Attention-Deficit Hyperactivity Disorder (ADHD).

Signs and Symptoms.

According to the Diagnostic and Statistical Manual of Mental Disorders, ADHD (previously known as ADD or attention deficit disorder) starts in childhood before the age of 12, and symptoms are persistent beyond 6 months (American Psychiatric Association, 2013). ADHD symptoms can be divided into 3 domains as described below:

Depending on age, 5-6 symptoms in the inattentiveness domain and/or 5-6 symptoms in the hyperactivity and impulsivity domains may indicate ADHD (American Psychiatric Association, 2013).

ADHD is best described as an Executive Function Disorder of Attention Budgeting. It’s not that an individual with ADHD is deficient in attention; it’s instead that the individual has a neurodevelopmentally derived difficulty choosing one thing to focus on over another in a world of stimuli that compete for attention.

The consequence is a gap between ability and performance, where the abilities one has do not match current performance. The DSM does not consider the consequent emotional strain and emotion dysregulation that becomes a core problem arising from this gap.

Causes.

The DSM diagnosis of ADHD is descriptive and does not address the cause. Because executive functioning is the final common pathway (i.e., it’s what our brains should be doing), there are several areas of potential breakdown. Therefore, there is not likely one single cause.

ADHD tends to run in families, with greater than 75% of individuals having a family history (Thapar et al., 2013). Those with a first-degree relative (e.g., mother or father) with ADHD are 2-8 times more likely to have ADHD. Beyond family history, specific genetic markers cannot be used for predictability as they are not consistently supported in research. It is likely that the interaction of genes and environmental causes (aka epigenetics) contributes to the development of ADHD.

Some environmental risk factors associated with the development of ADHD include substance use during pregnancy, in-utero exposure to environmental toxins, exposure to environmental toxins in childhood (E.g., lead), low birth weight, and brain injury (Thapar et al., 2013).

Outside of the perinatal experience, childhood or developmental trauma is a leading cause of ADHD symptoms. Originally emerging as a protective defense, ADHD symptoms become pervasive and problematic over time. Therefore, treating trauma rooted in childhood may alleviate ADHD symptoms.

Suboptimal performance of key body systems, developed over time, contributes to ADHD symptoms as well. These systems include the adrenal (stress), gonadal (sex hormone), gut, thyroid, immune, and micronutrient systems. Those with ADHD symptoms often struggle with B-complex, vitamin D, iron, and zinc deficiency. It is also common for those who struggle with ADHD symptoms to have mitochondrial and methylation impairments.

All of these potential causes and contributing factors can be thoroughly evaluated and addressed by an integrative psychiatry specialist.

Statistics.

ADHD is the second most common psychiatric condition (following depression).

3-10% of children have ADHD, 50-80% continue to meet criteria in adolescence, 50-65% continue to meet criteria in adulthood, and 4% of adults have ADHD (Kessler et al., 2006; Michielsen et al., 2012).

If not treated as a child, the adult has an increased incidence of anxiety, low self-esteem, antisocial behavior, alcohol and drug use, interpersonal difficulties, and occupational instability. Poor outcomes are associated with lower intelligence, lower socioeconomic status, conduct problems, and family dysfunction.

Neurobiology.

From a bird’s eye view, attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that arises from impairment in the communication between a number of brain networks or circuits. Below are the key brain areas within particular networks that are related to the key symptom domains:

It’s important to note that all of these areas are a part of the prefrontal cortex, the front and topmost region of the brain that is responsible for executive functioning. Because the executive part of the brain does not develop properly, ADHD becomes a “top-down” disorder, where the executive is not able to manage things such as impulse control and emotions.

Zooming in a little closer, we find that those with ADHD have difficulty “tuning the prefrontal cortex”. This tuning is maintained by the brain chemicals (neurotransmitters) dopamine and norepinephrine. Normally, there is a slow or tonic release of dopamine and norepinephrine, allowing for the appropriate transmission of signals (called transduction). Norepinephrine contributes to an increase in signaling, making appropriate connections. On the other hand, dopamine reduces noise in order to help decrease inappropriate connections.

In ADHD, there is an overall reduction in slow or tonic firing, leading to an increase in noise and a decrease in signaling.

