ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Often brimming with enthusiasm and happily productive in some settings, when the focus turned to sitting quietly in their seats doing paper and pencil assignments, they are like caged lions. Kids medicated with Ritalin or other psychoactive drugs alter their brain chemistry in such a way that they can adapt to the rules that society imposes on them. However, this doesn’t solve the problem of finding a match between their unique brains and a favorable niche. The traditional classroom is one of the worst possible places for a child with an ADHD brain.
Origins of ADHD
In the mid-1970s, these kids were regarded as suffering from “hyperactivity”, “hyperkinesis” or “minimal brain dysfunction”. ADD or attention deficit disorder was first described in 1970 but it was not until the late 1980s that ADHD became a widely known disorder and children with ADHD were being placed in special education programs.
The current consensus is that ADHD affects 3-5% of all children and that 60% will continue to have the disorder into adulthood.
ADHD is characterized by three key groups of symptoms: Hyperactivity (e.g. being fidgety or restless), impulsivity (e.g. interrupting or grabbing things from others) and distractibility (e.g forgetting things or having difficulty organizing life tasks). Three different forms of ADHD are recognized: one that is primarily “inattentive” involving distractibility (this is often referred to as ADD, one that is primarily “hyperactive” and “impulsive” (de-emphasizing distractibility), and one that includes all three groups of symptoms.
Although there are far more males diagnosed with ADHD than females, the primarily inattentive type has been increasingly observed in girls.
The primary treatments are adaptive in nature and include the use of medications, especially psychostimulants like Ritalin and Adderall, and behavior modification programs in the home and at school.
The nature and connections in the brain appear to be a disruption in the circuitry between the restraint and planning areas of the brain (the prefrontal lobes) and the emotional and motor areas (the basal ganglia and the cerebellum). The restraint areas do not keep the emotional and motor areas in check resulting in hyperactivity and impulsivity. Problems with executive functions of the prefrontal lobes appear to result in difficulty with planning, organization, and focused attention, resulting in distractibility. The actual volume of these three brain areas has been shown to be 3-4% smaller in kids diagnosed with ADHD than matched controls.
ADHD: An Evolutionary Leap for Humanity?
Children labeled ADHD undergo normal patterns of brain growth, but they lag behind normal children by an average of three years. They attain peak thickness in half the sites that integrate the sensory-motor areas that integrate planning, problem solving and inhibitory areas at an average age of ten and a half years old whereas matched controls matured at seven and half. The rate of ADHD in any given age group declines by 50% every five years.
They are thus best described as late bloomers and not kids with defective brains. They simply act younger than their peers and need more time to mature. Rather than this immaturity being a negative thing, this kind of youthful behavior in someone chronologically older may actually be an evolutionary step forward in our species.
The concept of neoteny (Latin for “holding youth”) refers to the retaining of childlike qualities into later development. Einstein’s fame as the absentminded professor would likely have qualified him for the “distractible” variety of ADHD. Many of civilization’s most celebrated individuals were in some ways like children in adult bodies, including Picasso, Mozart and Shakespeare (whose childish puns and insults offended the serious critics of his day).
Neoteny may be a progressive feature of evolution: the more evolved a species is, the more likely there are to be childlike features held into adulthood. Some of these behavioral qualities include curiosity, playfulness, wonder, creativity, flexibility, inventiveness, and humor. They disappear in others who’ve tended to become rigid over the years.
These patterns need to be retained into adulthood if we’re going to continue to survive and thrive as a species. If we lose the ability to be flexible as we grow into adulthood, we’d have a civilization of inflexible people, which could be disastrous in the event of a global showdown that threatened us, for example, a nuclear war. It may provide a kind of protective influence for international stability. Childish qualities constitute the most valuable possessions of our species, to be cherished, nurtured, and cultivated.
Creating “Good Chemistry” in the ADHD Brain
Many brain chemicals are involved, but dopamine, associated with, among other things, motor activity, motivation, and reward seeking, is particularly important. People with ADHD appear to have lower levels of dopamine in their brains, thus causing a constant hunger for stimulation. This helps explain their need for constant motor activity, impulsivity, and thrill seeking. The traditional classroom or office cubicle is not enough to satisfy their starved dopaminergic brain pathways. Contrary to what many people believe, people with ADHD are actually unstimulated. What stimulates the average person is not enough for them. They need a higher dose of thrills and chills. This is why psychostimulants are so very often effective. By increasing the levels of dopamine in the brain, the higher level of stimulation paradoxically calms them down.
