A person who “acts or feels as if driven by a motor” might need screening for the hyperactive-inattentive form of ADHD. (Image: Sergey Zhumaev / Pexels)
ADHD is a brain disorder.
ADHD doesn’t exist.
Both are true. Both are false. It depends on who you ask.
A diagnosis of attention deficit hyperactivity disorder in the early years of the 21st century drops you into a strange world where the ground is always shifting.
Those on the “ADHD exists” side say it affects 190 million children and adults worldwide.
A signature symptom of ADHD is difficulty focusing on a task. That’s the attention deficit. The person may also move around incessantly or act impulsively. That’s hyperactivity.
But the major medical groups recognize ADHD as a valid condition that should be treated.
Kids as young as 4 with ADHD symptoms can have differences in brain structure, compared with kids the same age with no symptoms, according to a U.S. study published in 2018.
A countervailing cadre of experts insists that ADHD is a fictitious illness. They say it is overdiagnosed in some people and misdiagnosed in folks who have illnesses that cause ADHD-like symptoms.
“Usually, once the original condition is found and treated, the ADHD symptoms go away.” said Richard Saul, writing in TIME magazine. He is a behavioral neurologist and author whose book title makes clear his position: ADHD Does Not Exist.
It’s a minority opinion. A study in The Lancet is part of an ever-growing body of evidence that the condition is valid.
One challenge in diagnosing adults with ADHD is that they tend to internalize their restlessness.
Researchers from nine countries scanned the brains of people aged 4 to 63. The group included about 1,700 with ADHD and 1,500 without. Across the board, small differences in brain size were found between those with the condition and those without.
If we accept that ADHD is real, it’s time to focus on the lack of awareness in our society, in which undiagnosed adults are often left to live dysfunctional lives, said Dr. Perry Roy, a pediatrician and internist with a special interest in treating ADHD
Part of the challenge in diagnosing adults is that they are more likely to “internalize their inner restlessness rather than act it out as children do,” Roy said.
“This may manifest as mood swings, difficulty getting along with others, problems holding down a job, substance-abuse problems, and a pattern of being irresponsible and making poor decisions. These behaviours may be incorrectly attributed to personality problems, anxiety or depression, rather than ADHD.”
Saul, on the other hand, expressed concern over the criteria used to prescribe stimulants For ADHD, most commonly methylphenidate.
He argued that, under the criteria for diagnosing the condition, “the entire US population could potentially qualify. We have all had these (symptomatic) moments and, in moderate amounts, they’re a normal part of the human condition.”
Cases of ADHD are growing
If you find the opposing points of view confusing, think of how ADHD patients and their families feel.
There are enough of them. Documented cases of ADHD have increased dramatically. Among children in the U.S., the diagnosis rose 40 percent in the eight years leading up to 2011, according to the U.S. Centers for Disease Control and Prevention.
Confusion about ADHD is nothing new. Children experiencing a serious lack of focus, impulsivity and hyperactivity were documented as early as the 18th century. At the time, it was not seen as an illness.
Over the years, the disorder has been known by a series of names, reflecting the puzzlement over what it is.
In three out of four childhood cases, the disorder continues into adulthood.
Previous names for ADHD include, minimal brain dysfunction, hyperkinetic reaction of childhood, and attention-deficit disorder, not necessarily with hyperactivity.
The otherwise common behaviors ascribed to ADHD become a diagnosable illness when they are so severe they make it hard for a patient to function normally at work, with family, and in social situations. In three out of four childhood cases, the disorder continues into adulthood.
A diagnosis of ADHD doesn’t necessarily prevent a person from being successful in life. The ideal course of events is for a patient to be diagnosed early and receive effective treatment at once.
Lacking proper medical care, most children with ADHD will suffer the same symptoms in adulthood. A patient is subject to failure in school, stress at home, depression, relationship problems, substance abuse and, later, job failure.
Some patients will outgrow their symptoms before adulthood. But they are the exceptions. It is tough to distinguish those lucky ones when ADHD symptoms first emerge, typically in early childhood.
One hallmark of childhood ADHD is that patients tend to mature later than their peers in their ability to function independently. They also may experience slight delays in learning language, motor skills and social development.
