Most people have heard of attention-deficit/hyperactivity disorder (ADHD, also known as attention deficit hyperactivity disorder) and may think they know what it is. They are probably wrong. ADHD is so little understood that few people can point to anyone famous, real or fictional, and say, “That is ADHD.”
The common perception of someone with attention-deficit/hyperactivity disorder is a child who can’t stay focused on anything for very long, is constantly in motion, earns poor grades, and is probably on medication such as Adderall or Ritalin. That’s a stereotype.
There is a lot of misinformation about ADHD out there, such as:
- It’s not real, or it’s not serious. Everybody has a touch of ADHD.
- Some students fake ADHD because they think that ADHD drugs will improve their grades, make them study better, and even make them smarter.
- It was invented by physicians, psychologists, or pharmacists to sell more goods and services.
- It doesn’t affect females, and males always grow out of it.
- It’s caused by lax or bad parenting and/or too much electronic screen time.
- The drugs used to manage ADHD are overprescribed, are addictive, aren’t necessary, or don’t work.
None of that is true. To correct that knowledge gap, in 2015 the United States government first recognized October as ADHD Awareness Month.
What is true is that the definition and prevalence of ADHD have changed over time as our knowledge has improved. That is what science does.
The current estimate is that ADHD affects 5% of children and 2% of adults, according to the nongovernmental Brain & Behavior Research Foundation. The Centers for Disease Control and Prevention (CDC) puts the number of children ever diagnosed even higher, at 9.4%.
What is ADHD?
At its simplest, ADHD is an accumulation of observable symptoms, an inability to:
- Pay attention for very long.
- Sit still.
- Resist impulsive behavior or actions.
Some argue that ADHD shouldn’t be called a disorder. It is not a lack of attention, they say; it’s a lack of consistent, focused attention. When people with ADHD are interested, they may experience hyperfocus.
Some say people with ADHD have higher IQs and/or are more intelligent, but others say there is no correlation.
Because ADHD is most often diagnosed in children, some people concluded it was simply “kids being kids.” Kids can’t sit still, don’t pay attention, etc. What they need, some say, is more discipline, not drugs and therapy, and for adults to take away or limit their time on smartphones, tablets, and laptops. Some claim the disorder was invented by pharmaceutical companies and physicians to make money.
It isn’t new, though. ADHD dates back decades, centuries, maybe millennia.
History of ADHD
As early as the fifth century BC (more than 2,400 years ago), Greek physician Hippocrates described something like ADHD. In 1693, philosopher John Locke wrote of students with symptoms of what might have been ADHD. In 1798, a Scottish physician provided a similar description. And in 1902, modern science identified it as hyperkinetic impulse disorder.
All of these predate digital devices.
By the time the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) came out in 1980, the term attention deficit disorder (ADD) was officially coined. In 1987, the revised third edition (DSM-III-R) changed it to ADHD.
So, ADHD isn’t new.
Types and Symptoms of ADHD
The DSM-IV divided ADHD into three main types (though the DSM-V later changed them to what it called presentations):
Inattentive, but not hyperactive:
- Easily distracted
- Doesn’t complete tasks or follow directions
- Doesn’t answer questions or seem to be listening
- Makes careless mistakes as if not paying attention
- Forgets daily commitments
- Is disorganized
- Doesn’t like sitting still or tasks that require sitting still
- Frequently loses important items
- Lacks focus; daydreams
Hyperactive and impulsive but not inattentive:
- Often squirms, fidgets, or engages in self-stimulating behaviors (“stimming,” which could include drumming their fingers on tables or tapping their feet)
- Won’t stay seated during common situations
- Can’t seem to play quietly
- Always on the go, running around and trying to climb on things
- Talks more in some situations than is socially acceptable and blurts out answers prematurely
- Finds it hard to wait and interrupts others
Combined inattention, hyperactivity, and impulsiveness.
Also, ADHD is ranked by levels: mild, moderate, and severe. In general, the worse the ADHD level, the earlier the symptoms appear.
Those symptoms might not be enough to officially qualify as ADHD, however. Since the symptoms of ADHD can resemble those of other disorders, it is sometimes misdiagnosed. Other possible causes include:
- Poor vision or hearing
- An overactive thyroid gland
- Domestic abuse
- Too much caffeine
- Too much screen time
- Another mental health issue such as stress, anxiety, or mood disorders
To meet the diagnostic criteria for ADHD, the symptoms must:
- Not be explainable by some other diagnosis
- Occur in multiple settings, not just one (school, home, activities at other venues)
- Interfere with education, employment, or social activities
- Appear before the age of 12
ADHD and Age
Despite most cases of ADHD being diagnosed between ages 3 and 6, and the average age being 7, ADHD is not only a child’s disorder. Four percent of U.S. adults (18 or older) struggle with at least some symptoms of ADHD, as opposed to 5% of children.