These problems of dopamine regulation appear to have a genetic basis. ADHD is one of the most easily inherited of all psychiatric disorders, present in 25% of the close relatives have the disorder compared to 5% of the general population. An identical twin has a 75-91% chance that the other twin will also have it. One variant of one allele of a gene that is involved in the production of dopamine receptors (called Dopamine D4 Gene 7-repeat allele, or DRD4 for short) is more prevalent among ADHD children. It has been called the “novelty-seeking-gene and is also more prevalent in individuals who enjoy activites such as bungee jumping, skydiving, and other high0intensity thrills.
Besides its association with risky behaviors, it has furthered human evolution. DRD4 arose comparativel recently in human evolution, between 10 and 40,000 years ago as an unusual spontaneous mutation, which became an advantage for humans. Novelty seeking was particularly important when the earliest forms of culture and civilization were being created. Those individuals might have been more likely to explore new territory, discover new food sources, or create new forms of social orgnaizatioin, and thus might have been in a better position to survive and pass their genes on to future generations than those without the allele.
The Gifts of ADHD in Other Times and Places
Hyperactivity, distractibility, and impulsivity have numerous potential advantages for coping with difficulties during prehistoric times. Hyperactive people do a better job at foraging for food, seeking shelter, and engaging in other important survival tasks. Distractibility makes a person constantly vigilant to possible threats to his safety and the safety of his family and tribe. The capacity to respond quickly to one’s instincts (impulsivity) is vital to quick action, such as meeting dangers from other humans or animals in their immediate area. They were hunter’s in a farmer’s world. The hunter is always moving, always vigilant, always tuned into his instincts while seeking food and shelter and trying to avoid becoming prey. The farmer plants seeds, in the ground and waits. Patience is required. Instead of living in the present, the farmer needs to think in the future and plan ahead. Hunting and farming represent two distinct energy styles that still persist in our contemporary world.
Many cultures view ADHD symptoms as positive traits. The Puluwat culture in the South Pacific live on 500 different islands, so the ability to navigate has high cultural value. Children memorize the constellations to use for navigation, they recognize little bumps on the horizon, and they identify light and dark patches in the water to show coral reefs. In this culture – multitasking, always moving , constantly shifting perceptions – are traits of the gifted children.
Different cultures require different abilities and have different expectations of behavior. Whether you are labeled as gifted or disabled has more to do with when and where you were born than anything intrinsic to you as an individual.
dEven in our complex modern society, traits of ADHD confer distinct advantages. The traits for creative people are indistinguishable, but labeled differently – impulsive vs spontaneity, distractable vs a divergent mind (thinking outside the box by following their ideas, images or instincts wherever they might lead), hyperactive vs vitality (constantly on the prowl for the answer to a creative problem).
The disadvantage of the term ADHD speaks of a deficit in attention. Children (and adults) labeled ADHD are actually very good at paying attention – they excel in paying attention to what they’re not supposed to be paying attention to – this is called “incidental attention” and is another trait of the creative person. They see things that other people miss – a peach has color, texture and grows in a field; books on marine life makes them imagine life beneath the sea.
People with ADHD are also very good at paying attention to what interests them. They can spend hours building with Lego, dancing, video games, or engaging in other absorbing tasks. This may be called “hyperfocus”, another warning sign of ADHD, rather than the trait of an exceptional mind able to concentrate on a single task. The term “flow” describes highly proficient individuals like rock climbers or surgeons engaged in a 12-hour operation.
Their “roaming” attention can notice many different things in a short period of time and a “homing” attention that can fasten onto one thing for a period of time. They are actually good at two different forms of attention but have problems with one kind referred to “central-task” attention that requires sustained attention at routine and often boring events that have been externally imposed.
Nice Construction for ADHD Kids: Keep it Stimulating
Find the microhabitats and construct niches that provide more time in favourable environments. Brains of children with ADHD are under stimulated including a boring classroom. Construct classrooms with music, color, movement and interaction (educational Ritalin). Provide two desks so that whenever he gets up, he has another desk to move to. Provide a special lectern so that class work can be done sitting or standing. Install a pedal at the base to keep his feet in motion. Use large, bouncy therapy balls instead of chairs.
Special education classes are of the more boring so homeschooling may be the answer. Positive niches give more freedom.
Even in children as young as five, show a significant reduction in ADHD symptoms when engaged with nature. The more natural and “wilderness-like” the setting, the more the children’s behavior improved. When you have to struggle to maintain attention – like a task like writing or doing computations – neurotransmitters in the brain’s prefrontal cortex get depleted and “attention fatigue” occurs. Being in nature seems to replenish neurotransmitters. As ADHD people are already chronically dopamine depleted, it is recommended to give ADHD kids “green time” before any activity that requires attention.
