The brain, like a surly movie critic or a high school clique, specializes in rejection. The chief rejecter is the brain’s decision-making center in the prefrontal cortex, just behind your forehead. Signals flood in from other brain regions, and all over the body. Most get vetoed.
Get up while having a conversation with the boss? Absolutely not. Pick up the phone while a spouse is pouring their heart out about a bad day? No. Say the real thoughts about a friend’s new outfit? Nope.
“We all drift, but we can usually pull ourselves back,” said Rachel Fargason, M.D., Patrick Linton professor of psychiatry and department value officer in the University of Alabama at Birmingham’s Department of Psychiatry and Behavioral Neurobiology. “People with attention-deficit/hyperactivity disorder, as a group, have lower levels of dopamine receptor activity in key portions of the brain involved in cognitive control.”
She often uses a battery pack as an example with patients. “It is as though the executive control center of your brain is on low power.”
According to the Centers for Disease Control and Prevention, nearly 6 percent of adults in the United States have ADHD. Fargason says the real problems for adults with ADHD are sustaining attention for tasks they find boring or routine — and high levels of distractibility. The normal attention span in someone with an average IQ is 50 minutes, which is why a typical class is set for that time frame, she says.
One of her favorite initial screening questions is to ask a patient, “How long can you sit and read something that is not super interesting to you?” If the answer is “two minutes, and I’d have to re-read it,” that is a hallmark of ADHD.
“For a long time, ADHD was over-diagnosed in primary care and underdiagnosed in psychiatry. A lot of people were being treated for depression, bipolar disorder or anxiety when they had underlying ADHD,” she said. “I have had patients come in with a diagnosis of anxiety, but what they are anxious about is they can’t get anything done. I say, ‘Your anxiety is secondary to what seems to be an underlying ADHD.’”
This does not mean that ADHD is at the root of all problems with concentration and focus, Fargason notes. There is overlap between ADHD and other psychiatric conditions, as well.
“About 50 percent of people who meet criteria for ADHD also meet criteria for generalized anxiety disorder, and about a quarter will have at least one depressive episode,” Fargason said. “I would argue that treating the ADHD often will help with the depression or anxiety as well; but if the depression or anxiety is profound, we will treat that first.”
About 70 percent of people respond to treatments for depression, but the efficacy rate for psychostimulant medications in ADHD such as Adderall and Ritalin is “extremely high — 90-plus percent,” Fargason said.
For those adults who do have ADHD, Fargason recommends implementing the following behavioral strategies to assist with day-to-day life.
Set a sleep schedule: “What I have observed from treating adults with ADHD over the years is that most have some form of insomnia,” Fargason said.
Fargason and Karen Gamble, Ph.D., her colleague in the psychiatry department, found in their own research and in a review of literature that “about 70 percent of adults with ADHD have delayed circadian sleep disorder,” Fargason said. That is, their natural sleep cycle is “shifted later, so they are awake when the rest of society is sleeping.”
Delayed circadian sleep disorder can be treated with light therapy, getting exposure to light in the mornings and dimming the lights at nighttime, and evening use of melatonin.
The behavioral component is “to get out of bed at the same time every day,” both weekdays and weekends, Fargason said. “If you get up at 6 a.m., you will be tired 16 hours later, and the circadian rhythm can shift.”
Stick to your routine: “People with ADHD need to be a little more rigid in sticking to their organization methods,” Fargason said. “It’s a ‘never’ thing; when you get to the house, your phone can never go anywhere except the charger. Don’t ever lay it down, because you will lose it.”
Become a minimalist: “Clutter is anathema to ADHD,” Fargason said. “Get a one-touch system; don’t buy extra things, keep things neat; keep a trash can in the car.”
Prioritize exercise: “Pretty much all people with ADHD perform better if they exercise because they burn off that excess motor restlessness.”
For those adults wanting to pursue diagnostic evaluation for ADHD, Fargason says the best place is to start with a primary care physician. A PCP can assist with diagnosing and treating minor cases or can provide a referral to a psychiatrists or psychologists for formal clinical assessment.