Attention Deficit Hyperactivity Disorder

 

Attention deficit hyperactivity disorder (ADHD) is a complex neurobiological condition that affects a person’s ability to exert age-appropriate self-control. ADHD is characterised by persistent and developmentally inappropriate patterns of hyperactivity-impulsivity and inattentiveness (American Psychiatric Association, 2013), and is frequently accompanied by emotional regulation challenges (Beheshti et al., 2020). It is associated with a broad range of neuropsychological differences (Onandia-Hinchado et al., 2021) that significantly compromise a person’s ability to self-regulate. These differences appear to arise from atypical brain development, neural anatomy and functional processing.

ADHD is highly genetic in nature and tends to affect a person’s everyday function, self-esteem and self-worth, mental and physical healthy, and quality of life across the life course. Research indicates ADHD is a risk factor for poor academic achievement, social rejection and isolation, and the development of anti-social behaviour, anxiety and depression, alcohol and substance abuse issues and eating disorders. Later in life, it is also a risk factor for workplace and financial difficulties; relationship breakdown and divorce; driving infringements; accidents and injuries; criminality; self-harm and suicide; and other adverse long-term health outcomes which can reduce life expectancy (Cherkasova et al., 2021; Faraone et al., 2021; Franke et al., 2018).

To mitigate these risks, it is vital children and adults with ADHD receive the treatment and support they required to develop in a healthy manner and thrive.

 

What is self-regulation?

Russell Barkley (2014) defines self-regulation as the ability to inhibit, to delay, to separate thought from feeling, and to consider an experience and change perspective.

Being able to self-regulate enables a person to pause, contemplate alternative options or perspectives, choose how one is going to respond in-the-moment, and take wilful, considered action that facilitates goal attainment and positive social standing. While poor self-regulation leads to impulsive, thoughtless behaviour that is reactionary, inconsistent, risky, unpredictable, and sometimes, downright dangerous. Behaviour that can derail goal attainment and destroy relationships. 

Although social interactions shape and affect a person’s ability to self-regulate, a person’s innate capacity to self-regulate does not appear to be developed through social interactions. Instead, one’s capacity to self-regulate appears to be neurogenetically determined.

 

Isn’t everyone inattentive or impulsive sometimes?

Yes. However, while it is common for everyone to occasionally be impulsive or inattentive, a person with ADHD will be more frequently challenged and more severely impaired by these traits in comparison to another person of the same age or developmental stage.

 

Executive cognitive abilities

Executive function is an umbrella term that describes the top-down, intentional mental abilities people rely on to monitor and control their thoughts, words, actions and emotions. They also enable a person to perceive time, delay gratification, plan and problem-solve and take action over time and thus facilitate goal attainment and social success.

The use of one’s executive function (or controlled processing) is effortful, limited by the amount of information that can be processed at one time, as well as slow and prone to errors (Fabio, 2017). However, controlled processing is also flexible. It enables a person to consider alternative options or perspectives.

While there is no universally accepted definition of the term executive function (Barkley, 2012), most academic papers refer to the executive functions as the neurocognitive processes that assist with problem-solving and goal attainment. They also tend to agree that the executive functions include response inhibition, working memory and cognitive flexibility.

Executive function abilities develop sequentially (one skill-building atop the next) inline with brain development, starting around age two, and tend to be fully developed by age 30. However, research indicates:

• Brain development in children with ADHD may be significantly delayed, possibly by 2-3 years. As a result, children with ADHD may develop their executive cognitive abilities much more slowly than their neurotypical peers. 
• Children with ADHD continue to display atypical brain anatomy and connectivity in adulthood and do not develop the same executive function capacity of neurotypical adults.

 

Non-executive cognitive abilities 

Non-executive functions refer to the bottom-up, automatic (or reflexive) mental processes involved in sensory processing, perception, language development and learning. These mental processes are fast, effortless and tend to be error-free (Fabio, 2017). They work simultaneously with other cognitive processes and can be involuntarily accomplished (Fabio, 2017).

The non-executive function or automatic cognitive processes are proposed to include:

• alerting attention
• reward processing
• long-term memory.

Research indicates that it is possible that individuals with ADHD may have atypical automatic cognitive processes that impact alertness, non-executive attention, and information/memory coding and recall.

 

The non-executive functions and executive functions work together

There is an inextricable (entangled/inseparable) bidirectional relationship between the non-executive functions and the executive functions.

For example, while the ability to regulate attention and behaviour relies on a person’s executive function capacity, the information acquired while controlling attention and behaviour is encoded for storage by their automated cognitive processes and becomes part of the embedded information resource they use during automated cognitive processing (Fabio, 2017).

