ADHD Brain Changes Appear to Persist Into Adulthood

THURSDAY, Nov. 10 (HealthDay News) — Adults who were diagnosed with attention-deficit hyperactivity disorder (ADHD) as children have less gray matter in certain areas of their brains as adults than people who didn’t have ADHD in their youth, researchers say.

“The majority of individuals with ADHD improve in adulthood, but it was still somewhat disappointing to see that even with improvement, there continue to be challenges for those with ADHD,” said the study’s lead author, Dr. F. Xavier Castellanos, a professor of child and adolescent psychiatry at New York University Langone Medical Center in New York City.

Castellanos and his team also found a trend toward even more significant brain changes in people who continued to have ADHD symptoms as adults.

Results of the study are published in the November issue of the Archives of General Psychiatry.

ADHD is a common childhood disorder, according to the U.S. National Institute of Mental Health. Symptoms include an inability to pay attention or focus, being easily distracted, becoming quickly bored, daydreaming a lot and hyperactive behavior.

Previous research has found reduced brain volume in children with ADHD, and those reductions are especially pronounced in areas of the brain that help regulate attention and emotion, according to background information in the study.

The current study included boys who had participated in an ongoing study that began in the 1970s. At that time, the study consisted of 207 white boys between the ages of 6 and 12 and 178 age-matched boys who didn’t have ADHD to serve as the control group.

Castellanos’s research included 59 of the study volunteers who’d had ADHD in their childhood and 80 who had not. Their average age was 41. Of the 59 with ADHD, 17 continued to have symptoms of ADHD as adults, according to the study.

The study volunteers underwent magnetic resonance imaging (MRIs) in 2002 and were interviewed about their current symptoms and medication use.

The researchers found that the outer layer of the brain (the cortex) was significantly thinner in people who’d had ADHD when they were young compared to those who hadn’t had the disorder. These changes were seen in people who continued to have ADHD symptoms and in those who didn’t. However, Castellanos said there was a consistent trend for those who still had symptoms to have an even thinner cortex.

The areas most affected by thinning are regions involved in “top-down control of attention and the regulation of attention,” said Castellanos. For example, he explained, the amount of attention you give a task is a complex calculation of what’s going on around you; how much noise there is; if something else is moving in the room and so forth. If you hear a loud noise, you’re at least momentarily distracted unless you can rationally explain the noise away, such as if you’re having construction done. If you can rationally explain the noise away, you can get back to work without further distraction. But, this process doesn’t work as well for people with ADHD.

“To me, these kinds of studies are exciting because they get to the real neurobiology of ADHD,” said Dr. Sara Hamel, a behavioral/developmental pediatrician at Children’s Hospital of Pittsburgh. Hamel said some people still see ADHD as a weakness in personality or as caused by bad parenting, but this study and others like it show that “ADHD is a physiologic phenomenon and a real neurological deficit.”

Both experts said that it’s important for people to realize that ADHD can be a lifelong condition, and if symptoms persist into adulthood, they shouldn’t be ignored.

“It’s not your fault. It’s something different in the way you’re wired, and it’s probably inherited,” explained Hamel. She recommended both medications and behavioral therapy for people with ADHD.

Castellanos pointed out that almost all of the people in his study had taken stimulant medications for their ADHD, and yet the changes in the brain volume persisted into adulthood. That means that while medications can help control the symptoms of ADHD on a day to day basis, they’re not likely having any impact on the underlying cause of the disease.

More information

To read more about attention-deficit hyperactivity disorder in adults, visit the U.S. National Institute of Mental Health.

The case against adult ADHD

The case against adult ADHD goes something like this: Attention deficit hyperactivity disorder is a dubious condition promoted by Big Pharma to push stimulant drugs; the small number of children with true ADHD (rather than lax parenting) will outgrow it by their teens, so adults have no business using the diagnosis as an excuse for failing to meet their commitments as employees, spouses and parents.

Judging by its public face, you’d think ADHD was a loser’s gambit.

But Sarah Blyth, a Vancouver parks board commissioner who was diagnosed with ADHD as a child, begs to differ.

Although the 39-year-old politician and manager of a Vancouver housing shelter had to overcome years of poor grades and low self-esteem, she eventually developed the skills that people with ADHD are known to lack, such as attentive listening and time management, she says.

Ms. Blyth, who is up for re-election in November, recently “came out” as having ADHD in Vancouver’s Georgia Straight newspaper to encourage acceptance of others with the disorder, she says. “There’s so much stigma attached to it.”

But when people with ADHD learn coping strategies to work toward their goals, “you really can do it.”

The challenge is that the vast majority of adults with ADHD don’t know they have it, says Russell Barkley, a clinical professor of psychiatry at the Medical University of South Carolina in Charleston, and author of Taking Charge of Adult ADHD.

