Paying attention to ADHD

20 April 2013
Presented by Hannah Critchlow.

Is ADHD overdiagnosed? How can parents and teachers help those affected? What happens when ADHD children enter adulthood? And do diet and genes pave the way to developing the disorder? Plus in the news, we turn on pleasure pathways through music and find out what gets a Prof up with the larks...

In this episode

01:23 - What is it like to have ADHD?

Kicking off the programme, I spoke with Terry Laverty who was recently been diagnosed with ADHD...

What is it like to have ADHD?
with Terry Laverty

Kicking off the programme, I spoke with Terry Laverty who was recently been diagnosed with ADHD and as a result, has co-founded an ADHD support group called ADDapt Ability at Cambridge.  I asked him what people with adult ADHD might experience.

Terry -   People with ADHD tend to process their emotions more quickly Eyesthan people without, so you might find yourself apologising for temper tantrums quite a lot or perhaps not planning ahead and considering the consequences of your actions.  You might be addicted to extreme sports or even conversely maybe having more serious addictions and self-medicate with coffee, alcohol, or even hard drugs.  Some of the flags to look out for could be if you've been through the mental health services for example with diagnosis of depression, anxiety, even bipolar.  Maybe the medication of the treatment isn't working or isn't as effective as you think it should be.

Hannah -   That was Terry Laverty who's diagnosed with adult ADHD at the age of 33.  I wanted to find out more about the clinical symptoms and diagnoses of both child and adult ADHD and so, I met Dr. Sam Chamberlain, Clinical Lecturer and Psychiatrist at Cambridge University....

02:25 - Revealing ADHD symptoms and diagnosis

To find out more about the clinical symptoms and diagnoses of both child and adult ADHD we meet Dr. Sam Chamberlain.....

Revealing ADHD symptoms and diagnosis
with Dr Sam Chamberlain, Clinical Lecturer and Psychiatrist at Cambridge University

I wanted to find out more about the clinical symptoms and diagnoses of both child and adult ADHD and so, I met Dr. Sam Chamberlain, Clinical Lecturer and Psychiatrist at Cambridge University.

Sam -   The core symptoms that make up ADHD - there's three kinds essentially.  There's impulsivity, there's hyperactivity, and there's inattention. 

And these aren't just things that we might all have problems with day to Dissection - learning from deathday.  So, just you know, being at work and not being able to concentrate all the time.  These are really extreme symptoms that impair what you're doing day to day. 

So, just to give a few examples from say, children, so kind of impulsive symptoms you might get, a child might run out into the road unpredictably all by themselves into danger or sort of push in and get into trouble with other children, so maybe being violent.  They may also be hyperactive, so they find they can't sit still in the classroom, fidgeting all the time, say to a cinema, they might be unable to sit still and might have to leave.  And then you've got the inattentive symptoms, so a child with ADHD with these symptoms, they might just not be able to concentrate on a school work.  They won't achieve as they should in many cases and ADHD is a very treatable condition and that's why it's important that we recognise it. 

The symptoms can look a little bit different in adults because many people who grow up with ADHD learn sort of coping strategies.  And the kind of things adults with ADHD might say is they might be impulsive, so they might tend to get in trouble with the police.  Sometimes they might use illicit drugs or overuse alcohol.  They can be hyperactive.  So again, similar things as in children, such as not being able to sit still, not being able to be more in place and just focus on one thing.  And then the problem is with attention.  Again, that can affect how they do at work, but it also can lead to problems in their relationships as well. 

So, for diagnosis of ADHD, you have to have some of these symptoms, but they have to - what we call functionally impair you in at least two domains, so that could be for example in your workplace, but also in the home environment.  Another example would be in your social life as well.

Hannah -   Sam, can you tell us a little bit about how child and adult ADHD is diagnosed and how common it actually is?

Sam -   So, there are a set of criteria that you use to diagnose ADHD and really, what's needed here is quite a careful and specialists assessment.  So, if you're worried that your child may have ADHD or if you're an adult with worries who might have ADHD, the first step would really be to see your general practitioner to see whether it's appropriate for you to be referred for a more detailed assessment. 

