ADHD affects around 70% of the people I treat. I consult nationally in this area, and have a deep and curious interest in individualized care of ADHD and all its associated traits and experiences.
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) describes adult ADHD as having at least 5 inattentive features, at least 5 hyperactive/impulsive features, or a combination of 5 symptoms from each category. The symptoms must have been affecting at least two major life areas (such as work, school, social, family) since before the age of 12.
The screener standardly used is the ASRS v1.1, and a public domain diagnostic tool is the ADHD-RS with adult prompt questions.
Using just these instruments, how am I as a clinician to tease out ADHD from difficulty with agitation, motivation, and focus, possibly caused by depression, or trauma?
ADHD has common clusters and patterns in the way that symptoms present, and common clinical correlates.
ADHD is not a condition of thinking,
it is a whole-person experience
Diagnostic criteria aside, individuals living with ADHD might explain it thusly:
ADHD is an interest-based condition (“importance”, or salience, may not register): if they have interest, passion, novelty, time pressure, or competition, they focus beautifully – sometimes too well. If they are not interested, or bored, focus seems illusive. Boredom is the hub around which difficulties with mind-wandering, distractibility, prioritization, procrastination, organization, all revolve.
People with symptoms of ADHD have trouble with starting and stopping: dopamine is motivation and movement. People with ADHD have difficulty with action potentials – with initiating tasks, especially if they are difficult and/or boring. And many folks have trouble stopping – once they start a project, they may either impulsively jump off to other things, or wander off to other things due to boredom, or they may carry their task into the wee hours due to…
Hyperfocus – some people hyperfocus only when they have procrastinated and are on a deadline, but many have laser focus for an interesting research project, or sports stats. Some people are “sticky”, they have an uncomfortable feeling in their chest, even becoming irritable, if asked to stop their project or if interrupted. As with OCD, there is a “just right feel” to seeing the project to completion. Unlike OCD, there is not the discomfort of overfocus.
And many people with ADHD have an evening chronotype – around 2/3 have a naturally late bedtime, around 1 or 2 in the morning. They will get their best quality sleep if they go to bed at this time. People with ADHD will speak of a “second wind” with creativity and drive that they get at around 10 or 11 PM.
People with ADHD are also likely to have sleep disorders, with 20–30% having sleep apnea, 2/3 having the circadian rhythm shift, and around 44% living with restless legs syndrome or periodic movements of sleep (PLMS).
Mood difficulties are common: 1 in 13 lives with bipolar disorder, and around 30% have had depression. When depression is chronic, long-standing, involves poor interest and motivation, and intersects with ADHD, this may be called low hedonic tone.
Dopamine and norepinephrine neurotransmission are involved. These are the two neurochemicals that our FDA-approved medicines for ADHD work with, for motivation and focus. Norepinephrine is also associated with impulsivity, and serotonin with aggression and hyperactivity. Acetylcholine also has sway, it impacts memory. The ability to hear and remember what people say to you, to not lose your keys/wallet/phone, to hold things in mind so you can multitask.
ADHD is neurodevelopmental, and these brains have structural differences distinct from others
The default mode network (DMN) connects the prefrontal cortex, salience network, limbic system, and other areas of the brain allowing them to work in concert, to do work and react appropriately to the environment.
The salience network pulls the strings, directing the DMN, but in an interest-based brain, salience (importance) may have less pull.
People with ADHD spend time inside the DMN more often, rather than using it to orchestrate. This is where mind-wandering takes place, and mindfulness meditation can train them back to focus.
Other structural changes, seen in studies involving as many as 5000 overlapping scans, show differences in grey matter density, white matter abnormalities (e.g., the DMN), differences in structure and volume of cortical structures, reduced total brain volume, reduced cortical thickness in adults. This page has a good overview of structural differences between those with ADHD and others, with illustration.
Trauma is a common experience in ADHD. Children with ADHD often get into accidents. They suffer poor self esteem from difficulty with performance and family and social relationships. They may get into difficult relationships and situations due to impulsive acts, and due to the fact that they mature around 2 years behind their peers when young. Substance misuse is common as a coping strategy for many with ADHD. The Atlantic has a thoughtful article and Gabor Mate believes that many people with trauma are misdiagnosed with ADHD (though trauma alone is not an interest-based condition with many of the other correlates of ADHD, represented on this page).
