Dec 21, 2018 | Research Updates
Attached is an important update of the European Consensus statement regarding the diagnosis and treatment of adult ADHD. This is yet another important resource that includes several APSARD members as authors.
CLICK HERE TO VIEW THE FULL PAPER.
Abstract
Background Attention-deficit/hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that often persists into adulthood and old age. Yet ADHD is currently underdiagnosed and undertreated in many European countries, leading to chronicity of symptoms and impairment, due to lack of, or ineffective treatment, and higher costs of illness.
Methods The European Network Adult ADHD and the Section for Neurodevelopmental Disorders Across the Lifespan (NDAL) of the European Psychiatric Association (EPA), aim to increase awareness and knowledge of adult ADHD in and outside Europe. This Updated European Consensus Statement aims to support clinicians with research evidence and clinical experience from 63 experts of European and other countries in which ADHD in adults is recognized and treated.
Results Besides reviewing the latest research on prevalence, persistence, genetics and neurobiology of ADHD, three major questions are addressed: (1) What is the clinical picture of ADHD in adults? (2) How should ADHD be properly diagnosed in adults? (3) How should adult ADHDbe effectively treated?
Conclusions ADHD often presents as a lifelong impairing condition. The stigma surrounding ADHD, mainly due to lack of knowledge, increases the suffering of patients. Education on the lifespan perspective, diagnostic assessment, and treatment of ADHD must increase for students of general and mental health, and for psychiatry professionals. Instruments for screening and diagnosis of ADHD in adults are available, as are effective evidence-based treatments for ADHD and its negative outcomes. More research is needed on gender differences, and in older adults with ADHD.
Dec 10, 2018 | Research Updates
Russell A. Barkley, Ph.D.
Nearly 15 years ago, suggestive evidence began to arise that ADHD may have a detrimental impact on life expectancy. Such opinions were based on what were then new findings from a longitudinal study at Stanford university initiated by Terman of gifted children followed their entire lifespan. The findings by Friedman and colleagues (2002) indicated that even among this gifted sample, children who placed below the bottom 25th percentile of the population in the personality trait known as Conscientiousness had a 7-8 year reduction in their lifespan compared to the remainder of their sample. Conscientiousness refers to the use of one’s conscience in making decisions about one’s actions and their consequences for one’s self and others that contribute to the individual’s longer term welfare. When low, Conscientiousness acts to reduce life expectancy due to its being a background trait that predisposes people to engage in adverse health and lifestyle activities that are known to reduce life expectancy, such as smoking, alcohol and drug use, risk taking, poor health maintenance activities, poor diet, etc. Indeed, low Conscientiousness has been repeatedly shown to mediate the risk of earlier death by all causes (Bogg & Roberts, 2004). The trait is negatively related to self-regulation generally and behavioral disinhibition specifically. Naturally, then, it is also negatively related to ADHD that includes disinhibition as one of its central symptom dimensions. Hence, if those in the bottom quartile on this trait had a significant reduction in lifespan, even among gifted children, those with ADHD would be expected to have an even greater reduction in life expectancy as those with ADHD place in the bottom 5-7 percent of the population in their poor inhibition.
Besides being low in Conscientiousness, there are a number of other reasons to expect that ADHD would be linked to a reduced life expectancy by young adulthood. For one thing, ADHD is linked to increased adverse consequences in nearly every major domain of life activity studied to date (Barkley et al., 2008), some of which are linked to shortened life expectancy. For instance, ADHD is associated with higher risks for accidental and self-inflicted injuries in childhood and adulthood (Nigg, 2013). Adverse driving outcomes, including more vehicular crashes (Barkley, 2015c; Barkley & Cox, 2007), are also associated with ADHD. ADHD is also associated with an increased risk for suicidal ideation, attempts, and completions (Barbaresi et al., 2013; Barkley et al., 2008). And teens and adults with ADHD-C are far more likely to be involved in interpersonal hostility generally and antisocial activities specifically that include violent crimes, reactive aggression, and intimate partner violence even when conduct disorder is not present or is statistically controlled (Buitelaar, Posthumus, & Buitelaar, 2015; Mohr-Jensen & Steinhausen, 2016; Saylor & Amann, 2016). All of these variables would predispose to an increased risk for greater morbidity and likely earlier mortality by violent means.
