours. These behaviours include not following important rules in the family, kindergarten, and school. Additionally, they do not respond to instructions from adults, often have outbursts of anger, and engage in frequent conflicts with siblings and other children.

In adolescence, it can occur that individuals with ADHD disregard important social rules. This can lead to various behaviours: some lie to gain advantages, some steal within or outside the family, or they skip school and stay out later at night than allowed. As a result of theft or property damage, individuals with ADHD often eventually come into conflict with the law.

Tics

Motor tics are sudden, involuntary movements such as eye blinking, nose twitching, or jerking of the head. Vocal tics are involuntary vocalizations, such as throat clearing, or even words and phrases that are suddenly spoken out. Such tics occur more frequently in children with ADHD, often starting in childhood and persisting into adolescence and adulthood.

ADHD Nervous System

Attention Deficit Hyperactivity Disorder (ADHD) is an enigmatic and often perplexing condition. The diagnostic criteria employed for the past four decades have left many individuals uncertain about whether they truly suffer of this condition.

Clinicians confront exhaustive lists of symptoms, with the DSM 5 encompassing a staggering 18 criteria, while other compilations cite up to 100 traits.

Seeking a more comprehensible approach, practitioners have endeavoured to elucidate the complexities of ADHD. The leading psychiatrist who took a fresh look at ADHD was Dr. William Dotson. His research has unveiled a crucial aspect of the ADHD, leading him to a revelation about the fundamental nature of the ADHD brain, one that sets it apart from neurotypical (“normal”) individuals. Consulting over two decades hundreds of ADHD individuals, he found a common thread that defines their uniqueness: the ADHD Nervous System.

Dr. Dodson is a board-certified adult psychiatrist who since decades specializes in adults with ADHD. He was named a Life Fellow of the American Psychiatric Association (APA) in 2012 in recognition of his contributions to the field of adult ADHD.

Specific qualities of ADHD nervous system

People with ADHD possess a remarkable nervous system that operates differently from their neurotypical (“normal”) peers. Being wired differently doesn’t diminish a person’s worth or validity. ADHD individuals may naturally approach things in unconventional ways, often deviating from societal norms, but this divergence doesn’t equate to being incorrect or inferior.

Understanding the structure of the ADHD brain can provide valuable context. The frontal lobe, often regarded as the conductor of the brain’s orchestra, governs executive functions. These functions encompass problem-solving, working memory, motivation, judgment, impulse control, planning, decision-making, attention, and the ability to delay gratification. Coincidentally, these are areas where many individuals with ADHD encounter challenges. Struggles with organization, decision-making, and impulse control can create difficulties for those with ADHD in a society governed by rigid societal structures.

One prevailing theory suggests that ADHD individuals face issues with dopamine processing, a neurotransmitter crucial for motivation and stimulation. Lower dopamine levels can impede task gratification, making it challenging to initiate and complete tasks. Decision-making can also become overwhelming, trapping individuals in a state of indecision.

Interest versus importance based nervous system

The ADHD nervous system operates differently when it comes to motivation. Dr. Dodson, introduced the concept that people with ADHD possess an interest-based nervous system, whereas neurotypical individuals (“normal people”) have an importance-based one.

Importance-based nervous system

In the case of an importance-based nervous system, tasks are completed because they are deemed important. It might be a personal sense of importance or driven by external factors, such as rewards or consequences. The task is carried out because it’s believed to be the right thing to do, driven by a sense of duty or because someone else values it.

Interest-based nervous system

In contrast, an interest-based nervous system finds motivation through genuine interest or passion for a task. Mere “shoulds” or the fear of consequences are not motivating factors. Instead, what drives them forward is their inherent curiosity and engagement with the task at hand.

Even if someone with an interest-based nervous system recognizes the importance of a task, such as for example cleaning, they may struggle to initiate the action because it lacks engagement. Cleaning is repetitive, mostly unpleasant, and time-consuming. While individuals with ADHD may genuinely want ro do a task and dislike being yelled at, the lack of interest makes starting the task challenging.

Misunderstandings and misconceptions about ADHD

The key issue lies in misunderstanding the interest-based nervous system, leading to misconceptions that individuals with ADHD are lazy or indifferent to others’ needs. In reality, a task can hold importance but still lack the inherent engagement necessary for motivation.

Without interest, there’s a dearth of dopamine, the neurotransmitter responsible for motivation. This deficiency in motivation transforms tasks into uphill battles, often exacerbated by external shame from those who fail to comprehend the difficulty individuals with ADHD face.

