What is ADHD?

Attention-deficit hyperactivity disorder (ADHD) is the current term for a specific developmental disorder seen in both children and adults. The main symptoms are:

  • Impairment in behavioral inhibition (self regulation of behaviors, motivation, impulsivity, restlessness, or hyperactivity/self control of emotions)
  • Impairment in sustained attention (focus/concentration)
  • Impairment in working memory, organization, and time management
  • Impaired resistance to distraction (staying on task)

This disorder has had numerous labels over the past century, including hyperactive child syndrome, hyperkinetic reaction of childhood, minimal brain dysfunction, and attention deficit disorder (with or without hyperactivity).

ADHD starts in childhood but can continue through adolescence and adulthood. In order to be diagnosed with ADHD, the symptoms must occur in more than one setting, such as at work, school, home life, or in social settings.

You may see ADHD sometimes referred to as ADD. This is because some forms of ADHD do not have the hyperactivity (H) component.

Some professionals, such as Dr. Daniel Amen, believe that there are seven different types of ADD. Currently, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) only adheres to three different subtypes. While more peer-reviewed studies are needed to support Dr. Daniel Amen’s view of the seven different subtypes, he has helped enormously in categorizing the different forms of ADHD that have co-occurring conditions, such as depression, anxiety, over-focusing and bipolar. This greatly aids in treatment, since treating only one of two or three underlying conditions impeded effective treatment. It is critically important to do a comprehensive evaluation to differentiate all the underlying conditions that are contributing to a person’s struggles.

ADHD occurs in approximately 9 percent of the childhood population and approximately 5 percent of the adult population. Among children, the gender ratio is approximately 3:1, with boys more likely to have the disorder than girls. Among adults, the gender ratio falls to 2:1 or lower.

The disorder has been found to exist in virtually every country in which it has been investigated, including North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the Middle East. The disorder may not be referred to as ADHD in these countries and may not be treated in the same fashion as in North America, but there is little doubt that the disorder is virtually universal among human populations.

The disorder is more likely to be found in families in which others have the disorder or where depression is more common. It is also more likely to occur in those with conduct problems, delinquency, tic disorders, Tourette’s Syndrome, learning disabilities, or those with a history of prenatal alcohol or tobacco-smoke exposure, premature delivery, or significantly low birth weight, or significant trauma to the frontal regions of the brain.

 

ADHD is not...

  • ADHD is not a myth or a fake disorder. It is a medically recognized neurobehavioral disorder that can be managed.
  • ADHD is not only a "kid's disease." About half of children with ADHD will continue to present symptoms into adulthood.
  • ADHD is not about intelligence. School, work and social interactions can be challenging when it is hard to pay attention, stay organized, and regulate your behavior. But ADHD is not a matter of intelligence.
  • ADHD is not a learning disorder. Symptoms of ADHD can affect a person at school or work, but ADHD is not classified as a learning disorder.
  • ADHD is not your fault.
  • ADHD is not caused by bad parenting, bad teachers, or by anything you have done.
  • ADHD is not an "excuse."
  • ADHD is a medically recognized disorder and the symptoms cause real challenges.
  • ADHD is not a “catch-all” term that describes impulsive and distracted behavior. Although most people are distracted or impulsive once in a while, this does not mean they have ADHD. A person must meet the criteria that have been established by the American Psychiatric Association.

 

In our field we say, “ADHD does not always travel alone.” A number of psychiatric disorders may be confused with ADHD or may be simultaneously present with ADHD. Given the possible overlap in symptoms, it is important to differentiate ADHD from other psychiatric disorders to arrive at an accurate diagnosis. Dr. Neal will accurately diagnose ADHD or determine if there is another disorder responsible for the symptoms; or he will confirm a diagnosis of both ADHD and additional conditions.

 

ADHD MYTHS & FACTS

Our understanding of attention deficit has grown significantly over the last decade. Dr. Thomas E. Brown who is a leading researcher in the field of ADHD helps to separate facts from myths about this complex disorder.

Findings from neuroscience, brain imaging, and clinical research have made the old understanding of ADHD as essentially a behavior disorder no longer tenable. It is being replaced by a new understanding of ADHD as a developmental impairment of the brain’s self-management system, its executive functions.

This new paradigm can provide a useful way to put together many of the not-yet-integrated pieces of research on this puzzling syndrome, which causes some children and adults to have great difficulty in focusing and managing many aspects of their daily life while being able to focus on other tasks well. This new understanding provides a useful way to more readily recognize, understand, assess, and treat this complex syndrome, which impacts about 9 percent of children and almost 5 percent of adults.

Here are 16 prevailing myths about ADHD, along with the latest facts, to update your thinking about the condition.

MYTH: Really Something New?

The new model of ADHD as developmentally impaired executive function is completely different from the older model of ADHD.

