ADHD
ADHD Clinical Care with Dr. Sultan
Tracing ADHDS Origins and Evolution
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, impulsivity, and hyperactivity. The understanding and recognition of ADHD have evolved significantly over time, with its roots tracing back to hunter-gatherer societies and its formal recognition emerging in the late 18th century.
In hunter-gatherer tribes, behaviors akin to ADHD were often seen as beneficial rather than pathological. The ability to rapidly shift attention, for instance, could be advantageous in a constantly changing environment where quick reactions were necessary for survival. It was not until societies became more structured and education became formalized that these behaviors began to be seen as problematic.
The first known medical description of an ADHD-like condition was provided by Scottish physician Alexander Crichton in 1789. He described a condition in which a person, from a very early age, was incapable of attending with constancy to any one object of education. Crichton noted that this condition diminished with age but could impact long-term educational attainment.
In 1890, the concept of inattention in ADHD was further developed by William James, a renowned psychologist. He described a "confused, dazed, scatter-brained state," a condition the French referred to as "distraction."
The behavioral aspect of ADHD, particularly impulsivity and disruptive behavior, was first described by German psychiatrist Heinrich Hoffman in 1845. He observed youngsters who often created chaos, more from careless and impulsive acts than intentional misbehavior.
However, it was Sir George F. Still, a British physician often regarded as the father of British pediatrics, who is credited with the first clinical descriptions of ADHD. In a series of lectures delivered in 1902, he described a group of children with significant behavioral problems, caused by a genetic dysfunction and not by poor child-rearing—children who were often defiant, resistant to discipline, excessively emotional or passionate, who showed little inhibitory volition, had serious problems with sustained attention and could not learn from the consequences of their actions; though their intellect was normal.
Throughout the 20th century, the medical classification, understanding and treatment of ADHD went through several notable changes. In the early 20th century, Charles Bradley, an American Psychiatrist, serendipitously discovered the effects stimulants had on children with ADHD. Bradley originally intended to use an amphetamine stimulant to alleviate headaches caused by an early brain-imaging technique, but found the stimulant made hyperactive children calmer, more organized, and better in their learning.
Years later, in the 1980’s, the diagnosis of ADHD underwent a revolutionary paradigm shift with the introduction of the DSM-III. In the DSM-III, the previously etiological model of ADHD was changed to a behavioral model. This was significant as it allowed for a more inclusive and flexible approach to diagnosis and treatment, and focused on the immediate symptoms rather than the overwhelmingly complex nature of the underlying causes of the disease. Additionally, ADHD began to be understood as a lifelong condition, despite the initial understanding of ADHD as a childhood disorder.
The Science of ADHD in Present Day
Since the reclassification of ADHD in the 1980’s, we have developed a much clearer picture of the biology and neuroscience of ADHD, and how it affects someone's life from childhood to adulthood. Through neuroimagery, we have determined that the brains of people with ADHD are quite distinct from the brains of people without the condition. People with ADHD have structural differences in two major brain areas: the frontal lobe and the basal ganglia. The frontal lobe plays a key role in executive functions, attention, decision making and impulse control, while the basal ganglia is crucial for reward-processing and movement. These brain areas are typically underdeveloped in people with ADHD. Additionally, the volume of the amygdala, a brain structure involved in emotional processing, is more intense in people with ADHD. This is why people with ADHD generally have a more intense sensitivity to emotions like frustration or excitement: like if they started to sweat and overheat at a temperature that most people find comfortable. ADHD is also associated with dysregulation of dopamine and norepinephrine - two neurotransmitters essential for motivation, attention, reward processing, and emotional regulation.
To a person with ADHD, this should come as no surprise. It is harder for an individual with ADHD to maintain focus and attention on a task like reading or a school lecture, motivate themselves to carry out everyday chores like making the bed or completing a work assignment, or control their emotional reaction to a setback or negative event like an insult directed at them by a classmate. It only makes sense that the way chemicals in the brain operate and the physical structure of the brain aligns with how someone with ADHD experiences the world and differs from someone who lacks these symptoms.
In modern society, an individual may benefit from having ADHD. For example, it enables individuals to hyperfocus on something or respond well to dynamic and fast-paced environments. However, individuals with ADHD face many roadblocks and challenges that their neurotypical peers are less likely to experience. People with ADHD frequently suffer from psychiatric comorbidities. In children with ADHD, the most common comorbidities are oppositional defiant disorder (ODD), conduct disorder (CD), and learning disorders, while adulthood ADHD is more commonly comorbid with substance use disorders (SUD), mood and anxiety disorders, antisocial personality disorder, and sleep disorders. ADHD is associated with worse academic, occupational, and social outcomes, and increased mortality rates. Individuals with ADHD are also more likely to suffer from low self-esteem.
For many individuals with ADHD, these negative outcomes may persist into adulthood just as their ADHD does. However, effectively treating ADHD in childhood and adulthood may counteract many of these negative outcomes, and lead to drastic improvements in individual success and quality of life. ADHD can be effectively treated pharmacologically, most commonly with stimulant medication, and non-pharmacologically with cognitive behavioral therapy (CBT) or mindfulness-based interventions.
The causes of ADHD are highly complex, but we understand that there is a strong genetic component involved in ADHD. Roughly 75% of the variation in ADHD occurrence in the population can be attributed to genetics. Additionally, some environmental factors are implicated in the development of ADHD, such as prenatal exposure to alcohol or tobacco. Males are generally diagnosed at higher rates than females, however, females are believed to experience ADHD at a similar rate as males. One explanation for this underdiagnosis is that boys tend to display hyperactive symptoms while girls more commonly display inattentive symptoms, with the former easier to identify than the latter.
The Sultan Lab & ADHD
Dr. Sultan and the Mental Health Informatics Lab have worked to advance our understanding of ADHD, especially in young people. Their research has shown that teenagers with ADHD often face additional mental health challenges and are at higher risk for behaviors like substance abuse and aggression. This work emphasizes the complexity of ADHD, suggesting the need for comprehensive treatment approaches.
Another study by the Sultan Lab explored the use of antipsychotic medications in youths with ADHD, uncovering how often these medications are prescribed and what factors influence this decision. Their findings highlight the importance of careful and evidence-based treatment choices for ADHD, contributing to better care practices.The Mental Health Informatics Lab is working to make a meaningful impact on how ADHD is understood and treated, advocating for approaches that are both effective and sensitive to the needs of young patients.