For another, ADHD is associated with various adverse medical conditions, including increased rates of seizures, obesity, eating pathology, traumatic brain injury, tobacco, alcohol, and marijuana use, dental trauma and caries, sedentary behavior or low rates of exercise, sleeping problems, migraines, and risk for future coronary heart disease, as well as decreased involvement in preventive health, nutrition, and dental hygiene activities (Barkley, et al., 2008; Barkley, 2015b; Nigg, 2013). Many of these conditions are well-known correlates of reduced life expectancy and are used in algorithms that predict life expectancy as occurs in public health research and in the life insurance industry.
Over the past decade, a few studies have specifically examined the issue of greater mortality in ADHD using large epidemiological samples or even entire populations. They showed that in childhood, the mortality risk is nearly doubled that of the typical comparable population, and in adulthood, that risk is more than quadrupled (Dalsgaard, Ostergaard, Leckman, Mortensen, & Pedersen, 2015; Jokela, Ferrie, & Kivimaki, 2009; London & Landes, 2016). This risk of earlier mortality by midlife seems to be largely a result of a greater proneness to accidental injury but also, to a lesser extent, from an elevated risk for suicide (Barbaresi et al., 2013; Dalsgaard et al., 2015). These studies do not address, however, the cumulative risk of chronically engaging in adverse health and lifestyle activities that can reduce life expectancy after mid-life. Thus, Mariellen Fischer, Ph.D. and I decided to use our Milwaukee longitudinal study to examine the possibility of reduced life expectancy in our ADHD and control children at their young adult follow-up (mean age 27 years) by entering 14 variables related to disability, health, and lifestyle into a recently available estimated life expectancy (ELE) calculator provided by the University of Connecticut Goldenson Center for Actuarial Research. We presented our initial pilot findings at the APSARD meeting in January of 2018 that suggested just such a significant impact on life expectancy. We then proceeded to undertake a more complete analysis of our data the results of which will soon be published in APSARD’s affiliated journal, The Journal of Attention Disorders. (Barkley & Fischer, in press).
Our study found that cases having hyperactive child syndrome, or ADHD-C, in childhood manifested a 9.6 year reduction in estimated healthy life expectancy in remaining years, a 1.2 year period of greater unhealthy life expectancy in remaining years, and an overall 8.4 year reduction in total life expectancy than did control children by young adulthood. Moreover, the persistence of ADHD to adult follow-up was associated with an even worse impact on these ELE measures, with a 12.7-year reduction in healthy life expectancy and an 11.1-year reduction in total ELE than was seen in control cases. Persistent cases had a 5.3-year reduction in healthy life expectancy and a 4.6-year reduction in total ELE than nonpersistent ADHD-C cases. And both persistent and nonpersistent ADHD cases had significantly lower ELEs by adulthood than did control cases. This is the first study to compute estimated remaining years of life expectancy by adulthood in children with ADHD-C and to compare persistent and nonpersistent ADHD cases on these ELE parameters.
The magnitude of such reductions in life expectancy can be appreciated by understanding that such reductions are far greater than those associated with smoking, obesity, alcohol use, high cholesterol, and high blood pressure either individually or combined! Why? Because ADHD has been found to predispose individuals to engage in a number of such adverse health and lifestyle activities. For instance, we noted that the disorder reduced ELE in our study through its association with 8 of the 14 variables entered in the ELE calculations. These included the demographic factors of reduced education, lack of high school graduation, and lower annual income in the ADHD-C groups but also in the health and lifestyle factors of greater alcohol consumption, poorer overall health, reduced sleep, increased likelihood of smoking and of smoking more than 20+ cigarettes per day, and possibly greater adverse driving consequences resulting in license suspensions and revocations. Beyond these first order or more proximal factors that were adversely affecting life expectancy, we showed that the background trait of behavioral disinhibition explained more than 30% of the variance in life expectancy in our samples, consistent with the findings noted above concerning the role of low Conscientiousness in reducing lifespan.