Anxiety is a common experience – while there are many way anxiety presents, it’s perhaps most common for people with ADHD to experience generalized anxiety, sometimes generated solely by their inability to complete tasks, be timely, not lose things or make errors, and organize well. Treating the ADHD can lend clarity to the diagnosis. Around 2/3 of my clients with ADHD also live with social anxiety – giving a talk, meeting with strangers, with superiors, engaging in small talk, many presentations.
Social anxiety may feel similar to Rejection sensitivity dysphoria (RSD), a feeling that someone with ADHD may have when they feel rejected, misunderstood, or judged. It is so disappointing and impactful, some say it feels as though they were hit hard in the chest.
RSD may intersect with deficient emotional self-regulation (DESR).
Both experiences stem from a lack of top-down control over the limbic system by the prefrontal cortex (where executive function lives), with impulsivity interrupting the connection.
Think you might have RSD? Take the quiz.
What causes ADHD?
As with all conditions, there are biopsychosocial contributors.
But ADHD is highly biologic.
Genetics, herritability: if a child has ADHD, it’s a 30% chance that each of her parents meets criteria. Heritability (the chance of one identical twin to have a condition if the other is diagnosed) in ADHD is 72%.
While this is a complex topic, we'll cover some broad strokes:
How is ADHD treated in my practice?
I aim to offer a very comprehensive selection of natural and pharmaceutical options, so that clients may receive treatment that aligns with their interest and values, and so that people who have had difficulty with treatment in the past still have many options to choose from.
Medicines and supplementation
FDA-approved medicines include psychostimulants for focus and impulsivity; alpha-2 agonists for impulsivity, rejection sensitivity, and emotional regulation (they also smooth out the experience of stimulant medicines); and atomoxetine.
There are natural strategies for managing stimulant tolerance should that arise, reestablishing dopamine receptor density if downregulation occurs, and for limiting the neuroinflammation and free radical damage stimulants have been shown to pose.
“Off-label” strategies include several antidepressants available to treat social anxiety, rejection sensitivity, and to create a nice base underneath stimulants to build on for focus and motivation. There are also drugs originally designed for Parkinson’s disorder, Alzheimer’s dementia, and narcolepsy, that have utility in ADHD. These strategies and others are helpful to those who cannot take stimulants due to medical conditions, or who choose not to.
There are strategies for working with the catechol-o-methyltransferase (COMT) enzyme (which degrades dopamine), for those with the Val/Val or Met/Met allelic (genetic) variants, to enhance cognition or reduce anxiety.
Omega 3 fatty acids with high DHA content, amino acids, SAM-e, L-5-methylfolate, magnesium L-threonate, adaptogenic plants, and cholinergics are all natural options for improving cognition instead of or in addition to medicine.
While I have favorite strategies, I will consider any medicine or supplement on the market that might help my client without causing harm. My goal is to provide the broadest selection of agents possible, to maximize choice, personalization, and to always offer options should any trial not be optimal.
Lifestyle Matters – the Big 5
Just as with any other condition involving mood and anxiety symptoms, clients are encouraged to treat their bodies well, doing as many of the following as suits them. According to the CDC, only 6% of Americans have a healthy body mass index (BMI), sleep adequately, drink alcohol moderately or not at all, exercise adequately, and are never smoking. And only 12% of American adults are metabolically healthy! Here are some possible goals:
1 Many people living with ADHD report better attention and memory function on a gluten-free diet; gluten is a proinflammatory substance, and wheat is grown and harvested with liberal amounts of glyphosate (a toxic herbicide) in the United States. Casein (from milk) is also proinflammatory to the gut, and eliminating this substance in addition to gluten, sugar, and sometimes soy and wheat have been tried in clinical trials to good effect. Some of my clients choose ketogenic or paleo diets, which automatically eliminate the aforementioned foods.
