What is Attention Deficit Hyperactivity Disorder (ADHD)?

Jul 29

Attention deficit hyperactivity disorder is one of the most common neurodevelopmental conditions. Children living with ADHD struggle with paying attention, regulating their emotions, and controlling impulsive behaviors. A child with ADHD may struggle to form social relationships, have difficulty resisting temptation, and engage in risky behavior without concern for consequences. Children with ADHD generally do not simply outgrow these behaviors, as they arise from dysfunction in foundational neurological pathways. This often results in considerable functional challenges for adults that continue to struggle with ADHD.

How Common is ADHD?

It is estimated that 6.4 million children in the United States struggle with ADHD.

Boys are more likely to be diagnosed with ADHD than girls (1).

6 in 10 children with ADHD have at least one other mental, behavioral, or emotional disorder. These include behavior or conduct disorders, anxiety, depression, autistic spectrum disorders, or Tourette’s syndrome (2).

What are the Symptoms of ADHD?

Those with ADHD most often show symptoms of excessive movement, frequent outbursts and uncontrolled talking, and intrusive daydreaming. Forgetfulness and careless mistakes are common. ADHD children have difficulty avoiding unnecessary risks and resisting temptations. Children living with ADHD may also have difficulty making friends, taking turns, and getting along well with others. (3)

What Causes ADHD?

The cause of ADHD is still up for debate, and however genetics do appear to play a key role in the development of the disorder. There are several different subtypes of ADHD, including ones that are primarily hyperactive, primarily inattentive, and mixed presentations. It is likely that combinations of factors that vary between individuals give rise to and individual ADHD presentation. Other factors that contribute to ADHD include early concussions and brain injuries, premature delivery, and maternal alcohol or tobacco use during pregnancy (1).

ADHD is considered a neurodevelopmental disorder, in which the normal path of development for important brain regions and circuits becomes impaired. ADHD is not often something an individual will simply outgrow with time. Proper diagnosis and early intervention can change the progression of ADHD, and are critical for putting the child back on the path of normal neurological development.

What are the Consequences of ADHD?

ADHD often persists into adulthood. Adults with ADHD continue to struggle with executive function, working memory, and paying attention. These lead to ongoing challenges with anxiety and depression, poor self-esteem, poor academic performance, conduct disorders, and substance abuse. This may result in poor job and career performance, difficulty with social and family relationships (5).

How is ADHD Diagnosed?

ADHD is usually diagnosed through questionnaires and rating scales. These assess the child according to various criteria, including several measures of inattention. These can include failing to pay attention to details, struggling to organize tasks, being easily distracted, and not seeming to listen when spoken to. There are also criteria for hyperactivity and impulsivity that must be met. These may include being unable to engage in quiet activity, constantly squirming or fidgeting, talking excessively, and moving around when expected to sit still. Several of these symptoms need to be present before age 12, they must be present both at home and at school, and there must be evidence that they interfere with the quality of school work and social functioning (3).

What Happens in the Brain With ADHD?

ADHD has been traditionally seen as a disorder involving the production and breakdown of norepinephrine and dopamine. These are neurotransmitter chemicals the brain uses to facilitate communication between neurons in important brain pathways. This is an overly simplistic view. While there are particular neurological pathways involved in ADHD that require these chemical messengers, these neurotransmitters are used throughout the nervous system in pathways that are not affected in ADHD.

ADHD is best viewed as a disorder involving the function and integration of several important brain regions and pathways. These include:

The frontal and prefrontal cortex: These regions are involved in cognition, reasoning, planning, and other tasks considered to be executive functions. This is where most high-level cognitive processing takes place. Dysfunction in these regions leads to inattention, poor organization, and loss of impulse control.

The limbic system: This series of structures are found deep within the brain. They regulate emotional responses. Problems in these structures result in frequent emotional outbursts, having an extremely short fuse, meltdowns, agitation, and inattention.

The basal ganglia: These circuits receive input from throughout the brain, and are responsible for regulating communication between different brain regions and circuits. They function essentially as the gas pedal and brake pedal for the brain. Every thought, emotion, sensory input, movement, and behavior is turned on and turned back off by the basal ganglia. Problems with these systems result in poor impulse control, obsessive and compulsive thoughts and behaviors, poor emotional control, and poor attention and focus.

The reticular activating system: This is the brain’s primary arousal system. It lives at the top part of the brain stem, and sends neurotransmitters up into the frontal lobe to activate a host of brain regions. Problems here can create inattention, fatigue, poor concentration, and sleep problems.

How is ADHD Usually Treated?

ADHD is most commonly treated with psychiatric medications that influence norepinephrine and dopamine. These include Ritalin, Adderall, Concerta, and several others. In some cases, these medications may be very helpful. However, there are no medications that can only address neurotransmitter function in one pathway without affecting all of the other pathways that use this messenger. This often results in a number of side effects including sleep disorders, decreased appetite, delayed growth, tics, headaches and stomach aches, and rebound irritability when the medication wears off (4).

How is the NeuroRescue Program Different?

Many of the brain regions that give rise to ADHD are also involved in the generation of particular classes of eye movements. Research demonstrates that in ADHD, specific types of eye movements are impaired. A number of oculomotor abnormalities have been demonstrated in children with ADHD (11)

While there are several classes of eye movements involved in ADHD, the most well researched are saccades, which are fast eye movements to a target of interest, and anti-saccades, which are a higher-level cognitive task involving making an intentional saccade away from a novel target. Saccades and anti-saccades are generated by regions of the frontal lobe that are also involved in many of the brain’s inhibitory processes. Slow or inaccurate saccades can lead to problems with inhibition, including the inhibition of behavior. Failure to inhibit reflexive eye movements toward the target on an anti-saccade task can lead to poor response inhibition and lack of impulse control.