These findings in the context of the other research on increased mortality by mid-life due to risk of accidental injuries and suicide argue for ADHD being viewed as a public health and not just a mental health disorder. They should also give impetus to efforts to try to reduce those first order factors that are predisposing to reduced life expectancy, such as obesity, smoking, excess alcohol use, poor diet, poor sleep, limited exercise, etc. in children and adults with ADHD. After all, estimated life expectancy is malleable – change the adverse health and lifestyle factors affecting it and one can improve quality of life as well as life expectancy. But our results also suggest that without efforts to address the background trait of poor inhibition specifically and ADHD symptoms more generally, trying to improve only those first order factors may have only limited success. Adding ADHD medications and evidence based psychosocial treatments to address the background traits predisposing those with ADHD to engage in these first order adverse activities is also likely to be necessary. Our findings also argue for making primary care physicians more aware of the linkage between ADHD, poor inhibition, and reduced life expectancy as they are the one’s most likely to be trying to improve the adverse health and lifestyle activities of individuals and yet are not screening for the significant role that ADHD may be playing in their failures to do so.
References
Barbaresi, W. J., Colligan, R. C., Weaver, A. L., Voigt, R. G., Killian, J. M., Katusic, S. K. (2013). Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: A prospective study. Pediatrics, 131, 637-644.
Barkley, R. A. (2015c). Health problems and related impairments in children and adults with ADHD. In R. A. Barkley (ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th Ed)(pp. 267-313). New York, NY: Guilford Press.
Barkley, R. A. & Cox, D. J. (2007). A review of driving risks and impairments associated with Attention-Deficit/Hyperactivity Disorder and the effects of stimulant medication on driving performance. Journal of Safety Research, 38, 113-128.
Barkley, R. A. & Fischer, M. (in press). Hyperactive child syndrome and estimated life expectancy at young adult follow-up: The role of ADHD persistence and other potential predictors. Journal of Attention Disorders. DOI: 10.1177/1087054718816164
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford Press.
Bogg, T. & Roberts, B. W. (2004). Conscientiousness and health-related behavior: A meta-analysis of the leading behavioral contributors to mortality. Psychological Bulletin, 130, 887-919.
Buitelaar, J. N. J., Posthumus, J. A., & Buitelaar, J. K. (2015). ADHD in childhood and/or adulthood as a risk factor for domestic violence or intimate partner violence: a systematic review. Journal of Attention Disorders. ePub ahead of print, doi: 10.1177/1087054715587099.
Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. (2015). Mortality in children, adolescents and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet, 385, 2190-2196.
Friedman, H. S., Tucker, J. S., Schwartz, J. E., Tomlinson-Keasey, C., Martin, L. R., Wingard, D. L., & Criqui, M. H. (1995). Psychosocial and behavioral predictors of longevity: The aging and death of the “Termites.” American Psychologist, 50, 69–78.
Jokela, M., Ferrie, J. E., & Kivimaki, M. (2008). Childhood problem behaviors and death by midlife: The British National Child Development Study. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 19-24.
London, A. S., & Landes, S. D. (2016). Attention deficit hyperactivity disorder and adult mortality. Preventive Medicine, 90, 8-10.
Mohr-Jensen, C., & Steinhausen, H. C. (2016). A meta-analysis and systematic review of the risks associated with childhood attention-deficit hyperactivity disorder on long-term outcome of arrests, convictions, and incarcerations. Clinical Psychology Review, 48, 32-42.
