Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder or ADHD is a neurodevelopmental condition that was previously separated into ADHD and Attention-Deficit Disorder (ADD). ADHD is now the umbrella term for 3 different conditions: Inattentive, Hyperactive/Impulsive, and Combined. ADHD occurs in about one in every twenty children with a third of children retaining their diagnosis into adulthood. You are more likely to have ADHD if you have a first-degree family member with ADHD, such as a parent or sibling. ADHD is diagnosed twice as often in males than in females. Males are more likely to have readily apparent hyperactivity symptoms whereas females tend to have inattentive symptoms. As a result, ADHD is more often missed in females.

For many individuals ADHD symptoms can be chronic and lifelong. Although more than 50% of individuals with ADHD are diagnosed in childhood and adolescence, many people are not formally diagnosed until adulthood. Symptoms of ADHD can present differently across the lifespan, with teens and adults showing fewer symptoms of hyperactivity than children.

Inattentive symptoms:

• Lack of attention to detail or tendency toward careless mistakes in school or at work.
• Difficulty sustaining attention during task completion.
• Tuning out when spoken to, even without external distraction.
• Failing to follow instructions or complete work or school assignments.
• Often having difficulty organizing tasks or activities (keeping belongings in order, disorganized work, poor time management, failing to meet deadlines).
• Avoiding, delaying or reluctance to engage in tasks requiring sustaining mental effort.
• Often losing or misplacing things.
• Frequently being distracted by inner thoughts or outside stimuli.
• Forgetfulness for day-to-day activities (house maintenance tasks, paying bills, keeping appointments).

Hyperactivity-impulsive symptoms:

• Often fidgeting with hands, feet, or having difficulty sitting still.
• Difficulty staying seated for longer periods of time in situations where this is socially expected.
• Feeling restless.
• Difficulty engaging quietly in activities.
• Often being “on the go” and feeling uncomfortable staying still for extended periods of time such as at restaurants or in meetings.
• Talking excessively.
• Interrupting others in conversation, blurting out the answer before the question is completed, finishing other people’s sentences.
• Difficulty with waiting, such as in line.
• Interrupting or intruding on others’ conversations, games, or activities, or using other people’s things without asking.

If you experience several of the above inattentive, hyperactivity-impulsive symptoms or a combination of both, and these symptoms are interfering with your functioning at school, work, and/ or in your social life, it is possible that you have ADHD. A formal assessment can help clarify whether a diagnosis of ADHD is appropriate.

Individuals can receive a diagnosis of ADHD from a mental health provider (e.g., psychologist or psychiatrist) or a primary care provider (e.g., family physician). However, it is important to note that diagnosis of ADHD can often be complicated in the presence of other medical, psychological, neurological, or circumstantial conditions, such as nutritional deficiencies, thyroid dysfunction, severe anemia, medication side effects, history of mood or anxiety disorder, history of concussion and other neurological conditions, or circumstances such as high stress or sleep deprivation.

In other words, difficulties with attention are not specific to ADHD and can occur for several reasons. Likewise, ADHD is frequently missed in people with psychiatric and neurological conditions as the related symptoms can mask those of ADHD. A comprehensive neuropsychological evaluation can provide a clearer understanding of relevant medical, neurological and psychiatric conditions, and whether they are contributing to or accounting for your attentional difficulties.

Moreover, neuropsychological evaluations include a detailed clinical interview of your personal history and current symptoms, review of medical documentation, diagnostic psychological evaluation, psychometric measures of psychological symptom severity, and objective psychometric testing of your attention and other cognitive abilities.

Neuropsychological assessment involves an examination of brain and behaviour. Your performance on a variety of paper-pencil and computer tests provides a cognitive profile and information about the integrity of your brain function. Cognitive testing can take several hours to complete depending on the reason for referral. For many conditions, objective cognitive tests are more sensitive in detecting brain dysfunction or changes than current neuroimaging methods. Thinking abilities tested can include attention, IQ and academic abilities, processing speed, learning and memory, language skills, visuoperceptual abilities, motor coordination, and executive functions, such as problem solving, planning, reasoning, impulse control, and working memory (the ability to hold and manipulate information in mind).