ADHD is fairly common in children.  It depends where you look.  It does appear to be diagnosed more so in America so that has raised some worries about whether it's being over diagnosed.  But in fact, the European countries and many countries has a pretty consistent rate of ADHD which would be maybe 4% to 6% of children will have the condition at some point. 

In fact, it's one of the most common psychiatric diagnoses that we find in young people.  We know that around 40% to 60% of children with ADHD will still have ADHD symptoms as adults.  In many cases, as I mentioned earlier, they may develop coping strategies so their symptoms might become less of a problem, but there'll be a significant proportion of people where it should be treated.

Hannah -   So, about 1 in 20 children in the UK will be diagnosed with ADHD with the majority being prescribed medication to help treat it and half of these will then go on to continue with their symptoms into adulthood.  I'll return to Terry who set up an adult ADHD group after his diagnosis to help support others.  I wanted to find out, are there any benefits associated with it.

05:59 - Are there any benefits with ADHD?

Are there any benefits to ADHD? Why has it persisted through generations?

Are there any benefits with ADHD?
with Terry Laverty, ADDaptability, Dr Sam Chamberlain, Cambridge University

Hannah -   So, about 1 in 20 children in the UK will be diagnosed with ADHD with the majority being prescribed medication to help treat it and half of these will then go on to continue with their symptoms into adulthood.  I'll return to Terry who set up an adult ADHD group after his diagnosis to help support others.  I wanted to find out, are there any benefits associated with it.

Terry -   I find actually that people tend to respond really well to my enthusiasm, but at the same time, some people can occasionally get a bit put off because I'm going to be quite intense.  I find that people with ADHD can often be quite empathic and be really good with people, and I think there's actually a lot of positivity with ADHD as well.  We can be really creative.

Hannah -   I asked Sam about this aspect of ADHD...

Sam -   So, it's important when we think about ADHD, not to think of just the negative things but to also think whether there might be a reason why ADHD persists, why over evolution have the symptoms sort of remained in the population, especially milder forms.  So, people with mild ADHD symptoms, it might actually be useful in terms of being creative in their jobs or coming up with new ideas.  So, it's not always a negative thing, but I would say that in people who have sort of fully blown form of ADHD then by definition, that is really impairing what they're doing day to day.

07:06 - Is there a brain basis to ADHD?

So, other than the symptoms that people with the disorder present, what other ways can we start to understand it?

Is there a brain basis to ADHD?
with Professor Trevor Robbins, Cambridge University

Hannah -   So, other than the symptoms that people with the disorder present, what other ways can we start to understand it?  To find out, I visited Professor Trevor Robbins who's head of the Behavioural and Clinical Neuroscience Institute at Cambridge University.

Trevor -   So, then going to the other levels of analysis, the psychological level, we can ask the question, what is impulsivity, and abnormality as a reward system?  For example, we can ask whether ADHD individuals are somehow understimulated or underaroused so that they need to indulge in this overactivity to get themselves to a natural level of behaviour. We can ask whether they have problems with reward or is there problems in what we called executive control of their behaviour, which is often the case for example if your frontal lobes are impaired in the brain. 

At the brain level, we can use quite a lot of evidence from brain imaging to show for example that in ADHD, there are problems in areas like the frontal lobes so the grey matter may not be fully formed in these areas, or maybe the connections between different areas don't form particularly well and there is certainly emerging evidence for that. 

There may also be biochemical evidence in the brain of abnormalities.  For example, in the neurotransmitters dopamine or noradrenaline and they've been focused on a lot because these neurotransmitters which are of course chemical messengers are affected by the drugs which are customarily used to treat ADHD.  So for most among these is Ritalin, also called methylphenidate which is a kind of amphetamine and amphetamine itself is also used under the name of Adderall.  And methylphenidate increases the levels of dopamine and noradrenaline that are available to stimulate the nerve cells.  It does this by blocking a molecule called the transporter which stops these neurotransmitters being catabolised or metabolised.  Instead, they're taken back up into the nerve cells.  So that's very interesting.  The fact that these drugs like Ritalin and amphetamine works, suggests that there is some abnormality possibly in these transmitters.

