Understanding ADHD 

We can all agree that ADHD is a hot topic. Statistics show that the demand for ADHD assessments is growing exponentially year on year. This has thrown up a range of questions. For example, is this merely a fad or a trend? Why are more ADHD diagnoses being made? Does everyone have ADHD? This article will explore some of these issues.

What is ADHD?

ADHD (Attention Deficit Hyperactivity Disorder) is a neurodevelopmental disorder characterised by inattention, hyperactivity, and impulsivity. The term ‘neurodevelopmental’ indicates that it is concerned with the way in which the brain is wired.
Symptoms of ADHD vary widely amongst different individuals. Some people only have inattentive behaviour e.g. difficulty sustaining focus, getting easily distracted, being forgetful, procrastinating, and being disorganised. Others only have the hyperactive/impulsive cluster of symptoms, e.g. being impatient, restless, fidgety, interrupting others, or having excessively high energy levels. Some people have both sets of symptoms. 

The terminology can sometimes be confusing. You may hear reference to people having ADD only, which signifies the inattentive subtype in the absence of hyperactive/impulsive symptoms. The consensus opinion is that whilst some people may only exhibit a limited range of symptoms, ADHD is an umbrella term that covers both of the different subtypes, but there is no need to make this distinction (between ADD and ADHD), as the treatment does not vary necessarily for the different subtypes. We will therefore refer to ADHD only henceforth.

What causes ADHD? 

There has been extensive research into ADHD, and therefore our understanding of it is heavily supported by neuroscientific research. In essence, the underlying issue appears to be a lack of the ‘neurotransmitter’ (chemical messenger) dopamine in two main pathways in the brain. Brain imaging (e.g. functional MRI scans) supports this hypothesis.

One of the dopamine pathways goes to the prefrontal cortex, a part of the brain responsible for our so-called ‘executive functioning’ skills, e.g. organisation, planning and attentiveness. A lack of dopamine in this pathway causes the inattentive ADHD symptoms. A second dopamine pathway goes to the basal ganglia, brain structures that play a role in our motor coordination. The lack of dopamine there causes the hyperactive and impulsive symptoms.

The research indicates that ADHD is accounted for overwhelmingly by so-called genetic factors i.e. it is predominantly a condition that is inherited. This does not mean that if you have a relative with ADHD, you will definitely develop it, but you are more likely to have it than somebody who does not have a first-degree relative (parent or sibling) with ADHD. 

80% of cases of ADHD are thought to be explained through heritability, i.e. genes; this does not mean that there is an 80% risk of developing it and it is thought to be a ‘polygenic’ condition. i.e. one that is caused by multiple genes rather than a specific ‘ADHD gene’.

ADHD has also been associated with environmental factors, which are thought to account for 20% of its prevalence. These factors include a low birth weight, exposure of the foetus to nicotine, gestational diabetes (diabetes in pregnancy), premature birth, assisted delivery (with forceps or a Ventouse suction device) and other forms of birth trauma, such as neonatal hypoxia (a lack of oxygen on delivery). 

There is a very small amount of evidence suggesting that other environmental factors may lead to the onset of ADHD, including exposure to toxins such as lead, artificial food colouring and passive smoking. Despite well-publicised theories around parenting styles impacting on ADHD, this is not supported by the psychiatric literature. 

Is ADHD related to other conditions?

ADHD is commonly associated with a number of psychiatric and non-psychiatric conditions. People with ADHD are more likely to have other mental health conditions, such as depression, bipolar disorder, and obsessive compulsive disorder (OCD). In some cases, symptoms of ADHD are mistakenly attributed to those other conditions, but in time it becomes clear that ADHD is a better explanation for this. This is most likely due to the significant overlap between symptoms of ADHD and other psychiatric conditions. 

For example, people with depression may struggle to concentrate when they feel low in mood, but the difference is that when the mood lifts, the concentration levels also tend to improve. Similarly, people with anxiety disorders may feel fidgety or restless, both of which are (hyperactive) symptoms of ADHD.

ADHD is considered to be one of several conditions that fall under the umbrella of neurodiversity, i.e. a number of related phenomena that result from different wiring of the brain. These include autism spectrum disorder, dyslexia and developmental coordination disorder (more commonly referred to as dyspraxia). If you have ADHD, you are more likely than a member of the general population to have one of these other conditions, and vice versa.

ADHD is also strongly associated with specific physical health conditions. These include conditions that affect the cardiovascular and gastrointestinal (i.e. the ‘gut’) systems. Examples of these are dysautonomia, PoTS (postural orthostatic tachycardia syndrome), hypermobility (such as Ehlers-Danlos syndrome) and inflammatory bowel disease. Emerging research suggests that there may be underlying mechanisms common to these conditions, which would indicate that ADHD may be part of a wider systemic set of disorders. 

When does ADHD first appear?

ADHD is generally diagnosed from the late childhood onwards; it is therefore rare that a diagnosis would be made below the age of 7, although some of the symptoms may be evident before this age. Historically, it was thought that ADHD symptoms faded as people hit adulthood (that they would ‘grow out of it’), but there is extensive research to indicate that the symptoms persist to varying degrees in somewhere between 30-80% of people diagnosed with childhood ADHD. 

The consensus opinion is that ADHD is a condition that appears below the age of 12, though there is a small body of evidence to suggest that a fraction of people may have symptoms that only begin to appear in their adult life. 

ADHD symptoms are not necessarily static i.e. for some people they will improve significantly, whilst for others, their symptoms may affect them to greater or lesser degrees at various points across the lifespan. For example, it is known that around the time of the menopause, ADHD symptoms can worsen for some women. ADHD symptoms may also appear to be more prominent during the menstrual cycle (period).