Nigg, J. T. (2013). Attention-deficit/hyperactivity disorder and adverse health outcomes. Clinical Psychology Review, 33, 215-228.
Saylor, K. E. & Amann, B. H. (2016). Impulsive aggression as a comorbidity of attention-deficit/hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 26, 19-25.
Nov 12, 2018 | Research Updates
Joel L. Young, MD
The brain is a plastic organ that changes and reacts to its environment. In recent years, researchers have become increasingly interested in how brain injuries can affect development well into adulthood. More than 300,000 children are treated for traumatic brain injuries (TBI) each year. Two new studies point to a link between childhood TBI and later development of ADHD.
TBI and ADHD: Untangling the Connection
A cohort study that followed 187 children was published in the journal JAMA Pediatrics earlier this year. Each child had been hospitalized overnight for a traumatic brain injury between the ages of 3 and 7 years old. Researchers followed up with participants for several years following the study, and parents completed questionnaires about their children’s behavior and development at regular intervals.
The results suggest that the effects of TBI may extend well beyond the period immediately following the injury. Even as late as 6 years following the injury, children with a TBI history were more likely to have ADHD. Overall, 62% of children who sustained a TBI developed ADHD, compared to 15% of the non-TBI cohort.
New research published within the past few months arrives at similar conclusions. That study, published in the journal Biological Psychiatry, compared symptoms of ADHD in 418 children with a history of TBI to symptoms in 3,193 children with no prior TBI. They also assigned a genetic risk score to each child. They found that a higher genetic risk score correlated with higher risk of ADHD only in children with no history of TBI. This suggests that genetics may only play a role in ADHD risk in children with no TBI history.
Brain Changes Related to ADHD
Most children who experienced a severe TBI who later developed ADHD began showing symptoms of the disorder within 18 months. However, children with a mild or moderate TBI developed symptoms as late as more than six years following the initial injury.
Participants’ last follow-up visit coincided with many children’s entry into middle school. This is a time when many children must rely more on executive functioning skills. So it’s unclear whether this later development of ADHD coincides with continued brain changes, or is due to increased demands on a child’s brain.
While this research strongly suggests that a TBI may change brain regions associated with ADHD, it did not identify or test a causal connection between ADHD and TBI. More research is needed to fully flesh out this connection. However, other recent research strengthens the connection between ADHD and TBI, and suggests why one might lead to the other.
Does TBI Cause a Distinct Form of ADHD?
Stojanovski and colleagues’ 2018 study published in the journal Biological Psychiatry followed 3,611 youth, 418 of whom who had sustained a traumatic brain injury. Researchers also calculated each participant’s genetic risk score based on known genetic risk factors for ADHD.
Predictably, an increased risk of ADHD was found among participants who had a higher genetic risk score. What was surprising, however, is that there was no increased risk of ADHD among TBI survivors who had a higher genetic risk score. This suggests that ADHD following TBI develops differently, not due to genetic risk.
Brain imaging scans were conducted to look at brain structures associated with ADHD. Researchers found that brain volumes in structures, such as the basal ganglia, linked to ADHD was similar between the two groups. But an analysis that looked at connections between the two brain hemispheres found distinct differences in those with TBI-related ADHD and those with genetic ADHD.
This points to different neural underpinnings for the different manifestations of the disorder. TBI-related ADHD may even be a different disorder altogether.
TBI: A Permanent Injury?
For decades, most researchers thought that, should a person survive and thrive immediately following a TBI. We now know that ADHD is just one potential complication of TBI.
A 2017 study followed 285 patients who sustained TBIs. Researchers then followed a subset of 110 people who showed lingering concussion symptoms for three months or less. Only 27% fully recovered from their symptoms. Of those who did, 67% did so within the first year.
This suggests not only that symptoms following a TBI are common, but that the longer they last, the more likely the symptoms are to be permanent. The authors of that study emphasize the need for further research to better understand and interpret their findings.