THE FACTS: The new model of ADHD differs in many ways from the earlier model of this disorder as essentially a cluster of behavior problems in young children. The old model does not adequately capture the breadth, complexity, and persistence of this syndrome. The new model is truly a paradigm shift for understanding this syndrome. It applies not only to children, but also to adolescents and adults. It focuses on a wide range of self-management functions linked to complex operations of the brain.

MYTH: Not Always a Challenge

A person who has ADHD always has difficulty with executive functions, such as sustaining focus on a task and keeping several things in mind, regardless of what he is doing.

THE FACTS: Clinical data indicate that executive function impairments characteristic of ADHD are situationally-variable; each person with ADHD tends to have some specific activities or situations in which she has no difficulty in using executive functions that are significantly impaired for her in most other situations. Typically, these are activities in which the person with ADHD has a strong personal interest tor about which he believes something very unpleasant will follow quickly if he does not take care of this task right now. Multiple studies have shown that performance of persons with ADHD is highly sensitive to contextual factors — reward, nature of the task, and internal cognitive and physiological factors.

MYTH: Signs in Childhood

Anyone who has ADHD will show clear signs of it during early childhood and will continue to have difficulties with executive functions for the rest of his life.

THE FACTS: For decades ADHD, under various names, has been seen as essentially a disorder of childhood; DSM-V (Diagnostic and Statistical Manual of Mental Disorders-V) diagnostic criteria stipulates that at least some of the symptoms must be noticeable by age 12, changed from age 7 just a few years ago. More recent research has shown that many with ADHD function well during childhood and do not manifest any significant symptoms of ADHD until adolescence or later, when greater challenges to executive function are encountered. Over the past decade research has shown that impairing symptoms of ADHD often persist well into adulthood. However, longitudinal studies have also shown that some individuals with ADHD during childhood experience significant reductions in their ADHD impairments as they grow older.

MYTH: High IQ and Challenges

People with high IQ are not likely to have executive function impairments of ADHD because they can overcome such difficulties.

THE FACTS: Intelligence as measured by IQ tests has virtually no systematic relationship to the syndrome of executive function impairments described in the new model of ADHD. Studies have shown that even extremely high-IQ children and adults can suffer impairments of ADHD, which significantly impair their ability to deploy their strong cognitive skills consistently and effectively in many situations of daily life. Clinical observations indicate that high IQ individuals with ADHD often face lengthy delays before they obtain a correct diagnosis and appropriate treatment. This is due largely to uninformed teachers, clinicians, and patients themselves, assuming that high IQ prevent a person from having ADHD.

MYTH: Executive Functioning Struggles and Adolescence

Executive function impairments of ADHD usually are outgrown when the person reaches her late teens or early twenties.

THE FACTS: Some children with ADHD gradually outgrow their ADHD-related impairments as they get into middle childhood or adolescence. For them, ADHD is a variety of developmental lags. Most often hyperactive and/or impulsive symptoms improve as the individual reaches adolescence, while the broad range of inattention symptoms persist and sometimes get worse. Often the most problematic period is during junior high, high school, and the first few years of college. That is the time when the individual faces the widest range of challenging activities without opportunity to escape from the ones in which they have little interest or ability. After that period, some with ADHD are fortunate enough to find a job and a life situation in which they can build on their strengths and work around their cognitive weaknesses.

MYTH: Mapping Deficits

Modern research methods have established that executive function impairments are localized mainly in the prefrontal cortex.

THE FACTS: Executive functions are complex and involve not only the prefrontal cortex, but also many other components of the brain. Individuals with ADHD have been shown to differ in the rate of maturation of specific areas of the cortex, in the thickness of the cortical tissue, in characteristics of the parietal and cerebellar regions, as well as in the basal ganglia, and in the white matter tracts that connect and provide critically important communication between various regions of the brain.

Recent research has also shown that those with ADHD tend to have different patterns in functional connectivity, patterns of oscillations that allow different regions of the brain to exchange information.

MYTH: A Brain Chemical Problem?

ADHD-related executive function impairments are due primarily to a “chemical imbalance” in the brain.

THE FACTS: The term “chemical imbalance in the brain” is often used to explain impairments of ADHD. This suggests that there are chemicals floating around in the cerebral spinal fluid that surrounds the brain that are not in correct proportions, as though there were too much salt in the soup. This assumption is wrong. Impairments of ADHD are not due to a global excess or lack of a specific chemical within or around the brain. The primary problem is related to chemicals manufactured, released, and then reloaded at the level of synapses, the trillions of infinitesimal junctions between certain networks of neurons that manage critical activities within the brain’s management system.

