060 | Understanding ADHD Pt. 1

Welcome to the Brain People Podcast, a show where four mental health experts team up to bring you practical tools for overcoming mental health challenges. The Brain People don't replace your doctor or therapist, but we will give you some extra tools to help you on your journey. So join us as we fight mental illness, one episode at a time. Welcome to the Brain People Podcast. I'm your host, Dr. Daniel Binus, and I'm a psychiatrist, and I'm joined today by my co-host. Jonathan Eatons. I'm a psychiatric PA. All right. Well, today we are going to be talking about understanding ADHD. And we did have a relatively recent podcast on ADHD, episode number 44. And that was with Sharonette and Amanda. And they really focused on the pediatric population, diagnosis, treatment, et cetera. We are now in the process of starting a bit of a mini series on ADHD. And so we wanted to give kind of a 30,000 foot overview of ADHD as our first session of that series. And then from there we'll dive into some very important topics when it's related to ADHD. And one of the reasons that I think it's really important to look at this topic is because ADHD is something that I think a lot of people have become more aware of recently. And there's a lot of people wondering, how can we address this? Not just with a traditional model, but also from a holistic perspective. So Jonathan, you want to tell us a little bit about some of your thoughts about ADHD, how we diagnose it, that sort of thing, why don't we just dive into it? Yeah, we'll start with a definition of ADHD. And we can obviously go very extensive in terms of a definition and we will dive into a little bit of like the understood sort of mechanism behind it. But on a basic sense, it's basically a disorder that's predominantly characterized by symptoms of inattention, impulsivity, and hyperactivity. What did you say? Maybe we need to make a diagnosis today, right? So yeah, so those are the big three, inattention, hyperactivity, and impulsivity. And often when we're in the adult population, I guess I'll ask you this question. In the adult population, what are some of the significant differences that we see from that of a pediatric population? Well, oftentimes, at least from my experience, I haven't seen as much of the hyperactivity. But with young people, kids, the girls often don't have as much of the hyperactivity either. But they can. They can. But definitely in adults, generally less hyperactivity, although I have seen that aspect. And then the impulse control can still be pretty bad, but it's often in different ways. One of the things that I notice a lot in terms of the relative impulsivity is in conversation. So maybe somebody with a child, obviously you're going to see that a lot, but it's kind of expected that a kid may not be able to wait their turn to interrupt you. But with adults, socially, that's not really good practice. And so often that might be the case. Even when I'm doing the diagnostic or going through the screening questions, and as they're thinking of the answer before I finish, they're interrupting me and giving me the answer beforehand. Finishing your sentences, et cetera, I'll try my best, especially in this episode, not to do that. Sometimes I do that myself, but yes, good point. So talk to me a little bit about it used to be predominantly seen as an adolescent disease. And now it's gaining more popularity and awareness about it being within the adult population. So maybe even in the time that you've been practicing, there's been more acceptance of that. Can you walk through that a little bit? Just what you've seen? Yeah. You know, a lot of people think that, oh, you're just going to grow out of ADHD once you hit adulthood. And it is true that for most people, they are able to focus a little better once they become adults. And a big part of that is because the frontal lobe is developing, that's the last part of the brain to develop. And that has to do with attention and impulse control, tasks switching, that sort of thing. And it really doesn't fully develop until we're 25 to 30 years old. So oftentimes the symptoms do improve, but studies actually show that probably the majority of people with ADHD in childhood actually do have at least some degree and could even meet criteria for ADHD in adulthood. Some studies are showing maybe around 60% of those that have had ADD in childhood actually have it in adulthood. So it doesn't just evaporate for a lot of people. Sure. Now, I notice you just, you switched between ADHD and ADD. So I get this a lot. And would you mind kind of clarifying for us what the differences are and whether or not that difference is meaningful? Yeah. So ADD stands for Attention Deficit Disorder, and that's just kind of a general umbrella term. ADHD is Attention Deficit Hyperactivity Disorder. And so there's not a huge difference in my mind. That's