ABCs and 123s of ADHD

This is an overview of ADHD (Attention Deficit and Hyperactivity Disorder), primarily numbers and names.

123s…

What’s the prevalence? It’s estimated to be about 5-6% of the world population of children and 3-4% of the world population of adults (using DSM-IV criteria, DSM-5 criteria increase the estimates slightly). It’s estimated that about 1-2% of children without childhood ADHD may meet criteria for ADHD after 12 years of age. This suggests that about half of the population of adults with ADHD develop it “late.”

123s and ABCs…

When did the first formal description of ADHD appear, albeit under a different name? One best guess is 1798 by Alexander Crichton. Dr. Faraone at SUNY Upstate Medical University suggests it goes back even farther…to Weikard and a 1775 German medical textbook. See https://adhdinadults.com/a-brief-history-of-adhd/

Fast forward to 1968, when it became an official diagnosis here (the U.S.), being added to the DSM-II, clinicians’ reference for diagnoses of mental disorders. It was called Hyperkinetic Disorder of Childhood. The name changed over the years but the essence of the disorder as one of childhood hyperactivity, impulsivity and wayward attention remained.

In 1980, the DSM-III came out and added specifics to the diagnosis, such as indicating that symptoms had to appear before 7 years of age. There was no research showing that 7 was a magic number; only enough clinicians believing this made sense.

In 1994, the DSM-IV softened the age of onset “rules” requiring only some of the symptoms to appear before age 7. Subtypes were also added. It is during the 1990s that Adult ADHD becomes recognized as a valid disorder.

In 2013, the DSM-5 changed the requirement that symptoms be present before age 7 to before age 12.

WHAT IS IT? ADHD is a self-regulation disorder. Regulation is, essentially, flexible self-control described by 4 Ss: starting, sustaining, stopping and switching attention, action, motivation, and more. It is understood as a neurodevelopmental disorder, which is to say it is a way that the brain (“neuro”) develops that affects, more than anything, self-regulation, essentially, decreasing it compared to what’s seen for those without ADHD. And here’s the disorder part: It is associated with distress and/or dysfunction, including poorer results at school and work, higher levels of health-risking behaviors, and being less satisfied with oneself.

What Causes It? It’s believed to result from certain combinations of genes and environmental factors. Genes are believed to be necessary and… insufficient. So are environmental factors.

Sources:

https://www.ncbi.nlm.nih.gov/pubmed/?term=annual+research+review+does+late-onset+attention-deficit

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000907/

What gets us to change?

A 2018 review out of the Annals of the New York Academy of Sciences asks how we can use what we know about the brain to influence behavior (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175225/). Specifically, the ones that feel good at the moment and, ultimately, hurt us.

Three essential factors surfaced along with remedies that apply across disorders and diseases.

  1. Reward valuation. Where does our brain land on the pros and cons of a behavior (e.g., eating the donut)? Sometimes where our brains land gets us into trouble (e.g., our brains may say the pleasure now outweighs the pain later…and be wrong). What’s the remedy? Research suggests that our brains need to see the personal relevance of behaviors (exercise, healthy eating, etc.). That is, is it really relevant to me and/or those who matter to me? So messages about exercise, for example, will influence us more when we can connect them to our values. When people reflect on core values, what deep down really matters to them, and then get messages about healthy behaviors, it predicts they will move toward health (e.g., exercise, healthy eating, loving relationships). People who receive the same messages without having first reflected on who and what they really care about are unlikely to be moved.
  2. Delay discounting. Delay discounting refers to our tendency to discount/devalue the value of a reward the longer we have to wait for it. As a result, we often choose smaller rewards with immediate gratification over bigger ones with delayed gratification. Eclairs over exercise. The remedy? Research suggests episodic future thinking (EFT), which is the capacity to imagine or simulate personal future experiences that may occur. It works like this: You have a talk coming up, so you imagine giving this talk and different ways it may play out. Or you imagine desired health results, such as a healthy weight, as you leave work knowing the gym is on the way home. Or you mentally play out ordering salad before you go to dinner with your friend. Being able to imagine or simulate our intentions increases the chances we will act on them.
  3. Self-control (aka self-regulation), the capacity to direct different parts of ourselves (thoughts, urges, cravings, emotions, actions) toward achieving future-oriented goals. One remedy that the researchers discuss to enhance self-control is physical exercise. In https://tonyalippert.blog/2017/08/01/understanding-adhd/, you can find several ways (regardless of whether you have ADHD).

I invite you to try one, two or all three of these and see what you notice.

Relationships: Turning Toward or Away

I know relationships from both a work and personal perspective. What I want to share as a level-2 certified PACT therapist (https://thepactinstitute.com/dividedpage/what-is-pact/) applies to intimate relationships with or without the influence of ADHD. PACT stands for Psychobiological Approach to Couple Therapy (fancy, I know).

When a couple enters into troubled territory, its members can turn to each other for solace and connection, right? Even when the trouble is each feels hurt and misunderstood by the other.

