What is ADHD?

Students diagnosed with Attention Deficit Hyperactivity Disorder and a professor of psychology discuss the basics of the disorder and debunk some common misconceptions.

News reports and anecdotal evidence suggests diagnoses of Attention Deficit Hyperactivity Disorder are increasingly prevalent in both children and adults. Is this trend because of an increase in cases or just an increase in the effectiveness of diagnoses? And what’s the difference?

“ADHD is not a problem of knowing what to do, but doing what you know,” said Liz O’Laughlin, professor of psychology at Indiana State University, who studies the disorder.

O’Laughlin was drawn to psychology largely because of its practicality — “being able to understand, share and participate in collecting information that can have a practical significance in helping people to lead happier, healthier lives.”

As a researcher, she strives to clarify and contribute to that pool of information, share it with others who are practicing and close the gap between research and practice, a gulf that exists in many areas.

“You have very well-structured studies of therapy interventions of — my area is children — and they find good results but that doesn’t necessarily translate really well into the real world,” said O’Laughlin. “You have kids who have more than one diagnosis who don’t engage in the planned therapy interventions, so I think as a clinical psychologist in particular, addressing that gap between what we know to be a fact and what’s actually happening out in the field is also something that feels like kind of an obligation.”

ADHD is a chronic disorder of self-regulation and self-control with the primary symptoms of impulsivity, hyperactivity and inattention, as indicated in the name, said O’Laughlin. However, not all individuals with ADHD feature all of these characteristics at once, falling into one of three categories. Individuals with Predominately Hyperactive-Impulsive Presentation (ADHD with hyperactive type) may display as predominantly hyperactive or impulsive. ADHD with hyperactive type is usually a diagnosis limited to young children who are not yet old enough for situations that demand a high level of attention, who eventually grow into a Combined Presentation — the most common — where they display signs of impulsivity, hyperactivity and inattention. A third subtype (formerly referred to as ADD until subtypes were established in the diagnostic and statistical manual for psychologists) is ADHD with inattentive type or Predominantly Inattentive Presentation, where the individual does not experience hyperactivity.

This distinction is important to student Victoria McSwain, a freshman language pathology major from Lafayette who prefers the term ADD because of her lack of hyperactive symptoms and would even correct her family doctor. McSwain was diagnosed in the first grade and said she has the most severe case she has ever encountered in another person.

Clues to her condition started when she would complete her homework but routinely forget to take it to school with her.

“(They were) just like, ‘You did it, so why didn’t you turn it in?’ and I’d say, ‘I just forgot!’ I just couldn’t pay attention. When my mom told me to do something — like she said, ‘Do this, this and this,’ and I’d say okay … and then I’d go do one thing and forget all the rest.” Consistent forgetfulness and inattention that was more aggressive than normal in other children McSwain’s age led her parents to seek advice.

“I found out later that sometimes when (a teacher) asked me a question, I would completely zone out and not even know it,” said McSwain. “I would just go to this ‘white place,’ and I would think about absolutely nothing. He would call my name, and I would just sit there and (the class was) really confused. I felt like I was paying attention, but I wasn’t.”

Senior Kristina Nuñez, a psychology major from Hinsdale, Ill., was not diagnosed with ADHD until last summer.

“Once I came to college, school was more difficult for me than it was before, and I noticed those struggles — and my brothers have ADHD, and they were diagnosed when they were very, very young,” she said. “And so when I talked to my parents about the academic struggles I had, they suggested that I would go see a psychologist, because it’s genetic and my brothers had it, so they wanted to make sure.”

Nuñez underwent a year of various tests until doctors were able to determine she had ADHD.

“I kind of felt relieved when I figured out what was going on with me,” Nuñez said. It put her struggle into context and gave her a plan to combat challenges.

Like McSwain, she also has inattentive-type and experiences no hyperactivity, but she rates her ADHD as upper-mild. The change in environment — less restraint and greater workload — from high school to college was enough to aggravate the symptoms of her disorder.

Situational factors can have an enormous impact on the presentation of ADHD symptoms, O’Laughlin said.

“Executive functioning deficits — the foundation of ADHD — is clearly on a continuum,” said O’Laughlin. But what are these functions, and what are the ends of the spectrum?

O’Laughlin offered an example.