Red flags for ADHD include having a tough time dealing with frustration, failing to control emotions well, and experiencing mood swings.
The urgency for diagnosis and treatment of children is easy to understand, considering the problems they may face as teenagers and adults. The disorder can lead to:
- Trouble fitting in with peers,
- Difficulties in social situations,
- Academic delays or failure,
- Driving problems,
- Risky sexual behavior, and
- Substance abuse.
The hyperactive-impulsive kind of ADHD includes symptoms such as excessive talking. (Image: ICSA / Pexels)
Girls with ADHD are at greater risk for eating disorders during adolescence. Both boys and girls with ADHD may be diagnosed with oppositional defiant disorder or conduct disorder.
The types of symptoms exhibited by a patient tend to lean toward either the attention-deficit or the hyperactivity-impulsivity side of the condition.
- Easily distracted
- Doesn’t pay close attention to details or makes careless mistakes
- Has a tough time sustaining attention
- Appears not to listen
- Following through with instructions is tough
- Organization is a challenge
- Dislikes tasks that require sustained attention.
- Loses things
- Is easily distracted
- Is forgetful in day-to-day activities
- Gets fidgety in a chair
- Finds it challenging to stay seated
- Climbs and runs around excessively in children
- In adults, extreme restlessness
- Has trouble participating quietly in activities
- Acts or feels as if driven by a motor
- Talks to excess
- Blurts out answers before a question is completed
- Has a hard time waiting or taking turns
- Constantly interrupts or intrudes upon others.
If the lengthy lists of symptoms isn’t confusing enough, the changing name of the disorder is.
There was no official name for a condition described in 1798 by the Scottish physician Sir Alexander Crichton. In a book, he noted his observations from multiple clinical encounters.
“It becomes evident at a very early period of life and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education,” Crichton wrote.
“But it seldom is in so great a degree as totally to impede all instruction, and what is very fortunate, it is generally diminished with age.”
A century later, British pediatrician Sir George Still reported “an abnormal defect of moral control in children.”
Sixty-six years after that, the name hyperkinetic impulse disorder was used by the American Psychiatric Association when in 1968 it formally recognized the disorder as a diagnosis.
The name persisted from 1968 to 1980, when the APA changed it to attention deficit disorder or ADD.
After new research indicated hyperactivity was usually part of the disorder, the psychiatrists’ group in 1987 broadened the name to attention deficit/hyperactivity disorder, ADHD.
The APA in 2000 established the three subtypes of ADHD that doctors were already using in their diagnoses:
Physicians were instructed to gauge the severity of each case as mild, moderate or severe.
The increase in diagnoses of ADHD has added fuel to the fire of critics who complained the disorder was overdiagnosed, if it existed at all. Their opponents said the rise in cases may have been caused by:
- The increased ability of doctors to diagnose ADHD,
- Greater awareness among parents, and
- More children actually developing ADHD.
Transitioning to adulthood is especially hard on sufferers of ADHD. They must manage their symptoms while handling an ever-increasing load of demands. (Image: Inzmam Khan/Pexels)
It was assumed for a long time that ADHD patients naturally outgrew their symptoms at puberty. Research shows, however, that more than half of children diagnosed with ADHD will have at least some symptoms as adults.
The years between childhood and adulthood are among the toughest for ADHD sufferers. They must cope with symptoms of the disorder, while at the same time handling the burgeoning demands of school and life, peer pressure, emerging sexuality, and the need to establish independence.
When they become young adults they’ll face further complications, often including mood or conduct disorders, depression and substance abuse. It is not unusual for ADHD-related problems to arise at work and in important relationships.
Career and academic success for people with ADHD can be limited by difficulties with executive function, which is the brain’s capacity to complete tasks, remember important things and consider the long-term impact of various actions.
Origins Cloaked in Mystery
Numerous studies have failed to unlock the secret of ADHD’s origins. It is brain-based and tends to run in families, so a genetic link is suspected. But further research is needed to go beyond saying it’s caused by multiple interacting genes.