Rough and tumble play is another important niche activity. It requires adequate spaces and opportunities to express the natural biologic need for vigorous free-play, each and every day. Unfortunately, the cultural trend is toward a more sedentary childhood, where children sit passively watching television, “playing” video games, working at their computers and being involved in adult-supervised competitive games (also not true play). The solutions are: more recess time at school and more time at home to build forts, play wrestle, do cartwheels and somersaults, and engage in more child-centered informal physical games like sandlot baseball or football.
Niche Construction for Adults: Use Your Dynamic Brain
Physical movement, change, novelty, high stimulation, and hands-on activity are all factors in good niche construction. Most of these elements are found in firefighting and EMT work that provides an intense, fast-paced world and is tailor made for someone who craves constant change and adrenaline-producing situations. Creativity, risk-taking and quick decision making are all required.
Business and entrepreneurship are also good matches. Being able to distill complex facts and come up with simple solutions – the ADHD brain naturally searches for better ways of doing things. With a tendency to wander, spending less time in an office for an executive and moving from store to store noticing what people were doing right and discovering many wonderful ideas to help expand the business. ADD people are high energy and extremely good brainstormers. They will happily work 12-15 hours by choice.
Potentially good careers for ADHD: disc jockey or radio announcer, traveling salesperson, music or dance therapist, choreographer or dancer, aerobic or fitness instructor, forest ranger, recreational worker, itinerant teacher, radio, television or newspaper reporter, freelance writer, artist of editor, police officer or firefighter, private detective, nature photographer, building contractor, craftsperson, artist or sculptor, inventor or designer, community ombudsman, truck, bus or taxicab driver, airline pilot, ship captain or train engineer, emergency room physician, freelance researcher, farmer or ranch worker, athlete or coach, lecturer or workshop leader, surveyor or cartographer, fashion model public relations consultant.
Each of these careers has at least one element that favours ADHD abilities: out in nature, traveling around or moving frequently, working with one’s hands, being actively involved with new situations from day to day, handling emergencies, being physically engaged, doing many different things in a short period of time, engaging in creative pursuits such as the arts, and being able to work for oneself.
In addition to career choice, new technologies can help build a comfortable niche: personal digital assistants to help organize and manage different aspects of one’s hectic daily schedule. They can provide reminders for appointments, prioritizing commitments, communicating with others (email and cell phones), access the internet, navigating using GPS, organizing accounts and budgets, taking notes, (word processing, digital software, documenting events (camera, video recorder), providing stimulation and entertainment (computer games, radio, movies).
Human resources can help them prioritize, focus and get things done. It is best to surround themselves with individuals who are good at the specifics of a business – assistants who help write letters and keep their calendar. They don’t get bogged down in the details but hire people to handle that. Trainers and personal coaches (via phone, email or in person) help with organization, time management, follow through, motivation, and discovering “work arounds” for dealing with challenges. They can help to develop their ability to listen – don’t talk until the other person has completed his sentence, and recap with them to make sure you understand what they said. Write reminders to do these things at the top of their notepad.
Medication
For some, medications can provide an important ”platform” on which a positive niche can be created. But especially with children, medications should be viewed with caution. Ritalin and other psychostimulants have rare serious side effects and have a potential for abuse (adolescents use them as a street drug). They may tend to attribute their improved behavior to their ”good pill” rather than their own personal effort. There’s a danger in using medications to provide chemical stimulation as a substitute for good living. It’s important to provide children, who are just starting out on life’s journey, with a strong developmental foundation of play, sensory-rich experiences, and dynamically interactive environments. If problems continue after the healthy lifestyle ahs been instituted for a period of time, the psychoactive medication become more appropriate. People with ADHD may discover that their greatest improvements in mental health come about not so much through drugs but through changing the ecology of their outer surroundings to match the brisk and ebullient nature of their joyful hyperactive brains.
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ADHD and FEMALES
Women are being diagnosed with ADHD at unprecedented rates. Here’s why.
Women and girls with attention-deficit/hyperactivity disorder have historically been under and misdiagnosed. Is the world finally catching up?
At age 22, Rach Idowu was convinced she had dementia. She found herself forgetting birthdays, missing meetings at work, and struggling to manage credit card debt. A Google search suggested that she had early-onset dementia, which her doctor quickly dismissed. It would take her another four years and the assessments of two psychiatrists, but eventually Idowu was diagnosed with ADHD.
Suddenly, everything in her life began to make sense: her constant fidgeting as a child, the caffeine-fueled all-nighters to finish school assignments, taking weeks to answer messages from friends. “It was a massive eureka moment,” Idowu, now 29, says.
