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Living with ADHD

Understanding and empowerment

BY Elizabeth Adams, PhD, LP, ABPP

An Overview

ADHD is a developmental condition. It has its origins before birth. It affects cognitive, behavioral, social and emotional functioning. The symptoms are seen during childhood and, in various forms, throughout the lifespan. Often, the earliest symptoms of ADHD are seen most clearly in retrospect when the more commonly recognized symptoms surface during school years.

ADHD has a neurobiological origin. In most cases, the origin of ADHD stems from one or a combination of the following: genetics, prenatal factors, birth conditions or early environmental factors. Most children with ADHD have at least one parent with the condition (diagnosed or undiagnosed).

ADHD brains are measurably different. The feeling and quick-acting part of the brain is toward the back in the very center and develops first (limbic system). The planning and thinking-about-consequences part of the brain in the prefrontal cortex develops slowly, still developing into the mid 20s. The fibers that facilitate connections within the brain determine the efficiency of communication between parts of the brain. ADHD brains show anatomical differences such as underdevelopment of the prefrontal cortex and/or structural differences in the fiber pathways. ADHD brains show neurochemical differences, such as lower levels of dopamine and norepinephrine, both of which are particularly relevant for the prefrontal cortex.

Children with ADHD grow into adults with ADHD.

Over the past two decades, neuroimaging research in ADHD has documented neuroanatomical differences in the brains of people with ADHD via various imaging modalities including structural MRI, functional MRI (fMRI), diffusion tensor imaging (DTI) and positron emission tomography (PET). Structural MRI studies have consistently identified volume reductions in the prefrontal cortex, basal ganglia and cerebellum, regions associated with attention and executive function. Functional MRI has revealed altered activation patterns in the default mode network and fronto-striatal circuits, which are crucial for attention regulation and impulse control. DTI has highlighted disruptions in white matter integrity, suggesting impaired connectivity between key brain regions. PET imaging has been used to explore neurotransmitter systems, particularly dopamine, providing insights into the neurochemical basis of ADHD. 

ADHD is a lifespan condition. Children with ADHD grow into adults with ADHD. It does not go away. For children, the executive function challenges associated with ADHD show up in multiple domains and, which is important, are not always obvious in the school setting. ADHD symptoms can show up at home, in social relationships in sports, in emotional regulation challenges, and in basic self-care routines. The symptoms often change in adulthood. Adults with ADHD are less likely to show motor hyperactivity and instead often experience impulsivity in cognitive functioning (quick decision making), emotional functioning (reacting quickly and intensely) and behavior (having trouble waiting, or interrupting others in conversation). Adults with ADHD often experience challenges in relationships, job changes, financial struggles, driving infractions, trouble following through on health maintenance, trouble with basic self care routines and other areas of life.

ADHD presents several challenges, including “time blindness,” where individuals struggle to focus on future tasks, making it hard to prepare and find motivation for tasks outside their immediate time window. This isn’t mere procrastination but a difficulty in maintaining future goals in mind. Additionally, those with ADHD often find it hard to resist distractions, feeling a strong pull away from tasks, especially nonpreferred ones. This difficulty is compounded by challenges in re-engaging with tasks once attention has been diverted, linked to working memory inefficiencies. These factors can make task completion feel daunting, requiring more effort than typical to overcome these obstacles. Individuals with ADHD can, however, develop strategies to manage these challenges effectively.

The main types of interventions that have been found to be effective for ADHD are:

• Medication
• Executive Function Coaching
• Therapy

Medications

When ADHD medications are working, the individual may experience:



• More control over one’s own attention, where it goes, how long it stays there
• An easier time getting started on tasks (big ones and small ones)
• A bit more tolerance for the boring but necessary things in life
• Enhancement of the “reward value” of nonpreferred tasks
• Improved working memory, ability to hold on to mental to-do lists
• Improved convergent attention, making it easier to focus on just one thing at a time

ADHD medications work by increasing the availability of dopamine and/or norepinephrine within the frontal lobe networks of the brain, the networks involved in executive functioning.

By decreasing the “noise” and increasing the “signal” within the frontal lobe network connections, ADHD medications can help to improve the “self-management” aspect of executive functioning, improving communication between the frontal lobe and the posterior aspects of the brain. Ritalin and Adderall are the two main stimulant medications. They both have the same end result, which is more dopamine in the synapse (space between two neurons). They have different mechanisms of action. Ritalin is a dopamine reuptake inhibitor, so it binds to the dopamine receptors on the receiving neuron, resulting in less dopamine leaving the synapse. Adderall is a dopamine agonist, so it results in increased production of dopamine, resulting in more dopamine going into the synapse.

