ADHD: Beyond DSM-5

ADHD is not a simple problem of restless behavior, not listening carefully, or not staying focused on a task. Research has demonstrated that ADHD is a complex syndrome of impairment of brain functions essential for self-management, the executive functions of the brain. Impairment of these executive functions impacts motivation and prioritizing for tasks, focusing and shifting focus as needed, managing sleep and alertness, sustaining effort, modulating emotions, self-monitoring actions, regulating processing speed, and utilizing working memory to keep information in mind while attending to multiple tasks. Impact of these ADHD-related impairments is not like inadequate focusing of a camera to take a photo; it is more like difficulties with the multiple functions involved in focusing on one’s driving.

Strong objective evidence has demonstrated that ADHD is highly heritable and that individuals with this disorder typically experience delays of two to three years or more in development of specific areas of the brain that support executive functions. Data have also shown that ADHD is associated with unique weaknesses of functional connectivity between regions of the brain and is associated with different patterns of cortical thinning. Multiple controlled trials have shown that well-tailored treatment with approved medications significantly improves ADHD symptoms during the time the medications are active for about 70 to 80 percent of those affected.

Although ADHD often appears in childhood, for some, especially those with a higher IQ, symptoms of this disorder are not apparent until they encounter the challenges of high school, college, graduate school, employment, and/or other challenges of adult life.

Current diagnostic criteria for ADHD make no mention of problems with managing emotions. However, recent research has shown that individuals with ADHD often have great difficulty in monitoring and managing their emotions. They tend to struggle with impulsive and/or excessive reactions to frustration, anger, discouragement, anxiety, and other emotions.

Many assume that ADHD is really a problem only during school years, that it has no lasting or significant impact on an individual’s adult life. Long-term studies comparing samples of individuals with ADHD to matched controls show that those with ADHD are less likely to complete high school, complete fewer years of post-high school education, are less likely to complete a college degree, are more likely to be employed in unskilled occupations, are more likely to have a substance use disorder, and are more likely to quit or be fired from a job. Some with ADHD are very successful in adult life, but, for many, ADHD-related impairments bring many continuing difficulties during their adult years.

The “central mystery of ADHD” is the fact that all those with ADHD tend to have a few specific activities or tasks in which they perform quite well, effectively utilizing their executive functions in ways they are unable to do for most other activities, including tasks they recognize as important. For example, an individual may be able to focus very well on playing a sport or video games, making music or drawing, repairing or building things, or cooking. Yet that same person may be seriously impaired in deploying their executive functions for many other tasks that they consider important and want to do.