In addition to problems consistent with young people with ADHD — disorganization, anxiety, problems managing time, being forgetful and impulsive — some symptoms or signs of adult ADHD include:
- Lack of focus or hyperfocus. It’s not true that people with ADHD have no attention span. They just have no attention span for things that don’t interest them. For a hobby or private interest, they can have incredible focus. This can be a good or bad thing.
- Poor self-image, low self-esteem, and emotional problems.
- Low motivation and restlessness, which can relate to procrastination, unexceptional work performance, and frequent job changes.
- A tendency to become frustrated easily.
- Boredom and tiredness.
- Trouble concentrating well enough to read.
- Mood swings; trouble controlling anger.
- Problems with their health or relationships, such as multiple divorces.
Causes of ADHD
ADHD isn’t just those observable symptoms or behaviors. It’s at least partially physical or biological.
The brains of people with ADHD have observable physical differences. Their overall brain volumes and the size of five regions of their brains tend to be smaller, which can cause delayed development. Their brain structures are also different enough that researchers have concluded that ADHD is a brain disorder.
Further evidence includes the fact that the ADHD brain has lower amounts of norepinephrine, a neurotransmitter connected to dopamine, which affects how the brain communicates between different regions.
So, ADHD is real. We can see how the brains of individuals with ADHD differ with an MRI (magnetic resonance imaging) scan. That doesn’t explain how or why the brains are that way.
A genetic predisposition seems among the most likely factors that contribute to ADHD. Studies have found that the condition runs in families. In 2019, an international research team identified areas on 11 human chromosomes that were risk factors for ADHD.
Another possible cause is environmental factors. This is a broad category that includes:
- Prenatal factors. If the mother smoked or drank during pregnancy, those could be a factor.
- Premature delivery. Low birth weight is associated with ADHD.
- Chemical exposure. Exposure to pesticides, lead, or other harmful compounds can cause brain damage and learning disabilities.
- Traumatic brain injury (TBI). Secondary ADHD can occur following concussions or other TBIs.
- Nutrition. Too much sugar is suspected of contributing to hyperactivity.
- Screen time. This is not confirmed, but limiting exposure to televisions and other electronic devices for the first few years of a child’s life is probably a good idea anyway.
Whether these are bona fide causes or just risk factors that may increase the likelihood of developing ADHD are disputed.
While it doesn’t seem that ADHD causes other mental health issues, ADHD and other disorders frequently co-occur. “More than two-thirds of individuals with ADHD have at least one other coexisting condition,” according to the advocacy group Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
It may be that the conditions that predispose people for ADHD also predispose people for conditions such as:
Disruptive behavior disorders
- Oppositional defiant disorder (ODD): A pattern of being irritated with, angry, vindictive, or defiant towards parents or other authority figures. It may develop in as many as 40% of ADHD cases.
- Conduct disorder (CD): Frequently antisocial and violent behavior, including stealing or destroying property and fighting or harming people or animals.
- Disruptive mood dysregulation disorder (DMDD). A fairly recently identified disorder, clients with DMDD are between the ages of 6 and 18, angry pretty much all of the time, have out-of-proportion tantrums or outbursts at least three times a week, trouble functioning in more than one setting (school, home, other venues), and have had these problems for at least one year.
Approximately 38% of adult ADHD clients also have a mood disorder, including:
- Depression. Depression, major depressive disorder, or clinical depression is characterized by a lack of interest in most things and feeling sad most of the time. Children with ADHD are 14 times more likely to feel depressed compared to other children.
- Mania. Abnormally elevated mood and energy.
- Bipolar disorder. As many as one in five individuals with ADHD suffer from this: periods of depression alternating with mania. Bipolar disorder is sometimes known as manic depression.
- Anxiety. Though not usually considered a mood disorder, anxiety disorders (such as obsessive-compulsive disorder) do affect mood and affect almost a third of children with ADHD and more than half of adults with ADHD.
- Autism spectrum disorder (ASD). Like ADHD, a neurodevelopmental disorder, ASD has many similarities to ADHD — including intense focus and underdeveloped social skills — but in more severe cases, language and intelligence are so impaired that normal life and social interactions aren’t possible.
- Tourette syndrome. Another neurodevelopmental disorder. Tourette’s causes involuntary tics such as unwanted motions, facial expressions, and sometimes offensive language. Most people with Tourette’s syndrome have ADHD, but fewer than one in 10 people with ADHD have Tourette’s.
- Learning disorders. As many as half of children with ADHD also have a learning disorder — such as dyslexia (a reading learning disorder) and dyscalculia (a mathematics learning disorder) — about 10 times the rate of children without ADHD.
- Sleep disorders. One-quarter to one-half of parents of children with ADHD report that their children have difficulties with sleeping, both falling and staying asleep.
ADHD and Substance Use Disorder
Alcohol use disorder, drug use disorder, and other substance use disorders co-occur with mental illness so often that it could be considered an epidemic by itself, but it’s only beginning to receive the attention it deserves. That’s because medicine and addiction for too long were regarded as separate disciplines instead of as parts of a whole.