Environmental factors believed to increase the chances of ADHD are:
- Early-childhood exposure to lead or pesticides,
- Brain injury, and
- Premature birth or low birth weight.
Some environmental factors, while they don’t cause ADHD, can worsen it:
- too much sugar,
- excess television watching and
- unenlightened parenting.
Knowing the causes and symptoms of ADHD is helpful if you’ve been diagnosed. But therein lies therub. How do you get diagnosed? Unfortunately, where ADHD is concerned, diagnosis is more of a project than an event. There is no single test that can definitively detect or rule out the disorder.
Diagnosis Is Tricky
What’s more, not all medical professionals are equal in their ability to recognize and treat ADHD. Many stories of blind alleys are traded among patients and families who’ve received the diagnosis after a lengthy process of bouncing from one specialist medical professional to another.
Experts suggest taking the diagnosis one step at a time. The first step for many is the moment it hit them that their (or their child’s) problems might be a brain-based condition like ADHD.
It might be reading an article that makes the information gel. For parents, it might be when a teacher contacts them to report that their child is disrupting the class or falling behind in assignments.
An adult with ADHD could reach a crisis point that leads to a doctor’s office when their job is at stake following a series of incidents involving things like coming in late, blowing off deadlines or missing meetings.
Adults may want to take an online test developed by the World Health Organization specifically to self-screen for the possibility of ADD: https://add.org/adhd-test/ .
Parents who suspect ADHD is behind their child’s problems may fill out a screening test. If the suspicion is confirmed, medical help should be sought right away, as with any potentially serious condition. The children’s test is here: https://www.additudemag.com/adhd-symptoms-test-children/ .
The first stop for parents seeking confirmation of a diagnosis is to see a pediatrician or internist with considerable ADHD experience. Referrals may be sought from the family doctor, other parents or an advocacy group, like the local chapter of Children and Adults with Attention-Deficit Hyperactivity Disorder.
When a parent contacts the health professional, it is the parent’s responsibility to confirm any recommendation by doing their own research beforehand, and screening the physician on the phone.
“Ask how many other cases of ADHD the doctor has treated, and what the plans and outcomes were,” Russell Barkley, a professor at the Medical University of South Carolina, told the advocacy magazine ADDitude.
Even with a glowing recommendation, a doctor who has handled only a few cases is best passed up. One approach is to go immediately to a specialist, like a developmental pediatrician, psychiatrist or psychologist whose practice is heavy with ADHD patients.
“Regardless of how experienced your [doctor] is,” Barkley says, “you should strongly consider a medical specialist if your child’s ADHD is accompanied by another diagnosed disorder, such as oppositional behavior, anxiety, or if there are urgent issues involved.”
Key symptoms are listed in the Diagnostic and Statistical Manual, Fifth Edition, the doctors’ bible of illnesses and their symptoms. The tome should be the backbone of the process of diagnosing your child.
The manual says a patient must demonstrate at least six of the nine symptoms of inattention or hyperactivity-impulsivity before age 12 to be diagnosed with ADHD. The symptoms also must make it tough for the patient to function in more than one setting.
Common Diagnostic Errors
The difficulty of determining whether someone has ADHD, some other condition, or no condition at all doesn’t stop some people from trying to use shortcuts. Among the more common mistakes medical professionals make in trying to diagnose ADHD are:
- Prescribing ADHD medication without a proper diagnosis, to “see if it helps”,
- Reaching a conclusion based on too little information, and
- Failing to consider that the patient may have additional disorders.
‘The clinical interview is the core of any evaluation.’ -Prof. Thomas Brown, Yale
A specialist typically makes a diagnosis after a clinical interview of up to two hours, including a family medical history, standardized ADHD rating test, and screening test to rule out conditions that often accompany ADHD, like mood and learning disorders.
Adults are harder to diagnose than a children. For one thing, the criteria in the diagnostic manual are aimed at children.
A specialist must conduct a careful clinical interview that includes talking with the adult patient, as well as someone close to them, like a spouse, close relative or close friend.
A checklist for adult symptoms of ADHD may be used. The interview results might suggest additional tests, including ones for other disorders as the source of symptoms.