The data is compelling, suggesting a clear relationship between brain damage and ADHD. We don’t yet know what this means, whether there may be interventions that can prevent ADHD, or to what extent TBI-related ADHD differs from traditional ADHD.
Clinicians must be mindful of the potential impacts of brain injuries, and should urge patients to seek prompt treatment for any new symptoms following a head injury.
References:
Bowser, A. D. (2018, April 16). Children, adolescents with TBI at risk of secondary ADHD. Retrieved from https://www.mdedge.com/pediatricnews/article/161152/mental-health/children-adolescents-tbi-risk-secondary-adhd
Long-term consequences of TBI. (n.d.). Retrieved from http://ohiovalley.org/informationeducation/long-termconsequences/
Stojanovski, S., Felsky, D., Viviano, J. D., Shahab, S., Bangali, R., Burton, C. L., . . . Wheeler, A. L. (2018). Polygenic risk and neural substrates of attention-deficit/hyperactivity disorder symptoms in youths with a history of mild traumatic brain injury. Biological Psychiatry. doi:10.1016/j.biopsych.2018.06.024
Study identifies distinct origin of ADHD in children with history of brain injury. (2018, August 14). Retrieved from https://www.sciencedaily.com/releases/2018/08/180814101302.htm
Traumatic brain injury & concussion. (2017, April 27). Retrieved from https://www.cdc.gov/traumaticbraininjury/get_the_facts.html
Hiploylee, C., Dufort, P. A., Davis, H. S., Wennberg, R. A., Tartaglia, M. C., Mikulis, D., . . . Tator, C. H. (2017). Longitudinal study of postconcussion syndrome: Not everyone recovers. Journal of Neurotrauma, 34(8), 1511-1523. doi:10.1089/neu.2016.4677
Nov 12, 2018 | Research Updates
The presence of mental health disorders in preschool children, such as anxiety, depression, bipolar disorder and ADHD has been documented more frequently in the past 10 years (Luby, 2017). However, despite recent evidence that early detection of mental health disorders may help in decreasing the severity and even the development of such conditions, child psychiatrists may not have an opportunity to screen young children for mental health disorders as parents usually do not use the service of these specialists when their children are very young.
Although pediatricians usually screen older children for symptoms of ADHD, parents usually report that pediatricians rarely assess, treat, and refer preschool children for symptoms of mental health disorders. There is evidence that the prevalence of preschool children with ADHD is 2 to 8% (Egger & Angold, 2006).
Longitudinal studies have indicated that when children are not diagnosed and correctly treated with ADHD, they may develop more impairments and comorbid disorders in adolescence and adulthood (Barkley, 2015). Pediatricians are the first professionals who are able to diagnose children with ADHD and comorbid conditions in early childhood.
Why is it important to diagnose children who are showing significant impairments and symptoms of ADHD at such an early age? Because early diagnosis and intervention may lead to more effective, successful and hopefully, shorter treatment. In addition, the brain’s ability to change in response to experiences is much higher in early childhood (Center on the Developing Child, Harvard University).
1. Preschoolers need to be fully assessed for many areas of functioning, such as emotional, social, cognitive, speech and language, and behavior. It is also important to conduct a behavioral assessment to learn about the environment the child lives in, and to develop a contingency program for a preschooler along with parent education/treatment.
2. Helping parents understand ADHD as an impairing condition and guiding them in developing behavioral strategies and contingency plans that actually may work well for children with symptoms of ADHD may prevent the development of more serious symptoms and impairments even before children enter formal education.
3. It is important to conduct a full assessment with a detailed developmental history, family history, and by using multi-informants and multi-methods to assess ADHD and comorbid conditions in preschool age children. It is recommended to obtain information through questionnaires, such as the Conners parent and teacher rating scales (Conners,2001), or the Child Behavior Checklist (Achenbach & Edelbrock, 1991). It is also important to conduct clinical observations of preschool children at school and in other settings (Luby, J.L., 2017).
