Why I Love ADHD

Disclaimer time: this site should not be used to diagnose or treat readers. Although I am a psychiatrist, if you have any concerns you should go see your doctor to talk about any symptoms you're struggling with That being said: let's talk about good old Attention Deficit Hyperactivity Disorder. This was previously classified as two disorders, Attention Deficit Disorder, and it's "hyperactive cousin" Attention Deficit Hyperactivity Disorder. Now, it's one disorder with three classifications: predominantly inattentive type, predominantly hyperactive or impulsive type, and combined type. This is a disorder of the frontal lobe of the brain. The frontal lobe is the part of your brain responsible for things like focusing, paying attention, and stopping to think before acting. It's also responsible for what we call "executive functioning" which is what helps you get things done. It teaches you how to make decisions, see the "big picture," and work through a problem. It helps you plan, remember details, and multitask. Dysfunction in this region leads to the problems you see in people diagnosed with this disorder. Not only is it hard to sit still or focus on a problem, it's difficult to start a task and see it through to completion. People with ADHD have difficulty getting started on things, especially if the task has too many "part." They don't know how to organize or prioritize. They also have trouble regulating their emotions. In kids, this can sometimes be seen as an explosive temper. All of a sudden your tiny friend is enraged, having a tantrum, but quickly defuses and often acts as if nothing happened. They can have trouble in social situations. Things like getting to close to others, talking over other people, or being impulsive and impatient can make it hard to make friends. ADHD, like all psychiatric disorders, is based on a set of criteria found in the Diagnostic and Statistical Manual, or the DSM. We are on version 5 now. Within the DSM we have our list of symptoms. Things like, inability to focus, pay attention, losing things easily, not completing work (or rushing through tasks), not turning things in, being disorganized, etc. Other symptoms could include not being able to sit still, fidgeting, feeling like an internal motor is running inside you, speaking without thinking, being impulsive/risky, not waiting your turn, etc. They must struggle in multiple settings (like home or school, or home and work). Symptoms have to be present by age 12, but some people don't get diagnosed until much later in life. It isn't considered a "benign" problem. People who suffer from symptoms of ADHD have difficulties with social situations. They often say things they regret (lacking a filter), are intrusive, can be "too much" to deal with, and are seen as unreliable. It's difficult to succeed at school or at work. They also can struggle quite a bit with emotional regulation. They have fits of anger or passion that can be easily triggered, often easily defused (though not always), and quickly forgotten. Although often seen as only a problem "getting ahead in school," people with ADHD can have lifelong dysfunction in a variety of settings. Not being able to pay attention can cause motor vehicle accidents. Impulsive behaviors increases your risk of drug use. Other disorders can go hand in hand with ADHD. Many are diagnosed with conduct or behavioral disorders. Some have anxiety disorders, or depressive disorders. There's a connection between ADHD and Autism Spectrum Disorder. It's also highly genetic. Parents who struggled with ADHD have a higher chance of having a child with ADHD. It's no longer considered a problem only of childhood. There's a general thought that about 50% of kids grow out of ADHD. Why? Currently ADHD is conceptualized as a dysfunction of frontal lobe development, but some of these kids eventually catch up. We also think that treatment with a stimulant may hurry along the development, allowing the brain to catch up. Of those that don't "grow out of" ADHD (ie, they have difficulties extending into adulthood), half generally can do well without medications. Either through learning coping skills (like taking notes, getting an organizer, etc), or by finding a lifestyle that fits them better than sitting in a classroom or office all day. But that still leaves 50% of the ADHD population that has symptoms into adulthood, and 50% of THAT population still needs medication. But since so many health care professionals think of it as a childhood disorder, they feel hesitant to provide medications. And the medications that work best are addicting, controlled substances they don't want to prescribe. So why do I love ADHD? Because it's such a highly treatable disorder! In psychiatry, we really don't have "miracle medications." Our success rates with medication are not as high as we'd love to see. But with ADHD, 70%+ of people respond to treatment. SEVENTY PERCENT Y'all! Those numbers might not seem impressive, but they ARE. And treatment can be (not for everyone, but for the majority) really easy. Our treatment of choice is stimulants. These are medications like methylphenidate and amphetamines. Stimulants get a bad rap, but I think they're awesome. Stimulants directly and indirectly release dopamine, which helps focus, attention, motivation, impulsive behaviors, and executive functioning. They generally work fast (usually within days