09:42 - Biological test for ADHD?

Could we use these chemical and structural brain changes in ADHD to help develop biological markers for ADHD diagnosis?

Biological test for ADHD?
with Dr Sam Chamberlain, Cambridge University

Hannah -   Could we use these chemical and structural brain changes in ADHD to help develop biological markers that could help with the diagnosis of the disorder?  Back to Sam...

Sam -   I think this is a very exciting area.  As I said, the diagnoses of PET Image of the human brain showing energy consumptionADHD requires quite a detailed assessment and we don't always get it right.  So, there is an on-going search for what we call 'endophenotypes'.  Actually, what it means is it's an intermediate marker.  So, it's a biomarker.  It might be a measure of your cognitive abilities.  It might be a measure of your brain structure that you might work out using a simple brain scan.  And what we hope is that we'll be able to develop techniques to get more objective diagnoses of ADHD so you might come in to the laboratory and do some different cognitive tests, maybe have a brain scan and we can use that information to help us clarify what the diagnosis is and work out what treatment will be best for you.

Hannah -   Promising experimental results that might help with the diagnosis of ADHD in the future. 

10:43 - Genes and Diet in ADHD?

We now bury our heads into the next level of understanding of ADHD – so genes and the environment. Back to Trevor Robbins for this…

Genes and Diet in ADHD?
with Professor Trevor Robbins, Cambridge University

Hannah - we now bury our heads into the next level of understanding of ADHD - so genes and the environment.  Back to Trevor Robbins for this...

Trevor -   At a genetic level, there's also some evidence for the Dnahelix_genetic_fingerprintinvolvement of these chemical messengers because some of the genes that have been linked to ADHD which turns out to be a very highly heritable condition are implicating dopamine and noradrenaline mechanisms.  But this is not to say that we think ADHD is purely a genetic condition.  Of course, it isn't. 

There are very strong environmental determinants and this might be the diet.  They might be things like lead poisoning or some toxins in the environment which affects your brain development early on, or it may be psychological.  So, there's some evidence that levels of ADHD are greater in those Romanian children who were brought up in horrible adoption homes.  Their level of ADHD-like behaviour is much higher in some of those children, suggesting that social deprivation may also play a role in some sense. 

So, those are the main levels I would suggest by which we can understand ADHD - the psychiatric or the clinical level, the psychological level, the brain level, the neuroscience level, and the genetic and causation level.

Hannah -   Thank you, Professor Trevor Robbins from Cambridge University.  And perhaps these genes could also be used to help provide markers for ADHD diagnosis in the future. 

Is ADHD hereditary?

Sam - Possibly, up to 60% or 70% of the expression of ADHD has to do with genes. Probably, there's many genes that each confer a small risk of developing ADHD. So, if you have many of these genes, you might be at heightened risk. The kind of genes that we find to be involved are those involved in brain function such as genes involved in the noradrenaline system and genes involved in the dopamine system. These are two chemical systems in the brain that help to regulate our cognitive abilities such as our ability to concentrate on things or supress impulsive behaviours.

Can diet affect ADHD?

Kirstie Abbey has been in touch asking, are poor diet an ADHD linked? So again, Trevor mentioned these environmental factors like diet being implicated in ADHD but by how much and what diet is good and what's bad?

Sam - There isn't any clear cut evidence that diet plays a big role in ADHD. That said, there's a lot we don't understand about the causes. So, there is some emerging evidence that omega 3 oils might be helpful in ADHD. There's been some control trials of this. Not really enough evidence yet. So say to people in general, you should be going out and taking omega 3 oil as supplements, but it is an important area that we're looking into.

Parents and teachers of ADHD children?