Idowu is one of millions of women and people assigned female at birth diagnosed with ADHD as an adult. And while the number of diagnoses among adult women has been rising for decades, 2020 to 2022 saw a massive increase: the number of women aged 23 to 49 receiving an ADHD diagnosis nearly doubled. The COVID-19 pandemic, the rise of telehealth, and ADHD’s popularity on social media have prompted some concern that the diagnosis trend is a fad. But are women being overdiagnosed? Or is the world just catching up?
There are three types of ADHD: hyperactive, inattentive, and combined. Girls and women tend to have the inattentive type, characterized by disorganization, forgetfulness, and struggles with starting and staying on task.
They’re more likely to be seen as daydreamers, or lost in the clouds.
Even hyperactive or combined-type girls often display their symptoms differently than boys—such as excessive talking, twirling their hair or constantly shaking their legs, and emotional reactivity. Their symptoms are just as impairing, but can fly under the radar.
A ‘boy disorder’
When clinical psychologist Kathleen Nadeau co-authored Understanding Girls with ADHD in 1999—one of the first real attempts to characterize how ADHD appeared in young girls—the research community still thought of ADHD almost exclusively as a “boy disorder.”
“We were laughed at during conferences,” says Nadeau, now recognized as an authority on women with ADHD.“They said, ‘We’ve got these guys that are in the principal’s office three times a week, getting suspended and throwing spitballs. And you’ve got these quiet girls making honor roll grades and you think they have ADHD?’”
While that attitude has started to change, the overwhelming majority of research on ADHD has been done in boys and men, leading to the hyperactive, disruptive boy stereotype of ADHD.
Many girls with ADHD excel in school, though it comes at a price—they may get an A on a paper but stay up the night before writing it after being unable to focus for weeks.
“Girls work very hard to hide their problems. ‘I don’t want the teacher to be mad at me, I don’t want my parents to be mad at me,’” Nadeau says. Experts call this masking, or how people socialized as females tend to find ways to compensate for their symptoms due to societal expectations. “They have to put in at least twice the effort of other people if they’re determined to do well,” Nadeau says.
“You can’t let people know that you’re falling apart,” says Janna Moen, 31, a postdoctoral research scientist at Yale Center for Infection and Immunity with a PhD in neuroscience, who was diagnosed with ADHD in her late 20s. Like many girls who go untreated, Moen scored top grades in school and went on to have a successful career, but years of masking her symptoms contributed to her developing mental health and self-esteem issues, and struggling in personal relationships.
Like Moen, who showed symptoms of ADHD from childhood, girls and women are more likely to have their symptoms mistaken for emotional or learning difficulties and are less likely to be referred for assessments. Gender bias also may play a role: in two studies where teachers were presented with vignettes of children with ADHD, when the child’s names and pronouns were changed from female to male, they were more likely to be recommended for treatment and offered extra support.
All these misconceptions mean that girls with ADHD are being overlooked and untreated well into adulthood. As David Goodman, the director of the Adult Attention Deficit Disorder Center of Maryland and an assistant professor at Johns Hopkins School of Medicine, points out, the ratio of boys to girls with ADHD in childhood is about three to one, while in adults, it’s about one to one, suggesting that ADHD prevalence is more equal across genders, with women being diagnosed later.
Children get diagnosed because they’re disruptive and a pain to other people. The adults get diagnosed because they’re a pain to themselves.
A disorder of executive functioning
Ultimately, ADHD is a disorder of executive functioning; the mental processes like planning, working memory, and emotion regulation that govern an individual’s ability to operate.
As women move into adulthood, demands on executive functions grow, and symptoms can become even harder to recognize as ADHD. Hyperactivity may manifest as inner restlessness, inattention may look more like struggling to complete chores or meet deadlines, and impulsiveness can appear as difficulty managing a budget. Despite these challenges, many women with ADHD may appear externally as high-achieving perfectionists. But the consequences of a missed or misdiagnosis can be severe.
(Is there a link between ADHD and binge eating?)
Compared to their neurotypical peers, women with ADHD are more likely to suffer from anxiety and depression, substance abuse, and eating disorders. They are also five times more likely to experience intimate partner violence, seven times more likely to have attempted suicide, and have higher rates of unplanned or early pregnancy. One Danish study showed that the risk of premature death in women with ADHD was more than twice that of men with ADHD, potentially due to women being less likely to be diagnosed and receive treatment.