why I tend to use them kind of interchangeably, because even when we look at the diagnosis and we diagnose according to the ICD-10 and the DSM, there's actually subtypes. So even though they say ADHD, the subtype would be predominantly inattentive, for example, rather than hyperactive or yeah. So if it's ADHD, predominantly inattentive, that is synonymous with ADD is what you're saying. Right, exactly. So let's go through some of the inattention symptoms real quick. So these would be things like difficulty focusing on tasks or activities, being easily distracted or forgetful, failure to follow instructions or complete tasks, difficulty in organizing tasks, and avoidance of tasks that require sustained mental effort. Yeah. Any comments on any of those? No. I mean, basically, it's just you can't pay attention. You can't stay with something until it's completed, and you tend to bounce around a lot, going one thing to another, which can lead to a great difficulty getting anything done. Sure. The one I wanted to comment on was the forgetfulness. I've had individuals in their 30s and 40s that have come to me and they're complaining of the primary symptom of forgetfulness, and obviously they're not dealing with dementia. But oftentimes, this can be kind of the prevailing symptom that is recognized by them and those around them that they have an inattention issue. They're just, they're forgetting things constantly, right? Yeah. Well, let's talk about the hyperactivity impulsivity symptoms. So Jonathan, you want to? Yeah. So those would include things like fidgeting, squirming, difficulty with remaining seated, aggressive talking, interrupting others or blurting out answers or difficulty waiting for one's turn. So as Dr. Bynas said, we don't see these quite as often to the extent in adults that we see them with children. So often that that is going to manifest itself a lot of times with some fidgetness and restlessness, wanting to get up, say, during meetings or during church or something along those lines, right? But given the societal pressures, many, many individuals can kind of restrain themselves. That doesn't mean that they don't want to get up, right? That doesn't mean that they're not shifting around in their seat often, but it is not as intense. You know, usually adults aren't bouncing off the walls, for example. Right. And oftentimes that excessive talking and interrupting is more prominent so that, I guess we could say would be kind of part of the hyperactive part in many adults. So there's a couple other common symptoms that we just wanted to briefly address. And these are not necessary by any means for the diagnosis, but just because of the way in which ADHD affects people, a lot of times we see these as kind of secondary symptoms. So emotional dysregulation, which basically just means difficulty with managing your emotions. This can manifest itself with mood swings, irritability, et cetera. Also executive functioning skills. So this would be things like planning, organizing, and prioritizing tasks we do tend to see as being often challenging for those with ADHD. Absolutely. And it actually goes along with what I was saying earlier, it really can become very difficult for people to get things done. And I've had some patients with ADHD who have been trying to like move, for example, out of their house for months. And some people even for years, and it's like they cannot get organized enough to actually put that all together. Because there's so many elements with some of these things, like whether it's moving or having some other more complex task that actually putting that all together and executing it properly can become very difficult and sometimes seem impossible. Sure. Moving on, let's go through just real quick. And I know Shannon covered this in the previous one, but the specific criteria that we use for diagnosing ADHD according to the DSM, Dr. Bynas, would you mind walking us through those? Sure. So inattention and/or hyperactivity must be present for at least six months to a degree that is inconsistent with developmental level and negatively impacts social and academic and occupational activities. And I think that's important to realize like, you know, you can't compare exactly the symptoms of a five-year-old with a 10-year-old or a 12-year-old because you want to basically realize that, yeah, there's going to be progression, but if they're really lagging behind with their ability to focus, then it's like, okay, now we need to take a look. Is this still within that range of normal and they're going to develop better concentration skills more quickly here? Or are they really lagging significantly than that could be a sign of the ADHD? Several symptoms actually have to be present before the age of 12. Again, this is for the DSM criteria. You actually have to have, even for adult ADHD, some of those symptoms early on in childhood. Several