Tom - My name is Tom Hughes. I'm a Doctoral Trainee Educational Psychologist. I study at the University Birmingham and work for Cambridgeshire Educational Psychology Service. As part of my role, I work with families and children that have ADHD. I typically work with schools and teachers and parents to try and help them cope with aspects of their life. I think typically, the parents or the teachers will represent that the children struggle in school either academically or socially. So, we would talk to them about interventions and strategies to help. You know, whilst we would stress with schools and parents that there are no generic support measures if you like around working for children with ADHD or with children with ADHD. They're all different and typically, there are strategies that work. My advice would be to look at the environmental factors around the child and organising the environment to maximise the chances they have over success. And it may be that the child settles better with certain peers. It may be that they need a work station to work from. There may be environmental cues that help them concentrate in certain environments. So, that might be things like setting up trays to help them manage the inflow and outflow of work. Help limit their distractions. And then certainly with parents and teachers, we talk about behaviour management strategies which are certainly applicable to all children, but maybe more so to children with ADHD. And we would talk about the routines and schedules within school and at home to then helping them understand the expectations that they or the adults have of them, and the setting has of them. And I think often, children with ADHD needs support with things like - we would call them 'calming manipulative' so, things for them to hold in their hands maybe when they're in school and they're starting to get anxious, and they start to feel their attention wandering or providing them escape valves. So, allowing them to leave the class if they feel they're starting to get out of control or they can't cope. So, we would certainly advise parents and teachers on some of those strategies to help them cope.

Is ADHD overdiagnosed?

Tom - I think that's an area that you'd probably hear very different responses from from medical professionals than you may do from educational professionals. There's certainly an argument that the diagnoses of ADHD represents the medicalization of inattention or hyperactivity, and those sorts of behaviours. And that medicalization of those behavioural difficulties locates the problem within the child. So, there is an argument that would say ADHD is better regarded as a cultural construct rather than a bona fide medical disorder.

How best to treat child ADHD?

Tom - I think that's the key to any of the guidelines associated with intervention to support children with ADHD. If medication is involved, it needs to be as part of a coherent integrated package that might involve psychological or behavioural interventions, educational advise, and environmental changes. So, key to supporting children with ADHD with or without medication often involves managing the environment around them.

Can ADHD be treated with video games?

Tom - I haven't seen any information that we talked to whether those are interventions that work for children with ADHD, whether those would be interventions or rewards, I'm not sure. Rewards absolutely, I do think, as long as the child signs up to what those rewards are, they're forgettable, they clearly understood, and generally, intrinsic as opposed to extrinsic. So, something that's important to the child rather than money or something similar, you know, we do see those working with all children but they may be particularly useful for children with ADHD.

Hannah - So, for example, I like going to bike rides. So, my reward would be going for a bike ride on a Sunday, but concentrated during the week.

Tom - Absolutely and part of that is about helping identify what it is about the target that's important and being specific enough that the child can understand what it is and then achieve it. And I think we are all guilty sometimes of identifying woolly or loose targets that are setting the child up to fail. So, investing in that upfront process, setting the targets, getting the child, and then having a reward that's significant and important to them, again, this is relevant for all children but will be specifically effective for children with ADHD.

Are boring schools to blame?

Tom - I think all children that I work with see some elements of school work more stimulating than others and it's very different from individual interest based activity like sitting on a computer game. The majority of the classes that I go into, if not all of the classes I go into are stimulating and interesting. I think they may be less stimulating and interesting if you're less likely to attend to the content. If you do have high levels of inattention or hyperactivity, then it may be that you're less focused on the work that's going on in front of you and more on the distractions around you and I think that sometimes contributes to the sense of not being engaged with the content. To the question, what could be changed, well, we would always advise teachers to think about how they would differentiate the content or t process, or indeed the outputs of the classroom and to insure that children are engaged with whatever work is going on in the class.

Long term effects of an ADHD diagnosis?

Tom - I think one area that's becoming increasingly well understood at the moment is the psychological impact of an ADHD diagnosis for a child. And so, increasingly, I meet children now that are in the receipt of a diagnosis and potentially, taking medication. And I think as we start to see that affects taking cause over a longer term and the psychological impact of that diagnosis becomes clearer. So, research now indicates that children who have received an ADHD diagnosis may perceive themselves to be less able than their peers. Or it may mean that they perceive their behaviour to be uncontrollable. So, I can't go from this situation and that's because I have ADHD. As soon as children start to locate the source of their difficulties outside themselves and it means they don't think it's worth trying for example or they're less likely to take responsibility for that success and failure. And clearly, in school, that's a difficulty.