ADHD, the exception from the Role

In a world where 90 percent of individuals are considered “normal” or “neurotypical,” it’s crucial to understand that this term doesn’t imply superiority or normality. It means that their neurological makeup aligns with societal norms. For neurotypical (“normal”) people, interest, challenge, novelty, or urgency can be motivating but are not mandatory prerequisites for task execution.

The geniuses from the past and the presence were and are everything but not “normal” as per the understanding of their epoch or culture.

One of the most brilliant minds of the past century, C.G. Jung used to say:

“To be normal is the ideal aim for the unsuccessful.”

Living in the World of “Normal Peaple”

Normal (neurotypical) individuals rely on three key factors when deciding what to do and how to see tasks through:

1. Main importance:

They believe a task should be completed.

2. Secondary importance:

External validation, such as the approval of parents, teachers, or bosses, motivates them.

3. Rewards and consequences:

They respond to the prospect of rewards for task completion and consequences for inaction.

ADHD. Living in incompatible world

For individuals with an ADHD nervous system, importance and rewards do not serve as effective motivators. They acknowledge importance, appreciate rewards, and dislike punishments, yet these factors merely register as nagging distractions.

This difficulty in utilizing importance and rewards profoundly impacts the lives of individuals with ADHD:

• Decision-making becomes challenging when these concepts offer no guidance or motivation.
• Major life choices become daunting because conventional motivators don’t apply.

The above mentioned difficulties in utilizing importance and rewards explain the misalignment while living in the world governed by different roles. The difficulties face by ADHD individuals manifest in various ways:

• The standard education system, founded on prioritizing and emphasizing what others consider significant, doesn’t accommodate individuals with ADHD.
• Conventional employment, which pays for adhering to someone else’s priorities (i.e., the boss’s), often proves stifling.
• Organizational systems, cantered on prioritization and time management, are ill-suited for individuals with ADHD who struggle with these aspects.
• Decision-making becomes an ordeal because everything appears equally unimportant, making alternatives indistinguishable.

Losing Interests in Tasks

Research using PET (Positron Emission Tomography) imaging has unveiled insights into why the ADHD brain often loses interest in tasks. In individuals with ADHD, chemicals that activate reward-recognizing circuits in the brain show reduced binding to receptor sites compared to neurotypical counterparts. This difference explains why people with ADHD struggle to anticipate pleasure or find satisfaction in tasks with delayed rewards.

One significant consequence of this brain chemistry variance is the difficulty ADHD individuals face in initiating tasks that lack inherent interest. Moreover, they struggle to maintain motivation when the rewards are not immediately attainable. These challenges in task activation and motivation contribute to the common experience of tasks losing their appeal for those with ADHD.

Levelling the deficiency with medication

Medication plays a crucial role in providing individuals with ADHD the necessary attention span, impulse control, and inner calm. Typically the medication beeing used in ADHD treatment are the stimulants. They enhance day-to-day functioning, facilitating task completion. However, stimulants fall short in addressing the internal hyperarousal that many with ADHD contend with.

The power of self-understanding

Encouraging individuals with ADHD to document what triggers their optimal performance fosters self-understanding. Whether it’s intrigue, competition, or urgency, recognizing these triggers empowers individuals to proactively engage with tasks. This approach doesn’t seek to alter the ADHD nervous system but capitalizes on its inherent strengths.

Developing a manual

Medication alone cannot drive substantial change if ADHD individuals employ strategies used by “normal people.” The second crucial component involves crafting a personalized ADHD owner’s manual. The key is to determine what motivates ADHD individuals and enables them to excel in their existing life circumstances, rather than fixating on their shortcomings. The focus has to be shifted to identifying the triggers that facilitate exceptional performance.

Practical Exercises for Individuals with ADHD Nervous System

Caring a notepad and analysing the following instances:

Intrigue:

What tasks or situations are interesting or intriguing?

Competitiveness:

What aspects of the “opponent” or situation ignites the competitive drive?

Armed with this knowledge, ADHD individuals gain a profound understanding of how their unique nervous system functions and which techniques prove beneficial when engagement and performance are paramount.

These strategies have yielded notable success for many with ADHD. They don’t endeavour to transform individuals with an ADHD nervous system into neurotypical counterparts – an unattainable goal. Instead, they offer enduring support by harnessing and amplifying the individual’s innate strengths.