In regards to ADHD, ADHD-related executive function challenges (i.e., difficulty regulating thoughts, words, actions and emotions), and the ADHD-related atypical automated cognitive processing (i.e., atypical  information processing and memory encoding), impede a person’s ability to learn and acquire more complex concepts. They also result in the acquisition of less efficient automatic cognitive processing as when basic mental processes are not well automatised, cognitive load increases. This is proposed to lead to a person’s automated cognitive process completing with their executive function for limited resources (Fabio, 2017), and may result in a person’s mental load exceeding their information storage and rehearsal capacity (Sarver, & Raiker 2010).

 

Situation variability

The executive function difficulties and associated symptoms experienced by individuals with ADHD are generally more or less pronounced depending upon the environment they are in, as well as the demands placed upon them. For example, Barkley (2015) informs us:

• Individuals with ADHD display fewer symptoms when in novel or unfamiliar surroundings or when tasks are more unusual and interesting.
• The more complicated a task is (or the more a task relies on planning, organisation and self-regulation of behaviour) the more evident ADHD symptoms will be.
• ADHD symptoms are also more evident when tasks are deemed boring or tedious, or when reward for effort is delayed (delayed gratification), with the exception of hyperfocus which is more evident when an individual engages in a task that they find immensely interesting.
• Immediate reward or positive reinforcement can reduce ADHD symptoms and increase participation, compliance and completion.
• Fatigue (tiredness) and time of the day can impact on ADHD symptom severity.

 

An important message

As you can determine from the above information, ADHD related hyperactivity-impulsivity and inattentive behaviour is due to a natural, inbuilt tendency rather than wilful, self-determined action. 

Unfortunately, many people still blame parents for their child’s ADHD related challenges or believe ADHD is just an excuse for naughty or disrespectful behaviour. Whilst others interpret ADHD related situation variability or an individual with ADHD’s struggle to achieve their goals as a sign that the individual with ADHD is not trying hard enough, is deliberately not paying attention or is unintelligent and lacks knowledge and skills. Many also attribute ADHD related emotional dysregulation and social inappropriateness to selfishness and rudeness.

However, as you can see, this is far from the truth. These assumptions are also harmful.

Many individuals with ADHD report trying so hard, over and over again, and still not being able to achieve their goals or meet societal expectations. This failure makes them think negatively towards themselves – “there is something wrong with me,” “no matter what I do it is never good enough,” and sometimes “what is the point of trying?” These feelings, accompanied by the resultant criticism from self and others, can lead to poor self-esteem and toxic shame, and contribute to an individual with ADHD developing anxiety and depression. The risk of suicide is thought to be 1.8 times higher for individuals with ADHD.

Please help fight against this misinformation and stigma surrounding ADHD, and actively support individuals with the disorder by showing them compassion and understanding, so they can learn to successfully manage their symptoms to the best of their ability and achieve to their full potential.

For a deeper understanding of ADHD please click on the links below.

 

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association.

Barkley, R.A. (2015). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. New York: Guilford Publications.

Brown, T. (2017). Outside the Box: Rethinking ADD/ADHD in Children and Adults—A Practical Guide. Arlington, VA: American Psychiatric Publishing.

Cherkasova, M., Sulla, E. M., Dalena, K. L., Pondé, M. P., & Hechtman, L. (2013). Developmental Course of Attention Deficit Hyperactivity Disorder and its Predictors. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 22(1), 47–54.

Cunha, M., Almeida, R., Cherpe, S., Simões, S., & Marques, M. (2017). A longitudinal approach to the contribution of trauma and external shame on depressive symptoms in adolescence. European Psychiatry, 33 , S139 – S140.

Egger, H.L., Kondo, D., & Angold, A. (2006). The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: A review. Infants & Young Children, 19(2), 109–122.

Galéra, C., Côté, S.M., Bouvard, M.P., Pingault, J., Melchior, M., Michel, G., Boivin, M., & Tremblay, R.E. (2011). Early Risk Factors for Hyperactivity-Impulsivity and Inattention Trajectories from Age 17 Months to 8 Years. Archives of General Psychiatry, 68(12),1267-1275.

Gerrig, Richard J., & Philip G. Zimbardo. (2002). Psychology and Life, 16^th Ed. Allyn & Bacon; Boston, MA.

Lahey, B.B., Pelham, W.E., Loney, J., Lee, S.S., & Willcutt, E. (2005). Instability of the DSM-IV Subtypes of ADHD from preschool through elementary school. Archives of General Psychiatry, 62(8), 896–902.