Interview with Forsakken

ADHD
By N. A. Foy

Introduction

Approximately 3 to 6 percent of the population constitutes people with attention deficit hyperactivity disorder (AD/HD).  This figure may be controversial, as some experts believe that this condition is over diagnosed while others believe it is under diagnosed.  Some health professionals still believe that AD/HD is a made up condition that is used as an excuse for bad behavior; fortunately this isn’t what most believe (Strong & Flanigan 2005, pp. 1).  While AD/HD is generally diagnosed in children this disability has been found to continue into adulthood with many people.  Adults that struggle with AD/HD experience higher divorce rates, poorer driving records, lower academic and vocational achievement, higher rate of emotional struggles, and a higher incident of sexually transmitted diseases (Ramsey and Rostain 2007).  People with AD/HD are usually noted as having trouble focusing and sitting still.  However, there are more symptoms to this complex disorder and I will be discussing these in this paper.  I will be discussing possible causes such as genetics and brain activity and various treatments being used to treat AD/HD. 

Symptoms

Attention Problems

The two main symptoms of AD/HD are inability to pay attention and hyperactivity/impulsivity.  Some with the disorder may have more trouble paying attention than hyperactivity while others will be the opposite.  Some will have both symptoms quite prominently.  These symptoms can be broken down into more specific problems.  First I will discuss the symptoms related to the inability to pay attention.  AD/HD is often associated with lack of concentration such as when trying to do such tasks as reading, homework, or other activities that require focus.  Interestingly, people with AD/HD may be able to have a high degree of focus on one thing and struggle with something else.  Similarly, times of focus may vary.  An example would be someone being able to focus on a project at one time, but then when they return to the project, concentration becomes difficult.  Those with AD/HD may struggle with filtering out their surroundings and therefore become easily distracted.  The classic example is a student looking out the window during class and zoning out what the teacher is saying.  Forgetfulness is another symptom of AD/HD and therefore misplacing things may be a struggle.  Being late for appointments and other important events may be another thing that they struggle with.  Procrastination may be a struggle for someone with AD/HD.  This is because he may start a project then become distracted with another project and continue this process and end up getting behind on everything that he is trying to do.  This symptom is also related to difficulty with organization skills.  Carelessness is another trait such as making mistakes by overlooking details.  For example, a job that requires workers to move fast yet pay attention to details may be difficult for someone who has AD/HD (Strong and Flanigan 2005, pp 32-34).

Hyperactivity/Impulsiveness

Now let’s take a look at the symptoms that are related to the hyperactive/impulsive aspect of AD/HD.  One example would be the student who blurts out an answer to a question that the teacher asks or the adult that finishes sentences for other people.  Similarly a person with AD/HD may tend to interrupt others in the middle of a conversation.  Thrill seeking and risk taking such as driving fast or some other activity that helps get the adrenaline flowing may be a behavior that those with AD/HD take part in.  Impatience may be a prominent trait present in those who struggle with AD/HD.  Perhaps impatience at a stoplight will be more frustrating for this person as compared to someone without the disorder.  A person with AD/HD may want things immediately and may be more at risk at impulsive spending or running up the credit card.  Sitting still can be a difficulty, as a person with AD/HD may often feel edgy and want to get up and do something rather than sit still.  This person may tend to often seem to be restless (Strong and Flanigan 2005, pp 34-37).

Inhibitory Control in Adults

One study was done to compare the inhibitory control of adults with AD/HD to those without it.  One study was done to test the intentional inhibition of distracting information.  In this test participants were asked to look at a certain part of a computer screen and when a distraction was presented they were to delay attention to that distraction.  In this test it was found that AD/HD adults showed a lower ability in the intentional inhibitory of distracting information.  It is thought that the reason for this is connected to the functioning of the frontal eye fields.  Automatic inhibition of distracting information was also tested however the differences between adults with AD/HD and without were not significantly different (Roberts et. al). 

Other Symptoms Derived from AD/HD

AD/HD may lead to other symptoms such as boredom, low self-esteem, insomnia, learned helplessness, excessive worry, frustration, and even substance abuse (Strong and Flanigan 2005, pp 38-40).  