4. Empirically-based treatments for ADHD in young children include behavioral and parenting treatment, such as Parent Child Interaction Therapy (Eyberg & Funderburk,
2011), Behavior parent training adapted to preschool population (BPT), and Community Parent Education (COPE).
5. There has been some research to study the contribution of medication in addition to parent-child and parenting interventions (and education), such as the Preschool ADHD Treatment Study (PATS), and the long-term PATS follow-up study. The PATS focused on the effect of one type of medication only (MPH). More recent studies have been completed for this age population. Most studies strongly suggest that one should consider behavioral treatments for preschoolers with ADHD as well as the protocols discussed above before including medication for preschoolers due to the strong side effects of medications for this age population.
6. “The apple does not fall far from the tree”: ADHD is highly genetic, and for this reason, it is important for pediatricians and others working with families with children with ADHD to assess whether parents also show symptoms of ADHD in order to help parents with the same diagnosis so that they can follow through with treatment recommendations for their own children.
7. Thus, it is necessary to provide education to the public in general and to other health care providers (especially pediatricians) about the advantages of diagnosing and treating children with ADHD early in life to help prevent the development of more severe and impairing comorbid conditions.
References:
Achenbach, T.M. & Edelbrock, C.S. (1991). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: University Associates in Psychiatry.
Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th Edition). New York: Guilford Press.
Center for the Developing Child at Harvard University. https://developingchild.harvard.edu/
Conners, C.K. (2001). Conners’ Rating Scales- Revised: Instruments for use with children and adolescents. North Towanda, NY: Multi-Health Systems.
Egger, H.L. & Angold, A. (2006). Common behavioral and emotional disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47, 313-337.
Eyberg, S.M. & Funderburk, B. (2011). Parent-child interaction therapy protocol. Gainesville, FL: PCIT International.
Luby, J., editor (2017). Handbook of Preschool Mental Health: Development, Disorders, and Treatment. Second edition, New York: The Guilford Press.
Oct 9, 2018 | Research Updates
Thomas E. Brown, Ph.D. Keck School of Medicine of University of Southern California
Despite the many differences among children and adults with ADHD, there is one similarity shared by virtually all of them. Although they have considerable chronic difficulty in getting organized and getting started on many tasks, in focusing their attention, sustaining their efforts, and utilizing their short-term working memory, all of those diagnosed with ADHD tend to have at least a few specific activities or tasks for which they have no difficulty in exercising these very same functions quite well.
Many children with ADHD who struggle painfully to focus on their schoolwork and daily chores are able effortlessly to focus very well for playing a favorite sport or video games. Many college students with ADHD earn top grades in one or two courses for which they have strong interest due to the content or the skills and charisma of the professor, yet they fail out of college because they are unable to sustain their attention and effort for many other courses required for their curriculum. Many adults with ADHD are not promoted at work or repeatedly lose their jobs not because they do not do many aspects of their job quite well or very skillfully, but because they are consistently unable to awaken themselves to get to work on time or because they are excessively forgetful about attending to important assignments or fail to hand in required reports accurately done before established deadlines.
Many of all ages with ADHD demonstrate amazing ability to recall all the details of the storyline of a movie seen years earlier, or words and music of countless songs they once heard, or random details of long ago incidents they observed, yet they are often incapable of recalling what they have read or have heard just a few minutes ago. All those with ADHD tend to have a few tasks or situations where they demonstrate impressive or, at least, quite adequate competence in exercising various cognitive management skills that they are unable to exercise with consistency in most other activities of daily life, even though they see the importance of doing those tasks and very much want to perform them successfully.
Symptoms of ADHD are chronic, but in each person they appear with notable exceptions, usually in situations where the person has strong personal interest in that particular task or activity, or when they believe that something very unpleasant for them is likely to occur very quickly if they do not attend to this specific activity right here, right now. Clinical observations and empirical research have consistently demonstrated that ADHD symptoms are situationally variable, that there is much intra-individual variability in the symptoms of this disorder. This is the central mystery of ADHD.
