Can you remember a time when you, or a family member, felt so distracted and unable to concentrate that frustration boiled over and you spoke, or acted rashly or impulsively? Maybe this is a pattern that seems unavoidable…
Perhaps you have a child at home who seems unable to follow through on things despite repeated instructions and constant nagging. Maybe you have a child who struggles at school and with their peers even though they study, they care about their schoolwork, and they want to make those around them happy. For all their effort to do their best, they keep struggling…
ADHD Today
These scenarios provide a snapshot of what it is like for 7 million children age 3-17, and 8.6 million adults in the United States who live with ADHD, Attention-Deficit Hyperactivity Disorder. As our examples show, ADHD is a pervasive medical condition in which a person has problems with paying attention, hyperactivity, and impulse-control. ADHD interferes with a person’s ability to learn, to form and maintain healthy relationships, and to realize their potential for success at school/work.
ADHD is the most common and most widely studied neurodevelopmental (brain and nervous system) disorder. Our understanding of ADHD has come a long way since the 1960’s, when it was officially recognized in medical literature. Research has led to new perspectives of how biology, development, and environment contribute to ADHD. Along the way, we’ve learned a lot about many different types of treatment. Both conventional medical treatments (e.g., prescription medicine and behavioral therapy) and a variety of holistic interventions exist for people living with ADHD.
What is ADHD?
Considered a lifetime condition, ADHD is usually first diagnosed in childhood and often lasts into adulthood. People who have ADHD experience problems with executive functioning tasks such as organization; short- and long-term planning; time management; and the cognitive and emotional processes that allow us to shape ideas into goals and follow through with sustained effort. They can struggle with managing their emotions and impulses because they aren’t able to focus and think through their actions in ways that are developmentally appropriate for their age. In other words, their behavior isn’t what is expected for a person their age.
ADHD is recognized by disruptive patterns of thought and behavior that affect a person in these 3 areas:
- Attention (to attend, focus, and concentrate with sustained effort)
- Impulse Control (emotional and behavioral)
- Hyperactivity (excessive energy level)
ADHD Symptoms and “Types”
There are three different ways ADHD can present in a child or an adult. Clinicians consider the variety of symptoms that a person has in order to make a diagnosis, while also ruling out other medical or nervous system conditions with similar symptoms. Clinicians refer to the diagnostic manual, DSM-V to guide their assessment and determine which of three “presentations of ADHD” best fits a person’s experience. You might hear these described as “types” or “sub-types”:
ADHD Inattentive Presentation
- Inability to give close attention to details or makes careless mistakes
- Has difficulty sustaining attention, daydreaming
- Does not appear to listen when directly spoken to
- Struggles to follow through with instructions, starts but is easily sidetracked
- Has difficulty with organization, managing time,
- Avoids or dislikes tasks requiring sustained mental effort
- Is easily distracted
- Is forgetful in daily activities
- Loses things, including items of importance
ADHD Hyperactive-Impulsive Presentation
- Fidgets with hands or feet or squirms in chair
- Has difficulty remaining seated
- Runs about or climbs excessively in children; extreme restlessness in adults
- Difficulty engaging in activities quietly
- Acts as if driven by a motor; adults will often feel inside as if they are on autopilot
- Talks excessively, feels restless
- Blurts out answers before questions have been completed
- Difficulty waiting or taking turns
- Interrupts or intrudes upon others
ADHD Combined Presentation
The person meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.
The symptoms need to have been present prior to the age of 12. To make an ADHD diagnosis:
- children should have six or more symptoms
- adolescents 17+ and adults should have at least five symptoms
- symptoms must be evident in different settings (home, school, work, social/recreational activities), and cannot be better explained by another health condition
Resource: a helpful infographic for parents and this infographic for teens.
Diagnosing ADHD
Symptoms of ADHD can be mistaken for childhood defiance, teen rebelliousness, or for simply being “difficult.” Symptoms of other medical conditions, such as anxiety or depression can also make it difficult to identify ADHD. Other factors that make diagnosis tricky, and the reason why a well-trained professional needs to be involved in making an assessment, include:
- Boys are more likely to be diagnosed because they tend to show more observable, disruptive behaviors that grab the attention of caregivers and teachers.