Hannah - Thank you, Tom Hughes, Doctoral Trainee Educational Psychologist at Birmingham University. If you've got any burning questions about your brain and the nervous system, just email them to neuroscience@thenakedscientists.com, you can tweet us @nakedneuroscience, or you can post on our Facebook page, and we'll do our best to answer them for you.

21:51 - Are ADHD brains wired up differently?

Connectivity differences between the brains of people with ADHD and the general population

Are ADHD brains wired up differently?

David -   So, the first paper I'd like to talk about ties into this whole theme of attention and ADHD.  And as we know, ADHD is quite a tricky disease to diagnose.  It involves a subjective opinion from doctors and psychiatrists.  So, a study published this month in biological psychiatry has looked not just at the structural differences between the brains of ADHD patients and the general population, but also, differences in the connectivity of different brain regions. 

And what the lead author of this paper, Samuel Cortez and his colleagues at the Child Study Centre in the USA have found is that, the brain connectivity of ADHD patients is actually slightly different from those of normal population.  Saggital transection through the human brain

So, they measured the connectivity of the brain using a technique called diffusion tensor imaging which is a type of MRI scan that look specifically at the connectivity of white matter tracks in the brain.  They found differences in the white matter tracks of subjects with ADHD whether they had the ADHD as an adult or as a result of a childhood diagnosis.  And these white matter tracks are the pathways that connect areas of the brain involved in higher cognitive functions. 

So, this study indicates that changes in brain structure may be persistent in child diagnosed with ADHD that carries forward to adulthood.  And this supports the idea that neurological changes made during childhood could stick around during adulthood.

23:47 - Music lighting up the pleasure zone

New research published in Science reveals brain scans can predict if somebody is likely to buy a new piece of music

Music lighting up the pleasure zone

Hannah -   Well, I'm going to move on to my paper now and we're going to stick with the subject of brain connectivity.  But this time, putting a more musical and rewarding twist to it.  So, music (I hope you agree) seems to be an important aspect of human evolution culture and society.  And (Valerie Salimpour) and colleagues at McGill University Montreal published a paper in science this week.  Basically, she wanted to get to the bottom of the scientific drive to music.  So, she took 19 participants, 10 were females and 9 were males.  And she them on a donut-shaped fMRI machine which is basically functional Magnetic Resonance Imaging.  

So, she was measuring levels of oxygen going to particular areas of the Music and the brainbrain.  And whilst she was measuring these oxygen bursts in the brain, she was playing a 30-second sound bites of different tunes to these volunteers and these were all new tunes that the volunteers haven't heard before.  And then she was watching as different areas of the brain lit up with oxygen.  Perhaps unsurprisingly, when the participant rated that they liked a particular new tune or sound bites then a bit of their brain called nucleus accumbens which is buried deep in the brain.  It's involved in reward during addiction, eating and sex.  And it's known as the pleasure or reward zone of the brain and perhaps then surprisingly, lit up with oxygen bursts using a money paradigm of buying these tunes over iTunes.  

But the scientists also found that whilst the volunteers were listening to these different sound bites, different areas of the brain were getting recruited.  So, oxygen rush into the auditory cortices so, the bit by your ear, the bit that processes sounds and also, oxygen rushing to the medial prefrontal cortex which is the region that's involved in making decisions.  And then there was also oxygen rushing to the amygdala which is the small almond-shaped structure that's involved in emotions.  And then all of these different areas, these brain areas were connecting with each other and sending information it seems to the nucleus accumbens which was then lighting up, dependent on how these other brain regions were actually talking or communicating to it.

David -   So, the communication of different areas in the brain could tell us how pleasurable the music that we're listening to is?

Hannah -   Well, almost.  It's actually the response of the nucleus accumbens that could predict whether the people were likely to buy that new piece of music that they haven't heard before, but scientists think that the individual's previous exposure to different environments and different musical scenes might affect those connections which then connect with the nucleus accumbens and drive the reward or pleasure response to the music.