“The clinical interview is the core of any evaluation,” Thomas E. Brown, professor of psychiatry at Yale University School of Medicine, told ADDitude magazine. “The more input from different sources, the better.”
Communicating well with your specialist is essential for an accurate diagnosis, according to Harold Meyer, director of the New York City chapter of CHADD. He offered tips for participating in a clinical interview:
Be speciﬁc in describing the problems.
Figure out what concerns you want to address in your consultation. For instance: “At work, I find that I can’t stay on task or complete projects,” or, “My child is always losing toys and homework.”
Consider your attitude toward medication before your appointment. If you oppose it, say that upfront. Ask your doctor what other treatment options may be considered.
If you decide on medication, remember that the prescription and dosing process varies with the individual. It’s likely that you’ll need to try more than one drug and experiment with different dosages and combinations to find the right one.
Be prepared that the process could take awhile.
Ask the doctor about other options available for medication. You want someone who will not just write a prescription but who will also discuss the diagnosis and treatment process in detail.
Address which medications are being considered, the reason for starting with a particular medication, what you can expect to happen, the possible side effects, how to evaluate the medication’s effectiveness.
Your doctor should lay out a course of action, including treatment and follow-up appointments. How accessible will the physician be when concerns arise between appointments, like if a new medication creates an unexpected effect?
You’ll probably need to talk often on the phone or by email in the weeks following the diagnosis. Will the doctor charge you to consult? Will they provide medication refills without an office visit? What is the best form of contact?
Learn beforehand about alternatives to medication.
Find out about behavioral therapies you might try. Can your doctor work with you on these? Is your doctor sympathetic to non-medical treatment that has shown promise?
You may benefit from a referral to a psychologist who can offer behavioral help, such as ways to deal with problems at work, including time-management techniques.
Ask if the doctor will meet with your family.
A diagnosis of ADHD affects everyone close to the patient.
At this point, most people are anxious to know, “Does my child have ADHD?” or “Do I have ADHD?” But don’t expect an answer overnight. A thorough diagnostic process can take a week or more.
While waiting for your child’s results, tell their teachers and other school officials that they’re being evaluated for ADHD. Ask to meet with the school psychologist or special education teacher to discuss having your child evaluated for learning disabilities, which affect 30 to 50 percent of young patients.
If the school is unable or unwilling to give your child the right tests, you may opt to hire a private educational psychologist to do so
Undiagnosed ADHD in Adults
An adult with undiagnosed ADHD has to overcome even more resistance to the diagnosis, including their own, according to a collection of narratives in the New York edition of The Guardian newspaper.
Michelle Beckett, a 44-year-old entrepreneur, struggled for years to determine why she was different. Like many girls who suffer from ADHD, she had not fit the description of a typical child with the condition.
Her toughest hurdles came in adulthood. She failed to live up to her academic potential, endured two failed marriages and suffered from mental health problems.
Beckett decided to seek help at the age of 36. She was skeptical when a neuroscientist said her EEG, a recording of brain activity, suggested she had ADHD.
“I dismissed his diagnosis as rubbish,” she said, blaming the symptoms on herself. “How could I have ADHD? I was just [being] crap and needed to sort myself out.”
Beckett’s problems only got worse. Her mood swings became so extreme, any criticism could take her from ecstatic to suicidal. A failed business venture led her to conclude that her “family and the world would be far better off without me”.
A woman wrestled for years with mood swings, hyper-sensitivity, and, at times, suicidal thoughts. She was finally able to accept that she had ADHD that had gone undiagnosed when she was a childhood. (Image: Matthew Brodeur / Unsplash)
She wound up in the care of a local mental health crisis team. ADHD was mentioned again, this time by a psychiatrist.
At age 44, Beckett decided to seek a private diagnosis. The move not only transformed her life, it saved it.
“Everything fell into place. I wasn’t crap because I found VAT returns painful, blurted stuff out and was messy. I wasn’t crap at all,” she said. “I have a neuro difference, which gives me many advantages.”
Beckett is one of the unfortunate folks who slipped through the diagnostic net as children and were left to struggle on their own with ADHD into adulthood.