symptoms must be present in two or more settings. So in other words, it can't be just at school or just at home. It has to be at least in two settings. And there must be clear evidence of impairment in functioning. And that can be social functioning, occupational functioning, academic functioning. And the symptoms are not just because of another mental disorder. Yeah. So some of these, just to kind of focus on them, you know, there's many other conditions that would be like a differential. And you know, often I've had patients come to me and they kind of meet criteria. Other than say they didn't have those symptoms prior to, let's just say, adulthood, right? As a child, right, they function very well in school. There's no corroborating evidence to suggest that it was a problem then. And so in those types of situations, we're looking for alternative ways, right? And some people have come with the sort of hope for the diagnosis, been sort of disappointed by the fact that they just simply didn't meet criteria. So these can definitely be, these criteria are definitely useful when we're trying to make, you know, that sort of holistic assessment about whether or not it is something we want to... Yeah. And I think that's a really important point because ADHD often can become a secondary syndrome, if you will, or the symptoms of ADHD, meaning major concentration difficulties when I see people with high levels of anxiety, for example, or even depression. Those are some of the common ones, or of course, traumatic brain injury. All of those are very common disorders where we see major concentration deficits. So moving on, talking about the epidemiology, let's, well, first, do you want to define that word for us, Dr. Byrnes, because people may not know. Well, basically, epidemiology has to do with the study of the incidence of diseases and trying to basically look at, yeah, how many people have this specific issue. So talking about the prevalence of ADHD, according to this CDC, they suggest that ADHD affects around 5% to 10% of children and around 2% to 5% of adults globally. So this means that based on that percentage, that millions of people worldwide are affected by the disorder as defined by the DSM. Yeah, one of the interesting things that I was looking at recently was there's a study that they did in the Journal of the American Medical Association, and they were looking at the prevalence of diagnosed ADHD in children over the last 20 years. And they looked at numbers from 1997 all the way through 2016. And they actually found that back in 1997, there was a 6.1% prevalence. And then in 2016, that jumped up to 10.2%. And so it was quite a jump, a 67% increase. Of course, the authors say, hey, we don't know if this is because they're just more aware and increased diagnosis because of that, not only amongst practitioners of the awareness but also amongst the general public seeking for help, or if it is just related to an actual increase in the disease. And there's other interpretations of that data, which we'll maybe dive into here in just a second. So let's actually talk about the potential causes behind ADHD. So both the genetic and environmental factors, do you want to get us started? Sure. Yeah. I mean, certainly with any disorder, there's often, maybe I should say almost always, especially with mental health, some sort of genetic predisposition. So with ADHD, it's no exception. There is a genetic predisposition for a lot of people. And so that can then affect the way that the brain is developing and the levels of neurotransmitters such as dopamine, norepinephrine, which are really important when it comes to focusing and even levels of serotonin, which can help regulate anxiety. So there's different issues related to the levels of neurotransmitters that can affect. Yeah. That's definitely one of the most well-known hypotheses in regards to just mental health disorders in general. You know, most people have heard of neurotransmitters and what we'd call the catecholamine hypothesis, which is essentially dysregulations of the most common neurotransmitters that people are aware of. And so with ADHD, like you mentioned, dopamine, norepinephrine, but in ADHD, we also tend to see some structural differences in the brains of those that have been diagnosed. So the first one that we'll talk about is reduced volume and activity in the prefrontal cortex. So the prefrontal cortex is the region in the most front interior portion of the brain. This is involved with things like executive function, which we mentioned before. So somebody that has an underdeveloped prefrontal cortex is often going to have difficulty with planning, organizing, and prioritizing tasks. Do you want to talk about the next region of the brain that's affected? Sure. And before I do, one comment on the the frontal lobe, the prefrontal cortex, is there's a lot of factors that impact the