Understanding Attention Deficit Disorder (ADHD)

ADHD is an acronym that stands for Attention Deficit and/or Hyperactivity Disorder according to the DSM-V. Under this name are three recognized forms of the disorder. The first form mainly affects attentional abilities, the ability to stay focused on certain tasks for a long time. The second form affects psychomotor activity, which is higher than average, with frequent changes in activity and difficulty in standing still. The last form presents a combination of the first two forms, with attentional impairment and hyperactivity.

These forms are defined in relation to the most frequent symptoms, i.e. the signs that have a significant impact on the life and functioning of the individuals.

ADHD is a neurodevelopmental disorder, which means that clinical signs appear in childhood and may continue into adulthood. Sometimes, ADHD symptoms may be discreet in childhood due to a supportive environment, but may become more salient in adulthood when the individual is more challenged and stressors diminish the resources available to manage dysfunction.

For a growing number of researchers, ADHD is not actually an attention deficit, as ADHD individuals can be observed, in certain situations, maintaining intense and sustained attention for hours. Rather, it is a deficit in the regulation of attention and emotions, associated with a need for stimulation.

Like most neurodevelopmental disorders, the signs of ADHD fall into two categories: symptoms and specifics.

Symptoms are clinical signs that cause significant distress or dysfunction in cognitive functions or daily functioning. Specifics are other signs that are frequently found in people with the disorder, but which are not necessary for diagnosis. They can, however, help to ensure that the diagnosis is made correctly.

The symptoms are classified in diagnostic manuals. The DSM V defines ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development and is characterized by a number of the following signs.

Inattention

Six or more of the following symptoms :

• Fails to pay attention to details or makes careless mistakes
• Often has difficulty sustaining attention at work or at play
• Often does not seem to listen when spoken to personally
• Does not comply with instructions and fails to complete homework, household chores or work obligations
• Often has difficulty organizing work or activities
• Avoids, dislikes or reluctantly does tasks that require sustained mental effort.
• Often loses items needed for work or activities.
• Easily distracted by external stimuli.

Has frequent forgetfulness in daily life.

Hyperactivity and impulsivity

Six or more of the following symptoms :

• Often fidgets with hands or feet or squirms in seat
• Often gets up in class or in other situations where he/she is supposed to sit
• Runs or climbs around in situations where it is inappropriate (in adolescents and adults, this may be limited to feeling restless)
• Often has trouble keeping still in games or leisure activities.
• Is often "on the edge" or often acts as if he/she is "spring loaded".
• Often talks too much.
• Often lets slip the answer to a question that is not yet fully asked.
• Often has trouble waiting his turn.

Often interrupts others or imposes his presence.

Other signs are also frequently found in people diagnosed with ADHD. These include :

• Hyper-focus: when a person with ADHD begins a task that provides a high level of stimulation, it is possible to lose track of time and spend hours on the task, sometimes forgetting to eat or go to the bathroom. The task is often interrupted by an external source or body sensation strong enough to break concentration.
• Emotional sensitivity and/or instability: people diagnosed with ADHD have greater difficulty regulating their emotions internally, which can lead to a more intense or stressful perception of unpleasant emotions. The way their attention works can also lead to a rapid change in emotions depending on events and stimuli.
• Sleep disturbances are also common in people with ADHD, as difficulties in emotional and attentional regulation make it difficult to maintain a regular and healthy sleep pattern.
• Boredom Intolerance: Boredom is particularly difficult to manage for people with ADHD who have a higher need for stimulation. Boredom is a form of understimulation that can lead to high agitation, increased difficulty concentrating and directly influence mood and emotions.
• Poor working memory: remembering task lists, the different steps in a process, a name or a phone number can be particularly difficult for people with ADHD, who can quickly be overwhelmed by a large amount of information.
• Time blindness: This is a misperception of the passage of time and the time required to complete certain tasks, which can lead to regular delays, missed deadlines and difficulty in following a routine on time.
• Impaired object permanence: Object permanence means that an object continues to exist in a person's mind even if it is not in their field of vision. In people with ADHD, it is not as absent as in babies who completely forget the existence of a non-visible object, but it does make it more difficult to remember objects and people that do not have a regular presence in their lives.
• Executive dysfunction: executive functions are all the mental processes that enable the planning and execution of everyday actions. They include planning, flexibility, adaptation, inhibition and execution. In ADHD these abilities are impacted by a difficulty in filtering information from the environment correctly, a lower level of inhibition and poorer planning abilities. This makes it more difficult to perform common tasks, requiring a very high level of effort to complete simple tasks. Depending on the resources a person has, some tasks are mentally impossible to perform.