“The ADHD Zone”

The term “Attention Deficit Hyperactivity Disorder” doesn’t resonate with the nature of this condition. ADHD is not a disorder that implies damage or defect. Despite the association with learning difficulties, those with an ADHD nervous system often possess significantly above-average IQs. They utilize their intelligence differently from neurotypical individuals, excelling in problem-solving and innovating solutions that others may overlook.

Contrary to the hyperactivity stereotype, most adults with ADHD are not outwardly hyperactive. Their hyperactivity manifests internally, with racing thoughts and a mind juggling multiple thoughts at once. The core of ADHD isn’t an attention shortage but rather erratic attention.

In ADHD individuals the nervous system is functioning adeptly by its unique rules. ADHD individuals experience moments of brilliance, commonly known as “entering the zone.” In this state, impairments vanish, and executive functions soar. The trigger for entering the zone is often an intrinsic interest in the task at hand. Unlike external motivators, intrinsic interest fuels the ADHD nervous system.

People with ADHD tend to “enter the zone” becoming functional when they are genuinely interested or intrigued by a task, aligning with an interest-based nervous system. Critics may label them as unreliable or self-serving when they insist on doing things they like, but this is the nature of their ADHD nervous system.

Challenges and competitive environments also trigger the zone for individuals with ADHD, as does novelty, albeit temporarily.

The challenge of procrastination

The inability to rely on concepts of importance and rewards creates unique challenges for ADHD individuals. Procrastination is a pervasive challenge for ADHD individuals. The delay in starting tasks isn’t due to a lack of desire. When traditional motivators hold little sway AHD individuals face difficulties in the decision-making process. This intrinsic motivation is the key to unlocking their full potential.

Interestingly, the urgency of a task can propel those with an ADHD nervous system to engage and access their abilities. However, procrastination often plagues them, as they struggle to initiate tasks until they become interesting, challenging, or urgent. It’s a well known phenomenon, that students with ADHD tend to start learning few days or even hours before the exam, after the urgency reached the “critical point”.

Understanding and treating ADHD

The newfound understanding of ADHD carries significant implications. To begin with, it is imperative for coaches, doctors, and professionals to abandon the misguided endeavour of transforming individuals with ADHD into neurotypical counterparts. Instead, the focus should shift towards early intervention that accommodate their unique neurology. By acknowledging and leveraging the strengths of the ADHD nervous system, therapeutic strategies can prevent the frustration and demoralization experienced by ADHD individuals offering them lifelong benefits.

Importance versus revord system

The distinction between systems based on importance (normal people) or interest (ADHD individuals) is the key for understanding the nature of ADHD. It highlights that tasks can be important but uninteresting, making them challenging to tackle. From the education system to the workplace, the mismatch between the ADHD nervous system and established norms leads to disorganization, difficulty prioritizing, and an overall sense of feeling out of place.

Revelation of how ADHD operates offers a fresh perspective on managing this condition. By embracing ADHD’s particular characteristics can redefine success for individuals navigating in the world of neurotypical (normal people), relying on importance, rewards, and external validation as motivators.

Rather than attempting to reshape individuals with ADHD into neurotypicals (“normal people”), the emphasis should be on early intervention and a holistic approach that combines appropriate medication with the creation of personalized owner’s manuals.

It’s vital to recognize that individuals with an ADHD nervous system aren’t incapable or flawed. They possess intelligence and ingenuity. The primary challenge arises from being handed a manual designed for normal people that doesn’t align with their inner world and abilities.

Treatment Effectivness of ADHD (Multimodal Treatment Study)

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects millions of children and adolescents worldwide. The treatment of ADHD has long been a subject of research and debate, with various approaches available.  

A pivotal development in ADHD research was the establishment of the Multimodal Treatment Study of ADHD (MTA) in the late 1990ties by the US Federal Government.  The results of this study, published in December 1999, stands as the largest research undertaking on ADHD in children.

The design of multimodal treatment study

The MTA study involved 579 elementary school-aged boys and girls diagnosed with ADHD.

These children were divided into four different treatment groups to assess the effectiveness of various approaches.

1. The first group received medication tailored to each child’s specific needs.
2. The second group underwent intensive behaviour management, which included summer camp program, ongoing support for teachers, parent training and individual and group therapy.
3. The third group combined medication with behaviour management.
4. The fourth group received comprehensive assessments and referrals to community-based resources.

Results of the study

After a 14-month study period, the data has been evaluated. The first and third group that received medication showed remarkable progress, achieving significant improvements. Interestingly, adding the behavioral psychotherapy component did not substantially enhance outcomes, except in cases where individuals had co-existing conditions like anxiety or depression. In those cases, the combination of medication (preferably antidepressants) and behavioral psychotherapy made a notable difference.