Nonstimulant medications for ADHD typically result in higher norepinephrine levels, also an important neurochemical in the frontal lobe’s executive function networks. The primary nonstimulant medications include atomoxetine, guanfacine and clonidine. Atomoxetine, a selective norepinephrine reuptake inhibitor, works by increasing norepinephrine levels in the brain, which helps improve attention and reduce impulsivity and hyperactivity. Guanfacine and clonidine are alpha-2 adrenergic agonists that modulate the noradrenergic system, leading to enhanced attention and reduced hyperactivity and impulsivity. These medications are often considered for patients with coexisting conditions such as anxiety or tics, where stimulants might exacerbate symptoms. Nonstimulants generally have a slower onset of action compared to stimulants but can be effective in managing ADHD symptoms, offering a valuable alternative for comprehensive treatment plans.

Stimulant medications are usually the first-line approach to treatment of ADHD, for two reasons. They have a higher efficacy rate (about 75% likelihood of being effective) and they have a short half-life. They are effective within about an hour of taking them and then gone from the system about 10-12 hours later, which means it is easy to do a short trial of the medication, and make changes quickly if needed.

ADHD medications work by changing the chemistry of the brain, boosting dopamine levels so that the frontal lobe can be more effective. The neurochemical effects of the medications are temporary, but the beneficial behavioral and neuroanatomical effects of positive behavior change and habit formation can be longstanding.

In sum, the goal of using medication to help support persons living with ADHD is to help them be a more authentic version of themselves, to let the logistics of life be a little bit easier so that they can direct their energy to the things they love.

Coaching helps individuals develop self-awareness and adaptive strategies.

Prescribing ADHD medications, while often beneficial, comes with several potential downsides that warrant careful consideration. One significant concern is the risk of side effects, which can range from mild, such as appetite suppression and sleep disturbances, to more severe issues such as cardiovascular effects and potential impacts on growth in children. Additionally, stimulant medications, which are commonly prescribed, carry a risk of misuse and dependency, particularly in adolescents and young adults. There is also the potential for medications to mask underlying issues, such as anxiety or learning disorders, which may require different therapeutic approaches. Furthermore, the long-term effects of ADHD medications on brain development remain an area of ongoing research, raising questions about their impact over extended periods. Finally, reliance on medication alone may detract from the importance of a comprehensive treatment plan that includes behavioral interventions, psychoeducation, and environmental modifications, which are crucial for addressing the multifaceted nature of ADHD.

Executive Function Coaching

Executive function coaching is a personalized intervention designed to enhance the cognitive processes that govern goal-directed behavior, particularly in individuals with ADHD. This coaching focuses on strengthening skills such as planning, organization, time management and emotional regulation, which are often impaired in ADHD. The effectiveness of executive function coaching lies in its structured yet flexible approach, which tailors strategies to the individual’s unique cognitive profile and daily life challenges. By providing practical tools and consistent support, coaching helps individuals develop self-awareness and adaptive strategies, leading to improved academic, occupational and social outcomes. Furthermore, this intervention empowers individuals by fostering a sense of agency and self-efficacy, enabling them to navigate their environments more effectively and reduce the impact of ADHD symptoms on their daily functioning.

Therapy

Therapy is an effective treatment strategy for individuals with ADHD because it addresses both the cognitive and the emotional aspects of the disorder, facilitating comprehensive management of symptoms. Cognitive behavioral therapy (CBT) is particularly effective, as it helps individuals identify and modify negative thought patterns and behaviors, enhancing their ability to manage impulsivity and improve attention. Additionally, mindfulness-based interventions (MBIs) have shown promise in increasing self-awareness and emotional regulation, which are often challenging for those with ADHD. Behavioral therapy, often used with children, focuses on reinforcing positive behaviors and reducing disruptive ones through structured routines and reward systems. Family therapy can also be beneficial, as it educates family members about ADHD and fosters supportive home environments. These therapeutic modalities work synergistically to empower individuals with ADHD, helping them develop coping strategies, improve executive functioning and enhance their overall quality of life.

Nonmedication Techniques:

The following nonmedication techniques can be helpful for managing ADHD symptoms:

Mindfulness Consistent mindfulness practice has been found to be associated with improvements in working memory. The individual learns to remain present and focused on one thing (usually the breath) and to redirect their attention back to this thing when it inevitably strays. This process of redirecting the attention back is what builds the capacity for working memory and task persistence.