“We have eight-10 students in our graduate cohort, and inevitably there is one student who always knows when the deadlines are, when the next exam is, when the next paper is — they’re just always on top of it,” she said. “That’s somebody who’s clearly on the upper end of having high executive-functioning skills. They might not even need to write it down, they just keep track in their head. Then there are people on the low end (of executive-functioning skills) who lose their keys a lot or lock their keys in the car and just — are a little more scattered.”

Every day, McSwain struggles with self-direction and staying on task without strict scheduling and reinforcement. “Sometimes when I’m driving and I don’t think about where I’m going to go next and lock it in my brain, like ‘I’m going to the store and this is how I’m going to get there and memorize it in my head — I’ll go home because it’s a pattern. Or like, if I don’t make out a schedule of my day, then I will feel very confused, like ‘What do I do next?’”

Outside of medication, scheduling is McSwain’s most valuable treatment tool — and on days when she foregoes medication because it’s expensive, she must make greater use of lists and organization.

“I know my learning is definitely a lot slower than the average person,” Nuñez said. She carefully organizes her schedule and gives herself wide blocks of time to complete assignments, incorporating breaks between assignments to relax and regain focus.

Other disorders or problems contributing to executive functioning deficits include depression and anxiety — two of the most common co-morbid disorders (comorbidities) for people suffering with ADHD. A comorbidity refers to two or more chronic diseases that occur in someone at the same time, and individuals with ADHD have a 60-75 percent chance of experiencing an additional chronic disorder. In O’Laughlin’s experience as a clinical psychologist, early treatment can also lessen the severity of ADHD and keep comorbidities at bay.

“Typically, our kids will have more than one diagnosis,” she said. “So if we see a 5 or 6-year-old who is given services right away who just has ADHD, that to me is kind of lower on the level of impairment than those we’re seeing at a 9 or 10 who already have these other things going on. So it is true catching it earlier rather than later is helpful.”

Situational factors like stress can also emulate or aggravate symptoms of ADHD. Individuals may be on the upper end of executive-functioning skills but may find themselves making uncharacteristic mistakes, such as losing one’s car keys, when stress takes hold. Learning disabilities can affect social skills and executive-functioning skills in children. In adults, substance abuse, antisocial personality and other things may also look like ADHD.

O’Laughlin says individuals with ADHD will generally have problems later in the day rather than earlier in the day, especially the school day and during low-stimulation activities, such as listening to a lecture. Symptoms also seem to come out in situations that require restraint, where immediate reinforcement cannot be given — and in children, environments lacking close adult supervision, such as on the playground or in the lunchroom — can suddenly bring out symptoms of ADHD.

“So it’s not that kids or adults are constantly hyperactive or constantly inattentive — you see fluctuations in different settings and different circumstances, and that’s again where you see very different perspectives from maybe a teacher versus a parent versus an after-school caregiver,” O’Laughlin said.

This means children don’t have to be found to act out in all situations to have ADHD — and rather than solely going off the observations of parents, teachers and caregivers, psychiatrists use norm-based behavior-related scales for diagnosis. Symptoms have to be inconsistent with developmental expectations and last longer than six months.

Almost everyone has heard ADHD is on the rise, but is this true? It depends on how your data is gathered.

“If you ask a parent, ‘Has your child ever been diagnosed with ADHD?’ you get very different data than if you look at medical records for kids that were diagnosed,” O’Laughlin said. “And there are two other categories — you have kids who were diagnosed by a physician who may have just talked to a parent for 10 minutes, then there were kids who were diagnosed based on an actual evaluation.”

O’Laughlin explains that while rates based on a standardized assessment don’t seem to have differed greatly over time, parent-reported statistics, mainly used by the Center for Disease Control, have risen from seven to 11 percent. A graph by the Center for Disease Control tracking ADHD diagnoses from 2000 to 2011-2012 showed the biggest increase is not with the youngest children, but the adolescents — more specifically, the 10-17 age group, “and that’s due to the fact that we’ve finally begun to recognize it (in teens and adults),” said O’Laughlin.

Another myth that bothers O’Laughlin is that ADHD is “a little kid disorder.”

“That’s where we have made big changes in helping people understand that because it’s a neurodevelopmental disorder, it doesn’t go away,” she said. “There’s been more awareness that teenagers may have undiagnosed ADHD as well as adults — much more so than in the past — so that’s where you’re seeing part of that increase.”