Surprisingly, the intensive behavioral psychotherapy program, despite its considerable time and resource investment, proved less effective than medication alone.

The most disappointing finding was that the benefits of the psychotherapy program did not endure after the treatment ended. The hope had been that these techniques would become internalized by the children, allowing reducing the need of intensive treatment. Unfortunately, once the treatment ceased, so did the benefits, indicating the need for ongoing support and management.

Benefits of multimodal treatment

The Multimodal Treatment Study (MTA) study’s long-term tracking of participants into adolescence was crucial in understanding the evolving nature of ADHD and its comorbidities. Ongoing MTA follow-up reports offer valuable insights into the trajectory of ADHD throughout the childhood and adolescence, paving the way for more comprehensive and effective interventions.

A closer examination of the data reveals that children in the combined treatment group, receiving both behavioural psychotherapy (preferably CBT) and medication, exhibited similar levels of improvement with lower medication doses. This suggests that a combined approach may offer advantages in terms of optimizing medication dosage and potentially reducing side effects.

Another crucial aspect to consider is the variability in outcomes within medication management programs. The Multimodal Treatment Study demonstrates that not all medication treatments yield identical results. The study’s emphasis on regular follow-up and adjustments of the medication tailoring the pharmacotherapy to individual needs, rather than adopting a one-size-fits-all approach.

Moreover, the MTA study highlights the significance of addressing non-ADHD symptoms that frequently accompany the disorder, such as anxiety, depression, social skills deficits, and academic challenges. In this context, the combination of behavioral therapy and medication management appears to be superior to medication alone.

ADHD Overdiagnosis

Worldwide around 5.29% (5.29 out of 100) individuals suffer of ADHD. However, the rates vary, and it’s unclear if this is due to real differences or diagnostic discrepancies.

Accurate diagnosis of the disorder is vital as the unrecognized or wrongly recognized ADHD can lead to several problems. In the first cases untreated patients are likely to develop academic and social problems whereas overdiagnosed individuals treated with stimulants can develop psychiatric conditions including dependency.

Diagnosis of ADHD is a complex issue with evolving boundaries. The validity of ADHD diagnosis has become a topic of increasing concern due to what appears to be widespread overdiagnosis especially in adolescents and mature individuals.

The diagnostic procedures in childhood ADHD are well established and more precise due to long experience with child ADHD. On the contrary ADHD in adulthood is relatively new psychiatric diagnosis, therefore identifying this condition in older individuals, especially those who weren’t treated as children, is more difficult. In this context it’s worth to mention that not all attention problems in adults necessarily indicate ADHD, which typically requires a childhood onset.

ADHD overdiagnosis in children

One major concern is the relative age of school-age children. Children born closer to the school start age cutoff are more frequently diagnosed with ADHD. This suggests that ADHD diagnosis might be influenced by factors other than biology, such as relative maturity.

Screening tools for ADHD are designed for older children, and there’s limited research on ADHD in preschoolers. For that reason early preschool diagnosis is challenging because many symptoms typical of ADHD can be normal in younger children. Furthermore differentiating between transient symptoms and persistent ADHD is difficult which affects the decision to medicate.

Difference in ADHD diagnosis between boys and girls

There’s also a significant difference in ADHD diagnosis between boys and girls. Boys are diagnosed more often because they exhibit more stereotypical symptoms, like hyperactivity. Girls may show less disruptive behaviour and more intellectual impairment. This gender difference raises concerns about overdiagnosis in boys and underdiagnosis in girls.

These findings highlight the role of social institutions and perceptions in diagnosing ADHD. Appropriate diagnosis is crucial in the educational setting, as educators often initiate ADHD assessments. Adjustments should be made for children with varying maturity levels to ensure fairness.

ADHD Overdiagnosis and Racial Differences

A recent US study led by Professor Paul Morgan published in the Journal of Learning Disabilities, examined which sociodemographic groups of children are more likely to be overdiagnosed and overtreated for ADHD. The study analysed data from 1,070 U.S. elementary school children who had shown above-average behavioral, academic, or executive functioning the year before their initial ADHD diagnoses. These children were considered unlikely to have ADHD because they did not display the typical chronic inattentive, hyperactive, or impulsive behaviours that impair functioning. The study found that the group of high-functioning students diagnosed with ADHD were predominantly white.

