According to the Centre for ADHD Awareness Canada (CADDAC), Attention Deficit Hyperactivity Disorder (ADHD) has been documented for over two hundred years; yet more than 80% of adults with ADHD have never been diagnosed or treated. Despite huge advances in scientific research, many myths continue to surround ADHD, which perpetuates stigma and prevents access to diagnosis and treatment. Not only do these myths exist in the general public, but they also influence medical professionals. A leading expert in the treatment of ADHD, Ned Hallowell, MD, states that “most medical professionals have little training in ADHD, and do not know how to recognize it outside of hyperactive children.” Due to this outdated belief, many adults cannot find medical professionals willing to evaluate them.
Scientists have studied the ADHD brain and discovered that it operates very differently compared to a neurotypical brain. The behaviours associated with ADHD are because of this neurological difference, which cannot be overcome by sheer willpower. One of the most well-known figures in ADHD research, Russell Barkley, Ph.D., passionately believes that ADHD is an executive function disorder, as individuals with ADHD “have great difficulty using executive functions (self- directed actions) for self-regulation and attaining their goals.”
ADHD is a neurodevelopmental disorder that is present from birth. Jonathan Posner, MD, of the Posner Lab at Columbia University, uses structural MRIs to study ADHD brains. Posner explains that while MRI’s “cannot yet be a diagnostic tool for ADHD, it is an important research tool that allows scientists to obtain special insight into the development of the ADHD brain.” MRI scans can clearly show that there are differences in the size and shape of the brain, as well as differences in brain activity. There is a delay in maturation of the cerebral cortex in youth and impaired synaptic release of dopamine and norepinephrine.
ADHD is highly heritable. After height (80%), ADHD is the most heritable condition (76%) (Sprich S, et al. Adoptive and biological families of children and adolescents with ADHD. (J Am Acad Child Adolesc Psychiatry. 2000;39(11):1432-7). If there is someone diagnosed with ADHD, there is a high chance that other family members have this condition too.
ADHD does not affect children only. About 4.4% of adults: approximately 1.3 million
Canadian adults (Canadian ADHD Practice Guidelines, 4.1 Edition. CADDRA, Toronto, 2020) live with ADHD. Presentation in adults is different than in children; for instance, the hyperactivity of children would change to interrupting others, feeling restless, obsessions, argumentativeness, emotional dysregulation and substance use. This stereotypical image of young boys running around also contributes to the under- diagnosis of girls and women. Boys are three times more likely to be identified (Canadian ADHD Practice Guidelines, 4.1 Edition. CADDRA, Toronto, 2020). One of the reasons for this gender bias, is that the symptoms of girls and women often present quite differently. Girls are more likely to present as inattentive. They internalize their hyper-activity. Girls tend to try harder to compensate and cover up their symptoms more than boys.
Intelligent individuals can also have ADHD. They cope well until challenges are too overwhelming. These challenges include long-term relationships ending, final exams, writing academic papers and employment duress. The functional impairment can be seen in at least two settings of school, work or at home. Therefore, if someone is successful at work, simply because their job is what they like to do, it doesn’t mean that they don’t have ADHD.
You may see the comorbidity before you realize that the underlying diagnosis is ADHD. 50-90% of children and 85% of adults with ADHD have one or more comorbidity (CADDRA. Canadian ADHD Practice Guidelines, 4.1 Edition, 2020). These include Generalized anxiety disorder, depression and dysthymia, bipolar disorder, borderline personality disorder, Substance use disorder, binge eating and obesity, and more.
Individuals with ADHD may have more severe substance use, starting at a much younger age compared to their peers. Cannabis use is the most comorbid (51%) following by stimulants (49%), Alcohol dependence or abuse (45%) (Barkley RA, et al. ADHD in Adults: What the Science Says. Guilford Press, New York, 2010). The remission rate is less in people with ADHD, mainly due to the negative life consequences like failing relationships, employment, legal issues. Children with ADHD use marijuana at a much younger age. They are more than 1.5 times as likely to develop Cannabis Use Disorder. Effective treatment of ADHD has been shown to improve comorbid disorders and substance use. People with substance use need to be screened for ADHD. In order to treat one, we need to address the other.
If ADHD is left untreated/ undertreated, individuals have 2-4 times more MVA collisions/ violations; are more likely to be expelled from their job, lower grades, lower self-esteem, higher family conflicts and divorce, higher rate of criminalities, higher risk of substance use and risky sexual behaviors. They have less life expectancy (13 years less than non-ADHD peers (Barkley, 2018) due to poor health and/ or injuries.
Treatment of ADHD is relatively easy, effective, and very rewarding. It would be best if executive function skill training, psychoeducation and psychotherapy are combined with the medications. Long-acting stimulants are the first line and improve outcomes in many areas like injuries, MVAs, substance use and mood disorders. Red flags for ADHD in adults such as marital problems, parenting problems, money management, substance use and addictions of any kind, problems with driving, organizational skills like time management, losing jobs, and anger control problems.
Non-medical use of stimulants has not shown improvement in academic performance. (Arria AM, et al. Pharmacotherapy 2008l 28(2).). In fact, there is a correlation between lower grades and illicit use of prescription stimulants. (Bavarian N, et al. Drug Alcohol Depend 2013;132:665;).
ADHD management is life changing and helps both children and adults to better reach their potential. People need to be aware of this condition and seek help. Schools need to be able to recognize this condition in children early on and refer them to receive appropriate care. Unfortunately, ADHD is not included in training of general practitioners and even psychiatrists, therefore many of health care professionals do not feel comfortable dealing with ADHD. It is time for this to change.