Psychological psychometric testing is also completed. All psychometric scores are compared to normative datasets. Normative datasets can control for the effects of age, education, gender, neurological or psychological conditions on test scores. In addition to cognitive and psychological testing, neuropsychological evaluations include a detailed clinical interview, diagnostic psychological evaluation, and review of medical, psychological and/ or neurological documentation. Interpretation of the comprehensive neuropsychological profile and formulation of diagnoses are informed by considering the interplay and impact of many variables.

Questions that can be answered by a neuropsychological evaluation, depending on the nature of the referral, can include the following:

• Diagnosis of neurological or neurodevelopmental disorders and their impact on cognitive function.
• Provision of clinical opinions and information to assist multidisciplinary care teams in reaching diagnoses of complex conditions or determining whether a medical intervention or medication was successful in improving cognition.
• Diagnosis of psychological conditions including their impact on cognitive function.
• Types of cognitive abilities impaired or preserved.
• Severity of cognitive difficulties.
• Factors likely contributing to or causing cognitive difficulties.
• Improvement or decline in cognitive functioning over time with repeat testing.
• Recommendations pertaining to treatment plans for neurological and/or psychological conditions.
• How to optimize cognitive functioning via intact cognitive abilities (cognitive rehabilitation).
• Recommendations pertaining to accommodations for work and academic settings.
• Whether cognitive changes are normal for age or indicative of a neurodegenerative process.
• Guidance on future planning and decision making in cases of neurodegenerative or brain injury conditions (dealing with finances, medication administration, meal preparation, and driving).
• Informing prognosis and/ or recovery in neurological and psychological conditions.

Neuropsychologists have advanced training in the administration and interpretation of psychometric tests, psychological and neurological diagnosis, neurocognitive and behavioural interventions, and psychotherapy.

An accurate diagnosis of ADHD is important to effectively treat the underlying cause of attentional symptoms. For instance, if your difficulties with attention are due to underlying anxiety, then taking prescription medication for ADHD will not improve your symptoms. Once a diagnosis is attained, the first line of treatment for ADHD is a medication which can be prescribed by primary care providers and psychiatrists. Education about the nature of ADHD, related conditions diagnosed, and their impact on your symptoms and difficulties can be helpful in creating an effective treatment plan specific to your needs.

The benefit of combined treatment for ADHD, medication and cognitive behavioural treatment is supported by research and widely recommended as it can lead to better functional improvement than one type of therapy alone. For instance, stimulant medication, the primary pharmacological approach to treating ADHD, cannot cover the whole day due to the need for medication breaks to address side effects such as insomnia and appetite suppression. Likewise, learning and implementing cognitive behavioural strategies may be challenging without sufficient ability to focus.

ADHD is also often accompanied by other conditions such as depression, anxiety, sleep problems, low self-esteem and substance and/or alcohol misuse, that if treated, can improve one’s overall well-being, productivity and functioning.

Cognitive behavioural treatment for ADHD can include cognitive, behavioural and psychological strategies including:

• Time and task management
• Prioritization
• Problem management and decision making
• Planning and organization
• Goal management
• Dealing with distractions
• Procrastination and avoidance
• Initiation and motivation
• Environmental modifications
• Coping with task-interfering thoughts and emotions

Psychological interventions or psychotherapy for conditions often associated with ADHD may include the following approaches:

• Acceptance and commitment therapy
• Mindfulness-based approaches
• Cognitive behavioural therapy (CBT)
• Assertiveness and healthy boundaries in personal and professional relationships.
• Other evidence-based approaches, as needed, to treat accompanying psychological conditions, facilitate navigation of academic and workplace issues, or integration of cognitive remediation and behavioural tools (see above).