The researchers emphasize the need for standardized, multi-informant protocols for paediatric health professionals making ADHD diagnoses. They also suggest that social and cultural differences may contribute to disparities in ADHD diagnosis and treatment between white families and families of colour. Black communities may perceive ADHD diagnoses as stigmatizing, and families of colour may view diagnosis and treatment as an attempt to exert social control or as a result of unresponsive school environments.

To address these issues, knowledge-translation strategies are proposed. To make informed decisions parents should receive information about factors affecting behaviour and maturity of their children and educators should undergo training on managing maturity differences in the classroom. Practitioners should keep on their mind the birth dates and symptoms when diagnosing ADHD. For preschool-age children, clinicians should conduct lengthier assessments to improve accuracy.

Factors Contributing to ADHD Overdiagnosis

Low Diagnostic Agreement:

One major factor contributing to ADHD overdiagnosis is the “very low” level of agreement among diagnosticians, termed “interrater reliability.” Different professionals assessing the same individual may arrive at varying conclusions, leading to inconsistent diagnoses.

Ambiguous Diagnostic Criteria:

The diagnostic criteria for ADHD are often ambiguously worded, leaving room for interpretation. This ambiguity can result in overdiagnosis, as clinicians may rely on subjective judgments rather than clear-cut guidelines.

Reliance on Heuristics:

Some clinicians resort to “heuristics,” a method involving educated guesswork and stereotyping, when making diagnoses. This approach can lead to inaccurate assessments, especially when dealing with a complex condition like ADHD.

The “Halo Effect“:

This effect occurs when information from related but different diagnoses carries over into the ADHD diagnosis. This can lead to the misclassification of individuals who do not truly meet the criteria for ADHD.

Limited Reliance on DSM Criteria:

Shockingly, only one in four paediatricians reports relying on the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) criteria when diagnosing ADHD. This indicates a lack of adherence to standardized diagnostic guidelines.

Gender Bias:

Research has revealed a pattern of overdiagnosis of ADHD in boys, likely due to an inclination among evaluators to “overrate male externalizing behaviour.” This gender bias contributes to the disproportionate number of boys receiving ADHD diagnoses.

Relative Age Effect:

Children born close to kindergarten or school cut-off dates are 30% to 60% more likely to be diagnosed with ADHD. This effect is prevalent not only in the United States but also in other developed countries.

Health Policy Constraints:

Some healthcare systems require a diagnosis for access to treatment, resulting in intentional overdiagnosis to meet policy requirements. This issue is particularly pronounced in the United States.

Consequences of ADHD overdiagnosis

The consequences of ADHD overdiagnosis are multifaceted and concerning:

Stigmatization:

Overdiagnosis undermines confidence in the legitimacy of ADHD as a valid medical condition. This can lead to scepticism and stigmatization of individuals who genuinely suffer from ADHD.

Academic and Behavioral Problems:

Children who are falsely diagnosed with ADHD may experience lower academic achievement and behavioral issues due to mislabelling. Such misdiagnoses may lead to unnecessary interventions, including medication.

Overprescribing:

The meta-study indicates that overprescribing of medications like Ritalin is prevalent, especially among children who do not meet the criteria for ADHD. This exposes them to potential side effects without therapeutic benefits.

Medicalization of Normal Behaviour:

ADHD overdiagnosis can lead to the medicalization of normal childhood behaviours, such as restlessness or inattentiveness, potentially pathologizing what should be considered within the range of typical developmental variations.

How to avoid ADHD overdiagnosis

ADHD has effective treatment options, but these should only be pursued after ruling out co-occurring conditions. The key to improving ADHD care and diagnosis is establishing a minimum training standard for assessors, ensuring reliability and thoroughness in assessments.

One part of the problem lies in lack specific training standards for assessors, not specifying precisely their qualifications. Inadequate training can lead to misdiagnoses or overlooking co-occurring conditions such as autism, trauma, or PTSD, which can mimic ADHD symptoms. Approximately 80% of individuals with ADHD also have other concurrent conditions like anxiety, depression, bipolar disorder, or psychosis, underscoring the need for thorough mental health screening.

Attention Deficit Hyperactivity Disorde. Summary

ADHD (Attention Deficit Hyperactivity Disorder) is characterized by symptoms of inattentiveness, over-activity, impulsivity, or combination of both. ADHD typically begins in childhood and persists in adolescence and adulthood. As individuals grow older, the symptoms often become less pronounced compared to the earlier stages of childhood and adolescence. Some people are only diagnosed with ADHD in adulthood.