Right? Yes, some couples can. The secure functioning ones. The ones who understand that their relationship depends on this.

Many couples, however, do the opposite. They turn away. Each member feels too hurt, misunderstood, blamed, and afraid. Afraid of more of hurt, more of the same. Too caught up with thoughts of how the other one should know. Should know what I’m feeling, what I want. My hurt and mind. So the members turn away from each other and toward others and other interests to meet his/her own needs. One goes out with friends. The other delves into a creative venture. One joins a club. The other travels alone. Again and again looking outside the relationship for more and more. Each, little by little, turning away, and forgetting how to turn toward, each other. Until…it’s over.

If this is your relationship and you want to turn it around before you and your lover/partner/spouse kill it, try turning toward. Start by doing this physically. Get face-to-face, eye-to-eye with your partner, close enough to see each other’s pupils. Hold for a few minutes. Keep your faces soft and friendly. It may sound simple but can be really hard for couples to do. So no judgments. Of yourself or your partner. Approach it playfully. Then rinse, wash, repeat, as Stan Tatkin, the developer of PACT, likes to say.

My hope is that, for each member, this may be a start to turning toward, and getting to know, the person you once loved fiercely and may find yourself loving fiercely again.  

ADHD and Attentional Interference from Competing Brain Networks

As prior research out of MIT (Go, Go, Go and Slow, Slow, Slow?), research out of Oregon Health Sciences University (OHSU) recently examined the coordination between two brain networks:  the task positive network(s) and the default mode network. These networks have largely opposite functions. In the first–task positive network(s)–there’s increased activity when we have a particular task that demands focus, letting us start and sustain attention on the task. In the second–the default mode network–there’s increased activity when we have no particular task to do. In adults without ADHD, per the MIT research, these two networks cooperate:  When it’s time for one to get on stage, the other fades into the background. In adults with ADHD, these networks are uncooperative and can compete for attention at the same time.

vibrations-545138_1920In kids with ADHD, according to the results of the OHSU study (here), we see the same lack of coordination/cooperation between the networks as compared to children without ADHD, with this lack of coordination between networks increasing with age.

The result? Mixed signals. Attentional interference. Or, as the researchers put it, decreased attentional control. A reminder that behavior reflects brain activity, coordinated or otherwise.

Of interest, the OHSU researchers found that the brains of female children overall, with or without ADHD, showed more coordination between the opposing networks than the brains of male children.

Two Awesome ADHD Resources

One resource focuses on children and teens; the other is for adults. Both can be remarkably useful for those with ADHD.

The first is understood.org (here) for “learning and attention issues.”  What it offers is vast and, though, it’s targeted to parents of children and teens with ADHD, many adults with ADHD can find it of use. Much of what’s suggested for teens applies to adults, except for the context (e.g., work vs. school).  Also, given that 25-35% of parents of youth with ADHD are likely to have ADHD (source), parents using the site may want to use the recommendations for themselves as well as their children.

The second resource is JAN, Job Accommodation Network (here), which is all about workplace accommodations for employers and employees needing or wanting to know what the American with Disabilities Act (ADA) encompasses, including job coaches…even the possibility of free ones.  Who knew? From what I can tell, fewer than would have liked to have known.

I hope something here is of use to you.

ADHD Confusions

In the realm of ADHD research, OHSU professor Joel Nigg, Ph.D. is a major player.  He recently outlined the latest understanding of ADHD and three major confusions that have hurt this understanding (here).

Confusion #1:  It’s easy to fix.

Reality:  Long-term follow-up studies show that even the best “fixes” for ADHD barely change its long-term life outcomes.

Confusion #2:  It’s no big deal, anyway.

Reality:  Childhood ADHD has a strong association with future antisocial behavior, school and work failure, incarceration, and more, including serious injuries, shortening life spans.

Confusion #3:  It’s just inherited or it’s just a result of the environment.bees copy

Reality:  Its development appears to be a combination of uncommon gene mutations AND genetic factors common across psychiatric disorders, WITH the expression of these mutations and factors dependent on experience/environment (e.g., exposure to toxins/pollutants/contaminants).

The truth about us humans appears to be that we are just more complex and complicated than we’d like to believe sometimes.  This includes the reality that you, if you have ADHD, are more complex and complicated than it is.  It is a complex part of a complex you.

Mindfulness & Psychoeducation: “Everybody has won, and all must have prizes”?

The Dodo bird quote from Alice’s Adventures in Wonderland came to mind as I read the results of a recent study.  A randomised, controlled fMRI study of the effects of mindfulness and psychoeducation on the working memory of adults with ADHD found they both worked (for more on working memory, see What predicts ADHD symptom reduction over time?).  art-creative-flying-17679.jpg

After 8 wks, both interventions were found to increase working memory performance and to increase task-related right parietal lobe brain activity to a similar degree (study here).  Although I’d like to see the results for a third group who received neither intervention (to rule out any placebo effect), the good news is that, under both conditions, working memory increased.  What would be interesting to see next is what happens when we combine mindfulness and psychoeducation.

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