development of that. And so there's different things like high levels of stress and even trauma in childhood that can impact the development of the frontal lobe. And so if individuals have been subjected to high levels of stress and trauma, for example, then that can actually increase the likelihood of developing ADHD. And the next, the next one that we wanted to talk about was actually the basal ganglia. Basal ganglia in the in the brain actually has to do with more automatic movements, behaviors, habits. And there are some studies that actually show a reduced volume of that area of the brain as well. And so, and that seems to be more related to kind of this impulsivity. It's almost like, yeah, that automatically they don't have that regulation, they just kind of like do whatever feels, they feel like doing in the moment. So again, that also I think can be related sometimes to stress, trauma, et cetera, because the emotional part of the brain, it's not just the frontal lobe is underdeveloped, but the emotional part of your brain is actually hyperactive, and that can then in turn affect the, the way that the basal ganglia is functioning. So one other area, and there are other areas of the brain that are indicated in ADHD, but one other one that we wanted to focus on today was the cerebellum. So the cerebellum is typically thought to involve the coordination of motor movements, but it's also been found to have an important role in cognitive functions such as attention, which processing, executive functioning, error monitoring, inhibitory control, and working memory. Now that was quite a mouthful, Dr. Binus, do any of those kind of stand out to you that you wanted to comment on? Well, the one thing I think was interesting that they're looking at, so cerebellum actually has to do with balance as well. And so, if our cerebellum is damaged, for example, then it makes it difficult to walk in a straight line. And so one, one intervention that they've sometimes tried with kids with ADHD is learning, doing like balancing exercises and coordination exercises. And that does seem to help a significant proportion. And so, yeah, with the cerebellum, we're not sure if it's, you know, cause or effect. If it's that the ADHD actually causes the cerebellum to, in essence, either not develop properly or maybe even change, or if the cerebellar issues are actually part of what causes ADHD. So let's talk about some, some other potential causes and risk factors. So these are going to be more environmental, you know, risk factors. Any, you want to get us started? Well, one that really jumps out at me is actually media. And it's an interesting one because I think there's, there's certainly been some controversy around that. Does, you know, media really trigger ADHD and, and in, in my experience and also in looking at the literature, I think it can be a huge contributing factor. I don't think it's usually the one thing by itself. Oftentimes there's predispositions, there's other issues that are going on. Sometimes it might, if, if there's really a lot of excessive media overuse. And you know, simple study that I thought was really interesting is that there's researchers at the university of Sussex, they had three groups of individuals and they wanted to see how the, the phone, their smartphone actually affected their ability to focus. And so one group, they had their phone where they could actually see it. The other group was in their bag or somewhere, it was in the room, but it was where they couldn't see it. And then the third group actually had their phones away from them outside of the room. And so they saw a distinct difference between each one of those groups. The ones that had the phone removed out of the room actually had the best focus. And then those that had it where they could see it had the worst focus and, and this, the tricky thing about a phone and our use of media is oftentimes we don't realize that it is impairing our ability to stay on task and to focus. And there's other studies that have shown, like for example, when people use a lot of social media, uh, that that also can increase, um, ADHD and they're, they're not a hundred, the researchers aren't a hundred percent sure yet, um, if the link is because social media actually does increase the risk of anxiety and depression and that in turn triggers more ADHD or if it's just more direct, um, uh, caught causal, but, uh, certainly we know that those factors all can occur together. Yeah. And I've, I've heard, um, don't quote me directly on this, but I've heard something like one hour a day of sort of leisure entertainment, that's, you know, via a screen, right? Can be enough to sort of impair one's ability to concentrate, uh, to a degree that's significantly recognized, you know, in the study that's done, right? So, and that specifically saying, like using technology for the purpose of pure entertainment