You all know that one person who is always late, loses their keys, is constantly agitated and lazy  or procrastinating at the same time. It can be inferred that it is a character flaw, but “what if is not?”. What if this person might have ADHD? Attention-Deficit / Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder and one of the most researched areas in mental health. It is characterized by impaired concentration, impulsivity, and, in specific cases, hyperactivity. It is often diagnosed early, around the age of 7, as the attention issues become more clear when children enter primary school. The disorder persists into adulthood and affects social, academic, and occupational functioning.

The article includes:

• What is ADHD?
• The implications of having ADHD.
• Treatment CBT vs. Medication

What is ADHD?

Definition

According to DSM IV, Attention-Deficit / Hyperactivity Disorder (ADHD) is a mental, behavioral and neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that affects one’s social, academic, and organizational life [1]. Inattention manifests as having difficulty maintaining focus, being disorganized, and having periods of stimulus-independent thought. Hyperactivity is mirrored in excessive motor activity, such as fidgeting, constant movement, talkativeness, being unable to wait for one’s turn. In children, hyperactivity can be expressed by running haphazardly in different directions with no purpose, or not being able to stay sitting at the table. Impulsivity is represented by the tendency to act without forethought (e.g. running in the street without looking), making major life decisions without due regard to the impact of the consequences (e.g., buying a house without adequate information of bureaucracy), social intrusiveness (e.g., compulsively interrupting people) [1].

Diagnosis

ADHD is commonly diagnosed from childhood (i.e., developmental phase) and it should be present in several settings, such as school, home, work. It appears that ADHD is detected more often in males than in females, with a ratio of 2:1 in children and 1.6:1 in adults [1, 17].

During adulthood, it becomes more difficult to detect it, as the diagnosis relies on childhood memories. One must present at least 6 of the following symptoms (5, if the person is over 17 years old) for at least 6 months.

The displayed symptoms can be:

From the inattention sphere

• Failure to pay close attention and sustain attention
• Stay on task
• Disorganization
• Inability to follow instructions or finish tasks
• Avoiding engagement in activities that require sustained mental effort
• Forgetfulness often loses things
• Difficult to listen for a long period
• Poor planning

From the hyperactivity-impulsivity sphere:

• Restless movement
• Overactivity
• Tapping
• Often “on the go” as the person is not able to sit down or engage in leisure activities quietly
• Runs or climbs when inappropriate (mostly children)
• Often interrupts people (answering before the question has been completed, interrupts ongoing conversations, cannot wait for one’s turn)

According to the American Psychiatric Association (APA), there are three types of ADHD, each presenting different symptoms, and thus requiring different treatments[1]. Based on the above-mentioned symptoms we can distinguish between:

1. Inattentive Type (ADHD-I);
2. Hyperactive-Impulsive Type (ADHD-H);
3. Combined Type (ADHD-C).

The latter is most common among individuals for they present symptoms of both inattentive and hyperactive-impulsiveness.

It is unknown what exactly may be the cause that leads to ADHD; however, correlational studies show that genes can constitute a determinant factor for diagnosis. Twin studies suggest  heritability, with estimates ranging from 77% to 82% [4,9]. Several factors, such as low birth weight (<1500 grams), smoking during pregnancy and neurotoxin exposure are also correlated with ADHD [1,2]. However, these are not causal factors.

Misconceptions

It happens that people who suffer from other neuro-developmental disorders, such as learning disabilities, think that they have ADHD. This confusion may arise because there are some features associated with ADHD that are common in other disorders, but that are not strictly specific to the disorder [8]. These include learning disorders, motor disorders (tic, stereotypic movement, little coordination of motor skills), reduced behavioural inhibition, mild delays in language and social development, and a low tolerance for frustration[1].

Moreover, ADHD can also be confused with bipolar disorder, intermittent explosive disorder, autism, disruptive mood dysregulation disorder [1, 11]. For the mental health of the individual and their peers, it is crucial that the correct diagnosis is given.‍

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Implications for life

Individuals who are confronting this disorder showed to have reduced academic performance and low employment rates in adults. Because of their inability to sustain focus, listen to other people carefully or follow instructions, they are seen as being non-cooperative, lazy, and irresponsible. Their social life can be reduced as they often confront rejection from their peers. Family and friends' relationships are commonly described as negative. Additionally, people with ADHD are more likely to present antisocial personality disorder that can lead to substance abuse and, due to hyperactivity and impulsivity, there is also an increased risk of injury, criminal activity, traffic accidents, and rules violations [1,7].

Because of these setbacks in life, individuals who grow up with ADHD can have problems with emotional regulation, depression, anxiety, strong self-criticism and unhealthy self-beliefs [15]. Amongst these distorted beliefs are:  

1. All-or-nothing thinking - Where they view an event/task as entirely good or entirely back. If a minor flaw is found, the person considers that they have failed completely.
2. Overgeneralisation - A single event is seen as a pattern. If a person forgets their key, they think they always forget them.
3. Personalisation - Person takes the blame for the negative event without taking into consideration the fault of others.
4. Comparative thinking - A constant unhealthy comparison with others that is often unrealistic and leads to feeling inferior.

It is important to note that not everyone with ADHD necessarily experiences these distorted beliefs or challenges; how an individual copes with their ADHD may strongly depend on their upbringing and their environment. Some people may even barely notice the symptoms or ADHD or be completely able to manage them. Every experience is different.