Experts have agreed upon specific criteria that must be met for an ADHD diagnosis. They describe various manifestations of inattentiveness, hyperactivity, and impulsivity. ADHD tends to manifest differently in adults. Hyperactivity often diminishes, while inattentiveness, inner restlessness, and difficulties in regulating emotions become more prominent.

The perception of ADHD as a pathological disorder has been recently re-examined. People with ADHD possess creativity and an adventurous spirit; many exhibit the ability to hyper-focus, allowing extended concentration on enjoyable tasks.

It’s highly important to acknowledge that ADHD is a treatable condition. The first step in the treatment process is contacting the psychiatrist or psychologist to secure the diagnosis. In the majority of the cases the symptoms of ADHD can be fully controlled allowing the individual normal work and social performance.

ADHD in Adulthood

It is not uncommon for ADHD to be diagnosed first during adulthood. The reason is simple: the full understanding of ADHD in adults has been established around 30 years ago but got the full attention after 2000. Individuals born before the year 2000 or short after haven’t been screened for ADHD and remained untreated. During this period medical insurances in many counties refused the payment for ADHD treatment by people older than 18.

Today ADHD in adulthood is recognized psychiatric disorder. Adulthood ADHD symptoms cause significant neurocognitive deficits associated with academic, social, and occupational difficulties limiting patient’s ability to reach the full potential.

Even today adults with ADHD may encounter challenges in finding adequate support. Due to the prevailing perception of ADHD as primarily a childhood issue, the availability of counselling and treatment options for affected adults is not as widespread as those for children and adolescents.

Despite considerable scientific progress in field of Adult ADHD most adults suffering of the condition remain undiagnosed and untreated.

A detailed examination supported by psychometric tests secures the diagnosis of ADHD in adulthood. As the adult ADHD began in childhood the diagnostic requires careful evaluation of past social and academic performance.

The most effective treatment for adult ADHD is the combination of pharmacotherapy (medication) and psychotherapy, such as CBT as well as mindfulness and Life-Skills training.

Childhood ADHD

The original concept of ADHD (Attention Deficit Hyperactivity Disorder) understood the condition as a childhood developmental disorder. For this reason, scientists used to believe that ADHD was “outgrown” during the later stages of life.

First later research proved that ADHD symptoms last lifelong. Based on this finding scientists recognized ADHD in adults as a psychiatric diagnosis including the development of treatment protocols.

Preventing severe ADHD is a goal for parents. By following science-based recommendations, parents can take practical steps to reduce the risk of their child developing the condition.

While parents may not be able to prevent their child from developing ADHD, they can take comfort in the fact that ADHD need not be a liability. In the opposite, it could be rather an opportuni

Emotional Instability in ADHD

Many individuals with Attention Deficit Hyperactivity Disorder (ADHD) report experiencing emotional difficulties. Until now the emotional problems are not a part of the ADHD diagnostic criteria. The main reason for that is of methodological nature. Emotions are not always present and they are not esy to be quantified. However, the statistic methods require more constant presence of the symptoms.

The recent research on emotional instability in ADHD sheds light on the emotional struggles faced by the affected individuals. The research is focusing on the often-overlooked emotional aspects such as Rejection Sensitive Dysphoria (RSD) which involves extreme emotional sensitivity to rejection and criticism.

Recognizing and addressing these emotional challenges is essential for a more comprehensive understanding and management of ADHD, improving the quality of life for those affected.

Multimodal Therapy and Support for ADHD

The results of studies have shown that a multimodal therapy concept is the most successful for ADHD. In a multimodal approach, different interventions and therapeutic techniques are tailored to the individual case and can be applied in an outpatient, as well as a partial or full inpatient setting. Suitable measures are modularly integrated into the therapy concept.

Some interventions that can be applied include:

• Informing and advising the social environment of the affected individual, particularly involving family, teachers or the workplace.
• Cognitive behavioral therapy to reduce impulsive and disorganized task-solving, as well as self-management training to modify problematic behaviour.
• Pharmacotherapy to alleviate hyperkinetic symptoms.
• Separate treatment of any comorbidities.

ADHD nervous system

ADHD is not a disorder in the conventional sense. It signifies a unique nervous system with its own set of rules. The research on ADHD unravelled the secrets of the ADHD nervous system as resilient, adaptable, and unique in its cognitive skills.

The key to understanding ADHD lies in recognizing the inconsistency, not deficit, of attention. Unlike a shortage of attention, ADHD individuals grapple with an overabundance of it. Their minds juggle multiple thoughts simultaneously, creating a dynamic and ever-changing mental landscape.