The brain is essentially a huge electrical system that has multiple subsystems that need to communicate with one another constantly to get anything done. This system operates on low-voltage electrical impulses that carry messages from one tiny neuron to another in fractions of a second. However, these neurons are not physically connected; there are gaps at each point of connection. To get from one neuron to another, an electrical message needs to jump the gap. Arrival of the electrical impulse causes tiny “micro-dots” of a neurotransmitter chemical to be released. This works like a spark plug to carry the message across the gap and further down the circuit.

Persons with ADHD tend not to release enough of these essential chemicals, or to release and reload them too quickly, before an adequate connection has been made. Medications used to treat ADHD help to improve this process.

MYTH: The ADHD Gene

Recent research has identified a gene that causes executive function problems in persons with ADHD.

THE FACTS: Despite extensive exploration of the genome and the high heritability rate of ADHD, no single gene or genes have been identified as a cause of the syndrome of impairments known as ADHD. Recent research has identified two different groupings that together are associated with, though not definitively causal of, ADHD. This combination of some common variant genes and a group of deletions or duplications of multiple rare variants offers some promise of further progress in the search for genetic factors contributing to ADHD. However, at this point, the complexity of the disorder is likely to be associated with multiple genes, each of which, in itself, has only a small effect upon development of ADHD.

MYTH: ODD and ADHD

Most children with ADHD also have behavior problems of Oppositional Defiant Disorder, which usually lead to the more severe behaviors of Conduct Disorder.

THE FACTS: Among children with ADHD, reported incidence of Oppositional Defiant Disorder (ODD) ranges from 40 percent to 70 percent. The higher rates are usually for persons with the combined type (those who also have hyperactivity and high degree of impulsivity) of ADHD rather than the inattentive type. This disorder is characterized by chronic problems with negativistic, disobedient, defiant and/or hostile behavior toward authority figures. It tends to involve difficulties with management of frustration, anger, and impulsive negative reactions when frustrated. Typically, ODD is apparent at about 12 years of age and persists for approximately six years and then gradually remits. More than 70 percent of children diagnosed with this disorder never go on to meet diagnostic criteria for Conduct Disorder, a diagnosis that reflects much more severe behavior problems.

MYTH: ADHD and Autism

An individual with an Autistic Spectrum Disorder should not be diagnosed with ADHD and vice versa. These are separate disorders that require different treatments.

THE FACTS: Research has demonstrated that many individuals with ADHD have significant traits related to Autistic Spectrum Disorders, and that many persons diagnosed with disorders on the Autistic Spectrum also meet diagnostic criteria for ADHD. Studies have also shown that ADHD medications can be helpful in alleviating ADHD impairments in individuals on the Autistic Spectrum. Moreover, ADHD medications can also help those on the Autistic Spectrum with ADHD to improve on some of their impairments in social interactions, social perspective-taking, and other related problematic characteristics.

MYTH: Meds and Brain Changes

There is no evidence that medications for ADHD improve executive function impairments or that any improvements last.

THE FACTS: There are three different types of evidence that demonstrate the effectiveness of specific medications for ADHD improving impaired executive functions.

First, imaging studies have shown that stimulants improve, and may normalize, the ability of individuals with ADHD to get activated for assigned tasks, to minimize distractibility while doing tasks, to improve functional connections between various regions of the brain involved in executive functions, to improve working memory performance, to reduce boredom during task performance, and, in some cases, to normalize some structural abnormalities in specific brain regions of those with ADHD.

Second, experiments comparing performance of children with ADHD with matched controls or when on placebo, in comparison to prescribed medication, have shown that when on appropriate medication, children with ADHD tend to minimize inappropriate classroom behavior and control their behavior more like typical children in their class.

Experiments have also shown that medication can help those with ADHD improve their speed and accuracy in solving arithmetic problems; increases their willingness to persist in trying to solve frustrating problems; improves their working memory; and increases their motivation to perform and execute more adequately a wide variety of tasks associated with executive functions. These results do not mean that all children on such medications display these results, but group data demonstrate statistically significant improvements. However, it should be noted that these results are found only during the time the medication is actually active in the person’s body.

Third, a large number of clinical trials comparing the effectiveness of ADHD medications versus placebo for alleviation of ADHD impairments in both children and adults have demonstrated that these medications, both stimulants and some non-stimulants, produce robust improvements in a large percentage of patients with ADHD.

Despite the fact that the direct effects of medication do not last beyond the duration of the medication’s action each day, the improved functioning made possible by the medication has been shown to result in better school classroom and test performance, reduced rates of school dropout, increased rates of graduation, and other achievements that can have lasting effects. Medication may also help support a person’s adaptive performance while she awaits further brain development and enters into employment for which she is better suited, and/or improve her learning of concepts and skills she would otherwise be unlikely to master.

MYTH: Meds for Different Ages

The dose and timing of medications used to treat executive function impairment are quite similar for persons of similar age and body mass.

