Life Problems from ADHD

Children diagnosed with ADHD face considerably worse long-term outcomes than do those children who do not receive such a diagnosis. In one investigation, 135 adults who had been identified as having ADHD symptoms in the 1970s were contacted decades later and interviewed (Klein et al., 2012). Compared to a control sample of 136 participants who had never been diagnosed with ADHD, those who were diagnosed as children

• had worse educational attainment (more likely to have dropped out of high school and less likely to have earned a bachelor’s degree);
• had lower SES;
• held less prestigious occupational positions;
• were more likely to be unemployed;
• made considerably less in salary;
• scored worse on a measure of occupational functioning, indicating, for example, lower job satisfaction, poorer work relationships, and more firings;
• scored worse on a measure of social functioning, indicating, for example, fewer friendships and less involvement in social activities;
• were more likely to be divorced; and
• were more likely to have non-alcohol-related substance abuse problems. (Klein et al., 2012)

Longitudinal studies also show that children diagnosed with ADHD are at higher risk for substance abuse problems. One study reported that childhood ADHD predicted later drinking problems, daily smoking, and use of marijuana and other illicit drugs (Molina & Pelham, 2003). The risk of substance abuse problems appears to be even greater for those with ADHD who also exhibit antisocial tendencies (Marshal & Molina, 2006).

Causes of ADHD

Family and twin studies indicate that genetics play a significant role in the development of ADHD. Burt (2009), in a review of 26 studies, reported that the median rate of concordance for identical twins was 0.66 (one study reported a rate of 0.90), whereas the median concordance rate for fraternal twins was 0.20. This study also found that the median concordance rate for unrelated (adoptive) siblings was 0.09; although this number is small, it is greater than zero, thus suggesting that the environment may have at least some influence. Another review of studies concluded that the heritability of inattention and hyperactivity were 71% and 73%, respectively (Nikolas & Burt, 2010).

Figure 1. The left prefrontal cortex is often affected in ADHD.

The specific genes involved in ADHD are thought to include at least two that are important in the regulation of the neurotransmitter dopamine (Gizer, Ficks, & Waldman, 2009), suggesting that dopamine may be important in ADHD. Indeed, medications used in the treatment of ADHD, such as methylphenidate (Ritalin) and amphetamine with dextroamphetamine (Adderall), have stimulant qualities and elevate dopamine activity. People with ADHD show less dopamine activity in key regions of the brain, especially those associated with motivation and reward (Volkow et al., 2009), which provides support to the theory that dopamine deficits may be a vital factor in the development this disorder (Swanson et al., 2007).

Brain imaging studies have shown that children with ADHD exhibit abnormalities in their frontal lobes, an area in which dopamine is in abundance. Compared to children without ADHD, those with ADHD appear to have smaller frontal lobe volume, and they show less frontal lobe activation when performing mental tasks. Recall that one of the functions of the frontal lobes is to inhibit our behavior. Thus, abnormalities in this region may go a long way toward explaining the hyperactive, uncontrolled behavior of ADHD.

By the 1970s, many had become aware of the connection between nutritional factors and childhood behavior. At the time, much of the public believed that hyperactivity was caused by sugar and food additives, such as artificial coloring and flavoring. Undoubtedly, part of the appeal of this hypothesis was that it provided a simple explanation of (and treatment for) behavioral problems in children. A statistical review of 16 studies, however, concluded that sugar consumption has no effect at all on the behavioral and cognitive performance of children (Wolraich, Wilson, & White, 1995).

Figure 2. Although foods with high sugar content aren’t likely to be healthy and may contribute to temporary hyperactivity even in children without ADHD, no evidence supports the idea that the avoidance of sugar prevents or cures ADHD.

Additionally, although food additives have been shown to increase hyperactivity in non-ADHD children, the effect is rather small (McCann et al., 2007). Numerous studies, however, have shown a significant relationship between exposure to nicotine in cigarette smoke during the prenatal period and ADHD (Linnet et al., 2003). Maternal smoking during pregnancy is associated with the development of more severe symptoms of the disorder (Thakur et al., 2013).

Is ADHD caused by poor parenting? Not likely. Remember, the genetics studies discussed above suggested that the family environment does not seem to play much of a role in the development of this disorder; if it did, we would expect the concordance rates to be higher for fraternal twins and adoptive siblings than has been demonstrated. All things considered, the evidence seems to point to the conclusion that ADHD is triggered more by genetic and neurological factors and less by social or environmental ones.

Treatment

The management of ADHD typically involves psychotherapy or medications either alone or in combination. While treatment may improve long-term outcomes, it does not get rid of negative outcomes entirely. Medications used include stimulants and sometimes antidepressants. In those who have trouble focusing on long-term rewards, a large amount of positive reinforcement has shown to improve task performance. ADHD stimulants also improve persistence and task performance in children with ADHD.

The use of behavioral therapies in ADHD is the recommended first-line treatment in those who have mild symptoms or are preschool-aged (and often too young for medication). Psychological therapies used include the following: psychoeducational input, behavior therapy, CBT, interpersonal psychotherapy, family therapy, school-based interventions, social skills training, behavioral peer intervention, organization training, parent management training, and neurofeedback. Training in social skills, behavioral modification, and medication may have some limited beneficial effects. The most important factor in reducing later psychological problems, such as major depression, criminality, school failure, and substance use disorders, is the formation of friendships with people who are not involved in delinquent activities.

Figure 3. Exercising while on stimulant medication augments the effect of the medication on executive function. It is believed that these short-term effects of exercise are mediated by an increased abundance of synaptic dopamine and norepinephrine in the brain.

Regular physical exercise, particularly aerobic exercise, is an effective add-on treatment for ADHD in children and adults, particularly when combined with stimulant medication, although the best intensity and type of aerobic exercise for improving symptoms are not currently known. In particular, the long-term effects of regular aerobic exercise in ADHD individuals include better behavior and motor abilities, improved executive functions (including attention, inhibitory control, and planning, among other cognitive domains), faster information processing speed, and better memory. Parent-teacher ratings of behavioral and socio-emotional outcomes in response to regular aerobic exercise include better overall function, reduced ADHD symptoms, better self-esteem, reduced levels of anxiety and depression, fewer somatic complaints, better academic and classroom behavior, and improved social behavior.

Stimulant medications are the pharmaceutical treatment of choice. Stimulants have at least some effect on symptoms: in the short term, in about 80% of people. Methylphenidate appears to improve symptoms as reported by teachers and parents. There is little evidence on the effects of medication on social behaviors and as of 2015, the long-term effects of ADHD medication have yet to be fully determined. MRI studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD. A 2018 review found the greatest short-term benefit with methylphenidate in children and amphetamines in adults.