Neurotypical (“normal”) individuals navigate the world with a different set of motivators. Importance, external validation, and the promise of rewards guide their decision-making and task execution. In contrast, the ADHD individuals find themselves at odds with such conventional structures. They actions are triggered by interest and passion.

Multimodal Treatment of ADHD

Over the past two decades, there have been significant advancements in understanding and treating ADHD. Researchers have dedicated their efforts to validate the diagnostic criteria, ensuring that they are reliable and accurate. Simultaneously, there has been substantial progress in identifying effective treatment methods.

The MTA study has provided invaluable insights into the treatment of ADHD in children and adolescents. The study’s findings underscore the remarkable effectiveness of medication management in alleviating core ADHD symptoms. In this context medication remains the main pillar of ADHD treatment in children and adolescents. However, it’s important to understand that medication is not a magical tool solving all problems caused by ADHD. It’s more a gateway, enabling individuals with ADHD to engage in the necessary work that they need to do.

While medication management stands out as highly effective for core ADHD symptoms, it is crucial not to disregard the benefits of behavioral therapy, especially when dealing with comorbid conditions.

The study emphasizes the importance of multimodal and personalized treatment approach that considers individual needs and aims to improve the overall well-being of affected children.

ADHD types

The symptoms of ADHD vary not only in different individuals but also across their development. While during the preschool years, symptoms of hyperactivity and impulsivity are more often, they can change in later development, especially during adolescence, with the inattention in the forefront.

The classification system of American Psychiatric Association, DSM 5 differentiates ADHD in three subtypes: inattentive, hyperactive-impulsive and combined presentation.

Due to their restlessness, impulsive behaviour, children with ADHD often exceed boundaries more frequently compared to other children. This creates a vicious cycle of admonishments and boundary setting. Positive experiences become overshadowed by these negative events affecting the interaction within family, scholl and in later age in professional and social circle.

These negative experiences increase the risk of the child or adolescent responding with even greater restlessness, impulsivity, and inattention, as well as an increase in oppositional behaviour. As a result, the symptoms of ADHD and additional problems such as anxiety, depression but also aggressive and defiant behaviour continue to escalate.

Overdiagnosisng ADHD

Over- and underdiagnosis of ADHD in children based on relative age and sex is a concern. Correct ADHD diagnosis is is essential for a child’s education and well-being as well its future social development and success in life. There’s a “relative-age effect” where younger children, born close to the school start age, are diagnosed with ADHD more often.

Also, boys are diagnosed more frequently than girls, possibly because boys exhibit more stereotypical symptoms. These factors highlight the importance to consider a child’s relative maturity when diagnosing ADHD.

Overdiagnosis can lead to unnecessary medication, especially in preschoolers. Therefore guidelines and knowledge-translation strategies involving families and the educators help reduce inappropriate diagnoses.

Overdiagnosis also incurs costs for families and the healthcare system. Families without health benefits may be significantly impacted by the costs of ADHD assessment and treatment. Misdiagnosis can limit a child’s potential in education and future prospects.

Overdiagnosis poses a significant concern as it results in unnecessary treatment. The rising prevalence of adult ADHD diagnoses may result in the prescription of stimulants for individuals who may not actually benefit from them. It is crucial to approach the diagnosis of adult ADHD in a more systematic and cautious manner.

FAQ about ADHD

How Does ADHD Manifest in Adulthood?

Adult ADHD is less apparent than in hyperactive children and adolescents. Adults with ADHD primarily struggle with organizing their daily lives or work, maintaining focus on tasks for extended periods, or meeting deadlines.

However, they can also be very impulsive. For instance, adults with ADHD tend to be talkative and frequently interrupt others. Some may easily get into trouble, end relationships prematurely, switch jobs abruptly, or resign without having a new position lined up. Difficulties can also arise in traffic due to reckless driving.

Many adults with ADHD find it challenging to regulate their emotions. They are easily irritable and have a low frustration tolerance. When under stress, fulfilling their responsibilities becomes difficult. Adults with ADHD may also encounter difficulties in setting and achieving goals.

It’s highly advisable seeking professional advice when someone experiences symptoms of ADHD that significantly and persistently affect their quality of life. Therefore, it’s crucial to ensure a careful ADHD diagnosis to avoid unnecessary or incorrect treatments keeping in mind that other psychiatric conditions can be misdiagnosed as ADHD.

ADHD. Whom to Ask for Support?

