Navigating ADHD
Sailing is expensive, slow, frustrating, and one of my favorite activities. Nothing beats a lovely, calm sea with a breeze at your back. On the other hand, sometimes the wind is blowing from the exact direction you’re trying to go. When that happens, instead of a pleasant cruise, you have to zig-zag across the wind repeatedly, fighting wind and waves.
The varying ease of sailing with different wind directions is much like the differences we experience in how easily we can perform certain tasks. The most prevalent pediatric disorder, ADHD (Attention-Deficit/Hyperactivity Disorder), is a lot like trying to sail into the wind.[1] ADHD is a neurodevelopmental disorder, where inattention, hyperactivity, and/or impulsivity develop atypically.[2] ADHD affects tens of millions of Americans.[1,2,3] Genetics play a key role in the development of ADHD and are the highest risk factor.[4,5] The disorder is polygenic, which means many small genetic factors add together to make a significant change in function.[5] Think of it like a boat sinking; running into a rock will do it, but really the problem is poor navigation, planning, steerage, lookouts, and leak mitigation.
Diagnosing ADHD can only be done by a professional, who looks for key indicators like persistent hyperactive and/or impulsive behavior over six months that occurs in multiple settings: typically at both school and home.[3,6] Diagnosis can be difficult, as the symptoms of ADHD are nonspecific.[3] Boys are diagnosed at about twice the rate of girls, but studies show that this may be due to a difference in how the disorder presents in different sexes.[2,4,7] Boys are more likely to be diagnosed based on behavioral issues, whereas adults are more likely to recognize issues in girls based on cognitive or language difficulties.[7] Behavioral challenges are more likely to cause a disturbance in a classroom or at home, so there is a higher rate of recognizing a need for a diagnosis.[4] Interestingly, as people age the difference between the sexes decreases, and in adult population surveys there is near equivalency in ADHD diagnosis between men and women.[6]
Researchers have also found environmental risk factors that increase the risk of children developing ADHD. These include an unsafe school and neighborhood, economic hardship, exposure to toxins such as lead and pesticides, and excessive screen time.[3,5,6,8] Studies on screen time have found that TV, video games, tablet/phone use, and social media activate the same areas of the brain affected by ADHD.[4,5] Research shows that heavy screen time can temporarily worsen ADHD symptoms, such as impulsivity, inattentiveness, and working memory, and that frequent social media use can lead to persistent increases in impulsivity lasting more than a year.[4,5] These effects move in both directions, though, as people with higher risks of ADHD tend to have more and longer-lasting preferences for screens, which then exacerbate symptoms in a perpetual cycle.[5]
Let’s sail into the eye of the storm to find out what’s going on inside the brain with ADHD. At its core, ADHD seems to be a problem with two key neurotransmitters, dopamine and noradrenaline.[9] These are specific chemical signals in the brain that let neurons communicate and transmit information, so when their levels are low, like in ADHD, problems can arise. At a higher level, ADHD manifests as extra connectivity between three important networks.[1] The Default Mode Network is associated with self-focused attention and is usually active when engaged in self-reflection or mind wandering.[4] The Dorsal Attention Network is a top-down system that directs the mind’s attention to specific goals or ideas.[1,5] The Ventral Attention Network is a bottom-up system that automatically shifts the brain’s attention to unexpected or new stimuli (squirrel!).[1] In ADHD, these networks are more closely linked in activity than in other brains, so attention switches rapidly between internal, external, and top-down demands. This rapid switching may manifest as inattention and/or impulsivity.[1,4,5] Inattention may lead to obsessive thinking, which exacerbates anxiety, perfectionism, and inferiority complexes.[10] Impulsivity may lead to disobedience and defiance, which can have a negative effect on relationships, loneliness, and depression.[10]
