ADHD – It doesn’t always look the same

Dr. Akash Kumar MD is a board certified adult psychiatrist. He practices in Ann Arbor, MI. 
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25-hyper-active-kids-251011-1What does ADHD look like? The public imagination is not so imaginative. ADHD conjures up a very specific singular archetype: a male child who can’t sit still, blurts things out, and talks too much.

The science says differently. In reality, there are 2 main subtypes of ADHD, per the Diagnostic Statistical Manual for Mental Disorders (the publication upon which all psychiatric research is based.)

  1. Inattentive
  2. Hyperactive

Both of these can present in myriad ways. While hyperactivity is more obvious, what often goes missed are symptoms of inattention.

The symptoms, for various reasons, sometimes do not fully disrupt functioning until later in life. Unfortunately, when ADHD goes undiagnosed, lost productivity is not the only consequence. Typically, years of aversive experiences- where the brain does not cooperate with desire- results in a cascade of learned limiting beliefs about ones self.

Psychological fall out from unaddressed ADHD:

  • Reflexive anxiety/futility/resentment about any task or to-do list
  • Feeling “stupid” or “flaky”
  • Rejection Sensitivity
  • Learning to rely on procrastination induced anxiety to generate focus even when it “makes no sense”
  • Low self esteem
  • Anger management and emotional dysregulation
  • Chronic boredom and depressive symptoms
  • Difficulty with being told what to do
  • Issues related to needing to be in control, or paradoxically succumbing to always feeling out of control

How is ADHD diagnosed?
At it’s core, ADHD diagnosis requires a careful clinical interview assessing not only for symptoms of ADHD, but that these cause signficant distress- or impairment of functioning- in multiple domains of a patient’s life. This can be supplemented with certain diagnostic tools when needed, though psychological testing is not a requirement in the diagnosis of ADHD.

What are the Neurobiological Substrates of ADHD?
ADHD is characterized by hypo-perfusion in the frontal lobes (resulting in executive dysfunction) and enlarged lateral ventricles. While fMRI and PET imaging shows aggregate differences in the ADHD brain compared to control subjects, such testing is NOT diagnostic for ADHD. Furthermore, even if ADHD looks similar in the brain, it can appear very differently from person to person.


Symptoms of inattention

  • Careless Mistakes / lacking attention to detail:
    Examples: overlooks or misses detail; work is inaccurate
  • Lacking sustained attention
    Examples: has difficulty remaining focused during class, conversations, or lengthy readings
  • Poor listening
    Example: mind seems elsewhere, even in the absence of obvious distractions
  • Not following through on tasks
    Example: starts tasks but quickly loses focus and is easily distracted
  • Poor organizations
    Example: messy, disorganized work; poor time management; tends to miss deadlines
  • Avoids tasks requiring sustained mental effort
    Example: preparing reports, completing forms, reviewing lengthy papers
  • Losing things
    Examples: tools, wallets, keys, paperwork, glasses, phone
  • Easily distracted by extraneous thoughts
  • Forgetful in daily activities
    Example: returning calls, paying bills, keeping appointments


Symptoms of hyperactivity in the past 6 months

  • Fidgeting/squirming
  • Leaving seat when remaining seated is expected- Example: leaves place in the office or other workplace setting or in other situations that require remaining seated
  • Excessive running/climbing, or feeling restless- Example: in adults, may be limited to feeling restless
  • Difficulty with quiet activities
  • “On the go”- Example: is unable to be or uncomfortable being still for an extended time, as in restaurants, meetings, etc; may be experienced by others as being restless and difficult to keep up with
  • Excessive talking
  • Blurting out answers- Example: completes people’s sentences and “jumps the gun” in conversations,
  • Inability to wait turn- Example: swiping credit card before machine is ready, rolling the dice prematurely during board games
  • Intrusive- Example: butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; adults may intrude into or take over what others are doing