Adults with ADHD usually seek assistance from specialized medical professionals such as psychiatrists, or psychologists. When young individuals with ADHD reach adulthood, it is advisable to start searching for an adult psychiatrist. However, in some cases, individuals who have turned 18 can continue receiving treatment from their child and adolescent psychiatrist until they reach the age of 21.

Who can diagnose ADHD?

ADHD diagnosis in adults requires licensed mental health professionals or physicians: clinical psychologists, psychiatrists, neurologists, family doctors, or clinical social workers. Check their expertise in adult ADHD, as knowledge outweighs professional degrees. Reliable experts readily share their qualifications. Beware of reluctance to disclose information.

What Helps to Deal with ADHD?

Many adults with ADHD face challenges primarily due to their inattention and impulsivity. However, some develop effective strategies to deal with it, for example by:

• Carefully planning the day and creating reminder lists to avoid forgetting things, while being mindful not to take on too much.
• Breaking tasks down into smaller steps to make it easier to accomplish them gradually.
• Placing reminders in important locations, such as the front door, refrigerator, or car, to aid memory.
• Recording important appointments and tasks in a notebook or mobile app.
• Establishing routines and consistently keeping essential items like keys or wallets in the same place.

Since the challenges of ADHD are highly individual, it is difficult to provide universally applicable advice. However, many individuals discover over time what can help them navigate daily life more effectively. Support from friends and family proves valuable in this process.

How do you know if you need an ADHD assessment?

 Look for these common problems:

1. Inconsistent job performance,
2. frequent job changes
3. History of academic or career underachievement
4. Difficulty managing daily tasks, bills, chores.
5. Relationship strains due to unfinished tasks.
6. Forgetfulness, frustration, intense worry about unmet goals
7. Carelessness, neglecting detail.
8. Starting tasks but not finishing.
9. Poor organizational skills.
10. Lack of focus, prioritization.
11. Frequent item loss.
12. Restlessness, edginess.
13. Impulsiveness, talking out of turn.
14. Interruptions, blurting out.
15. Mood swings, irritability, quick temper.
16. Stress handling difficulty.
17. Extreme impatience.
18. Risk-taking, disregard for safety.

A professional can assess if these issues stem from ADHD or other causes. The life course of ADHD depends on several factors. While some individuals show symptoms early, others face challenges later in life. Bright individuals might compensate until high school

What is covered in the psychological assessment of ADHD?

Our comprehensive evaluation includes:

1. In-depth clinical interview and diagnostic screening.
2. Gathering reports from the patient and parents about symptoms and functioning.
3. Self-report measures from the patient and parents.
4. Analysis of all assessment results.
5. Explanation of results to patients.
6. Formulation of a diagnosis.
7. Recommendations for treatment and referrals.

Can I Expect Support for ADHD from my Company and Friends?

Individuals with ADHD often question whether they should share their diagnosis with others. Close friends and family members may already be aware, but the situation can be different in the workplace. Deciding whether to inform colleagues or supervisors about one’s diagnosis is a challenging and personal consideration. Many people choose to keep their diagnosis to themselves because they fear losing their job or facing difficulties in obtaining employment.

However, there are also reasons that support being open about one’s diagnosis. Heiding continuously the condition from others can be mentally exhausting and often not possible. Being open and honest about one’s challenges can be relieving.

Without knowledge of the diagnosis, it is impossible to seek necessary treatment. Colleagues and supervisors who might be aware of the diagnosis are more likely to provide support and understanding. In larger companies, there is often an option to approach the works council or occupational health service in strict confidence.

Read more about ADHD

ADHD Screening Tool

References

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CDC (2019-10-08). “Treatment of ADHD”. Centers for Disease Control and Prevention. Retrieved 2019-11-20

Stanford C, Tannock R (29 February 2012). Behavioral Neurobiology of Attention Deficit Hyperactivity Disorder and Its Treatment. Springer. pp. 10-. ISBN 978-3-642-24611-1

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“Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents (A Systematic Review)”. Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents (A Systematic Review) | PCORI. 2021-08-27

Moffitt TE, Houts R, Asherson P, Belsky DW, Corcoran DL, Hammerle M, et al. (October 2015). “Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study”. The American Journal of Psychiatry. 172 (10): 967–77

Godfrey J (March 2009). “Safety of therapeutic methylphenidate in adults: a systematic review of the evidence”. Journal of Psychopharmacology. 23 (2): 194–205

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Smith M (November 2017). “Hyperactive Around the World? The History of ADHD in Global Perspective”. Social History of Medicine. 30 (4): 767–787