The Pomodoro Method When working on a lengthy task or project, break the time down into 25-minute segments, separated by scheduled/timed 5-minute breaks. This time ratio (both the length and consistency) is important for the success of this method. A relatively shorter break will provide the default-mode time necessary to refresh the attentional network, without the subsequent uphill battle of returning to task after a longer break.

Movement Breaks  Scheduled, frequent and brief throughout a nonpreferred task.

Martial arts and yoga can be especially helpful because of the breath awareness emphasis as well as the discipline and routine of movements.

Sports and other athletic endeavors and endurance sports help to practice body awareness, motor control, breath connection, attention and precision.

Hands-on activities such as visual arts, cooking, puzzles, coloring, to shift motoric and cognitive attention and have a tangible product.

A behavioral approach to ADHD, for children, adolescents and adults is among the most effective forms of management for ADHD and involves a system of positive reinforcement that is consistent, immediate, frequent and concrete.

ADHD in Women and Girls

ADHD is underdiagnosed in women and girls due to limitations in awareness of how the condition presents in females versus males. It is important to note that ADHD symptoms tend to present differently in girls and boys. The average age of ADHD diagnosis in boys is 7, whereas in girls and women, there is a bimodal distribution, with one peak in diagnosis at age 13 and a second peak in diagnosis around age 50. Girls are more likely to exhibit primarily inattentive symptoms, appearing passive, disorganized and daydreamy, rather than hyperactive and disruptive. They may feel pressure to conform to societal expectations, leading them to work excessively hard to hide their struggles, contributing to underdiagnosis. Additionally, girls and women with ADHD frequently experience coexisting internalizing disorders such as anxiety, depression and eating disorders, which can overshadow primary ADHD symptoms and further delay accurate diagnosis and treatment. Hormonal changes can exacerbate ADHD symptoms in females (often manifesting as emotional reactivity, poor frustration tolerance and mood swings), making the symptoms more apparent and severe during this phase of development.

Hormonal Variations

Hormone level fluctuations during the menstrual cycle can affect executive functioning. Estrogen and progesterone levels rise and fall throughout the menstrual cycle, influencing neurotransmitter systems such as dopamine and serotonin, which are critical for executive functions like attention, working memory and cognitive control. During the follicular phase, estrogen levels gradually increase. Higher estrogen levels are generally associated with improved cognitive performance and executive functioning. Women with ADHD may experience a temporary improvement in symptoms during this phase. After ovulation, during the luteal phase, progesterone levels rise and estrogen levels fluctuate. Progesterone can have a sedative effect and may counteract the benefits of estrogen, potentially worsening ADHD symptoms and impairing executive functions such as planning, organization, and impulse control. The effect of menstrual cycle-related hormone fluctuations on executive functioning can vary widely among women with ADHD. Factors such as individual sensitivity to hormonal changes, baseline ADHD severity and the presence of comorbid conditions can influence the extent of these effects. Awareness of these cyclical changes can help in managing ADHD symptoms. Strategies may include adjusting medication timing and dosage, implementing lifestyle changes and using cognitive-behavioral techniques to cope with periods of increased executive dysfunction.

For women with ADHD who are approaching or in menopause, Hormone replacement therapy (HRT) could be considered. In women who are approaching or in menopause, estrogen levels are significantly lower. HRT is used to stabilize hormonal levels, potentially reducing symptom variability associated with hormonal fluctuations. The efficacy of HRT in managing ADHD symptoms in women remains uncertain, however, as research on this specific population is limited. Before considering HRT for ADHD management, it’s essential for women to undergo a comprehensive evaluation by a health care provider specializing in ADHD and hormone therapy.

Conclusion

In conclusion, understanding ADHD from a neuropsychological perspective allows us to appreciate the complexity and individuality of each person’s experience with the condition. At Minnesota Neuropsychology, we are committed to empowering individuals with ADHD by providing them with a comprehensive understanding of their unique neurodiversity and equipping them with a diverse array of tools and strategies. By embracing a multifaceted approach that includes medication, executive function coaching, therapy and nonmedication techniques, we aim to support individuals in navigating their challenges and enhancing their strengths. Our goal is to help those with ADHD live more authentically and effectively, enabling them to focus their energy on the aspects of life they are passionate about. Through increased awareness and tailored interventions, we strive to foster environments where individuals with ADHD can thrive and lead fulfilling lives.

Elizabeth Adams, PhD, LP, ABPP, is a board certified neuropsychologist. She is the founder and CEO of Minnesota Neuropsychology.