ADHD: Insights into Development, Emotions, and Treatment

Imagine Tigger from Winnie the Pooh, bouncing around with boundless energy, full of enthusiasm but often struggling to stay focussed. Tigger’s impulsive actions and constant need for movement are traits that many associate with ADHD (Attention Deficit Hyperactivity Disorder), a neurodevelopmental disorder affecting both children and adults. While Tigger’s behaviour is endearing in the world of the Hundred Acre Wood, for real people with ADHD, these characteristics can lead to daily challenges that affect their lives in significant ways.

Understanding ADHD and its impact is key to recognising how it shapes behaviour, learning, and relationships in the real world. ADHD is not just about being hyperactive; it’s a condition that affects attention, impulsivity, and emotional regulation. Research conducted by the Centers for Disease Control found that around 7 million individuals aged 3-17 are diagnosed with ADHD. The Global Health Epidemiology Reference Group (GHERG) in 2020 found that 6.76% of the world population – a staggering 366.33 million adults live with ADHD Despite its prevalence, many still misunderstand ADHD. It’s easy to dismiss it as merely an excuse for fidgety children or forgetful adults, but the reality is far more complex.

What is ADHD?

To understand this concept better, let’s break it down into its components:

• Attention: This refers to the ability to focus and concentrate on a specific task. People with ADHD struggle with this aspect, often losing focus easily and frequently. Their attention shifts rapidly from one point to another, and they become easily distracted by various stimuli in their environment, making it difficult to concentrate on a single task.
• Deficit: A deficit means a lack of something. In the case of ADHD, it refers to a lack of sustained attention. Individuals with ADHD find it challenging to maintain focus and stay on track, which can hinder their ability to complete tasks or follow through on plans.
• Hyperactivity: Hyperactivity involves excessive movement, energy, and impulsive actions, which can vary by age and individual. Common signs include fidgeting, squirming, or tapping, difficulty sitting still, and moving around when expected to stay in place. People with hyperactivity may talk excessively, interrupt others, and answer questions before they’re fully asked. They also struggle with quiet play, are easily distracted, and have a short attention span, making it tough to focus on tasks or remain calm in structured settings.
• Disorder: A disorder is a condition that disrupts normal physical or mental functions, causing significant difficulties, distress, impairment, or discomfort in daily life.

This aligns with the Centers for Disease Control and Prevention’s definition of ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that:

• Interferes with functioning or development
• Presents in two or more settings (e.g., at home, school, or work)
• Negatively impacts social, academic, or occupational functioning

Simply put, ADHD is a condition where individuals frequently have trouble paying attention, sitting still, or controlling impulses. With long-lasting effects that occur across various settings, such as home, school, or work, ADHD significantly impedes daily life, making it challenging to focus on tasks and maintain healthy social relationships.

Polanczyk, Casella, Miguel, and Reed (2024) noted that individuals with ADHD, due to their impulsivity and inattention, are likely to be associated with negative consequences such as injuries, accidents, premature pregnancies and sexually transmitted diseases. They are also prone to develop psychiatric and psychological comorbidities such as conduct disorder, anxiety, mood disorders and antisocial behaviours.

Types of ADHD

ADHD is categorized into three primary types, based on the dominant symptoms: inattentiveness, hyperactivity/impulsivity, or a combination of both.

1. Inattentive Type

In the case of the inattentive type, hyperactivity and impulsivity are not prominent enough to be considered significant. However, symptoms of inattention or lack of focus are predominant, leading to difficulties with concentration and attention to detail. Symptoms may include a persistent pattern of difficulty maintaining focus and organization. Individuals may struggle to stay on task or quickly lose interest, finding it hard to complete activities.

They often appear not to listen when spoken to and may have trouble following instructions or processing details. Forgetfulness, simple mistakes, and difficulty with organization and planning ahead are common, leading to frequent misplacement of belongings. Activities that require sustained mental effort, like studying, become especially challenging and unenjoyable, contributing to ongoing frustration and difficulty in managing daily responsibilities.

2. Hyperactive/Impulsive Type

The second type is characterised by the predominance of hyperactivity and impulsivity meaning the individual is impulsive and hyperactive. But they don’t have trouble paying attention. Marked by impulsivity and difficulty with self-control, often manifesting in an inability to wait for one’s turn or interrupting others during conversations. Individuals may blurt out answers or speak before thinking, without waiting for the complete question or being called upon.

Controlling strong emotions can be a challenge, sometimes leading to outbursts of anger or frustration. Those with hyperactive ADHD may also engage in risky behaviours without fully understanding the potential consequences, driven by impulsive actions rather than careful consideration, making everyday social interactions and decision-making more difficult.

3. Combined Type

The third type, which involves the combination of both these types is called the Combined type and is the most common type of ADHD. Combined type ADHD can include symptoms of inattention, impulsivity, and hyperactivity. Combined type ADHD is characterized by a persistent display of both inattentive and hyperactive-impulsive symptoms. Individuals with this subtype meet the criteria for both types, showing signs of difficulty focusing as well as impulsive or hyperactive behaviour. Children with combined ADHD often struggle to pay attention in school and may have trouble staying seated during class or social situations. In adults, this form of ADHD can lead to challenges in managing tasks and maintaining relationships.

