ADHD: Beyond the Classroom

ADHD: Beyond the Classroom

by
ADHD

Hello brave parents and caregivers!

I realize there is controversy surrounding the diagnosis and treatment of ADHD. Professionally and personally, I’ve encountered parents whose children have been diagnosed with ADHD but are hesitant to pursue treatment. Some cite particular discomfort with medication treatment related to concern about side effects or changing their child’s personality.

Dear parents, please let me be clear that I cannot make recommendations about the diagnosis and treatment of your child in the absence of a patient-doctor relationship. That said, over many years of practicing child and adolescent psychiatry, I’ve seen how the effects of untreated ADHD extend beyond the classroom. Untreated ADHD cannot only pose an academic burden, it also carries psychological, social, mental health, legal, and financial consequences.



The ADHD Brain: Executive Functioning

First, more about the ADHD brain. The ADHD brain is unique, complex, and not completely understood.  As in What You Really Need to Know About ADHD, it is thought that differences in the dopamine reward system affect what motivates kids with ADHD.  

In addition, the chemical and physical makeup of the frontal brain system may be different in kids with ADHD, leading to problems with executive functioning. Executive functioning involves the skills needed to perform tasks—planning, organizing, and starting a task then following it through to completion. Executive functioning skills are critical for kids to achieve independence and realize their full potential.


For a lot of children with ADHD, executive skills are impaired. For many, these include deficits in 1:

  1. Response inhibition: Thinking before acting (self-explanatory!).

  2. Working memory: Remembering information while following through with multistep directions (e.g., a daughter who struggles to complete a task of picking up her clothes then bringing her laundry downstairs).

  3. Time management: Having a sense of time, estimating how long a task will take, and adequately allotting time for a task (e.g., an adolescent who cannot meet school project deadlines).

  4. Sustained attention: Maintaining attention on something that is not considered interesting (e.g., a young child who cannot stay focused on folding his laundry or a teenager who cannot complete homework).

  5. Goal-directed persistence: Making, following through with, and completing a goal (e.g., a young child who struggles to get her desk in order for the day’s desk check).

  6. Task initiation: Beginning an assignment without delay (e.g., a young child who doesn’t start a chore right after you’ve asked or a teenager who waits until the last minute to start a project).


But how do brain differences in motivation and executive functioning interfere in real life?


The Effects of Untreated ADHD: The Research Is What It Is

Mental Health

  1. ADHD increases the risk of substance and alcohol abuse and is associated with using substances at a younger age.  Compared with kids with controlled ADHD symptoms, kids with uncontrolled symptoms are more likely to turn to substances. Furthermore, the combination of ADHD and substance use increases the risk of suicide attempt and depression. Indeed, children and adolescents with ADHD have a suicide rate three times higher than the national average.

  2. Children with uncontrolled ADHD who exhibit hyperactivity may be at higher risk for developing oppositional defiant disorder (ODD) or conduct disorder (CD). ODD and CD are behavioral disorders marked by a pattern of uncooperativeness, aggression, and defiance. CD is particularly serious and involves engaging in behavior that violates societal norms, such as stealing, bullying, or cruelty to animals .2

  3. It is common for people with ADHD to ruminate, or become fixated on repetitive negative thoughts. Why is this? The inattentive type of ADHD is linked to “sluggish cognitive tempo”—daydreaming and low activity.  And sluggish cognitive tempo is linked to ruminating. Ruminating is highly uncomfortable and associated with suicidal behavior, depressive, and anxiety symptoms. Anecdotally, some patients report that ruminating improves with ADHD treatment.3




Relationships

  1. Uncontrolled ADHD can lead to emotion and behavior dysregulation that negatively affects relationships with peers and adults. Not surprisingly, an inability to maintain positive relationships can take a major toll on a kid’s self-esteem.

  2. An estimated 25-70 % of kids retain an ADHD diagnosis into adulthood. Parents with ADHD may struggle to control their emotions and impulses, leading to conflict in the home and negative interactions with their children. 2


Development

Kids with ADHD can lag 1-3 years behind their peers in cognitive development, which may be compounded when symptoms are untreated. This could translate to deficits in learning, weakness in language skills, and reduced capacity for self-care.4 Women with ADHD may lag 10 years behind in their development, particularly with regard to education, employment, and attaining independence. 5


Social

  1. Untreated ADHD can affect social development. Poor listening skills, low frustration tolerance, and behavior dysregulation (e.g., interrupting, intruding on peers’ space, having trouble taking turns) can make it challenging for kids with ADHD to make and keep friends, ultimately driving peers away.

  2. Based on my clinical observations, challenges in decision-making can play out in heartbreaking ways. Difficulty with executive functioning (particularly when coupled with impulsivity) can result in adolescents with ADHD who are easily influenced by outside sources when it comes to decision-making.  This may, for example, involve succumbing to social media or peer pressure to send inappropriate photos, do drugs, or have sex.

Untreated ADHD is associated with higher rates of imprisonment, speeding, traffic violations, motor vehicle accidents, and criminality.

Financial

Untreated ADHD can lead to job instability, lower work efficiency (and longer work hours), and lower incomes.

Mortality

ADHD carries a higher mortality rate, particularly when coupled with ODD, CD, or a substance use disorder. 2

ADHD is Like Having a Superpower

If you’re reading this and feeling deflated, I understand. The research is what it is, but this is tough information to swallow.

In my eyes, though, ADHD is also kinda like having a superpower. Individuals with ADHD are bright, creative, spontaneous, and inspiring. As creative problem-solvers who think outside the box, they are assets to any school or work environment. Yes, they may be sensitive, but this also shows up as empathy, kindness, and generosity. And, yes, they make be risk-takers, but channeled risk-taking produces new ideas, innovations, and perspectives that have potential to benefit humanity. Also, it’s worth adding that careful, individualized treatment for ADHD should not compromise these attributes.


A Little on ADHD Treatment

Making decisions about how to approach management of ADHD can be challenging. Medication is considered the gold standard, but treatment for ADHD can encompass multimodal strategies involving parent training, school interventions, cognitive-behavioral therapy, skills training, psychoeducation, and/or medication.

If you’re interested in learning more about executive functioning and ADHD, check out Dawson and Guare’s Smart but Scattered; it’s a helpful resource for gaining insight into a child’s executive functioning strengths and weaknesses and for learning strategies to strengthen kids’ executive functioning skills.
  

Brave parents and caregivers,

If I’ve left you with anything, I hope it’s the knowledge that kids with ADHD have unique and complex brains. Their emotional and behavioral lives may seem more intense or disruptive, but this is driven by neurobiology, not flawed character. If you suspect your child may have ADHD, please seek evaluation with your pediatrician or a qualified health professional.


Until next time,

References:

  1. Dawson P. and Guare R. (2009). Smart but Scattered. The Guilford Press.
  2. Hamed AM, Kauer AJ, and Stevens HE. Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters (2015). Frontiers in Psychiatry. 1-10.
  3. Fredrick JW, Kofler MJ, Jarrett MA, et al. (2020). Sluggish cognitive tempo and ADHD symptoms in relation to task-unrelated thought: Examining unique links with mind-wandering and rumination. J Psychiatr Res. 123: 95-101.
  4. Berger B, Slobodin O, Aboud M, Melamed J and Cassuto H (2013). Maturational delay in ADHD: evidence from CPT. Front Hum Neurosci. 7: 691.
  5. O’Hara D. (2019) Ellen Littman brings attention to women with ADHD. American Psychological Association. https://www.apa.org/members/content/women-adhd

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