versus using it for more productive means, um, is going to, um, impair, impair attention. It is interesting, you know, when you're, when you're saying the, the study previously about the prevalence nearly, nearly doubling within that 20 year timeframe, it just so happens to be the 20 year timeframe that's involved with like the technological revolution, right? So I'm thinking, yeah, the early 2000s is when people started getting computers in their home, right? The, uh, 2010s is when people, everybody started having, um, computers in their pockets, right? So, uh, there definitely seems to be something at play there, uh, that is worthy of considering. And one other thing I'd say is, you know, for those that are maybe skeptical about how much media may play a role, um, or, or just technology may be playing a role in this is that while the evidence for, uh, this causing ADHD is not super clear for, um, not everybody would necessarily agree on it. Um, the, I think most people would realize that the preponderance of evidence is much more on that side of the aisle than on the other side of, of it being good for, you know, attention and, um, those that deal with ADHD symptoms. Yeah. We have to be really careful to realize, you know, when we have a previous position towards a media addiction, any kind of, uh, or just overd or reuse, maybe we'll say, but there's also an element of denial because especially if we're tending to overuse, uh, media, we don't want to really recognize that we don't have, you know, it's everyone else's problem. It's not my problem. Right. And so we, I think it's important to be open-minded with this. So a couple of the risk factors we'll just briefly address, um, brain injury. Dr. Bynas mentioned that earlier as being a potential sort of cause or exacerbating factor exposure to environmental, environmental risks such as lead, excessive copper can be a problem as well. Um, alcohol and tobacco use during pregnancy, uh, can, uh, increase the likelihood of ADHD premature delivery and low birth weight. Yeah. So, you know, it does matter, uh, what's happening to that fetus when, uh, they're in utero. And so, um, yeah, moms have to take extra special care. Otherwise it can really increase the risk of ADD in your kids. So we'll, uh, we'll conclude with, uh, treatment options for ADHD and we won't spend too much time on this cause, uh, as, as Dr. Bynas said earlier, this is going to be a series. And so I'll have much more time to kind of go through a lot of the more, uh, especially the holistic treatment options, um, in, in much more detail. But Dr. Bynas, why don't you tell us a little bit about just some of the medications that are used? Sure. So the main stay of treatment, uh, for ADHD has been, and I'm sure will continue to be a stimulant medication. Uh, so by stimulant medication, we're talking about medications like Ritalin, Adderall, Vivants, uh, Focalin, uh, those sorts of medications. And those medications actually work by increasing the availability of norepinephrine and dopamine, which in turn actually stimulates, uh, the prefrontal cortex to be able to, uh, focus. And you think like, well, a stimulant, how does that make sense to somebody that is actually already impulsive and seems like they're overstimulated, right? Uh, so what's interesting is that, uh, when you give the frontal lobe enough stimulation, not overstimulation, but just enough, uh, then that actually allows it to focus. Now, when people actually use, um, drugs like methamphetamine, which actually has the same, uh, mechanism of action as these, um, stimulant medications, it's a lot higher of a dose. And that high level dose of methamphetamine, instead of making people, you know, focus better will actually, it will impair frontal lobe function, especially in the longterm. And so that doesn't work. So the stimulant medications are different in that the, the doses are actually very small, just enough to actually cause the frontal lobe to work better. So would it be safe to say it's similar to micro dosing of sorts? Uh, we'll leave it at that. But, um, what are some other medications that are sometimes used? So there's also the non-stimulate medications, uh, ones like strutera. And then actually interestingly enough, there's, and, and well butchering off label as well. Th, those actually are, um, what we call SNSS and our eyes, well, what they do is they inhibit the reuptake of norepinephrine and on some levels, probably dopamine as well. Um, and then there's also some antihypertensives, uh, which should be like blood pressure, blusher, blood pressure pills. And Jonathan, I don't know if you want to comment on how, how those can sometimes be helpful for. Yeah. I find that they're often more helpful for the impulsive part. And so I don't really find a lot of utility in them, in my adult population, unless they tend to be somebody that had deals with, say a lot of