O’Laughlin also battles the age-old misconception that if a child can sit down to play video games or watch television, then they do not suffer from ADHD.

“It’s that reward condition. If you’re in a situation where you’re receiving constant reinforcement, you’re not going to see the symptoms,” O’Laughlin said. “And if the child is playing an active videogame, getting feedback every five seconds on performance, then it’s very stimulating.”

O’Laughlin acknowledges television is considered more “boring” than it was 20 years ago and many kids may not be able to sit through it, “but if it’s their favorite show and it’s kind of relaxing for them, you’re not going to see the symptoms.”

There is also a prevalent myth that allowing your child to take prescription medication for ADHD will cause them to be substance abusers.

“Teenagers and adults and even some older kids will abuse their prescriptions and share with friends and even sell them,” she said. “But in some ways, it’s the opposite. If you get a kid who doesn’t get any interventions for ADHD, they will be more likely to develop those problems into adulthood.”

One day, O’Laughlin found a Facebook post from a friend-of-a-friend that perpetuated a harmful and common idea: ADHD is made-up disorder manufactured by drug companies.

“ADHD is one of the most researched disorders out there, and there is a really strong body of research supporting the neurodevelopmental aspects of ADHD.”

O’Laughlin explains that heritability is 73 percent. If a twin has it, there is a 70 percent chance the other twin has ADHD. A first-degree family member with ADHD, such as a parent, will increase risk by two to four times. There is also research that shows differences with brain matter, slower maturation of neural networks and differences in genotypes. With genotype mapping, the latest research shows there are six genes that have some common markers that are much more common in ADHD.

“So we’re starting to see growing evidence of the biological factors that go along with ADHD, which argues against the idea that it’s not a disorder or that it’s a made-up disorder.”

O’Laughlin says diagnostic criteria for ADHD are behavioral, so although research shows it to be a neurodevelopment disorder, it is considered to be a behavioral disorder.

“If you can take 10 kids with ADHD and run them through the genetics and everything, and at least six or seven of them are going to show that genetic transmission,” she said. “You’re going to have at least two or three that don’t or that it’s just behavioral but they are still within a subtype of ADHD.”

It’s not all genetics — everything is nature-nurture. “You may have a vulnerability to ADHD and then you’re in a chaotic household, and you see the full expression,” she said. “Or the kid who has the vulnerability but you have the mother or father who keeps everything organized, and then you don’t see as much of it.”

There are things McSwain and Nuñez say they wish people knew about their lives with the disorder.

“I wish people knew how hard it is to focus and how hard it is to study with distractions,” McSwain said. “Most people who study are hanging out with their friends and they have a movie going, and I’m like, ‘I can’t do that, I have to watch the movie.’ If you try to talk to me during a movie, I will not hear a word you’re saying.”

Nuñez wishes people knew how much she appreciates people being patient with her. “I know sometimes I can lose focus or in class, it can take me longer to process things and I just can’t keep up sometimes,” she said. “You can tell sometimes when individuals lose patience (with us) … it’s not our fault, like we try so hard to keep up with everyone and things might be difficult and might take us a lot longer. If people would have more patience with us, it would just make our lives so much easier than it is.”

McSwain and Nuñez have found support in their friends and families. McSwain’s mother has a mild form of ADHD, so she was able to help her develop coping mechanisms.

Nuñez’s family already consisted of two brothers with ADHD, so they were experienced with the condition and ready to support her. She also calls Chi Omega sorority one of her biggest support systems. Her advisers meet with her regularly to see where she stands, and her psychology professors definitely understand. She thanks Student Services and Educational Support Coordinator Debbie Huckabee for their patience and support.

Nuñez says that although ADHD has caused her daily struggle, it has motivated her to succeed in spite of it.

“When people find out, they definitely view me differently. I’ve experienced both encouraging and discouraging feedback. I do enjoy the encouragement from people, but when I do feel discouraged, it’s very hard,” she said. “At one point, someone told me I wasn’t going to be able to get into grad school because I had ADHD, and I said that grad school wasn’t going to care that I had that disability. I ended up getting in, so it was a rewarding feeling to prove those people wrong. It’s definitely been a motivator for sure.”

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