It’s been three decades since the American Psychiatric Association agreed that ADHD was the best term to describe the condition.
The illness has long been viewed as something that predominantly affects children – mostly young boys. But increasing numbers of adults are now being diagnosed.
In ADHD, Boys Get More
According to the Royal College of Psychiatrists, ADHD is more common in boys than girls.
Studies of children between the ages of five and 15 have found that 4 percent of boys and 1 percent of girls had ADHD. With time, the condition improves and a total of around 1 percent of adults continue to have the condition, with 2 to 4 percent showing partial symptoms.
ADHD in adults has come under the spotlight with new advances in clinical research. Comedian Rory Bremner recounted in a BBC Horizon program his personal journey to understand the science behind the condition. A study of the social and financial impact of undiagnosed ADHD in adults was in progress.
Even though ADHD is viewed as a modern condition, discussions of it were recorded starting hundreds of years ago, possibly as a result of the advent of compulsory schooling.
Children with ADHD aren’t bouncing off the walls are less likely to receive a diagnosis in childhood. This is especially true for girls, whose ADHD symptoms tend to be less overt than those of boys.
Interestingly, the main symptoms of ADHD are the same in men and women, but “female patients’ inattention problems often are combined with daydreaming, whereas men have more hyperactivity and behavioural problems, which are more noticeable during childhood”, according to Dr. Ashok Roy, head of the Royal College of Psychiatrists’ intellectual disability faculty.
The difficulty of diagnosing girls is compounded by the fact that they tend to suffer from additional disorders that can affect mood and behaviour, he said.
Quiet and Suffering From ADHD
Across the Atlantic, writer Arielle was diagnosed with ADHD at 19. She remembered being quiet throughout her childhood.
“I didn’t show the classic signs people think of when they hear about hyperactivity,” said the Bostonian. “Instead of bouncing off the walls, I simply fidget constantly. I slept through most of school, but, if I was awake, I never was an attentive listener.”
Arrielle’s grades were never great, because she couldn’t focus on her homework. Teachers who recognized her capabilities told her she could be a straight-A student. All she had to do was complete her homework, stay awake in class, and become organised.
“Over the years, I started to assume I was just lazy,” Arielle said. “Instead of thinking there might be something wrong biologically, I assumed it was all my fault. And, every time, I’d resolve to be better at being attentive in class, or neat or diligent about homework, I’d inevitably fail.”
Going undiagnosed until adulthood was “pretty harmful,” she said. The delay in diagnosis has left her with lingering doubts about its accuracy. At times, she tells herself that, if she really had ADHD, someone would have noticed it sooner.
“I still frequently doubt that I have ADHD and sometimes believe I’m just fooling everyone in an attempt to excuse my forgetfulness, messy nature, issues with planning ahead and problems completing projects.”
Reinforcing her doubts, of course, is the lingering skepticism about the illness, even among psychiatrists. Not surprisingly, it is common for ADHD patients diagnosed in adulthood to report that they were told they had conditions like depression or anxiety before they discovered they had it.
Andrew Kavanagh, an animator from Dublin, didn’t receive a diagnosis until he was 43. “I often wondered why I had so many challenges in achieving what others found relatively easy to do,” he said.
Kavanagh suspected he might have the condition when he met the neuroscientist Áine Behan, CEO of Cortechs. The company was developing gaming technology to help children with ADHD improve their focus. “I knew little about the condition at the time, but as my research into the area deepened, I recognised many of my own traits in the symptoms attributed to ADHD sufferers.”
Kavanagh described himself as poor sleeper who is fidgety, impatient and struggles to complete tasks. “I often feel like when I start something, I should be able to do it immediately rather than having to go through a learning process. I’ve always been impatient for results and often start a lot of different things and quickly become overwhelmed.”
According to ADHD specialist Roy, many adults remain undiagnosed because psychiatrists do not receive enough training. He said more needs to be invested in educating physicians about the condition.
The idea has been floated that ADHD is not so much an illness as a different type of brain. What if those differences were partially responsible for the achievements of many successful people, including Albert Einstein?
Might the course of science be different if he’d been treated for ADHD? If so, would it have been for the better or worse?