- Girls and women generally show different ADHD symptoms (more inattentive type), are more often overlooked for an ADHD diagnosis, and tend have more severe outcomes as a result of having ADHD.
“It’s important to educate families on what to look for with regards to ADHD in children and teens, including distinctions between how boys and girls experience ADHD and the associated observable behaviors such as daydreaming, inability to maintain focus or “zoning out”, interrupting conversations, impulsivity, becoming easily frustrated, and having trouble managing emotions,” says Eileen Peirce, CRNP-PMHNP with P.S. Psychiatry of Doylestown, PA.
Another important consideration for getting a proper diagnosis is the fact that some children make incredible adaptations for ADHD symptoms, “It’s not until those adaptations stop working for the child, or the ways that the child is compensating leads to other problems (such as cutting, problems at school, anxiety), do the people around them take notice.”
It is crucial to have a well-trained professional evaluate a child to make a differential diagnosis to be sure that an ADHD diagnosis is not overlooked because of other symptoms.
The Process for Diagnosing ADHD
There isn’t a single test to diagnose ADHD—it’s a process. Diagnosing ADHD involves
- a physical exam (vision and hearing tests; tests to rule out other medical conditions that share similar symptoms as ADHD including sleep disorders, learning disabilities, and other mood disorders.
- individual medical history
- family medical history (including mental health conditions)
- standardized symptom questionnaires, and clinical interviews that utilize rating scales (scoring systems) that help a clinician determine if a person’s symptoms and history fit ADHD.
Clinicians must also be able to distinguish co-existing psychiatric disorders that commonly occur with ADHD and can be mistaken for ADHD (and vice versa).
Resource: Who Can Diagnose ADHD?
Proper and early diagnosis of ADHD can give children and adults the best opportunity to meet their potential by helping them develop the self-management skills and modifications that are essential for academic and career success, healthy relationships, and protecting them from other social-emotional difficulties and mental health concerns.
Causes of ADHD: Biology, Environment, Development
There is no one theory or exact cause for why a person develops ADHD. Research has led to new perspectives of how biology, development, and environment contribute to ADHD. Research shows that a combination of factors contribute to the development of ADHD:
- Biology, including genetics and family history
- Environment, including nutrition, exposure to toxins, physical activity etc.
- Development, such as the timing of what are widely accepted as ‘typical’ developmental patterns during childhood including self-awareness, motor tasks, language skills, and other developmental tasks.
Biology and ADHD
There is no question that ADHD is a biologically-based condition. Cross-cultural studies of children and adults with ADHD show the disorder has heritability, potential genetic markers, and people with ADHD show differences in brain structure/function under different types of diagnostic imaging.
Genetic research on ADHD is still in early development. Unlike other medical conditions such as Down Syndrome, there currently are no genetic tests to identify risk or conclusively diagnose for ADHD.
Studies show that ADHD runs in families, which points to its heritability. Every illness has a different level of heritability. Family heritability of ADHD is estimated to be 70-80%. That also means 20-30% of cases are not related to family genetics—there’s some other cause. If a parent has ADHD, there is an increased risk their child will have ADHD. Similarly, if a sibling as ADHD, there’s an increased chance that a younger sibling will also develop ADHD. But even if the increased chance is 50%, that’s not a certainty. Biology is not destiny—many things can intervene to lead to or to protect a person from developing a medical condition, even one with high hereditably like ADHD.
Sight, Sound & Information Processing in the Brain
ADHD also involves problems with auditory processing, and in some people, problems with visual processing. To clarify, auditory and visual processing is not about a person’s physical ability to hear or to speak. Auditory and visual processing problems happen in the brain, after a sound or visual input is observed (heard or seen) and that information is transported to brain to be interpreted. So, these are information processing problems that happen during communication between nervous system pathways and different regions of the brain.
