Attention Deficit Hyperactivity Disorder (ADHD)

Causes

• Genetics: ADHD is highly heritable, meaning it often runs in families. Several genes linked to dopamine and other neurotransmitters in the brain are thought to play a role.
• Brain Structure and Function: Studies show differences in brain structure, activity, and connectivity in people with ADHD, particularly in areas controlling attention, impulse control, and executive functions (e.g., planning, organizing). Neurotransmitters like dopamine and norepinephrine are often involved.
• Environmental Factors:
  • Prenatal exposure: Exposure to certain toxins during pregnancy (e.g., alcohol, nicotine, lead) or maternal infections.
  • Premature birth or low birth weight: These factors increase the risk of ADHD.
  • Early childhood trauma: Severe trauma in early childhood may be a contributing factor.
• Brain Injury: In rare cases, severe head injuries during development can cause ADHD-like symptoms.
• It's important to note: Poor parenting, excessive sugar intake, or too much screen time are not considered direct causes of ADHD, although they can influence symptom severity or management.

Symptoms

• Inattention:
  • Difficulty sustaining attention in tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Does not follow through on instructions and fails to complete tasks (e.g., homework, chores).
  • Difficulty organizing tasks and activities.
  • Avoids or dislikes tasks that require sustained mental effort.
  • Loses things necessary for tasks or activities.
  • Easily distracted by extraneous stimuli.
  • Forgetful in daily activities.
• Hyperactivity and Impulsivity:
  • Fidgets with hands or feet or squirms in seat.
  • Leaves seat in situations when remaining seated is expected.
  • Runs about or climbs in situations where it is inappropriate.
  • Unable to play or engage in leisure activities quietly.
  • Is often "on the go" or acts as if "driven by a motor."
  • Talks excessively.
  • Blurts out answers before questions have been completed.
  • Difficulty waiting their turn.
  • Interrupts or intrudes on others.

Diagnosis

• Detailed interview: Gathering information about symptoms from the individual (if old enough), parents, teachers, and other caregivers. This includes a review of developmental history.
• Symptom checklists and rating scales: Standardized scales (e.g., Vanderbilt, Conners) are used to assess symptoms across different settings.
• Ruling out other conditions: A physical exam and blood tests may be done to rule out other medical conditions (e.g., thyroid problems, vision/hearing issues, sleep disorders, other mental health conditions like anxiety or depression) that can mimic ADHD symptoms.
• Psychological testing: May be used to assess cognitive function, learning disabilities, or other co-occurring conditions.
• Diagnostic criteria: Symptoms must meet specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Treatment

• Medication:
  • Stimulants: (e.g., methylphenidate, amphetamines) are the most commonly prescribed medications. They help balance levels of brain neurotransmitters and are highly effective for many individuals.
  • Non-stimulants: (e.g., atomoxetine, guanfacine, clonidine) offer an alternative for those who can't take stimulants or experience significant side effects. They work differently and may take longer to show effects.
• Behavioral Therapy:
  • For children: Parent training in behavior management is highly effective, teaching parents strategies to reinforce positive behaviors and manage challenging ones.
  • For adolescents and adults: Cognitive Behavioral Therapy (CBT) can help improve organizational skills, time management, impulse control, and coping strategies.
• Lifestyle Management:
  • Structured routines: Consistent schedules for waking, sleeping, meals, and tasks.
  • Healthy diet and regular exercise: Can improve focus and reduce restlessness.
  • Adequate sleep: Crucial for managing symptoms.
  • Mindfulness and relaxation techniques: To help with focus and reduce stress.
  • Support groups: For individuals and families.
• Educational and Workplace Accommodations: Strategies like preferential seating, extended time on tests, or a quiet workspace can be beneficial.

Adult ADHD: Getting Treatment Right

ADHD in adults is diagnosed more often than it used to be and treated less consistently, partly because the medications are controlled substances and partly because the conditions that mimic it are common.

Stimulants, and the rules that come with them

Methylphenidate, amphetamine-dextroamphetamine, and lisdexamfetamine help most adults with ADHD within days, and the dose is adjusted at short intervals until it works through the afternoon without ruining sleep or appetite. As Schedule II drugs they carry no refills, each prescription is written separately, and Florida's prescription monitoring database is checked before it is issued; a controlled-substance agreement and periodic in-person visits are routine, not a sign of suspicion. Supply shortages have been frequent, so ask about an equivalent product before you run out rather than after.

Non-stimulants for those who cannot or should not

Atomoxetine and viloxazine take four to six weeks to work, are not controlled substances, and are often preferred when anxiety, tics, or a history of substance misuse complicates the picture. Guanfacine ER and clonidine ER help impulsivity and sleep, particularly alongside a stimulant, and suit people with uncontrolled high blood pressure or a heart rhythm problem.

Heart, sleep, and the numbers that are checked

Stimulants raise blood pressure and heart rate modestly, so both are measured before starting and at each visit, and chest pain, fainting, or sudden death in a young relative prompts an ECG before the first dose. Insomnia is usually a timing problem fixed by taking the dose earlier or choosing a shorter-acting form, while untreated sleep apnea or insomnia produces inattention that no stimulant will fix.

What adult ADHD is confused with

Symptoms must have begun in childhood, even if nobody named them; inattention that started at 40 is more often anxiety, depression, poor sleep, hypothyroidism, or the strain of caregiving. Bipolar disorder is excluded before a stimulant is prescribed, because stimulants can trigger mania. Our recognizing adult ADHD later in life article covers how the evaluation is done.

The parts medication does not do

Medication improves attention; it does not build the systems a disorganized life needs. Cognitive behavioral therapy adapted for ADHD, one external calendar that everything goes into, and a single place for keys and documents produce gains that persist when a dose wears off. Regular exercise and a consistent wake time are the two lifestyle measures with the best evidence. Our psychiatric team coordinates evaluation and prescribing. The National Institute of Mental Health and CHADD publish guidance for adults with ADHD.

If you suspect adult ADHD, or your treatment has lapsed because of shortages or prescribing rules, schedule a visit.