The treatment: CBT vs. Medication‍

Although the disorder can be detectable before preschool, only very few children actually receive treatment. Still, early interventions with children showed significant improvement in behaviour, executive function, social functioning[13], school performance (reading and math skills) [5], and family relationships (following parent-training as well)[12]. Therefore, prioritizing diagnosis and treatment at premature stages of development may be more beneficial in the long-run. Treatment for adults improves self-esteem, happiness, and increased productivity[3].

The treatment includes a combination of medication and cognitive-behavioural treatment (CBT).

Cognitive-behavioral therapy is a short-term, goal-oriented form of psychotherapy that aims to restructure the automatic thoughts that are prone to distortion, as well as challenge irrational thought patterns. CBT helps the individual identify the challenges and develop new coping mechanisms, action plans, realistic goals, and means to deal with negative emotions.

Group CBT treatment showed to be efficient for adults [3] and children as well [10]. CBT for children can include cognitive-behavioral self-control training (self-instructional training via modeling), play therapy, music therapy, art therapy, and anger management training for children who are hyperactive-aggressive [10].

Aside from CBT, a range of medications can also be prescribed [6] :

1. Stimulant medications - methylphenidate, mixed amphetamine salts, and dextroamphetamine;
2. Non-stimulant medications - tricyclic antidepressants (TCAs), modafinil, monoamine oxidase inhibitors (MAOIs), bupropion, and atomoxetine.

Stimulant medications are more commonly prescribed because they are more efficient in reducing overactivity, impulsivity, on-task behavior and they increase the availability of synaptic dopamine[16,14].

Additional sources:

Youtube

• https://www.youtube.com/watch?v=fWCocjh5aK0  - About the benefits of ADHD
• https://www.youtube.com/watch?v=FE0pYsmmego  - In the shoes of an ADHD person

Movie

• Take Your Pills

Reference list:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. 5th edArlington. VA: American Psychiatric Publishing.

2. Botting, N., Powls, A., Cooke, R. W., & Marlow, N. (1997). Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birthweight children at 12 years. Journal of Child Psychology and Psychiatry, 38(8), 931-941.

3. Bramham, J., Young, S., Bickerdike, A., Spain, D., McCartan, D., & Xenitidis, K. (2009). Evaluation of group cognitive behavioral therapy for adults with ADHD. Journal of attention disorders, 12(5), 434-441.

4. Chang, Z., Lichtenstein, P., Asherson, P. J., & Larsson, H. (2013). Developmental twin study of attention problems: high heritabilities throughout development. JAMA psychiatry, 70(3), 311-318.

5. DuPaul, G. J., Kern, L., Caskie, G. I. L., & Volpe, R. J. (2015). Early intervention for young children with attention deficit hyperactivity disorder: Prediction of academic and behavioral outcomes. School Psychology Review, 44(1), 3–20.

6. Faraone, S. V., Biederman, J., Spencer, T. J., & Aleardi, M. (2006). Comparing the efficacy of medications for ADHD using meta-analysis. Medscape General Medicine, 8(4), 4.

7. Fletcher, J., & Wolfe, B. (2009). Long-term consequences of childhood ADHD on criminal activities. The journal of mental health policy and economics, 12(3), 119.

8. Mayes, S. D., Calhoun, S. L., & Crowell, E. W. (2000). Learning disabilities and ADHD: Overlapping spectrum disorders. Journal of learning disabilities, 33(5), 417-424.

9. McLoughlin, G., Rijsdijk, F., Asherson, P., & Kuntsi, J. (2011). Parents and teachers make different contributions to a shared perspective on hyperactive–impulsive and inattentive symptoms: A multivariate analysis of parent and teacher ratings on the symptom domains of ADHD. Behavior genetics, 41(5), 668-679.

10. Miranda, A., & Jesús Presentación, M. (2000). Efficacy of cognitive‐behavioral therapy in the treatment of children with ADHD, with and without aggressiveness. Psychology in the Schools, 37(2), 169-182.

11. Pataki, C., & Carlson, G. A. (2013). The comorbidity of ADHD and bipolar disorder: any less confusion?. Current psychiatry reports, 15(7), 1-7.

12. Perrin, E. C., Sheldrick, R. C., McMenamy, J. M., Henson, B. S., & Carter, A. S. (2014). Improving parenting skills for families of young children in pediatric settings: A randomized clinical trial. JAMA pediatrics, 168(1), 16-24.

13. Rosenberg, L., Maeir, A., Yochman, A., Dahan, I., & Hirsch, I. (2015). Effectiveness of a cognitive–functional group intervention among preschoolers with attention deficit hyperactivity disorder: a pilot study. American Journal of Occupational Therapy, 69(3), 6903220040p1-6903220040p8.

14. Spencer, T., Biederman, J., & Wilens, T. (2000). Pharmacotherapy of attention deficit hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America, 9(1), 77-97.

15. Strohmeier, C. (2013). Adult ADHD and the relationship between self-reported frequency of cognitive distortions, anxiety, and depression.

16. Volkow, N. D., Fowler, J. S., Wang, G., Ding, Y., & Gatley, S. J. (2002). Mechanism of action of methylphenidate: insights from PET imaging studies. Journal of attention disorders, 6(1_suppl), 31-43
17. Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 9(3), 490-499.

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