Now, imagine that you can see and hear just fine, but when the complexity of sound / visual stimuli reaches your brain, then everything goes haywire. You feel overwhelmed, anxious, and unable to focus on what is being said or shown to you, which means you can’t understand the directions or figure out how to respond to a question. Some people will zone-out—their minds draw a blank and they withdraw in order to reduce the stress they are experiencing. Others may act-out; overwhelmed by the frustration of what’s in front of them they may become snarky, appear fidgety or agitated, or have an outburst depending on their age and the setting they are in.
“Visual and auditory processing problems, alone, can significantly interfere with a person’s ability to focus on, remember, and recall information,” says Connie McReynolds, PhD, an expert in the areas of neurofeedback and processing problems in ADHD and Solving the ADHD Riddle; The Real Cause and Lasting Solutions to Your Child’s Struggle to Learn.”
“These processing problems contribute to a person’s inability to concentrate, to learn, to develop flexible thinking and varied emotional responses. Auditory and visual processing problems, are root causes that contribute to the hallmark symptoms of an ADHD diagnosis.”
Environment and ADHD
Environmental factors are equally important to the onset of ADHD and can include:
- Exposure to toxins during pre-natal development and early childhood:
- nicotine, caffeine, alcohol abuse / use of illegal drugs
- certain prescription drugs
- lead, mercury, other heavy metals, pesticides, and other chemicals
- neurotoxin and allergen exposure
- brain injury / other medical conditions
- nutrition during prenatal period and early childhood
- specific nutritional deficiencies (vitamins, minerals, etc.)
- trauma during pre-natal development, birth, and early childhood
- stress during pregnancy and early childhood
Development and ADHD
The role of child development and onset of ADHD is an interesting but gray area. Usually, doctors and parents expect babies, toddlers, and young kids and teens to meet certain milestones at about the same age. A few examples: starting to talk, gaining mobility, standing, walking, showing awareness of self as different from another person, developing empathy, and onset of puberty.
When a child diverges from what is considered a typical development pattern, clinicians and parents have to determine if that divergence is cause for concern. They consider questions such as:
- What factors may be contributing to the delay?
- Is it related to biology (genetics, structural or physiological)?
- Is emotional/mental? Something in their environment? Is it a combination?
This line of questioning helps a clinician understand what they are observing (and what the person is experiencing) so they can make an appropriate diagnosis.
There isn’t any conclusive information on developmental delays and ADHD because not every person with ADHD experiences a delay in development—physical, emotional, social, or cognitive.
Cognitive delays are present in some children with ADHD (e.g., language, motor skills, executive function, and socialization), but doesn’t make such delays a “rule” for all children or for diagnosing ADHD. There are many aspects of development—and the brain and the environment interact throughout development, which makes identifying concrete answers a challenge.
So, why do we look at milestones in cognitive, social, physical, and emotional development? This information contributes to understanding of ADHD, in general. And, for each unique child or adult, information about their development allows clinicians to better understand their experience and design the best treatment plan to them navigate life with ADHD.
Things that Do Not Cause ADHD
People may say a lot of things cause ADHD, but those things may simply be associated with and oftentimes, not very strongly. Here’s a purely made-up example: if studies find that having headaches is common among people with ADHD, that does not make headaches a cause of the disorder. It simply means that headaches are a commonality among people with ADHD—further research is needed to understand why that is and what it means.
Some of the things that do not cause ADHD include:
Family conflict: It is more likely that the symptoms of ADHD give rise to conflict between family members. When family members are ill-equipped to self-manage their ADHD, or do not know how to properly support a family member who has ADHD, that creates stress. This makes symptoms worse and creates more stress until proper treatment breaks the cycle.
Eating too much sugar: Being a “sugar junkie” isn’t good for anyone’s health and can make anyone feel jittery or on edge, but that is not a cause of ADHD. However, some evidence suggests that sensitivity to food or food additives such as colorings and preservatives might be important contributors to ADHD onset for a small number of children, and other well-designed studies suggest a small effect on all children even if they do not have ADHD.
Watching too much TV or playing video games is not a cause of ADHD. In fact, some video games have been developed to help treat ADHD!
Treatment for ADHD: Conventional and Holistic
Conventional treatment
Conventional medical treatment for ADHD has included a combination of prescription medication, psychotherapy, and behavioral interventions for home, school, and work settings.