But another issue is that the consequent stress arising from the symptoms of slow or tonic firing can increase phasic or rapid firing. Phasic or rapid firing will also lead to an overall imbalance of dopamine and norepinephrine. This concept explains the issues that arise due to ADHD, such as anxiety and depression. This also explains why the reverse is true, for instance, why an individual suffering from depression has symptoms of ADHD.

Screening.

A number of screening tools are available to assist with the diagnosis of ADHD. As a rule, a screening tool in psychiatry only rules out a diagnosis if the test is negative, it does not confirm a diagnosis if the test is positive. To confirm a diagnosis, a psychiatric specialist will evaluate the nature and context of your symptoms to help determine the appropriate diagnosis.

Adults: Adult ADHD Self-Report Scale (ASRS) v1.1. An 18 item screening tool used during an initial evaluation to determine if an adult may have ADHD. This is best done by the individual with symptoms as well as completed by someone who knows the individual well. Sensitivity 84%, Specificity 66% (Glind et al., 2013).

Adults: Adult Self-Report Scale (ASRS) v1.2. A 6-item screening tool revised to include updates in the DSM-5. Sensitivity 91.4%, Specificity 96.0% (Ustun et al., 2017).

Children: Vanderbilt ADHD Parent Rating Scale (VADPRS). A 45-item screening tool that is made to provide information on a parent’s perception of social functioning and school performance in relation to ADHD symptoms. Sensitivity 80%, Specificity 75% (Gaba & Giordanengo, 2019).

Children: Conner’s Abbreviated Symptom Questionnaire. A 10-item screening tool used by a parent to evaluate for possible ADHD. Sensitivity 83%, Specificity 84% (Gaba & Giordanengo, 2019).

Differential Diagnosis.

As mentioned above, a screening tool does not confirm the diagnosis of ADHD. A psychiatric specialist will explore the possibility of other conditions that may explain ADHD symptoms using a method referred to as a “differential diagnosis”. This helps to ensure other conditions that mimic the symptoms of ADHD are appropriately explored and treated appropriately. Below is a list of conditions that commonly mimic ADHD:

• Vision, Hearing, or Speech Deficit

• Specific Learning Disorder

• Intellectual Disability

• Medication Side Effects

• Anemia and B12 Deficiency

• Lead Toxicity

• Hyperthyroidism

• Hypoglycemia

• Seizure Disorder

• Substance Use

• Sleep Disorder

• Unipolar Depression

• Bipolar Disorder

• Anxiety Disorder

• Trauma Disorder

• Oppositional Defiant Disorder and Conduct Disorder

• Cluster B Personality Disorder

• Obsessive-Compulsive Personality Disorder (OCPD)

Treatment.

From the neurobiology perspective, the goal is to “tune” the levels of dopamine and norepinephrine. If dopamine and norepinephrine activity is too low, all signals will appear the same and will not grab the individual's attention. If dopamine and norepinephrine activity is too high, the signals are jumbled. This can be achieved through the use of medication as well as therapy.

Psychopharmacologic Management.

General Considerations: In determining the most appropriate treatment for ADHD symptoms, a psychiatric specialist will explore the presence and influence of comorbidities. Comorbidities are co-occurring conditions that may influence the response to treatment. Examples of comorbidities influencing treatment option include anxiety disorders, mood disorders (depression or anxiety), substance use disorders, and tics.

Child Considerations: Other considerations are taken into account if the patient is a child. For instance, under the age of 5, a child is less likely to experience benefit from medication treatment and is more likely to experience side effects. It is therefore recommended to emphasize therapy (especially parent skills training) until after the age of 5 according to the PATS study and National Institute for Health and Care Excellence (NICE) (NICE, 2018).

Treatment, as discussed below, is guided by the most current evidence-based treatment guidelines as described by the NICE:

Order of Treatment: In the ADHD literature, it is recommended to treat ADHD with comorbidities in the following order: Substance use disorder > Mood disorder (bipolar disorder and depression) > Anxiety disorder > ADHD. When this is not done, the individual may experience a worsening of other conditions with ADHD treatment.

Estimated Treatment Response: Following are estimates of treatment responsiveness: Stimulants (80%), Atomoxetine (60%), Viloxazine (50%), Bupropion (20%).

Nutraceuticals.