Possible Causes of AD/HD

Genetics

There are many possible causes of AD/HD that have been looked into.  First, genetics seems to play a role in AD/HD.  One study showed that 81% of the time, if one identical twin has it, the other will have it, yet this is the case with only 29% of paternal twins.  Other studies have shown that when it comes to AD/HD children will resemble their biological parents more than their adoptive parents.  There is a possibility that AD/HD is connected with the dopamine D2 receptor.  Some researchers suggest that DAT1 and DRD4 are behind this disorder and one study suggested that the DRD4 7R gene may be associated with certain AD/HD symptoms such as impulsivity (Strong and Flanigan 2005, pp 24-25).
Brain Size and Shape

The role of the brain’s size and shape has been looked into but there seems to be a lot of conflicting data.  There is a possibility that the corpus collosum plays a role because it seems to be different in size of those with AD/HD when compared to those without it and perhaps even operates differently.  It is also possible that the basal ganglia may be asymmetrical in people with AD/HD.  One study done by Alan Zemetkin used a PET scan to measure brain activity and found that adults with AD/HD had a decrease of activity in the frontal lobe while those without AD/HD showed an increase.  Another study by Dr. Joel Lubar found that there is an increase in theta waves in the frontal area when a person with AD/HD tries to concentrate.  Dr. Daniel G. Amen found that there is an increase in the limbic system in people with AD/HD, which may be one of the root causes behind AD/HD.  There was also more activity found in the parietal lobe with those with AD/HD (Strong and Flanigan 2005, pp 25-27). 

Neurotransmitters

There is evidence to suggest that neurotransmitters play a role in AD/HD.  The two neurotransmitters that seem to play a role are dopamine and norepinephrine.  Since norepinephine is associated with agitation and even fight or flight response, too much of it is associated with AD/HD as it may play a role in hyperactivity.  Those with a high level of dopamine activity may be able to handle repetitive tasks without being bored.  However, those with AD/HD often are easily bored indicating that they have lower dopamine levels (Strong and Flanigan 2005, pp 27-28). 

Brain Activity

In one study a task-switching task was assigned to fifteen men diagnosed with AD/HD and a control group of 14 men.  All participants were adults so this experiment would pertain more to those with adult AD/HD rather than childhood AD/HD.  The findings in this study reveal that there was no difference in the executive control problems when it comes to behavior, however the areas of the brain differed from the experimental group to the control group.  The AD/HD group showed higher activity in the dorsal anterior cingulate cortex (dACC), middle temporal gyrus, precuneus, lingual gyrus, precentral gyrus, and insula while the experimental group showed more activity in the putamen, posterior cingulate gyrus, medial frontal gyrus, thalamus, orbitofrontal cortex, and postcentral gyrus.  The finding of an increase in activity in dACC is rather interesting.  This area has to do with negative feedback, error responses, and the detection of conflicting information.  It has been suggested that those with AD/HD may engage in a stronger activation of the dACC in order to attempt to pay better attention to the conflicting information during a task switching exercise.  Thus they would perform just as well as the control group.  Overall, the AD/HD participants showed more activation in the executive attention system and less activity in the alerting system.  This study confirmed that people with AD/HD show different activations in brain areas than those without this disorder (Dibbets et al. 2010). 

Treatments

Methylphenidate (Ritalin)

A study was done on the effects of methylphenidate (MPH; Ritalin) on children 7 years old with AD/HD.  This study was done to see how this drug affects academic, behavioral, and social functioning and what doses should be used.  This study did end up with various results indicating that MPH is only beneficial for some children and not others.  Findings also suggest a negative correlation between social engagement and dosage increase.  In fact, one child showed such a decrease in social activity that this problem outweighed the benefits of a decrease in disruptive behavior.  There seemed to be no correlation between dosage amount and disruptive behavior and academic performance.  This study also found that the effects of MPH were more short lived for academic performance as compared to reducing disruptive behavior.  This studied supports that MPH acts in various ways from individual to individual.  There is no straightforward answer on how effective MPH will be for various people (Northup, et al.  2001).