How is ADHD diagnosed?

ADHD is considered to be a mental disorder, but not a mental ‘illness’. It is important to emphasise that people with ADHD have many strengths. For example, a lot of people with ADHD have excellent communication skills, are positive risk takers and can think very creatively. 

However, by definition, there do tend to be areas in the lives of those with ADHD that cause challenges and, if left untreated, they are at high risk of experiencing major problems. These may include problems in the workplace, in relationships and with respect to physical health indicators.

ADHD-associated features are common, are distributed across a spectrum within the population and may be modified by the environment e.g. some people may be prone to distraction and procrastination when placed under severe stress, but when the stress is relieved, they are organised and able to complete tasks to a reasonable level. 

A smaller group of people have ADHD ‘traits’ which are present from childhood and less easily modified by the environment. When the traits are present alongside impairments or problems in daily life, ADHD may be diagnosed. 

It is thought that approximately 3% of the adult population have this combination of ADHD symptoms and functional impairment (as well as up to 7% of children and adolescents). Historically the number of people diagnosed with ADHD (in childhood or adulthood), fell way below this proportion for the general population (in the UK). 

It is therefore felt that the rapid increase in demand for ADHD assessment may have arisen from greater professional and public awareness over the past decade, particularly following COVID-19 lockdowns, where a large percentage of the adult population were forced to change their environment dramatically (in many cases working from home, having never previously done so). 

ADHD should be diagnosed by a suitably qualified professional. Historically, this was limited to paediatricians for under 18s and psychiatrists for over 18s. Increasingly, other professionals are playing a role in the diagnosis and treatment of ADHD.

The usual process is to conduct a psychiatric and/or developmental history, exploring sufficient background information to establish the onset and pattern of ADHD symptoms. An ADHD assessment may incorporate use of questionnaires and a semi-structured diagnostic tool to tease out whether the symptoms and functional impairment are evident and to what extent. 

The assessment process may also involve speaking to a relative and/or exploring information via school reports, or from speaking to one’s school teachers, in order to establish from external sources whether the symptoms have been present to a significant degree in different settings.

Is ADHD different in women?

A common perception is that ADHD is significantly different in women. It is true to say that historically ADHD has been underdiagnosed in adolescent girls and women alike. This is likely to have resulted from a variety of factors. The common image of a child with ADHD for many lay and professional people alike is that of a hyperactive boy.

Hyperactive and impulsive behaviours are thought to be more common in boys compared to girls, and therefore a shy, withdrawn and inattentive girl may not grab the attention of parents, teachers or healthcare professionals as possibly having ADHD.  Where impulsive behaviours are present, in adolescent girls they may be misattributed to other conditions, such as emotionally unstable personality disorder.

Thus in theory, ADHD symptoms do not inherently differ in girls or women, but they may be more readily missed or misdiagnosed. ADHD symptoms in women can be exacerbated during the menstrual cycle and become more prominent as women approach the menopause.

Is getting an ADHD diagnosis important?

There are a lot of videos circulating about ADHD via social media and whilst much of the information is extremely useful, it is often posted by non-clinicians and some of it is far from accurate. A lot of people may well identify with features of ADHD, but does not mean that they fulfil the full diagnostic criteria for ADHD. 

Some people with ADHD thrive and may not necessarily require medical support. However, for a large proportion of people with ADHD, it is associated with areas of challenge in their personal and professional lives. 80% of people with ADHD will respond to first-line treatment with stimulant medication and this can only be initiated after a firm diagnosis has been made. Given that the treatment can be transformational, a diagnosis of ADHD is something worth considering.  

What treatments are there for ADHD?

The first and second line treatment for ADHD is medication, which increases the amount of dopamine circulating in the brain and can lead to a substantial improvement in the symptoms of ADHD. Stimulant drugs represent the first line as they work in up to 80% of people with ADHD, whilst 50% of people with ADHD will respond to non-stimulant drugs. 
ADHD coaching can help people develop practical strategies to overcome areas of challenge. It does not have the same evidence base as medication, but anecdotally can be helpful for some people.

Are there any theological perspectives on ADHD?

There are few, if any, clear cut examples of Bible figures who definitely had ADHD! Scripture does point to some examples of ADHD features, such as impulsivity and risk-taking, but this highlights the broad nature of these behaviours, which are not exclusive to ADHD. 

The Bible teaches that every individual is created in the image of God, including those with ADHD. Christian faith also calls for understanding, compassion, and support for all members of the body of Christ. ADHD should therefore not diminish one’s value or purpose in God’s kingdom.

Difficulty with sustained attention can make spiritual practices like prolonged periods of prayer or Bible study challenging. Procrastination, a lack of attention to detail and forgetfulness, core inattentive symptoms, could impact negatively on Church ministries a person with ADHD is involved in. Interpersonal conflict may arise from the tendency of someone with ADHD to interrupt others, their poor timekeeping or impulsive activity. These difficulties may lead to feelings of isolation or frustration.

Christians with ADHD should be confident in seeking professional help, such as medication or therapy, as part of God’s provision for managing their ADHD. They may also derive comfort from community support within the Church community that makes them feel better understood and encourages those around them to be patient. Their personal faith may also be a source of strength and resilience in overcoming the challenges posed.

Where can I get more information?

For more information about ADHD please see here:
https://www.ukaan.org/

https://aadduk.org/

http://addiss.co.uk/

If you are concerned that you or a loved one might be exhibiting symptoms of ADHD, you should consider contacting your GP as the first port of call. Please note that waiting times within the NHS can be very long. 

Dr Chi-Chi Obuaya is a Consultant Psychiatrist working in an NHS ADHD service and in independent practice, as well as a Mind & Soul Foundation Director.