ADHD: Symptoms, Early Signs and Intervention

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder which disrupts cognitive abilities such as hyperactivity, impulse control, and attention. While it is typically diagnosed in childhood, it’s possible for symptoms to become noticeable or be diagnosed for the first time in adulthood. In fact, some adults with ADHD haven’t ever been diagnosed but when symptoms of ADHD occur during childhood, one study suggested they continue into adulthood 90% of the time.

Early Signs of ADHD:

Inattentiveness: 

Not being able to pay complete attention to anything, often causing accidents or problems. Research (Barkley, 2006) suggests that inattentiveness is a primary characteristic of ADHD, often manifesting as a persistent pattern that hinders academic and social functioning. It’s like having a head full of bulletin boards but with zero pins. 

Hyperactivity:

Hyperactivity is a word used to describe the actions of a person who moves, talks, fidgets, and interrupts more than is typical. A study by Shaw et al. (2012) highlights the persistence of hyperactivity as a key component in diagnosing ADHD, with symptoms usually evident before the age of 12. To understand it, imagine having a Ferrari brain with bicycle brakes. 

Impulsivity:

Actions without foresight that are poorly conceived, prematurely expressed, unnecessarily risky, and inappropriate to the situation, and often described as rash, hot-headed, unpredictable and unstable - impulsivity is a hallmark feature of ADHD (American Psychiatric Association, 2013). It’s like having your engine revving but you’re in neutral.

Social Challenges:

Difficulty making and keeping friends and jobs are common in individuals with ADHD, impacting their relationships at home, school, and in the community (Maedgen & Carlson, 2000). Imagine being in an ice rink with pro-skaters, but you don’t have your skates, that’s what ADHD can feel like.

3 Types of ADHD:

• Primarily hyperactive-impulsive type
• Primarily inattentive type (formerly called ADD)
• Primarily combined type

Primarily Hyperactive-Impulsive ADHD

9 Symptoms of ADHD – Primarily Hyperactive-Impulsive Type:

• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
• Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
• Often unable to play or engage in leisure activities quietly.
• Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
• Often talks excessively.
• Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for a turn in conversation).
• Often has difficulty waiting his or her turn (e.g., while waiting in line).
• Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).”

Primarily Inattentive ADHD (Formerly ADD)

9 Symptoms of ADHD – Primarily Inattentive Type:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
• Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
• Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
• Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
• Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
• Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
• Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)

Primarily Combined Type ADHD

Individuals with combined-type ADHD display a mixture of all the symptoms outlined above. A physician will diagnose patients with this Combined Type ADHD, if they meet the guidelines for Primarily Inattentive ADHD and Primarily Hyperactive-Impulsive ADHD. That is, they must exhibit 6 of the 9 symptoms identified for each sub-type.

ADHD Iceberg: The part you don’t see

The external symptoms of ADHD are behaviors that others see. However, they are merely a fraction of the ADHD experience. According to Dr. Daramus, PsyD, a licensed clinical psychologist, the internal experience of ADHD can include:

• Emotional dysregulation: People with ADHD may have trouble managing and expressing strong emotions. (Shaw et al., 2014)
• Mood swings: ADHD can cause people to experience fluctuations in mood. (Lundervold et al, 2020).
• Decision paralysis: Decision-making requires a number of skills and can be challenging for people with ADHD, causing them to experience decision paralysis. (National Institute of Mental Health, 2020).
• Executive dysfunction: Because ADHD brains process information differently, people with ADHD may struggle with executive functioning tasks like planning ahead, organizing things, or anticipating consequences.
• Motivation problems: People with ADHD have lower levels of dopamine in the brain, which leads to lower motivation levels. As a result, they may be less likely to take initiative or to complete tasks, and struggle with work, academics and relationships, as they may not always be rewarded with the rush of satisfaction one feels upon completing a task.
• Frustration: People with ADHD may often experience restlessness and boredom and have a low frustration tolerance.
• Hypersensitivity: People with ADHD may experience emotions more intensely and may be more sensitive to criticism. They may also be more prone to feeling overwhelmed by sensory stimuli.
• Time blindness: Most people develop an innate sense of time. However, people with ADHD may experience time blindness, resulting in a distorted sense of time. (Ptacek et. al,  2019). 
• Low self-esteem: Being unable to meet expectations—others and one’s own—despite best efforts can lead to a persistent sense of failure and low self-esteem.
• Disciplinary issues: People often mistake ADHD for disciplinary issues. However, this is due to the fact that expectations are centered around neurotypical society, and people with ADHD are not accommodated and supported appropriately.
• Complications: People with ADHD are more likely to have mental health conditions such as bipolar disorder, depression, anxiety, and learning disabilities. These conditions can add to the difficulties of living with ADHD.

Causes for ADHD

Most researchers point to genetics and heredity, certain illnesses such as meningitis, exposure to toxins such as lead, and nutrition deficiencies or substance use during pregnancy as some common causes of ADHD. Some scientists are investigating whether certain genes, especially ones linked to the neurotransmitter dopamine, may play a role in developing attention deficit disorder. Other experts contend that environment plays a huge role with our fast-paced, stressed-out, consumer-driven, smartphone lives that’s injecting 24/7 breaking news with clickbait headlines into our skull, social media that’s designed to get us scrolling and clicking like a skinner pigeon, food that’s weaponized with sugars in all forms and varieties, pharmaceuticals that you can’t put down once you start, excessive access to porn that saps away your libido, etc which together may aggravate ADHD.

To conclude, if you suspect that you or someone you know may have ADHD, it is crucial to seek professional evaluation and guidance from a healthcare provider or mental health professional. A comprehensive assessment typically involves a thorough review of the individual's developmental history, symptomatology, and functional impairments to determine an accurate diagnosis and develop an appropriate treatment plan.

For a more detailed understanding of ADHD, do watch Stanford Neuroscientist Andrew Huberman’s podcast on the topic:

ADHD & How Anyone Can Improve Their Focus | Huberman Lab Podcast #37

Or please visit the website of the National Resource Center on ADHD

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Barkley, R. A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Press.

3. Biederman, J., Mick, E., & Faraone, S. V. (2006). Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. American Journal of Psychiatry, 163(5), 816-817.

4. DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools: Assessment and intervention strategies (3rd ed.). Guilford Press.

5. Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43(4), 527-551.

6. Kratochvil, C. J., Vaughan, B. S., Harrington, M. J., Burke, W., March, J. S., & Emslie, G. J. (2011). Atomoxetine and methylphenidate treatment in children with ADHD: a prospective, randomized, open-label trial. Journal of the American Academy of Child & Adolescent Psychiatry, 50(10), 1041-1052.

7. Maedgen, J. W., & Carlson, C. L. (2000). Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Child Psychology, 29(1), 30-42.

8. Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171(3):276-293. doi:10.1176/appi.ajp.2013.13070966

9. Lundervold AJ, Halmøy A, Nordby ES, Haavik J, Meza JI. Current and retrospective childhood ratings of emotional fluctuations in adults with ADHD. Front Psychol. 2020;11:571101. doi:10.3389/fpsyg.2020.571101

10. Pelham, W. E., & Fabiano, G. A. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 37(1), 184-214.

11. National Institute of Mental Health. (2020). Attention-Deficit/Hyperactivity Disorder in Adults: What You Need to Know. U.S. Department of Health and Human Services, National Institutes of Health.

12. Ptacek R, Weissenberger S, Braaten E, et al. Clinical implications of the perception of time in attention deficit hyperactivity disorder (ADHD): a review. Med Sci Monit. 2019;25:3918-3924. doi: 10.12659/MSM.914225