people notice a benefit) and can be easily increased or decreased. They're relatively well tolerated. They can be addicting when misused, but in controlled prescribing we believe we can actually decrease the risk of substance use in ADHD patients (a huge co-morbidity) because we're helping people make better decisions, not be as impulsive, and giving the brain what it needs. Most common side effects are usually headaches, decreased appetite, and decreased sleep. Really worrisome side effects include aggression and risk of psychosis. The aggression can be a big problem, but often when aggression is a symptom of poor impulse control and mood regulation, a stimulant can be helpful. The risk of psychosis is real, but small. In high doses stimulants can cause psychosis, but not usually in the doses used to treat ADHD. This means, when I meet a kid with ADHD, I've got a 70% chance that by the next visit they're going to be doing great. And they usually maintain a level of stability going forward. Sure, we have to make dose adjustments, and sometimes have to change around meds a bit, but for the most part we do great. In a job with disorders that can be very difficult to treat, it can be so refreshing. When I was in training, I felt very differently. It was so easy to treat, there was barely a challenge in it. I felt like I was wasting my precious clinic time with these kids who do great, and I could be seeing more challenging patients needing more TLC. But after a few years of seeing very challenging kids struggling to get better, I now LOVE having a bit of ADHD sprinkled into my day. I'm generally surprised by how much stigma there still is around ADHD. Parents come in so defeated by their hyperactive, trouble making kids who are doing terribly in school. Homework is a constant fight. They're being called at work daily because of their children's behavior. They are at their wits end. But when I tell them it's ADHD, and we can easily treat it, they struggle with the decision. It seems so easy to me. Take this magic medicine and your kid will be "like new!" But the stigma around ADHD being some "behavioral problem" and treatment being "medicating your kid because you don't want to deal with them" is so prevalent in our society. Why do we treat people this way? We wouldn't shame a parent for treating their child's diabetes! ADHD can really mess up a person's life, so why not give people this potentially life changing disorder? But the stigma is real. And it lives within all of us. I know there will be some part of me that will feel like a "bad mom" if my daughter ever needs treatment. And I'm a professional! I'm sure I'll get all sorts of grief over it too, if she needs medicines. Why are we so desperate to power through this instead of giving ourselves the kindness of treatment? Heck, I'm starting to believe that I probably should have listened to the psychiatrist who years ago told me he thinks I might have ADHD and if I wanted a stimulant we could talk about it. But even for myself I was like "how dare you sir?! I can make it on my own." I think my high levels of anxiety are more the culprit of why I struggle to focus and do things (I generally get so overwhelmed by tasks I can't figure out where to start or how to finish a job). I've always adapted and done very well, but maybe things didn't need to be this hard. Medical school was definitely an eye opener, and maybe I wouldn't have struggled quite so much if I'd done something to address my inattention. Looking back, the combination of being so overwhelmed and fighting so hard to keep my focus on anything could have been ADHD. I like to tell my husband that I got by (obviously, I made it), but I probably could have taken over the world on a stimulant. Even now, getting things done is very difficult for me (this blog has taken me over a week of starting and stopping). I should probably go see someone about this instead of diagnosing myself... For more details on my dramatic journey through medical school, feel free to check out my other blog (I hate medical school). Last thoughts: ADHD is a highly prevalent disorder in the US. Why is that? When I was in residency we were talking about culturally bound syndromes. This is a "disorder" that shows itself only in a certain culture. For instance, anxiety disorders in Hispanic cultures often show up as "ataque de nervios" and is characterized by high emotional distress within a short period. You'll see things like crying, shouting, uncontrollable displays of emotions, headaches, seizure like/fainting episodes, and a sense of being out of control. It's seen mostly in people of Latino descent and is understood within a cultural framework. I won't get into it too much here, because that's not what we're talking about. But we were presented with the question: "Is ADHD a culturally bound syndrome of the west?" I was of the minority of people who thought that yes, maybe it is. Maybe there's a part of ADHD being so prevalent in the US that means our society is set up for it. Does our school system increase the incidence or prevalence of ADHD in our society? Or are we just better at understanding, recognizing, diagnosing, and allowing for treatment? I don't have the answers. I do believe that ADHD is a real disorder that can probably be found across the world, but does our culture have something to do with our high levels of it? Feel free to comment below.