Other Medications

There are several other medications that can be used to treat those with AD/HD and I will discuss a few of them here.  One of the first medications used on AD/HD is known as Dexedrine.  This drug works as a norepinephrine and dopamine agonist.  A similar drug called Adderall may be used to treat AD/HD, however this drug seems to focus more on working on the norepinephrine containing neurons than Dexedrine.  Cylert is a medication that is a dopamine agonist only, however it holds a high risk for liver damage so should be used with caution.  While the medications I have mentioned so far are all stimulates there are other classes of medications that can be used that I will briefly describe.  First there are monoamine oxidase inhibitors (MAOIs), which help prevent the breakdown of norepinephrine, dopamine, and serotonin.  Some of these medications include nardil, parnate, and eldepril.  Selective serotonin reuptake inhibitors (SSRIs) help to slow the reuptake of serotonin from synapses.  These medications may help to reduce certain impulsive or aggressive behaviors associated with AD/HD.  Prozac, Paxil, and Zoloft all fall under this category.  Sometimes serotonin/norepinephrine reuptake inhibitors such as Effexor are used along with a stimulant in helping with the symptoms of AD/HD.  Tricyclic antidepressants can affect dopamine, serotonin, and norepinephine to various degrees and medications such as Tofranil, Nortriptyline, and others may be used for their positive affects on AD/HD.  There are other various medications that may be used to treat various aspects that might come with AD/HD such as antidepressants, antihypertensives, and anticonvulsants (Strong and Flanigan 2005, pp 112-117).

Psychosocial Treatment

When it comes to psychosocial treatment is seems that cognitive-behavior therapy is the preferred therapy.  This may be due to this method’s used of developing skills where there are deficits and helping to elevate self-esteem and organizational techniques and other areas people with AD/HD struggle with.  It is often agreed upon that one of the first things that needs to be done when one is diagnosed with AD/HD is to educate the client about it.  Having the client understand what his symptoms mean and possible causes may help the client to understand himself better and will pave the way to furthering the therapy process.  Hopefully this process will help motivate the client to want to make the necessary changes to help alleviate the symptoms of AD/HD.  Another important element in the psychosocial treatment is for the therapist to remain direct, active, and focused and not let the session drift off.  A warm therapist/client relationship may be beneficial as many who struggle with AD/HD also struggle with feelings of guilt and failure and feeling like a failure in therapy may cause the client to give up too soon.  Since people with AD/HD may struggle with negative self-thoughts, cognitive modification may need to be used in order to helped alleviate feelings of low self-esteem.  This may not deal directly with the AD/HD itself but will help with feelings due to the struggle with AD/HD.  AD/HD coaching is also used to help adults with this disability to overcome difficult obstacles and boost the confidence of the individual.  Coaching is best used alongside CBT, as it doesn’t work as heavily with the complex systems of cognation and behavior as CBT does (Ramsey and Rostain 2007). 

Diet

Diet may play a role in helping with AD/HD symptoms.  Foods containing essential fatty acids such as Omega-6 and Omega-3 may be beneficial in helping with AD/HD.  This would include foods such as fruits, grains, raw nuts, raw seeds, fish, and avocadoes, among other foods.  A person should get two to four times as much Omega-6s in his diet when compared to Omega-3s, however, most people are deficient in the area of Omega-3s.  A supplement or seeking out grass fed meat may help to establish a better ratio between the two.  Sugary foods may also counter the affects of these essential fatty acids so a low sugar diet may be helpful.  Simple carbohydrates such as pasta, white rice, alcohol, simple sugars, and potatoes trigger high amounts of insulin which may help to produce certain symptoms that are associated with AD/HD such as tiredness and inability to concentrate so it might be helpful to cut down on these foods.  Instead, complex carbohydrates should be consumed such as whole-wheat products, beans, brown rice, etc.  The amino acids that make up good quality proteins such as lean meats are used to support neurotransmitters so those who struggle with AD/HD should eat these.   Another reason why following the above recommendations for eating is that it helps keep a healthy yeast balance in the digestive system.  For instance, if there is an overabundance of yeast called candida albicans when compared to other yeasts known as bifidobacteria bifidum and lactobacillus acidophilus foggy thinking may be a symptom.  Another thing that people with AD/HD may want to look for is the possibilities of food allergies.  Sometimes certain food allergies such as gluten sensitivity may cause a person to feel more cloudy minded after eating foods with gluten in them.  Sometimes it may be good to go on a restrictive diet only eating foods that people are generally not allergic to and slowly start adding other foods to diet and record, which foods seem to cause a negative reaction (Strong and Flanigan 2005, pp. 153-159). 