A classic example of this puzzling paradox of ADHD is Larry, a sturdy, sandy-haired high school junior who was the goalie for his school’s ice hockey team. It happened that the day before his evaluation, Larry had helped his team win the state championship in hockey by blocking many shots on goal. He was an extraordinarily fine goalie and he was also a very bright student who scored in the very superior range on IQ tests. He wanted to get good grades because he was hoping eventually to go to medical school. Yet he was chronically in trouble with his teachers. Often they said to him, “Once in a while you make very perceptive comments in class that show how smart you are, but most of the time you’re out to lunch—looking out the window or staring at the ceiling. Occasionally you turn in a really good homework paper, but most of the time you don’t even know what the homework is supposed to be.” The teachers kept asking Larry, “If you can pay attention so well when you’re playing hockey, why can’t you pay attention when you are in class? If you can work so hard to practice and stay in shape for hockey, why can’t you show some consistent effort for your schoolwork?”
After hearing his parents tell me about these recurrent complaints from his teachers, Larry quietly responded, “I don’t know why this keeps happening. I’m just as frustrated and even more worried about this than you are…I know what I need to do and I really want to do it because I know how important it is for all the rest of my life…I know I should be able to do it; I just can’t! I just can’t make myself pay steady attention to my work for school anywhere near the way I pay attention for hockey.”
This inconsistency in motivation and performance is the most puzzling aspect of ADHD. It appears that the child or adult with ADHD who can show strong motivation and focus very well for some tasks should be able to do the same for most other tasks that they recognize as important. It appears that this is a simple problem of lacking “willpower.” If you can do it for this, why can’t you do the same for that and that which are even more important? Yet ADHD is not a matter of “willpower.” It is problem with the dynamics of the chemistry of the brain.
One of my patients once told me, “I’ve got a sexual example for you to show what it’s like to have ADHD. It’s like having erectile dysfunction of the mind. If the task you are faced with is something that turns you on, something that is really interesting for you, you’re “up for it” and you can perform. But if the task is not something that’s intrinsically interesting to you, if it doesn’t turn you on, you can’t get up for it and you can’t perform. It doesn’t matter how much you tell yourself, “I need to, I ought to. It’s just not a willpower kind of thing! (Brown, 2005)”
Recent research offers considerable evidence that ADHD is not a “willpower thing,” even though, in many ways, it appears to be a simple lack of willpower. The missing piece for most people trying to understand this is the fact that when a person is faced with a task that is really interesting to him or her, not because someone told them that it ought to be interesting, but just because it is interesting—either because to them at that moment it appears to offer appealing pleasure or seems to warn of some imminent unpleasantness that they want to avoid, that perception, conscious or unconscious, changes the chemistry of the brain instantly. But this process is not under voluntary control.
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Brown, T.E. Outside the Box: Rethinking ADD/ADHD in Children and Adults—A Practical Guide
American Psychiatric Publishing, 2017.
Sep 28, 2018 | Research Updates
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
(A blog from the Psychosocial Sub-Committee of APSARD)
Medications approved for the treatment of ADHD are required to list documented side effects. Some of these may be relatively mild and well-tolerated and are far outweighed by the benefits of the medication for symptom reduction and overall well-being. On the other hand, for some individuals these side effects may be significant or, in some cases, intolerable and require discontinuation of a medication.
The prospect of side effects in some common non-medical, psychosocial treatments for teen and adult ADHD, such as family behavior management training, cognitive-behavioral therapy, ADHD coaching, and mindfulness-based treatments does not immediately jump to mind as an issue when recommending them. However, a special edition of The ADHD Report was devoted to this very topic. The link below provides access to the website for this issue and the articles, as of the date of submission of this blog, are listed as open access.
https://guilfordjournals.com/toc/adhd/26/2