A shortage of ADHD specialists
The explosion in diagnoses coincided with two potentially related factors: the COVID-19 pandemic and the rise of TikTok. One survey found that about 75 percent of newly-diagnosed adults said the pandemic played a role in prompting them to explore an ADHD diagnosis, in part because of more time on social media platforms like Twitter and TikTok. Google search trends for ADHD rose faster between 2020 and 2022 than any other period since 2004, and the hashtag ADHD has amassed 35 billion views on TikTok in the United States in the past three years. Many women report receiving a diagnosis only after self-referring to a mental health professional, some having been spurred by a post on social media.
Even for those who decide to get a neuropsychological evaluation, finding a skilled provider is a challenge.
Psychiatrists get about half a day of training in adult ADHD over three years.
For decades the prevailing attitude among psychiatrists was that kids grew out of ADHD. But even though that misconception has been debunked, there are still no official diagnostic guidelines in the U.S. for ADHD in adults.
(If you don’t have ADHD, Adderall and Ritalin won’t work for you.)
An assessment can require several sessions and may include interviewing family members and even looking at old report cards to determine if symptoms were present in childhood.
Finding a provider who can recognize ADHD in women is even harder. “My doctor told me she didn’t think I had ADHD because I graduated from university and had a job,” Idowu says.
Women are also more likely to have their ADHD mistaken for anxiety or depression. Janna Moen spent almost two decades being misdiagnosed with and treated for major depressive disorder and anxiety, only to find her symptoms resolved once she was treated for ADHD with therapy and medication. Moen thinks her anxiety and depression were more of a response to the pressure she put on herself to appear normal while struggling to keep up.
“Psychiatrists think let’s treat the anxiety, let’s treat the depression. And when those are better, let’s see if there really is any ADHD. When it should really be the opposite.
Sketchy telehealth ADHD services
With so few skilled providers, ADHD-focused telehealth startups have sprung up the past few years, promoting themselves as a panacea to expensive evaluations and long waitlists.
They advertised heavily on platforms like TikTok and Instagram. Hatie Parmeter decided to give one a try when faced with a four-month wait for an evaluation by a psychotherapist in her rural Wisconsin town. She was skeptical from the beginning.
“It was stupid fast,” she says, noting it took about five minutes for the provider to diagnose her with ADHD and offer her meds. “By the time it was over, I was left feeling that I wasn’t entirely sure it was correct.” Parmeter decided not to take her prescription, and later had her diagnoses confirmed after a proper evaluation by a psychologist.
Some of these companies are now under investigation by the DEA for their lax prescribing practices. “These evaluations were, in my opinion, inadequate. Too many people ended up on medication who likely did not have ADHD.
Goodman and other providers don’t think that misdiagnoses alone can account for the stark rise in women receiving ADHD diagnoses, though. Jennifer Gierisch, associate director of engagement at Duke’s center, notes that since women develop so many coping strategies for ADHD, it can often take a major life event or stressor—transitioning from high school to college, getting a promotion at work, or becoming a parent—for them to finally recognize something is seriously wrong. She thinks the pandemic was a catalyst for millions of women at once.
All of the ritual and structure that helps people with ADHD stay on track disappeared. The complex scaffolding [women] had built around themselves to fill in those deficits was no longer enough.
A lag in proper diagnosis
While Schechter praises social media for spreading awareness of ADHD in adult women, she notes it might have contributed to a watered-down image of the disorder.
A 2022 study from researchers at the University of British Columbia, for example, found that half the content of the 100 most popular TikTok videos about ADHD was misleading. “This is not a disorder where you lose your keys sometimes,” Schechter says. “When we reduce ADHD to a social media post, that real functional impairment gets lost in the mix.”
Experts emphasize that attentional issues brought on by the pandemic, remote work, and more time spent on social media are not enough to warrant an ADHD diagnosis.
Just because you have a hard time working from home, or get distracted by your phone, or can’t do your homework with the TV on does not mean you have ADHD. We’re looking for this pattern of symptoms and challenges that have been present across time and across settings. ADHD is ultimately a neurodevelopmental condition that is typically present from birth, and is about 80 percent genetic. While external factors can exacerbate symptoms, it can’t cause them. Saying, Aren’t we all a little ADHD’ is like saying, we’re all just a little diabetic. Ultimately, clinicians don’t think social media posts are resulting in a wave of over or misdiagnoses. “The ADHD was always there, we’re just finally catching up and being able to diagnose it properly.”
For women who do receive help, it can be life-changing. Idowu says since getting treatment and being on stimulant medication, she has gotten ahold of her finances, is thriving at work, and has improved her relationships. Her own journey and the lack of available information prompted her to start a popular newsletter, “Adulting with ADHD” in 2020, which she says has helped hundreds of people get diagnosed. “It’s very difficult to exist in a world where you feel like there’s something wrong with your brain,” Idowu says. “There’s a power in just knowing.”