Natural Supplements

Some believe that natural supplements may be beneficial for those with AD/HD.  A few studies have been done testing 2-Dimethylaminoethanol (DMAE) and there were significant improvements in AD/HD when compared to a placebo.  Zinc has shown some benefits in helping with AD/HD however the effects are rather modest.  In one study 28% of those using zinc improved but about 20% of the placebo also improved (Bratman 2007).  Some researchers have suggested that calcium and magnesium may help to reduce symptoms of AD/HD as they help the body to absorb B vitamins.  Vinpocetine may be helpful in that it works as a dopamine agonist and also increases blood flow in the frontal cortex.  Other supplements such as melatonin or valerian root may help one get better sleep and therefore improving concentration during the waking hours (Strong and Flanigan 2005, pp. 164-168).

Rebalance therapies may be helpful in helping decrease the symptoms of AD/HD.  Acupuncture is a Traditional Chinese Medicine system that is used to balance the Qi in the body.  It is thought that any disruptions of the Qi in the body result in illness.  A professional acupuncturist will look for this disruption in those with AD/HD and work on getting the flow of the Qi to run smoothly through the person and therefore reducing AD/HD.  Some believe that manipulation therapy such as chiropractic work, osteopathy, and CranioSacral Therapy can help alleviate some of the symptoms of therapy by corrected the flow of cerebrospinal fluid.  These therapies also help properly align the bones, which may improve neurological problems (Strong and Flanigan 2005, pp. 189-195). 

Neurofeedback

There is evidence that supports that the use of neurofeedback training may be an effective treatment for AD/HD.  The point of this training is to teach a person to be able to change brave wave patterns at will.  A professional will use a brain imaging system in order to view the patients brain and to see which parts of the brain are active.  The patient may be instructed to do various activities on a computer such as play a video game or something similar.  The professional will work with improving brain waves in parts of the brain that are typically low in activity for those with AD/HD which may include the prefrontal cortex.  This process may take up to 50 sessions (usually at least 20) and evidence supports that even after sessions have ceased that the affects are lasting.  Side effects seem to be rare as there may be some anxiety, insomnia, and fatigue that can result but usually wares off soon after.  One of the major downfalls of this method is the cost, as it isn’t typically covered by insurance companies (Strong and Flanigan 2005, pp. 176-179).

Conclusion

AD/HD is a rather complex disorder that may be difficult to diagnose and difficult to treat.  While there are some patterns that seem to emerge with those with the disorder the disorder also can be rather individualistic.  Certain treatments may be beneficial for some people while the same treatment may not help others such as the use of Ritalin.  While I have listed several treatment ideas, there are other possibilities that someone with AD/HD may want to look into that I have not listed.  Hopefully as technology and the availability to obtain information increases there will be continued improvement on helping those with have been diagnosed with AD/HD. 


References
Bratman, Steven M.D. (2007) – Collin’s Alternative Health Guide.  HarperCollins Publishers. New York, NY. 

Dibbets, Pauline; Evers, Elisabeth A. T.; Hurks, Petra P. M.; Bakker, Katja; Jolles, Jelle; Differential  brain activation patterns in adult attention-deficit Hyperactivity Disorder (ADHD) associated with task switching.  Neuropsychology, Vol 24(4), Jul, 2010. pp. 413-423.

Northup, John; Gulley, Veronica; Edwards, Stephanie; Fountain, Laura; The Effects of Mythelphenidate in the Classroom: What Dosage for Which Children for Which Problems.  School Psychology Quarterly, Vol 16(3), Fal, 2001. pp. 303-323. 

Ramsay, J. Russell; Rostain, Anthony L.; Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder in Adults: Current Evidence and Future Directions.  Professional Psychology: Research and Practice, Vol 38(4), Aug, 2007. pp. 338-346.

Roberts, Walter; Fillmore, Mark T.; Milich, Richard; Separating Automatic and Intentional Inhibitory mechanism of attention in adults with attention deficit/Hyperactivity disorder.  Journal of Abnormal Psychology, Vol 120(1), Feb, 2011. pp. 223-233.

Strong, Jeff; Flanagan, Michael O MD (2005); AD/HD for Dummies.  Wiley Publishing, Inc.  Indianapolis, Indiana.