Like ADHD, addiction wasn’t considered a real illness or disorder. Instead, people stigmatized addiction as a moral failing or a character flaw. Now we know that there is a genetic predisposition to addiction. Active drug use triggers changes to the brain, rewires it, and hijacks the reward system.
As the U.S. surgeon general’s 2016 report Facing Addiction in America made clear, addiction is “a chronic brain disease,” an “illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.”
ADHD does something similar, only the physical change seems to come first.
ADHD and Alcohol Abuse
Substance use disorder means drug abuse to most people — more specifically opioid abuse, which was declared a public health emergency in 2017 — but it also includes alcohol abuse. For individuals with ADHD, alcohol is a bigger problem.
Nicotine addiction is even worse than alcohol for those with ADHD, but it doesn’t cause intoxication.
One in four people in treatment for alcohol or substance use disorder also has ADHD. For adult alcoholics, the rate of ADHD co-occurrence is even higher.
ADHD is also a risk factor for alcohol abuse, though not a cause. Studies have found that people with ADHD:
What Treatments Are There for ADHD?
One treatment for ADHD is better known than the disorder itself: drugs.
It might seem counterintuitive to prescribe stimulants for a disorder characterized by hyperactivity since stimulants can make you jittery and hyper. Yet they work for 70%-80% of individuals with ADHD.
The reason is that, as with autism, much of a child’s hyperactivity is due to “stimming” or self-stimulating behavior. They are trying to stimulate themselves to reduce their ADHD symptoms.
By taking a stimulant, they receive a boost in their supply of neurotransmitters, such as dopamine and norepinephrine, and don’t need to self-stimulate.
Some parents and others think that prescribing ADHD medications will increase the risk of their children becoming addicted to illegal drugs. These medications are central nervous system (CNS) stimulants with similar effects to cocaine when taken in larger-than-prescribed doses. This can lead to dangerous results such as addiction to ADHD drugs like Strattera.
But studies find that children with ADHD who have used these prescribed medications are less likely to become addicted to any drugs compared to children with ADHD who haven’t used such prescriptions and non-ADHD youth who use ADHD medications as study aids.
People with substance use disorders (SUDs) take drugs for the rush. People with ADHD take prescription stimulants to return them to “normal.”
Also, ADHD drugs don’t take effect for an hour or so. Cocaine takes less than a minute. People with SUDs don’t want to wait.
The most commonly prescribed stimulant drugs for ADHD are:
- Amphetamines:Adderall XR, Dexedrine, Evekeo
- Methylphenidate: Ritalin, Concerta, Quillivant XR
- Others:Focalin XR (demethylphenidate hydrochloride), Vyvanse (lisdexamfetamine dimesylate)
For the other 20%- 30% of people with ADHD for whom stimulants don’t work, there are nonstimulant drugs. They are not as effective, may not be approved by the U.S. Food and Drug Administration for ADHD, and may have side effects. They include:
- FDA-approved medications: Strattera (atomoxetine); Intuniv (guanfacine); Kapvay (clonidine)
- Antidepressants: Wellbutrin (bupropion); Effexor XR (venlafaxine)
- Tricyclic antidepressants: Tofranil (imipramine); Desipramine (Norpramin, Pertofrane), Nortriptyline (Aventyl, Pamelor)
- MAOIs (monoamine oxidase inhibitors): Nardil (phenelzine),Parnate (tranylcypromine)
- Blood pressure medications: Tenex (Guanfacine), Clonidine (Catapres)
- Sleep disorder medications: Provigil (modafinil)
- Antiviral medications: Symmetrel (amantadine)
In 2019, the U.S. Food and Drug Administration authorized the prescription use of an ADHD medical device, the Monarch External Trigeminal Nerve Stimulation (eTNS) System. The size of a cell phone, the device delivers a low-level electrical tingle to a part of the brain associated with ADHD.
- Young children may not be ready or able to benefit from cognitive behavioral therapy (CBT) or other psychotherapies (talk therapies) until they are older, but they can benefit from social skills training.
- Parents and educators also can learn ways to modify their child’s ADHD behavior through contingency management, a practice that gives rewards for good behavior. In any case, they should work together with counselors and medical professionals to provide a team effort.
- The parents, siblings, and other relatives might benefit from family therapy to learn how to cope with a child’s ADHD.
CBT or other psychotherapies may be of use later in life. Adults have ADHD and so support groups may help. Regardless of the condition, it often helps to talk with people who are going through the same challenges and triumphs as you.
A couple of organizations that offer or provide connections to ADHD support groups are:
- Children and Adults with Attention-Deficit/Hyperactivity Disorder
- Affiliate and support group locator
- Attention Deficit Disorder Association (ADDA)
- Support groups for adults with ADHD
ADHD has no cure, though many children with the disorder do seem to grow out of at least some of the more severe symptoms. They may have to live with other symptoms.
You can improve some symptoms by making sure your child is getting enough sleep and eating a healthy, balanced diet.
ADHD is not a monolith. The same remedy will not help all people, but don’t give up. There are too many alternative therapies to list here. Keep trying until something helps.
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