The Importance of Precision and Personalization in ADHD Evaluation and Treatment
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with a complex origin, primarily linked to alterations in fancy-named processes like synaptogenesis (the process of creating connections between neurons) and myelination (the formation of a myelin sheath around a nerve cell to allow for improved conduction; Núñez-Jaramillo et al., 2021). Many things can throw a wrench into these brain-building operations, like premature birth, perinatal issues, nutrition during pregnancy, exposure to heavy metals, and genetic predisposition (Barry et al., 2020; Giannopoulou et al., 2018; Gharami et al., 2015; Aylward, 2005). These factors can cause changes in brain structure and function, giving rise to ADHD symptoms.
ADHD primarily becomes apparent in childhood and can continue into adolescence and adulthood. Individuals with ADHD may struggle with tasks that require sustained attention, organization, and self-control.
There are many causes of ADHD. There are also many conditions that present similar to ADHD, such as the cognitive-based symptoms of depression and anxiety. Additionally, ADHD can be mistaken for learning disorders, head injury, or Bipolar disorder. Therefore, it is crucial that the individual is being accurately diagnosed with ADHD in the first place. This is why it is important to be evaluated by professionals with extensive knowledge about mental disorders (e.g., psychologists), as not all medical professionals receive the extensive training in the intricacies of mental health disorders that psychologists undergo. This is not meant to be a dig at professions such as nurse practitioners or doctors of medicine, but I believe it is worth noting that they have their areas of expertise, and psychologists have theirs.
From a psychologist’s perspective, ADHD testing can come in various forms. Clinical psychologists evaluate ADHD using a variety of measures, including tests of general intellectual functioning (IQ testing), memory, complex attention, executive functioning, and other associated constructs. An evaluation for ADHD aims to do the following:
Confirm Diagnosis: Determine whether an individual meets the criteria for ADHD, considering their symptoms and history.
Rule Out Other Conditions: Exclude other conditions that may mimic ADHD symptoms, such as anxiety or learning disorders.
Assess Severity: Determine the severity of ADHD, as it can vary from mild to severe.
Identify Coexisting Conditions: Recognize any coexisting conditions like anxiety, depression, or learning disabilities, which can influence treatment decisions.
Individualized Treatment Plan: Create a personalized treatment plan that may include behavioral interventions, medication, therapy, or educational accommodations.
Improve Functioning: Improve an individual's overall functioning by addressing the specific challenges posed by ADHD symptoms.
Enhance Quality of Life: Ultimately, the evaluation seeks to enhance the individual's quality of life by improving their ability to manage symptoms, succeed academically or professionally, and maintain healthy relationships.
Now that we know a little more about the causes and diagnostic process of ADHD, let’s talk about treating it. Treatment approaches for ADHD work in various ways for different groups of people. This diversity in how treatments affect people isn't surprising because the reasons behind ADHD are also diverse. In other words, even though people with ADHD might show similar signs (which is how we diagnose it), those signs can come from different underlying problems. Since ADHD has different causes for different people, it is important to personalize how we treat it.
Although pharmacological treatments for ADHD are generally effective, their benefits are not consistent across all individuals, and they can also come with unpleasant side-effects. Alternative approaches to medication include behavioral parent training, Cognitive Behavioral Therapy (CBT), attention-improving techniques, cognitive training interventions, and Neurofeedback (NFB; Núñez-Jaramillo et al., 2021; Drechsler et al., 2020).
The impact of behavioral parent training on ADHD symptoms in children varies, but it consistently reduces stress in parents and fosters better home environments (Ciesielski et al., 2020; Zwi et al., 2015). CBT shows more evidence of effectively reducing ADHD symptoms (Pan et al., 2019; Knouse et al., 2017). Interestingly, according to the study by Pan and colleagues, the combination of CBT and medication produces stronger improvement in executive functions compared to CBT alone. However, there was no significant difference between the CBT group and the CBT + Medication group when it came to core ADHD symptoms, self-esteem, and emotional symptoms.
