The ADHD Brain

Painting of a human brain with rainbow colors and artistic paint spatter.

Attention Deficit Hyperactivity Disorder (ADHD) is a condition that is hard to understand and can have a lot of ups and downs. I like to call it consistently inconsistent. Many people don't know if they have the condition or not because the diagnostic criteria is so vague. Doctors have to go through a long list of symptoms and check them off. The Diagnostic and Statistical Manual of Mental Disorders (DSM) has 18 criteria, while some lists of symptoms include up to 100 traits.

But what is it that makes ADHD brains so different and hard to diagnose?

One factor that largely contributes to the difficulties diagnosing ADHD is that it frequently occurs with at least 1 comorbidity such as depression, anxiety, or dyslexia. This is sometimes referred to as Complex ADHD.

ADHD is linked to unusually low levels of dopamine and norepinephrine, neurotransmitters that transfer between the prefrontal cortex and the basal ganglia. Dopamine interacts with other powerful neurotransmitters to regulate mood and is tightly linked to reward areas in the brain. As a result of the low dopamine levels, the person seeks the reward feeling in other ways.

These differences in the ADHD brain can cause a number of neurodevelopmental symptoms.

These include:

Poor Working Memory

Sensory Overload

Emotional Dysregulation

Problems Prioritizing

Impulsiveness

These symptoms help to form the criteria used in the Diagnostic and Statistical Manual of Mental Disorders (DSM - 5) to Diagnose ADHD. Not all of these symptoms are used in the criteria however. Some of the symptoms such as Emotional Dysregulation have been difficult for scientists to quantify and therefore we haven't been able to get accurate studies done for them.

You can read about the DSM criteria for an ADHD Diagnosis here.

Criteria not listed in the DSM-5 that can be a key indicator of ADHD are:

Emotional Dysregulation: Often unable to regulate emotion. This can cause disproportionate emotional responses to events or stimuli such as becoming overly happy and excited over something you see or hear. Another example could be becoming easily frustrated or even explosively angry at someone because they said something with the wrong tone in their voice.

Hyper-focus: This one isn't directly in the DSM-5 but one of the criteria IS often caused by hyper-focus "Often does not seem to listen when spoken to directly." Hyper-focus happens when an ADHD brain hones in on something that is interesting or exciting. When this happens the brain will focus on this one singular thing so heavily that the rest of the world will seem to melt away and not exist. Think of being "in the zone" times 100. It can be so intensely focused that it may seem like the person is not listening when spoken to.

Sensory Sensitivity: Although sensory overload can impact anyone, it is most common in those with ADHD or other sensory or neurodevelopmental disorders, particularly children. Sensory overload occurs when something, usually an environmental factor, overstimulates one or more of the five senses.

Do you think you might have ADHD?

If you suspect that you have adult ADHD, it's important to seek medical advice to confirm the diagnosis. Contrary to popular belief, ADHD in adults does not always involve hyperactivity. Research on this topic has been conducted extensively over the years and includes data from sources such as the University of Massachusetts Medical School, Massachusetts General Hospital, and more than 100,000 scientific articles and books.

One of the challenges of ADHD is that individuals may not fully recognize the impact of their symptoms until their late twenties or early thirties. It's important to remember that ADHD is not a straightforward diagnosis, but rather a complex condition that can affect people in different ways. A helpful way to conceptualize ADHD is to think of it as a dimension, like a person's height or intelligence, where individuals fall at different points. Despite the challenges associated with ADHD, seeking appropriate treatment can help individuals manage their symptoms and improve their quality of life.

Typical adolescent and adult impairments:

Poor functioning at work
Frequent job changes
Risky sexual behavior/increased teen pregnancy and sexually transmitted diseases
Difficulties managing anger and frustration in intimate relationships
Unsafe driving (speeding, frequent accidents, numerous parking violations, possible license suspension)
Difficulties managing finances (impulsive spending, excessive use of credit cards, poor debt repayment, little or no savings, and so on)
Problems in dating or marital relationships (don’t seem to listen to or appreciate the needs of your partner, talk excessively and interrupt, fail to follow through on promises and commitments)
Prone to excessive use of substances such as tobacco, alcohol, or marijuana
Difficulty getting to sleep at a reasonable hour (insomnia), frequent night waking and restlessness, inefficient sleep leading to daytime tiredness

Less common but notable:

Antisocial activities (lying, stealing, fighting) that lead to frequent police contact, arrests, and even jail time; often associated with a greater risk for illegal drug use and abuse
Generally less healthy lifestyle (less exercise; more sedentary self-entertainment, such as video games, TV, surfing the Internet; greater use of social media; obesity, binge eating or bulimia, poorer nutrition; greater use of nicotine and alcohol); consequently increased risk for later coronary heart disease

Can you handle the problem on your own?

While it can be a relief to identify ADHD as a potential explanation for the difficulties you've faced, it's important to seek professional help for diagnosis and treatment. There are several compelling reasons for doing so:

To rule out other conditions that may be causing your symptoms
To determine whether you have additional conditions in addition to ADHD
To access medication that has been shown to be effective in managing ADHD symptoms
To receive psychological therapies that can help improve self-control
To identify areas of strength and weakness for targeted coping efforts
To obtain an evaluation that can be used to obtain accommodations under the Americans with Disabilities Act in educational or workplace settings
To access resources for improving overall health and wellness, such as weight loss support, smoking cessation programs, or sleep improvement techniques.