THE FACTS: Some medications can be appropriately prescribed in doses directly related to the patient’s age, size, or severity of symptoms, but this is not true for stimulants used to treat ADHD. Fine-tuning of dose and timing of stimulants for ADHD is important because the most effective dose depends on how sensitive the particular patient’s body is to that specific medication. Usually that needs to be determined by trial and error, starting with a very low dose and gradually increasing it until an effective dose is found, significant adverse effects occur, or the maximum recommended dose is reached. Some adolescents and adults need smaller doses than what is usually prescribed for young children, and some young children need larger doses than most of their peers.

MYTH: Preschoolers and Meds

It is quite risky to administer ADHD medications to preschool-aged children.

THE FACTS: While many children with ADHD do not show significant impairments until they begin elementary school, there are some preschoolers who manifest serious, and sometimes dangerous, behavior problems between the ages of three to six years. Research with children aged three to five-and-a-half years has shown that a majority of children in this age group with moderate to severe ADHD show significant improvement in their ADHD symptoms when treated with stimulant medication. With this younger age group, side effects are slightly more common than is usually seen in older children, though such effects were still minimal. In 2012 the American Academy of Pediatrics recommended that children aged four to five years old with significant ADHD impairments should be treated first with behavior therapy and then, if that is not effective within nine months, they should be treated with stimulant medication.

MYTH: A Lifelong Condition?

If a person with ADHD is hyperactive and impulsive during childhood, he is likely to continue that way into adulthood.

THE FACTS: Many individuals with ADHD never manifest excessive levels of hyperactivity or impulsivity in childhood or beyond. Among those with ADHD who are more “hyper” and impulsive in childhood, a substantial percentage outgrow those symptoms by middle childhood or early adolescence. However, symptoms of impairments in focusing and sustaining attention, organizing and getting started on tasks, managing emotions, using working memory, and so on tend to persist, and often become more problematic, as the individual with ADHD enters adolescence and adulthood.

MYTH: A Wide-Ranging Disorder

ADHD is just one of many kinds of psychiatric disorders.

THE FACTS: ADHD differs from many other disorders in that it cross-cuts other disorders. The executive function impairments that constitute ADHD underlie many other disorders as well. Many learning and psychiatric disorders could be compared to problems with a specific computer software package that, when not working well, interferes just with writing text or doing bookkeeping. In this new model, ADHD might be compared instead to a problem in the operating system of the computer that is likely to interfere with the effective operation of a variety of different programs.

MYTH: Emotional Connection

Emotions are not involved in executive functions associated with ADHD.

THE FACTS: Although earlier research on ADHD gave little attention to the role of emotion in this disorder, more recent research has highlighted its importance. Some research has focused solely on the problems in regulating expression of their emotions without sufficient inhibition or modulation. However, research has also demonstrated that a chronic deficit in emotions that comprise motivation is an important aspect of impairments for most individuals with ADHD. Studies have shown that this is related to measurable differences in the operation of the reward system within the brains of those with ADHD. Those with ADHD tend to have abnormalities in the anticipatory dopamine cell firing in the reward system; this makes it difficult for them to arouse and sustain motivation for activities that do not provide immediate and continuing reinforcement.

What Causes ADHD?

The exact origin of ADHD is unknown, but these are some of the factors that researchers believe are behind ADHD:

  • Brain chemistry. We believe ADHD is caused by an imbalance of neurotransmitters (chemical messengers) in the brain. Researchers think that these chemicals might play an important role in ADHD.

  • Genetics. Research suggests that ADHD tends to run in families. However, this does not mean that all children in a family will have the disorder. At the 2011 CHADHD Conference (Children and Adults with Attention Deficit/Hyperactivity Disorder), it was reported that several genes have been discovered that are thought to be responsible for ADHD.

  • Environment. Certain external factors, such as smoking during pregnancy or complications during pregnancy, delivery, or infancy, may contribute to ADHD.

 

What parts of the brain are involved in ADHD?

Research indicates that there is no single region of the brain that, if impaired, causes ADHD.  There are multiple regions that impact:

  • Attention
  • Verbal and non-verbal working memory
  • Planning
  • Organization
  • Time management
  • Motivation
  • Self-regulation of behaviors and emotions

Dr. Russell A. Barkley, a noted researcher and leader in the field of ADHD states,

“While precise causes have not yet been identified, there is little question that heredity/genetics makes the largest contribution to the expression of the disorder in the population … In instances where heredity does not seem to be a factor, difficulties during pregnancy … as well as post-natal injury to the prefrontal regions of the brain have all been found to contribute to the risk for the disorder in varying degrees. Research has not supported popularly held views that ADHD arises from excessive sugar intake, food additives, excessive viewing of television, or poor child management by parents.”

If you want to talk in more depth about the assessment process for ADHD, please call our office at
(815) 477-4727 or contact us to schedule an appointment.

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