Nutrients found important in ADHD include iron, vitamins B1, B5 B6, and B12, magnesium, folic acid, vitamin D, iron, and both zinc and copper and their ratio. An omega 3 index is important too, as most individuals are low.
These nutrients are on my baseline lab set, and I have protocols written for repletion with quality supplements should you need them.
Listen to Emily Deans and Chris Kresser discuss ancestral diet and psychiatry.
2 Limit alcohol use. The National Institute on Alcohol Abuse & Alcoholism (NIAAA) defines moderate drinking as up to four alcoholic drinks for men and three for women in any single day and a maximum of 14 drinks for men and seven drinks for women per week – a cardiologist or oncologist would have very different recommendations.
3 Exercise – aiming for half hour five times weekly. If regular walking is what suits you, this is largely what our ancestors did.
4 Sleep adequately, and well – learn how to hack your sleep to improve quality.
Have insomnia? Consider Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain by New Harbinger Press, and
5 I would round this out with a meditation practice. See below.
Coaching and Neurofeedback
Has been shown to help those living with ADHD to improve focus, and to put some time, pause, and room between their impulses and actions, and reactions.
Mindfulness meditation trains you to use your default mode network to connect brain areas such as the prefrontal cortex, limbic system, and salience network to each other so that they can coordinate, and perform work. When a person is conversely sitting within their DMN, rather than utilizing it for connectivity, they are daydreaming, mind-wandering. Mindfulness offers retraining.
See my book list below for instruction
Topics include procrastination, motivation, the “wall of awful”, clutter, how to stimulate your mind, exercise and sleep, lots of great topics, all short videos.
www.additudemag.com – phenomenal, my go-to.
Their download, Secrets of the ADHD Brain,
is a great introduction.
For parents and kids – who both may live with ADHD – www.understood.org – lots of tools and teaching for adults and kids alike
ADHD in Adults specifically: http://adhdinadults.com/
by Elaine Taylor-Klaus
For Parents of ADHD – including those living with ADHD
Tools and resources
Popular articles on INACTION, INDECISION, and INITIATION
Check out the Additude Podcast – Additude looks beyond the diagnostic manual and psychiatric frameworks and codification, to the who-you-are of ADHD, the super-power, and the pain points. Here’s another entrance to the Podcast Library.
Ned Hallowell has the Distraction podcast, also helpful – Hallowell focuses on the positive aspects of ADHD, the bright side.
Bookstore with resources: https://www.addwarehouse.com/
Support Groups, Websites, Podcasts and Books
LIVE SUPPORT GROUP
https://chadd.org/ – great organization with group meetings – by and for those living with ADHD and related conditions
Jessica of How To ADHD has weekly tips and tricks – it’s her ADHD toolbox – "a place to keep all the strategies I've learned about having and living with ADHD. It's also grown into an amazing community of brains (and hearts!) who support and help each other. Anyone looking to learn more about ADHD is welcome here!”
Thomas Brown PhD
By Thomas Brown PhD – who really understands ADHD from a whole-person perspective, has designed wonderful assessments, and is so wise and knowledgeable
Also by Thomas Brown PhD
By Kate Kelly and Peggy Ramundo
Classic workbook, for people living with ADHD
by Steven Safren et al.
by Kathleen Nadeau
By Judith Kolberg and Kathleen Nadeau
By Gina Pera
For loved ones to read
BOOKS ON NATURAL TREATMENTS FOR ADHD
By James Greenblatt
Very smart chapters on nutraceuticals, neurofeedback, sleep/exercise/diet, mindfulness.
Has excellent endorsement from David Perlmutter
Richard P Brown and Barbara Gerbarg have written a number of texts on integrative mental health and they include excellent directions and sources
by Lidia Zylowska and Daniel Siegel
Russell Barkley PhD
By Russell A Barkley, an out-of-the-box thinker in ADHD, author if the constructs sluggish cognitive tempo, and rejection sensitivity dysphoria
more Barkley, for clinicians
Ned Hallowell MD
Driven to Distraction (Revised): Recognizing and Coping with Attention Deficit Disorder
By Ned Hallowell and John Ratey
Companion book, by Ned Hallowell and John Ratey