Medication. The most common medications used for ADHD are amphetamines, which are controlled substances that stimulate the central nervous system. Sounds like the opposite of what a doctor would want to do for ADHD, right?
As it turns out, for people with ADHD amphetamines have a paradoxical effect, meaning they work the opposite way they would if a person who does not have ADHD took the same medication. In a person who doesn’t have ADHD, a stimulant medicine causes hyper-alertness and agitation. For a person with ADHD, the same medicine has a calming effect. (This supports the theory that the nervous system functions differently for persons who have ADHD).
There are many types of stimulant medicines for ADHD. And while they work effectively for many people, over time people become tolerant and doses have to be increased, regularly. Like all prescription medicines, people can experience undesirable side effects, depending on the medication. If a person cannot tolerate a stimulant medicine, or the side effects are too much, there are other options.
Therapy. Psychotherapy, life skills, educational skills and accommodations, and behavior modification are all part of a well-rounded treatment plan for ADHD. Parents and family members can benefit from skills training and coping strategies so they can more effectively respond to a child (or partner) who has ADHD. Family therapy or coaching to support healthy communication is essential to reducing conflict and preventing escalation of ADHD symptoms.
Holistic Treatment
New technology and a more robust understanding of the development of ADHD has brought evidenced-based holistic therapies to the treatment of ADHD. It’s just as important for a holistic medical treatment plan to incorporate psychotherapy, life and educational skills training, behavior modification, and support for family (parents, siblings, or partners). A holistic treatment plan will emphasize these strategies over stimulant or other prescription medications. To be clear, licensed naturopathic doctors/integrative physicians do not discount the effectiveness of prescription medicines for ADHD. Rather, a holistic, natural approach recognizes that those medicines, while great at treating the symptoms, do not address all of the underlying or “root causes” of ADHD from a holistic perspective. Holistic doctors want their patients to benefit from the least invasive, most natural and effective treatment approach possible for ADHD.
Holistic treatment for ADHD includes many of the conventional diagnostic approaches, often in partnership with neuropsychologists and other clinicians. Additionally, they utilize some or all of the following evidenced-based holistic approaches to test for imbalances that can contribute to or worsen ADHD for a child or an adult:
- dietary assessment (food diaries)
- lifestyle assessment (exercise, sleep habits, stress management)
- nutrient deficiency testing
- food and environmental allergy testing
- assessment of the gut microbiome
- testing for exposure to toxins/ heavy metals
After thorough assessment and testing, holistic physicians work very closely with patients and their families to create a treatment plan, which may include:
Dietary modification. A whole foods diet rich in nutrient dense fruits, vegetables, whole grains and lean cuts of poultry is a good foundation, but some people with ADHD may need to do more based on the results of a complete dietary assessment, allergen testing, and food sensitivity tests.
Physical Activity. ADHD symptoms can be effectively managed with exercise. Physical activity produces endorphins that enhance mood, reduce anxiety and tension, and support overall health. Research also shows that exercise supports healthy development of the brain and nervous system.
Vitamin N: time spent in Nature. New research shows, when children and adults with ADHD spend time in nature, they increase their ability to pay attention while lowering their levels of stress and anxiety.
Nutritional Supplements. Specific nutrients are involved in thousands of biochemical reactions in the body and brain. If there is a problem with nutrient absorption or a deficiency caused by eating a poor diet, or this can contribute to mood and behavior problems. Some of the nutrients that are important to ADHD treatment are Vitamin B6, iron, magnesium, zinc, Essential Fatty Acids (such as from fish oil), and probiotics.
Herbal (Botanical) Supplements. Herbal medicines used for ADHD tend to have a calming effect on the nervous system, helping to address restlessness, anxiousness, and irritability and promote quality sleep. Sleep is crucial to the health of the brain and nervous system. Herbal supplements can support sleep hygiene in children and adults, with minimal side effects and better tolerance. It’s important to know that herbal supplements can interact with other medications, Rx or over the counter, so they should be used while in the care of a licensed holistic physician. Overall, research on botanical medicine and ADHD is still emerging, but there is much promise for herbal treatments to address ADHD symptoms, a topic that we will explore in a future article.