Attention training techniques are still being studied, with clearer results in adults than in children and adolescents (Lee et al., 2017). Cognitive training (perhaps informally known as “brain-training”) through apps, computers, or manualized treatments show poor evidence of benefit. Specifically, research indicates that participating in these cognitive training programs has little impact on one’s academic performance or improvement in one’s ADHD symptoms–but they can improve working memory performance (Bikic et al., 2018; Cortese, 2015)!
Studies on NFB report mixed results, with positive, mild, or no effects, indicating it is not a one-size-fits-all approach (man… who saw that coming?; Van Doren et al., 2019; Loo et al., 2018). Despite this, NFB has advantages like direct targeting of brain activity, minimal side effects, and the potential for long-term changes in the central nervous system. It is worth noting that the meta-analysis by Van Doren and colleagues found neurofeedback had medium to large positive effects on inattention and hyperactivity/impulsivity immediately after treatment and during a follow-up period of 2–12 months. I personally had the opportunity to try out a neurofeedback device during my doctoral training. I’m not sure if it improved my attention/concentration skills–and I’m quite sure it didn't help with my chronic impulsivity–but it definitely raised my awareness of my brain activity and got me in the habit of periodically checking in with my mind and taking time to pause and anchor myself to the present moment. I recommend trying it if you ever have the chance.
Well there you have it–a crash course on the causes of ADHD, the ADHD evaluation process, and the variety of available treatments that are out there. If you think you may have ADHD, the best advice I can give is to speak with a professional in the mental health field who is trained to diagnose ADHD and other mental health disorders (clinical psychologist, psychiatrist, licensed clinical mental health counselor). Seek out an ADHD evaluation and avoid getting your advice from social media or self-diagnosing. As I’ve covered, incorrectly diagnosing ADHD can lead to improper treatment and a host of other issues. If you are already diagnosed with ADHD and don’t feel like your treatment is effective, it may not be the right approach for you. Taken together, a personalized approach aims to make ADHD assessment more precise and the treatments more effective.
References
Aylward G. P. (2005). Neurodevelopmental outcomes of infants born prematurely. Journal of developmental and behavioral pediatrics : JDBP, 26(6), 427–440.
Barry, M. J., Almotawah, F., Pani, S. C., & Ingle, N. A. (2020). A Comparison of Salivary Mercury Levels in Children with Attention Deficit/Hyperactivity Disorder When Compared to Age-matched Controls: A Case-control Observational Study. The journal of contemporary dental practice, 21(2), 129–132.
Bikic, A., Leckman, J. F., Christensen, T. Ø., Bilenberg, N., & Dalsgaard, S. (2018). Attention and executive functions computer training for attention-deficit/hyperactivity disorder (ADHD): results from a randomized, controlled trial. European child & adolescent psychiatry, 27(12), 1563–1574.
Ciesielski, H. A., Loren, R. E. A., & Tamm, L. (2020). Behavioral Parent Training for ADHD Reduces Situational Severity of Child Noncompliance and Related Parental Stress. Journal of attention disorders, 24(5), 758–767.
Cortese, S., Ferrin, M., Brandeis, D., Buitelaar, J., Daley, D., Dittmann, R. W., Holtmann, M., Santosh, P., Stevenson, J., Stringaris, A., Zuddas, A., Sonuga-Barke, E. J., & European ADHD Guidelines Group (EAGG) (2015). Cognitive training for attention-deficit/hyperactivity disorder: meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. Journal of the American Academy of Child and Adolescent Psychiatry, 54(3), 164–174.
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Lee, C. S. C., Ma, M. T., Ho, H. Y., Tsang, K. K., Zheng, Y. Y., & Wu, Z. Y. (2017). The Effectiveness of Mindfulness-Based Intervention in Attention on Individuals with ADHD: A Systematic Review. Hong Kong journal of occupational therapy : HKJOT, 30(1), 33–41.
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