Several nutraceutical products have been utilized to improve executive functioning including bacopa, ginkgo biloba, lion’s mane, rhodiola, SAMe, and L-theanine. An integrative psychiatry specialist can help you navigate through these nutraceutical options appropriately to determine what may be most appropriate based on your unique experience.

Psychotherapeutic Approach.

Behavioral: Reward positive behaviors through positive reinforcement, intermittent scheduling. Periodically vary the rewards. Maintain consequences for negative behaviors. Clearly define acceptable and unacceptable behaviors. Clearly define rewards and consequences.

Problem-Solving Therapy: Guide the patient in exploring values, setting SMART goals related to those values, and breaking down action steps. Use successive approximation to achieve goals. Integrate organization and time-management principles. Implement self-reward systems for achieving steps on action plans.

Emotional: Teach emotion-regulation and mindfulness-oriented skills. Mindfulness actively builds on attention networks. Defuse from thoughts and emotions and practice acceptance.

Trauma-informed: A trauma-informed approach may be helpful in exploring ADHD that is causatively linked to childhood and developmental trauma. This is commonly overlooked in conventional practice.

Educational: 504 plan can help with preferential seating, extra time on tests, and later for standardized testing (e.g., ACT or SAT). Consider an individualized education plan (IEP) for more support by spelling out everything teachers must do to help students succeed. Integrate a consultant for issues on management of ADHD for teaching staff. Educate on health aspects of ADHD to schools and community.

Other psychotherapeutic techniques and modalities may be required for comorbidities.

Psychotherapy for executive functioning, including those experiencing the symptoms of ADHD is best guided by a tool exploring which executive functions could benefit from improvement. In my book you’ll find a tool designed to evaluate all executive functions with dedicated sections for therapeutic techniques for each executive function.

References.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Asherson, P., Young, A. H., Eich-Höchli, D., Moran, P., Porsdal, V., & Deberdt, W. (2014). Differential diagnosis, comorbidity, and treatment of attention-deficit/hyperactivity disorder in relation to bipolar disorder or borderline personality disorder in adults. Current Medical Research Opinion, 30(8), 1657-72. doi: 10.1185/03007995.2014.915800

Gaba, P. & Giordanengo, M. (2019). Attention-deficit hyperactivity disorder: Screening and evaluation. American Family Physician, 99(11), 712.

Glind, G., Brink, W., Koeter, M. W. J., Carpentier, P., Ootmerssen, K. E., Kaye, S., … & Levin, F. R. (2013). Validity of the adult ADHD self-report scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug and Alcohol Dependence, 132(3), 587-596.

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., … & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States from the national comorbidity survey replication. American Journal of Psychiatry, 63(4), 415-424.

Michielsen, M., Semenij, E., Comijs, H. C., Ven, P., Beekman, A. T. F., Deeg, D. J. H., & Kooij, J. J. S. (2012). Prevalence of attention-deficit hyperactivity disorder in older adults in the Netherlands. British Journal of Psychiatry, 2012(201), 298-305.

National Institute for Health and Care Excellence (NICE). (2018). Attention deficit hyperactivity disorder: Diagnosis and management. https://www.nice.org.uk/guidance/ng87

Perugi, G. & Vannucchi, G. (2015). The use of stimulants and atomoxetine in adults with comorbid ADHD and bipolar disorder. Expert Opinion Pharmacotherapeutics, 16(14), 2193-204. doi: 10.1517/14656566.2015.1079620

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Edition). Cambridge University Press.

Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). What have we learnt about the causes of ADHD?. Journal of child psychology and psychiatry, and allied disciplines, 54(1), 3–16. https://doi.org/10.1111/j.1469-7610.2012.02611.x

Ustun, B., Adler, L. A., Rudin, C., Faraone, S. V., Spencer, T. J., Berglund, P., Gruber, M. J., & Kessler, R. C. (2017). The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry, 74(5), 520–527. https://doi.org/10.1001/jamapsychiatry.2017.0298

Viktorin, A., Rydén, E., Thase, M. E., Chang, Z., Lundholm, C., … & Landén, M. (2016). The Risk of Treatment-Emergent Mania With Methylphenidate in Bipolar Disorder. American Journal of Psychiatry, 174(4), 341-348. doi: 10.1176/appi.ajp.2016.16040467