Neurofeedback. A number of studies have shown that neurofeedback can be effective for treating ADHD. Neurofeedback is based on the relationship between brain and behavior. It aims to change a person’s behavior by retraining the brain’s electrical patterns, or ‘brainwaves.’ According to Dr. McReynolds, an expert in neurofeedback for ADHD, “to make lasting change in the brain, such as developing a more positive response in place of a negative one, a new pattern has to be repeated consistently and long enough to “rewire” the brain.” Neurofeedback for ADHD is a non-invasive approach to addressing problematic cognitive and emotional processes that underly symptoms.
Brain Training. You might come across ‘brain training’ approaches for ADHD—a diverse range of programs, exercises, or activities (including apps and video games). These tools are meant to strengthen the brain by changing how it responds, and thereby improve specific brain functions such as concentration, attention and focus, memory and recall, or processing speed. It’s really important to look at the claims and qualifications of any type of brain training program. Because there are many methods, there’s not conclusive evidence for brain training and ADHD, but we will explore this topic, along with neurofeedback in a future article.
Dietary and Environmental Toxins. Holistic physicians assess each person’s exposure to toxins. This can include substances used in food processing (food dyes and preservatives), and toxins in our environment, which can exist in the soil, the air, in products we use or in the food that we eat (arsenic, lead, mercury, pesticides and herbicides, cosmetic chemicals, phthalates, bisphenol A). Toxins can affect hormones involved in growth and development as well as the brain and central nervous system.
Lifestyle Interventions to Manage Stress. Chronic stress plays a role in many physical and mental illnesses, particularly in making symptoms of illness worse. Similarly, stress affects ADHD, making it harder for a person to manage executive functioning tasks, to focus, and to respond without an emotional outburst. Holistic lifestyle approaches to manage stress in ADHD include yoga, mindfulness, breathwork, self-compassion work, massage and acupuncture.
Remember: all treatment plans for ADHD will include close monitoring and making changes along the way. Treatment plans will vary based on a person’s age, severity of symptoms, accommodations needed for school and work, and supports needed at home, amongst family members. Becoming educated about ADHD and the different ways conventional and holistic interventions work – and what can work best for each person– is essential to living a life full of potential with a beautiful, neurodivergent mind.
ADD or ADHD: What’s in a name?
In the early 1900’s, the cluster of core symptoms—inattention, hyperactivity, and impulse control dysregulation—were first documented and thought to be a defect resulting from brain damage. In the 1960’s, the American Psychiatric Association (APA) first recognized “hyperkinetic impulse disorder” as distinct medical condition. By the 1980’s, changes in assessment and diagnostic criteria, brought about a change in name to ADD, and later ADHD.
ADD (attention-deficit disorder) is now an outdated term for ADHD, even though both terms refer to the same medical condition. Some people with ADHD have hyperactive behaviors and some don’t, which is why the ADD terminology was used.
As you learn about ADHD, keep in mind that diagnostic information is useful as a way explain and categorize a person’s experience of symptoms and to guide treatment and research. Different patterns of ADHD symptoms help us understand what a person is experiencing—and that is important because ADHD looks quite different in children compared to teens and adults.
Who is most likely to have ADHD?
ADHD prevalence varies among different groups, including by age, sex and racial/ethnic group. According to the National Center for Health Statistics (2022), more boys than girls are diagnosed with ADHD. Adolescents, 12-17 years old, followed by kids age 5-11, have a higher rate of diagnosis, compared to kids age 3-4. ADHD diagnosis is higher among Black, non-Hispanic children and White children compared to kids of other racial and ethnic groups.
Resources: Is it too good to be true? Evaluating an Alternative ADHD Treatment https://chadd.org/about-adhd/complementary-and-other-interventions/ Quick Facts: Complementary Interventions for ADHD https://d393uh8gb46l22.cloudfront.net/wp-content/uploads/2020/04/Complementary-Interventions-ADHD_QF.pdf
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