Research demonstrates a saccade “gap effect” impairment in children with ADHD, in which prolonged saccade reaction time manifests as gaps in visual attention. In the study, children with ADHD, and children without ADHD performed a saccadic eye movement to evaluate the gap effect. Children with ADHD had a much longer saccade reaction time than the other children. These results suggest that the measurement of saccadic eye movements is a valid method for measuring behavioral symptoms of ADHD. More importantly, it implies that rehabilitating these eye movements can lead to improvements in behavioral and emotional regulation (6).

Studies have shown that improving these saccade eye movements directly correlates with improvement in focus, attention, and other behavioral activities (6). Rehabilitation of these neuropathways can help to decrease impulsivity and improve response inhibition, and improve a host of other associated neuropsychiatric conditions such as anxiety and depression (10).

Anti-saccades have been shown to be significantly impaired in ADHD children (7). The circuits involved in visual response inhibition from the dorsolateral prefrontal cortex that generate anti-saccades are the same pathways that control impulse control for behavior.

Visual fixation, the ability to keep the eyes focused on a target of interest, has also been shown to be impaired in ADHD. Gaze stability is almost always impaired in ADHD. Gaze stability is also linked to postural stability, and research shows that the circuits involved in visual and attentional fixation are also involved in whole-body motor planning tasks (9)

The frontal cortex and basal ganglia are also involved in motor planning and execution. Motor planning deficits have been shown to be present in ADHD children. More importantly, research has shown that strategies designed to improve motor planning can also help improve attention and focus, cognition, and even scores on intelligence testing. A 12-week program of motor planning training has shown a greater than two grade-year improvement in these measures (8).

There are a series of reflexes that we are all born with, called primitive reflexes. These help the brain develop, by creating specific motor patterns in response to sensory input. These reflexes are normal in infants, but should be all fully attenuated by the first birthday. There are direct associations with neurodevelopmental conditions and retained primitive reflexes. Children with ADHD syndrome often demonstrate a series of retained primitive reflexes. These lead to impaired motor learning, along with problems in behavioral modulation (12). Exercises to attenuate primitive reflexes have been shown to be very helpful in a wide variety of neurodevelopmental disorders (13, 14).

Impaired connectivity in the frontal-cerebellar-basal ganglia network has been shown to exist in a wide variety of neurodevelopmental disorders, including ADHD (15). Impaired motor timing has been shown to be a feature of this dysfunction (16). Rehabilitation of motor timing has been shown to substantially benefit attention and focus (17). We use a computerized system called the Interactive Metronome to rehabilitate motor timing. This therapy has been demonstrated to markedly improve attention, focus, and concentration (18,19).

The vestibular system has been shown to be impaired in ADHD. Many people living with ADHD demonstrate obvious or subclinical balance deficits on neurodiagnostic testing. This can be a result of impaired integration of inner ear pathways, as shown by head impulse testing and vestibular evoked myogenic potential testing (20,21). Vestibular rehabilitation can improve balance in these individuals, as well as improve attention and focus (22).

Non-invasive neurostimulation techniques have shown good promise in resolving ADHD. Transcranial direct current simulation (tDCS) is one such therapy, which involves a safe, gentle electrical current applied to the scalp. This helps improve function and integration between frontal and basal ganglia pathways, and has shown to be effective in promoting response inhibition and behavioral modulation (23,24). Direct electrical stimulation of the trigeminal nerve has similarly been shown to help with attention and behavioral modulation (25)

Another advanced technology shown to help people living with ADHD is transcranial magnetic stimulation (TMS). This involves an MRI-strength magnet with a focused beam of magnetic energy applied to the forehead. It stimulates the dorsolateral prefrontal cortex directly through the skull. As we have already seen, the DLPFC is a primary center involved in executive function and inhibitory control. TMS therapy can produce significant improvement in attention, focus, and behavioral modulation (26). We reserve tDCS and TMS therapy for individuals over the age of 18. Unfortunately ADHD symptoms commonly persist well into adulthood.

Hyperbaric oxygen therapy has also shown promise in treatment of attentional issues. The basal ganglionic network is extremely oxygen-dependent, and as such increasing oxygen delivery to this tissue has been shown to benefit attention and focus (27).

Research demonstrates that by using a multimodal strategy of therapies that are targeted to deficiencies identified on neurodiagnostic testing, marked improvement in ADHD symptoms can be generated in a relatively short period of time (28).

Every NeuroRescue Program is different, with your therapies chosen based on your diagnostic testing and the realities of your condition. It is impossible to take a cookie-cutter approach to the treatment of a condition as complex as ADHD. The therapy plan we develop will be specific to your brain, and yours alone.

How Does the NeuroRescue Program Work?

We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.

We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your condition forward.

Our examination allows us to identify the areas and pathways of your brain that have been impacted by your injury. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your balance in a host of different sensory conditions.

We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance in different sensory conditions.

We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.

We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.

We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.

We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your fragile systems.

We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.

Your NeuroRescue Program allows us to maximize their efficiency and endurance or your relevant neurological systems. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to return you to living a healthy, vibrant, and fulfilling life.

Your Next Best Step:

Living with ADHD can be challenging, but there is hope for functional recovery and remission. To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.

And remember, it’s never too late to start getting better.