anxiety, um, really strong sort of racing thoughts. And they need, uh, maybe they're taking some time off from their stimulant medication on some days or they have difficulty falling asleep. Those medications I will sometimes use as an adjunct, but in general in the adult population, not as, not as useful in my experience. Yeah. Like you said, the impulsivity, the hyperactivity as well. So what about supplements, Jonathan? So there's a couple that are, that can be definitely really useful as a baseline, often iron, zinc, omega threes, or a good, uh, a good combination in addition to magnesium. And then there's some more kind of niche supplements that sometimes I'll stack things like ltyrazine, which is the dopamine precursor. It's going to be no acid that, that can help to upregulate dopamine. Uh, things like lthianine can be calming. And there's been a number of studies looking at, uh, lthianine, especially for the, uh, for sleep, yeah, for people with ADHD, um, and pine bark, uh, which helps with cerebral blood flow. Um, so there's been some, some convincing evidence suggesting that that's useful. So if you see Jonathan nine on a tree outside, you'll know, he's not acting like a beaver. You're just getting that pine bark, right? Exactly. So, and, and I found that, you know, for some people, B six does seem to help a little bit as well. So yeah. And we'll get into more of that in subsequent episodes as well. Um, and then behavioral therapy is, is, is another really important thing to consider when we're talking about ADHD interventions. Um, when we think about that, uh, what we're talking about is actually identifying, uh, ways of becoming more organized and, uh, essentially being very intentional with the choices that people are making, how they're spending their time getting schedules and that sort of thing to help them manage these symptoms. And there is actually there's, there's, there's evidence to, uh, that has demonstrated that has demonstrated convincingly that, uh, appropriate behavioral therapy over the longterm can now perform stimulant medication. So it, it's harder to get a lot of times, right? And it takes longer, but for those that are committed to the process and can find a therapist, uh, that is, uh, you know, well qualified in this, uh, they can definitely get some good results. Yeah. And so if you're willing to put in the effort, you can get good results, but that's part of the problem with ADD is like the follow-through and all of that. So the last point of, uh, intervention for ADHD that we'll mention, uh, in this episode is lifestyle changes. And, uh, the most important one of those is exercise. Exercise. All right. Yes. So exercise has actually shown, been shown to be extremely beneficial when it comes to, um, helping ADHD symptoms and also a diet can be a factor as well. Do you have, just out of curiosity, do you think there's a best form of exercise for those with ADHD? Well, I would definitely say that cardiovascular exercise where you're, you know, you're getting your heart rate pumping, you're getting your blood really flowing to your brain, uh, would be the most, uh, important. And then, you know, when we think about the, um, elements of neuroplasticity, ideally have, there's several things there, but not just doing like exercise machines. Like if you're outside, if you have like new sort of, uh, things that you're trying, whether it's running on a new trail or something like that. So there are some nuances there of types of exercise that can be most beneficial. Yeah. For me personally, in being able to kind of recognize what helps my mental health and my, uh, focus, the best, uh, trail running has, has definitely been, um, the most obvious in terms of the benefit. Uh, but you, you did mention, uh, you mentioned healthy diets, also, uh, getting adequate sleep and lastly, uh, reducing screen exposure, right? Is, is going to be another big component for a lot of people. Absolutely. And so I always emphasize with, uh, young people, uh, children, children, adolescents, uh, you want to really keep just the entertainment media less than an hour and then adults, uh, less than an hour and a half per day. So yeah, well, that's about all we're going to cover today in this first episode of the series on ADHD. I hope this has been, uh, informative and, uh, that there's some good key take home points. And, uh, I hope you'll join us in the subsequent episodes, uh, to learn more about not only how to recognize, but also how to treat and manage ADHD. So if you only take one thing away from today's show, remember this, if mental illness is a whole person problem, then it must have a whole person solution. I'm Dr. Daniel Bynas and I'm Jonathan Edens. And you've been listening to the brain people podcast. Thanks for listening to hear more episodes, find us on social media or support us financially. Visit the brain people podcast.com. you