David -   So, listening to music that you really enjoy could have the same effect to something like addiction or sex.

Hannah -   I think that's what we're saying here, yeah.

26:26 - Criminality and ADHD

Danish study evaluates the link between criminal behaviour and ADHD

Criminality and ADHD

David -   So, the second paper I'd like to talk about is about the link between ADHD and criminal behaviour.  And this paper was published in the journal of Criminal Behaviour and Mental Health and it looks at the long term impacts of having ADHD from childhood. 

So, the lead author of this paper, Soren Dalsgaard and his colleagues in Denmark have used data from psychiatric clinics and the Danish National Crime Register to track the criminal records of 206 girls and boy diagnosed with ADHD and they tracked their criminal records up until the time that they're in their early 30s.  what they did with this information was to compare the criminal records of those diagnosed with ADHD against the records taken from the general population.

Hannah -   And so, did they find a link between criminality and ADHD?Old Bailey Justice

David -   Yeah, the results showed that the children diagnosed with ADHD were five times more likely to be convicted with a crime compared to the general population.

Hannah -   So, these results seem to send quite a strong message, but are there any limitations with this study do you think?

David -   Yeah, I mean, the paper is really good in some respects because it's a very wide national level study, but there are caveats that we need to consider.  The study focused on children with quite severe ADHD and as we know, this sort of varies in its severity, so we can't make generalised conclusions about ADHD based on these very specific cases.

Hannah -   That was David Weston from Cambridge University.  I return to Psychiatrist Dr. Sam Chamberlain to get his comments on that last news story.

Sam -   So, it's a really interesting paper and what it seems to be showing is that if you follow children with ADHD up over time, they are at increased risk of being involved in the criminal justice system and according to this research, it may be up to half of children with ADHD then at some point, have some contact with the criminal justice system.  And we know from research conducted elsewhere that treatment does seem to reduce that risk of getting in trouble with the police. 

I think this research and other research like it, really emphasises the need that we don't forget about ADHD in adults.  So, there's increasing awareness about ADHD in children, but still, I would argue, not enough awareness, but let's not forget the adults with the condition as well.

29:08 - What gets a Prof up in the morning?

What gets Professor Nicola Clayton from Cambridge University leaping out of her bed with the larks?

What gets a Prof up in the morning?
with Professor Nicky Clayton, Cambridge University

Nicola -   Bird brain?  Never more.  There's something spectacular about songbirds - the sight of their wonderful wings, the sound of their melodious serenades, and the sheer beauty of their synchronous dancing displays.  Perhaps the most intriguing question of all however, is what lies beneath that beady eye. 

Until quite recently, it was assumed that birds were rather simple creatures with little ability to think.  We now know that's not true.  This mistake arose because the bird's brain has a very different structure to that of mammals, bereft as it is of the 6-layered structure of our cortex which has long been thought to provide the unique machinery for intelligence. 

History has it that when the Anatomist Ludwig Edinger first proposed the Flock of birds in flightnomenclature for the various brain regions, he thought that most of the avian brain matter was derived from the striatum and basal ganglia.  Indeed in mammals, these regions do have a striated appearance.  But we now know that birds do have a cortex.  Indeed, a large part of the bird's brain that lies above the basal ganglia is now recognised to be both functionally and developmentally akin to the mammalian cortex.  The difference however, is that rather than producing a layered cortex as mammals do, the bird cortex has a nucleated structure.  It's made of the same types of cells and has the same kind of connections, but with a different architectural design.  It's a weight saving device for the birds, just like their hollow bones. 

So, by analogy with cakes, the bird brain is more like a fruit cake whereas the mammalian brain is more like an Austrian Sacher-Torte. 

So next time you hear the derogatory term 'bird brain', take it as a complement - brainy birds.  For some songbirds are indeed quite brainy.  Consider the crows.  They have become known as feathered apes because their intellectual capabilities are actually on a par with chimpanzees.

Hannah -   That was Professor Nicola Clayton, explaining her intrigue with bird brains. 

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