ADHD is a neurobiological disorder that interferes with executive functioning – an umbrella term for thinking processes that include planning, attention, working memory and impulse control.

Dr. Barkley says the disorder persists in adulthood for as many as two-thirds of children with ADHD, and 4 to 5 per cent of all adults have ADHD. “It’s one of the most impairing disorders we see in an outpatient clinic.”

One-third of people with ADHD never finish high school, he says. As adults, they tend to have a checkered work history, money problems, broken relationships and inconsistent parenting skills. They are at high risk for depression, anxiety, substance abuse, eating disorders, dangerous driving and impulsive behaviour that can land them in jail, he says, noting research showing that one in four prison inmates meet the criteria for ADHD.

Nevertheless, society continues to dismiss it as a harmless condition, Dr. Barkley says. “This is the Rodney Dangerfield of disorders because the name, unfortunately, makes it sound so trivial.”

Despite misconceptions, adult ADHD is a legitimate diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders and recognized as a disability by government bodies such as Revenue Canada. (ADD is a misnomer used to describe people who are inattentive but don’t have other characteristics of ADHD. It’s a separate condition known in medical circles as “sluggish cognitive tempo.”)

Since expertise and services for adult ADHD are in short supply, however, getting a diagnosis can be a Sisyphean task.

British Columbia’s only adult ADHD clinic had an 18-month waitlist when it closed in 2007 after government cuts. In Ontario, the Toronto-based ADHD Clinic stopped seeing new adult patients about 18 months ago because it was overwhelmed by the demand, says medical director Doron Almagor.

Several private clinics have opened recently in Ontario, but assessment is only partly covered by the provincial health plan. At Toronto’s Springboard clinic, for example, a full assessment costs patients $1,200 out of pocket.

For those who do get an ADHD diagnosis, Dr. Barkley recommends stimulant medications such as Concerta, as well as Strattera, a non-stimulant drug. Although behaviour modification therapy can help, over 80 percent of adults with ADHD will need medication, he says.

But meds aren’t the only answer, says Pete Quily, a Vancouver-based life coach for people with ADHD.

Mr. Quily helps clients create systems for completing tasks on their to-do lists and foreseeing distractions that may interfere with their goals. As well, he brainstorms with clients to fill gaps in their social skills and find ways to maintain their self-care. “A big problem with ADHD is remembering to eat, exercise and sleep,” says Mr. Quily, whose services cost $250 to $360 a month.

Sarah Blyth, the Vancouver parks commissioner, does not take ADHD medication. She says that, for her, daily routines are essential. Her strategy for attending park board meetings includes going for a long walk beforehand to burn off excess energy and taking notes during presentations. “It’s enough to keep my focus.”

As a child, Ms. Blyth says, she was a “class clown” who later struggled with an eating disorder, academic failure and an inability to focus her scattered thoughts. She gained self-confidence in her late teens and 20s by excelling in snowboarding and skateboarding, and getting involved in community projects.

Her advice to others with ADHD is to “figure out ways to concentrate on the things that are really important to you.”

ADHD isn’t all bad, says Mr. Quily, who has the disorder himself. People with ADHD tend to be great multi-taskers and highly creative, and can “hyper focus” on activities that interest them, Mr. Quily says. He points to successful figures with ADHD such as athlete Michael Phelps and Kinko’s founder Paul Orfalea.

But Dr. Barkley says there is no scientific evidence to support the notion of “ADHD superpowers,” which he describes as an attempt to build self-esteem.

As for the oft-quoted laser-focused mind, he says, people with ADHD engage in what clinicians call perseveration – fixation on an activity in the absence of a rationale for continuing it.

“It’s a symptom of a frontal lobe disorder,” Dr. Barkley says. “This is no gift.”

ADHD red flags

Adults may not recognize lifelong problems as symptoms of ADHD. Those who can relate to several of the following red flags may have the disorder:

• A history of impulsive behaviour and difficulty regulating attention.

• Problems with time management (keeping appointments, completing projects).

• Checkered work history and low productivity compared with potential.

• Anger issues (argumentative with authority figures, episodes of rage).

• Marital problems (spouse complains that he/she does not listen, forgets important events).

• Being over-talkative, interrupting frequently, speaking too loudly.

• Parenting problems (inadequate household routines, inconsistent or over-controlling as a parent).

• Money problems (impulsive purchases, bankruptcy, failing to pay bills or do taxes).

• Substance abuse (especially alcohol or marijuana) or excessive caffeine use.

• Addictions (collecting, compulsive shopping, sexual addiction, overeating, gambling).

• Unsafe driving (speeding tickets, serious accidents or being over-cautious to compensate for attention problems).

• Being the parent of a child with ADHD.

Source: Canadian ADHD Resource Alliance

Published in The Globe and Mail