People with ADHD may exhibit functioning that seems strange or inconsistent to neurotypical people. For example, it is common for a person with ADHD to be stuck in boredom, so under-stimulated that it becomes too difficult to start a stimulating activity.
Sometimes an all-or-nothing mode on boring tasks can be observed. For example, doing a little bit of housework every day is very difficult, but embarking on a full-scale cleaning once a month because the person has felt a great rush of motivation and stimulation for those tasks at that particular time.

ADHD is a neurodevelopmental disorder, which means that it is caused by differences in the development of certain brain structures.

The first etiological hypothesis for the development of ADHD is genetic. Research shows that children born into a family where one or more members have been diagnosed with the disorder are more likely to be diagnosed with ADHD themselves.

Environmental factors also seem to increase the risk of developing the disorder: exposure to alcohol, lead, stress during pregnancy, premature birth, head trauma, abuse, etc…

Neurobiological and neuropsychological leads are increasingly explored, trying to identify the brain areas that would be responsible for ADHD. Some have been identified as slightly underdeveloped in people with the disorder, but these variations in volume are not sufficient to make a diagnosis on these values alone. In particular, the pre-frontal cortex is under-activated, which leads to a lack of inhibition.

The dopamine pathway is also being explored in relation to the need for stimulation. People with ADHD have lower levels of dopamine, the pleasure and reward hormone, than the general population, which leads to a higher search for stimulation and a higher intolerance to boredom.

The treatment of ADHD, especially when diagnosed early, is multidisciplinary and is based on the needs of the individual.

The avenues of work are threefold:

• Work on cognitive and functional abilities: this work is done with the help of psychologists, speech therapists, psychomotricians and occupational therapists. The objective is to train the failing cognitive functions and to find alternative strategies. The idea is to understand that the brain of a person with ADHD functions differently from that of a neurotypical person, and that it is therefore necessary to find a way of functioning that suits the person and his or her evolution in a social environment. The earlier the person is treated, the more effective cognitive remediation will be.
• Medication: some medical specialists (psychiatrist, pediatrician, neurologist, etc.) may prescribe, when the diagnosis of ADHD is confirmed, a treatment based on methylphenidate, which serves to stabilize the level of dopamine in the brain, thus improving alertness and concentration skills. It is a medication commonly used in the treatment of ADHD in North America and in some European countries, and is beginning to be used more widely in France. The main obstacle concerns people diagnosed as adults, as its delivery is based on the presence of signs of ADHD during childhood, which must be proven.
• Adaptation of the environment: as much as possible, an adaptation of the environment makes it easier for a person with ADHD to live, to save mental resources and to better focus on the elements of life that cannot be adapted. This adaptation also involves educating the people around the person, who will have to adapt their functioning and their demands to the needs and limitations of the person with ADHD.

ADHD remains a disorder that suffers from its bad reputation and misrepresentation. Children with a form centered on hyperactivity suffer the most socially from this poor knowledge of the disorder. Despite the difficulties that ADHD brings, it can also be a strength when people are properly accompanied.

It is necessary to improve the diagnosis process in order to avoid a maximum of late diagnoses, which increase life difficulties, but also to improve education about this disorder, especially among professionals of childhood and early childhood.