Many adults with ADHD also have other psychological disorders, including anxiety disorders, oppositional defiant disorder, learning disabilities, depression, bipolar disorder, addiction, and tic disorders.

Medications for ADHD have been shown to be highly effective, with studies indicating that they can normalize behavior in 50-65% of those with ADHD and substantially improve behavior in an additional 20-30%. Seeking professional help can provide you with access to the most effective treatments and resources to help you manage your symptoms and improve your overall quality of life.

Where can you go to get help?

To determine if you might have ADHD, a doctor who knows you well can use screening questionnaires. If you're looking for a professional who is experienced with ADHD, there are several options available.

First, you can call your primary care provider and ask for a referral to a specialist in your area. You can also check with your state psychiatric or psychological association, which usually keep lists of professionals organized by specialty.

Major nonprofit organizations such as CHADD and ADDA may have support groups or chapters in your area that can recommend adult ADHD clinical experts. You can also contact the psychiatry department at a local university or hospital, or the psychology clinic at a local university, to see if they have any practitioners who specialize in adult ADHD evaluations.

Additionally, you can search for psychiatrists and psychologists specializing in adult ADHD online or through directories provided by CHADD and ADDitude Magazine. If you know someone who is being treated for adult ADHD, you can ask for a referral to their practitioner. Websites for CHADD and ADDA can provide additional resources and information.

Questions to Ask before You Make an Appointment

What percentage of the doctor’s practice is made up of people with ADHD (as opposed to other disorders)?
If the practitioner sees both adults and children, what percentage are adults?
How long has the doctor been treating adults with ADHD?
What is the practitioner’s area of specialization in medicine or psychology? Fields that cover ADHD and related psychiatric disorders include psychiatry, clinical psychology, neuropsychology, and neurology (especially behavioral).
Is the practitioner board certified in this area of specialization? Board certification is a higher level of certification than a state license to practice medicine or psychology.
How long will it take to get an appointment? (This may be significant to you if you have a number of professionals to choose from and would like to be seen as soon as possible.)
Does the doctor treat people after diagnosing them? If not, where are patients referred for treatment?
Are other potential resources available nearby? Most mental health practitioners will not have coaching, skills training, support groups, and the like on site, but psychologists in private practice often rent space in office parks where related professionals work, and they all refer patients to each other.
How does the doctor charge, and what insurance plans does he or she accept?

What is needed for an ADHD evaluation?

To conduct a comprehensive ADHD evaluation, the following components are typically included:

Collection of rating scales and referral information prior to or during the evaluation.
An interview with the individual being evaluated.
Review of previous records that may document any impairments.
Psychological testing to rule out general cognitive delay or learning disabilities.
Interviews with individuals who know the individual well to corroborate their reports.
A general medical examination if medication may be part of the treatment or if there are any coexisting medical conditions that need to be evaluated.

To facilitate these steps, individuals should bring any relevant records from schools, physicians, mental health professionals, driving or criminal records, and any other documentation of problems that could be related to ADHD or another disorder. They should also provide the names of a few people who know them well and whom they trust to speak honestly and objectively with the evaluators. Results of a medical exam from a physician and a list of family members with mental disorders should also be shared. Additionally, a description of impairments during childhood and adolescence, as well as recent ones, should be provided.

The initial evaluation appointment can take several hours, so individuals should be prepared for this.

The evaluation may include a brief test of general cognitive ability to rule out limitations in intellectual or learning abilities that may contribute to ADHD-like symptoms. Tests involving reading, math, and spelling may also be given, especially in educational settings. Individuals with ADHD are more likely than others to have specific learning disabilities, and it’s important to know if this is the case. Tests of attention, inhibition, and memory may also be given, but not all psychologists use these tests, and they are not always accurate for diagnosing ADHD.

What Will the ADHD Evaluation Tell You?

The evaluation will provide a comprehensive assessment of your symptoms and overall functioning. The findings from all the information gathered will be discussed, and you will receive an opinion about whether you have ADHD or any other related problems. Additionally, a set of recommendations will be provided on what to do about your ADHD and any other problems uncovered.

To be diagnosed with ADHD, the professional conducting the evaluation must determine that you have high levels of inattention and/or hyperactive and impulsive behavior. These symptoms must occur far more often than in other adults your age and have had adverse consequences for you in many different domains in both childhood and adulthood. Your symptoms must have been present in their current form for at least 6 months and have developed before you were 12-16 years old.

While the DSM criteria for diagnosing ADHD require at least five symptoms from either the inattention or hyperactivity-impulsivity symptom list, many individuals can have ADHD symptoms without having all five symptoms. Recent research has shown that having four symptoms from either list may indicate ADHD to a degree inappropriate for an adult. It's worth noting that these criteria were originally designed to diagnose children, not adults.

Some common ADHD symptoms in adults include a short attention span or lack of persistence on tasks, which can make it challenging to complete tedious or drawn-out activities. Examples of these symptoms may include getting easily bored during repetitive tasks, shifting from one uncompleted activity to another, losing concentration during long tasks, or struggling to submit reports on time without being reminded by your boss.