Treatments for ADHD vary based on age and severity. For young children of preschool age, behavior therapy is the first line of treatment and usually aims to train the adults (parents, teachers) on how to manage a child with ADHD effectively.[3,4] Medications are usually only recommended if there is a significant impairment that behavior therapy does not reduce.[3] Older children may start medication at an earlier stage.[3] Front-line medications are stimulants and have been used for over 60 years.[9] Methylphenidate (Ritalin) is a dopamine and noradrenaline reuptake inhibitor that increases the availability of those neurotransmitters and counteracts the effects of ADHD.[9] Amphetamines like dextroamphetamine, lisdexamfetamine, and mixed amphetamines are also reuptake inhibitors, but accelerate the release of neurotransmitters and reduce the body’s ability to break them down, making for a more potent effect at the cost of stronger side effects.[6,9] Methylphenidate is recommended for children and adolescents, while amphetamines may be prescribed to adults.[6] These medications bring low levels of dopamine and noradrenaline to a more typical baseline for ADHD patients.[9] For people who have normal levels of these neurotransmitters, however, these medications act as a heavy stimulant and can be addictive.[9] Non-stimulants include guanfacine, which regulates dopamine and noradrenaline release, and atomoxetine, which selectively acts on noradrenaline.[4]
Beyond the pharmacy, a long-term solution for many patients is... patience! Around ⅓ of ADHD cases resolve themselves by adulthood, and for those that don’t, the symptom profile may lessen.[4,6] Researchers find that impulsivity and hyperactivity have moderated for those with long-term ADHD, though inattention continues.[6] Other treatments include behavioral therapy directed at the person living with ADHD and a wide range of dietary and supplement-based approaches, which have widely varying outcomes.[4] Evidence in this space is lacking and could benefit from a significant investment in randomized, controlled clinical trials to determine the effect of things like saffron and neurofeedback.[4] With the help of clinical trials, we hope to eventually say “Anchors Aweigh” to low-side-effect treatments for ADHD.Creative Director Benton Lowey-Ball, BS, BFA
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References:
[1] Norman, L. J., Sudre, G., Price, J., Shastri, G. G., & Shaw, P. (2023). Evidence from “big data” for the default-mode hypothesis of ADHD: a mega-analysis of multiple large samples. Neuropsychopharmacology, 48(2), 281-289. https://www.nature.com/articles/s41386-022-01408-z
[2] Ayano, G., Demelash, S., Gizachew, Y., Tsegay, L., & Alati, R. (2023). The global prevalence of attention deficit hyperactivity disorder in children and adolescents: An umbrella review of meta-analyses. Journal of affective disorders, 339, 860-866. https://pubmed.ncbi.nlm.nih.gov/37495084/
[3] Bozinovic, K., McLamb, F., O’Connell, K., Olander, N., Feng, Z., Haagensen, S., & Bozinovic, G. (2021). US national, regional, and state-specific socioeconomic factors correlate with child and adolescent ADHD diagnoses pre-COVID-19 pandemic. Scientific Reports, 11(1), 22008. https://pmc.ncbi.nlm.nih.gov/articles/PMC8580963/
[4] Faraone, S. V., Bellgrove, M. A., Brikell, I., Cortese, S., Hartman, C. A., Hollis, C., ... & Buitelaar, J. K. (2024). Attention-deficit/hyperactivity disorder (Primer). Nature Reviews. Disease Primers, 10(1), 11. https://www.proquest.com/docview/2930209032
[5] Yang, A., Rolls, E. T., Dong, G., Du, J., Li, Y., Feng, J., ... & Zhao, X. M. (2022). Longer screen time utilization is associated with the polygenic risk for attention-deficit/hyperactivity disorder with mediation by brain white matter microstructure. EBioMedicine, 80. https://www.sciencedirect.com/science/article/pii/S2352396422002201
[6] Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., ... & Wang, Y. (2021). The world federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neuroscience & biobehavioral reviews, 128, 789-818. https://www.sciencedirect.com/science/article/pii/S014976342100049X
[7] Berry, C. A., Shaywitz, S. E., & Shaywitz, B. A. (1985). Girls with attention deficit disorder: A silent minority? A report on behavioral and cognitive characteristics. Pediatrics, 76(5), 801-809. https://publications.aap.org/pediatrics/article/76/5/801/53947/Girls-With-Attention-Deficit-Disorder-A-Silent
[8] Wallace, J., Boers, E., Ouellet, J., Afzali, M. H., & Conrod, P. (2023). Screen time, impulsivity, neuropsychological functions and their relationship to growth in adolescent attention-deficit/hyperactivity disorder symptoms. Scientific Reports, 13(1), 18108. https://www.nature.com/articles/s41598-023-44105-7
[9] Del Campo, N., Chamberlain, S. R., Sahakian, B. J., & Robbins, T. W. (2011). The roles of dopamine and noradrenaline in the pathophysiology and treatment of attention-deficit/hyperactivity disorder. Biological psychiatry, 69(12), e145-e157. https://pubmed.ncbi.nlm.nih.gov/21550021/
[10] Roberts, C., Sahakian, B. J., Chen, S., Sallie, S. N., Walker, C., White, S. R., ... & Murray, G. K. (2023). Impact and centrality of attention dysregulation on cognition, anxiety, and low mood in adolescents. Scientific Reports, 13(1), 9106. https://www.nature.com/articles/s41598-023-34399-y