Wilens, Biederman, Faraone, Martelton, Westerberg and Spencer (2010) researched 107 individuals with ADHD and discovered that while inattentive symptoms were reported by more than 90% of the adults in the study, 62% had the Combined subtype, 31% the inattentive only and 7% the hyperactive/impulsive.

Role of hyperactivity and Impulsivity

So far, we’ve frequently linked ADHD with two key terms: hyperactivity and impulsivity. Let’s explore these concepts and how they relate to each other and their impact on individuals with ADHD.

Hyperactivity:

It is understood as continuous movements or an inability to sit still that can be disruptive in classrooms, homes, and other settings where some form of stability in behaviour is required. Hyperactivity may manifest as the individual becoming fidgety, tapping their hands or feet, or in some cases getting up from the seated position when it is expected of them to stay there. Overall, it translates to excess movement that does not fit the particular setting.

Impulsivity:

On the other hand, this reflects a lack of control over immediate reactions, leading to premature responses and actions without considering consequences. People with ADHD may often blurt out answers before a question is fully asked, struggle to wait their turn in conversations or activities, and frequently interrupt or intrude on others’ tasks or personal space. This impulsiveness is not limited to verbal exchanges—it can extend to decision-making, where individuals may act without thinking through potential long-term outcomes. These behaviours can interfere with social, academic, or occupational functioning, as the inability to regulate impulses often leads to misunderstandings.

Neurobiological Explanation of ADHD

ADHD has been understood as a condition that affects certain parts of the brain, especially those involved in planning, focusing, remembering things, and managing time, i.e., those involved in executive functioning. Brain imaging studies have shown that both children and adults with ADHD often have smaller brain structures, including the cerebrum, cerebellum, and cerebral lobes. These differences don’t seem to change as they grow older.

One study found that people with ADHD had smaller areas in the brain called the anterior cingulate cortex (ACC) and the dorsolateral prefrontal cortex (DLPFC). The DLPFC helps with working memory, which is the ability to hold information while using it for a task. This may explain why people with ADHD sometimes struggle with staying on task or reaching goals. The ACC is important for helping us stay focused on one task and make decisions.

Researchers have also looked at how the brains of people with ADHD develop over time. One study found that the cortical thickness (the outer layer of the brain) develops more slowly in children with ADHD compared to those without it. Although the general pattern of brain growth is similar in both groups, those with ADHD reach important development milestones later. Studies have shown that in adults with ADHD, these areas of the brain, especially the DLPFC, parietal areas, and ACC, remain thinner than in adults without ADHD. This shows that some brain differences continue into adulthood, potentially affecting focus and attention throughout life.

In the case of impulsivity, it is seen that the amygdala, which is a part of the limbic system, whose main function is to regulate emotions, is smaller in people with ADHD. Since the amygdala is involved in processing emotions, memories, and responses to stress or danger, its smaller size in adhd provides a possible explanation for intense emotional responses and the struggle with controlling impulsive actions. Interestingly, the right amygdala appears to have a larger influence on impulsivity and behavioural control than the left amygdala, which means that the right side might be more involved in how individuals manage their actions and reactions.

Research has shown that some structures in the brain in children with ADHD can be smaller than those areas of the brain in children without ADHD. In addition to this, it is seen Parts of the frontal lobe may mature a few years later in people with ADHD. Researchers have also identified several major networks that work differently in people with ADHD. These networks are involved in reward, focus, planning, attention, shifting between tasks, and movement.

Two neurotransmitters, chemicals that carry signals across a nerve synapse, work differently for individuals with ADHD. These are Dopamine and Norepinephrine. Norepinephrine (NE) plays a key role in ADHD by affecting attention, arousal, and executive functioning. NE acts as a neuromodulator, helping regulate overall alertness and focus by maintaining both tonic (sustained) and phasic (rapid) arousal. It enables individuals to stay alert during everyday tasks, like reading or studying and responds quickly to sudden stimuli, such as a loud noise, triggering heightened awareness and decision-making.

In ADHD, dysregulation of NE disrupts this balance. The locus coeruleus, a part of the brain that produces NE, helps process sensory information and determine the relevance of stimuli. When NE is not functioning properly in ADHD, it impacts the ability to filter out distractions, sustain attention, and engage in goal-directed behaviour. This explains why individuals with ADHD struggle with maintaining focus, controlling impulses, and staying on task. NE also interacts with other neurotransmitters, like dopamine, to manage executive functions like reasoning and problem-solving, which are often impaired in ADHD.

Dopamine (DA) plays a crucial role in the brain’s attention and reward systems, and its dysregulation is a key factor in ADHD. DA pathways originate primarily from the ventral tegmental area (VTA) and project to various regions, including the prefrontal cortex and nucleus accumbens, which are responsible for motivation, attention, and reward processing. In individuals with ADHD, there is a decreased sensitivity to dopamine, which affects their ability to sustain attention, particularly on tasks that are not intrinsically interesting. This explains why individuals with ADHD can hyper-focus on engaging tasks but struggle with mundane ones.

