Understanding ADHD

Attention deficit hyperactivity disorder (ADHD) is a common diagnosis, affecting roughly one in 20 children and one in 40 adults. But since it was formally recognized as a mental-health condition in 1980, ADHD has suffered somewhat of a misunderstood, even maligned, reputation.

Joshua Stein, MD, president of the Minnesota Society for Child and Adolescent Psychiatry, has a long history of diagnosing and treating ADHD. He’s encountered numerous misconceptions about the disorder, ranging from assumptions that individuals with ADHD are less intelligent (“In fact, they are often incredibly creative and talented people,” Stein says) to fears about the stimulant medications often used in treatment (more on that below).

Another common — and more complicated — popular belief is that ADHD is overdiagnosed, an issue Stein acknowledges. “ADHD should only be diagnosed after extensive screening and evaluation,” he explains. “But an accurate diagnosis and treatment can be incredibly protective, changing some kids’ entire life trajectory.”

Spotting and treating ADHD starts by understanding what it is, what it isn’t, and what parents can do about it.

Causes, Symptoms, and Subtypes

As with every mental-health disorder, both nature and nurture contribute to the development of ADHD, but the former is especially critical. If someone in your family has been diagnosed with the disorder, you have about a 75 percent chance that it will be passed down to you.

Researchers remain less certain of the environmental causes, but studies have linked ADHD with adverse early-life experiences as well as in-utero exposure to numerous substances, including tobacco and lead. What has not been shown to cause ADHD (despite popular belief) is sugar, TV, or poor parenting.

Stein describes ADHD “as an underactive brain that shows up as an overactive person.”  Compared to someone with an “average brain,” individuals with ADHD exhibit more theta (slow) brainwaves and fewer beta (fast) waves, especially in the frontal lobe, the brain’s command center. “This leads people with ADHD to seek out more stimulation,” he explains.

There are three types of ADHD. The inattentive type is characterized by difficulty sustaining attention, organization, and follow through. Individuals with inattentive-type ADHD often seem lost in their own world and are prone to misplacing or forgetting things. They’re easily distracted and tend to make careless mistakes or miss key details in projects.

The hyperactive/impulsive type has a hard time sitting still. These individuals tend to squirm and fidget, as if bursting with excessive energy. They often find it difficult to wait and quickly grow impatient with slower, quieter activities. They may talk excessively, interrupt others, or blurt out an answer before their parent, teacher, or peer finishes the question.

Many individuals present with a combined type of hyperactive and inattentive symptoms.

To meet diagnostic criteria, regardless of sub-type, symptoms must persist for at least six months and occur in at least two settings, such as school and home.

Adults can be diagnosed with ADHD, even if they never received a formal diagnosis as a child. But, in order to meet the diagnostic criteria, symptoms must have started prior to age 12. Verifying an ADHD diagnosis in adults often involves gathering ancillary information from other sources, such as family members, and reviewing school records for social or academic patterns indicative of the disorder.

What ADHD Isn’t

Many individuals present with ADHD-like symptoms without actually having the disorder. Undiagnosed hearing or vision impairments, for example, can manifest as distractibility in the classroom, while learning disabilities, such as dyslexia, can result in poor follow-through with homework. Kids with a history of seizures or concussions may experience difficulties with memory or processing; this may look a lot like the daydreaming and forgetfulness common in inattentive-type ADHD.

Environmental stressors can also yield ADHD-like symptoms. When chronically exposed to instability at home, kids often act out or “numb out.” The former can look like hyperactive ADHD — imagine the kid who can’t seem to sit still in class — while the latter may show up as the distracted, forgetful, inattentive type.

To ensure an accurate diagnosis, professionals complete a full medical assessment, which may include EEGs or MRIs to rule out other neurological issues. They also gather information from other people in the individual’s life, namely parents and teachers, and use formal assessments such as the Conners parent-teacher rating scale, which includes a long list of symptoms and pulls from multiple perspectives; and the Continuous Performance test, a computerized evaluation during which kids respond to purposefully boring flashing images to assess how long they can maintain attention.

“It’s so important to rule out other issues before making a diagnosis,” says Stein. “Often tutoring or extra time to complete a test may be more effective than medication.”

Why It’s So Important to Address ADHD

Unaddressed ADHD can lead to devastating consequences. Whether because they can’t focus or can’t sit still — or both — kids with ADHD are more likely to fall behind in school, and this can easily snowball into bigger and riskier issues.

“School is a stabilizing social structure,” Stein explains. “If you can’t function in the school setting, there’s a risk of dropping out and engaging in high-risk behaviors.”

Kids who consistently cause problems in class may be rejected by their peers, contributing to poor self-esteem and inadequate social support. Meanwhile, impulsivity can lead to delinquent behaviors, such as shoplifting or substance use: Individuals with ADHD are significantly more likely than average to abuse drugs and alcohol.

More broadly, untreated ADHD can damage kids’ sense of self. When parents and teachers focus on reckless behavior or poor school performance without taking time to understand why the child is struggling, that child may internalize the negative feedback and begin to see him or herself as a “bad kid” or “just not very bright.”

Treatment

Options for treating ADHD run the gamut, but medication is often the first-line approach.

“Of all the conditions we treat in mental health, ADHD is one of the most responsive to medication,” says Stein.

A wide variety of medications — not all of which are stimulants — can be used to treat the condition, and they tend to work almost immediately. Still, drugs do have side effects, including reduced appetite, worsening anxiety, and difficulty sleeping. Moreover, Stein notes that kids can outgrow symptoms and no longer need meds as they age, again highlighting the importance of regular assessments.

A range of nonpharmaceutical treatments have also shown potential. Some studies have supported the use of zinc, iron, and magnesium, though evidence remains inconclusive.

Neurofeedback, a form of “brain training” that teaches self-regulation through real-time brainwave feedback, also shows promise, though the cost of treatment can be prohibitive for some families.

A similar but more accessible option is Endeavor RX. The first FDA-approved gaming treatment for ADHD, available by prescription only, Endeavor RX has been shown to improve attention functioning.

Families should also participate in the treatment protocol. This can involve teaching parents how to help kids follow instructions in a way that works for their brains and create a consistent home environment with clear expectations about choices and consequences. And because ADHD often runs in families, parents may benefit from learning their own self-regulation skills.

Finally, parents can help kids learn how to “lean into” their ADHD. An ADHD brain isn’t dysfunctional so much as different, and individuals with this disorder often excel in nonlinear, creative endeavors or high-adrenaline physical activities.

“Kids with ADHD certainly face challenges,” says Stein. “But they also have incredible strengths.”