Dopamine also plays a significant role in executive functions such as working memory, planning, and impulse control. The mesocortical DA pathway connects to the prefrontal cortex, where it helps regulate thought processes and decision-making. When this pathway is underactive, as is common in ADHD, it impairs the brain’s ability to filter distractions, inhibit inappropriate responses, and maintain focus on long-term goals. This leads to common ADHD symptoms such as impulsivity, hyperactivity, and difficulty staying on task. Stimulant medications, like methylphenidate and amphetamines, enhance DA activity by blocking its reuptake, helping restore balance and improve attention and self-control in ADHD patients.

ADHD Across the Lifespan

Traditionally, ADHD has been viewed as a disorder that has its onset during childhood. However, with recent developments in research, it has been found that ADHD can develop during adulthood too. Concerning Childhood-Onset ADHD, DSMIII stated that symptoms appeared before age 7 and DSM5 stated before age 12. According to Franke (2018), for Adult-Onset ADHD, the idea that ADHD can emerge in adulthood is debatable, but these findings suggest that some individuals may have had imperceptible ADHD symptoms during childhood that only become fully apparent or led to significant impairment later in life, meaning ADHD symptoms can be subliminal, but not fully diagnosable until later.

Or, in some cases, ADHD symptoms were present but not recognized earlier. These individuals might have had ADHD symptoms in childhood that were either ignored or not entirely diagnosed, leading to a mistaken perception of adult-onset ADHD. With an early diagnosis of ADHD, its manifestations and corresponding complications are evidenced to change drastically over time.

In childhood, since ADHD is likely to be characterized by persistent inattention, hyperactivity, and impulsivity, common comorbid conditions include Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD), along with Autism Spectrum Disorders (ASDs), tic disorders, and learning disorders affecting reading, writing, and arithmetic. The presence of such comorbidities can exacerbate ADHD symptoms and increase the risk of future antisocial behaviours and mood disorders. As children with ADHD transition into adolescence, these symptoms and comorbidities evolve.

While hyperactivity may decrease, inattention and impulsivity often persist. During this stage, Substance Use Disorders (SUDs) become more prevalent, alongside mood and anxiety disorders.

Adolescents with ADHD are at higher risk of engaging in substance use and developing SUDs, and their ADHD symptoms can further impact academic performance, social relationships, and family dynamics. The challenges faced during this period can have long-lasting effects on educational attainment and career prospects.

In adulthood, ADHD symptoms can continue to affect work and personal relationships, though hyperactivity often diminishes. Persistent issues with organization, time management, and focus are common. The comorbidity profile shifts to include more mood disorders, anxiety disorders, and severe substance use disorders, with additional risks for antisocial personality disorder and sleep disorders. Thus, throughout the lifespan, the types of comorbidities experienced by individuals with ADHD evolve. An early diagnosis during childhood helps in managing and is crucial in mitigating the development of more complex comorbidities later on.

Life with ADHD and Treatment

Given the description of the disorder and the obvious impairment it causes, it could be easy to assume that life with ADHD is difficult, however, many individuals have described it as a “roller coaster of successes and failures”.

Jessica McCabe, creator of the YouTube channel How to ADHD, provides a candid portrayal of living with ADHD, blending the everyday struggles with moments of success. Her vivid account details the daily rollercoaster of distractions missed appointments, and the constant juggling act that characterizes ADHD. McCabe’s mornings often start in chaos, from missed alarms to last-minute scrambling, reflecting the common challenges of managing time and staying organized. However, McCabe also highlights the successes that come with ADHD.

Despite the hurdles, her hyperfocus allows her to dive deeply into projects, leading to significant accomplishments and a rewarding career. This ability to immerse herself in tasks, coupled with her persistence, demonstrates that ADHD while presenting ongoing challenges, can also foster creativity and lead to unique achievements. McCabe’s experience is a testament to how understanding and embracing ADHD can turn difficulties into opportunities for personal growth and success.

To further navigate the complexities of ADHD and leverage its strengths like McCabe, exploring various treatment options can be immensely beneficial. Medication is a cornerstone of ADHD treatment and typically includes central nervous system stimulants like Adderall and Ritalin, which help enhance focus and reduce hyperactivity. For those who cannot tolerate stimulants, non-stimulant medications such as Strattera and certain antidepressants may be prescribed. Both types of medication come with potential side effects, ranging from minor issues like insomnia and appetite loss to more serious concerns such as hallucinations or suicidal thoughts. Therefore, it’s crucial to work closely with a healthcare provider to find the most suitable medication and dosage.

In addition to medication, therapy plays a vital role in managing ADHD. Psychotherapeutic interventions, including cognitive behavioural therapy (CBT) and behaviour therapy, can help individuals develop coping strategies, improve time management, and address negative thought patterns. Support groups and social skills training are also beneficial, offering valuable connections and techniques for improving interpersonal interactions. By understanding and utilizing these treatments, individuals with ADHD can enhance their quality of life and harness their unique abilities more effectively.