ADHD….and concussions?

  What are the first images that come to mind when you hear Attention Deficit Hyperactivity Disorder (ADHD)? Do you picture a child or an adult, a boy or a girl, someone sitting and daydreaming or someone running around causing mischief? Do you have a strong feeling that ADHD is either “real” or “fake” without fully understanding why?  When you envision ADHD treatment, what images come to mind; do you picture a bottle of pills, shelf of supplements, counselor’s office, or a parenting class?   

It is estimated that 1 in 10 adolescents and 1 in 20 adults have been diagnosed with ADHD­­^1,2. There is a significant number of undiagnosed adults and the prevalence of Adult ADHD is on the rise globally³. This common condition continues to be a poorly understood and undertreated condition in the United States. Understanding ADHD is important as it has a strong connection to other conditions such as anxiety/panic disorders, depression, substance use disorder, PTSD, and TBI/concussion⁴.

ADD or ADHD? Children or Adults?

Attention Deficit Disorder (ADD) was renamed ADHD in the late 80’s. Some considered this a misnomer as not all individuals with ADHD are hyperactive. As public awareness of the condition expanded in the 90’s, the stereotype of the restless young boy with ‘bad behavior’ was reinforced. To counteract this, three  “sub-types” of ADHD were developed; inattentive, hyperactive, and combined type. Despite this, 15.1% of young boys are diagnosed (because they tend to exhibit more classic hyperactive traits) but only 6.7% of young girls being diagnosed (because they tend to exhibit less recognized or problematic inattentive traits)⁵.

While fewer than 5% of all adults have been diagnosed with ADHD, 8.1% of adults between 18 and 44 have been⁵. Lower rates in older adults may reflect a lack of recognition and diagnosis when they were young. Adult ADHD is common, on the rise, and has significant impacts on mental health, physical health, and social function. Unfortunately, many people still think that ADHD is a childhood condition that most kids “grow out of”.

What causes ADHD?

 ADHD is not caused by a single germ, gene, or exposure. This condition comes from complex interactions between genetics, environment, nutrition, parenting, individual and family mental health, head trauma, brain anatomy and physiology³.  Effective treatment should consider and address as many of these factors as is possible.

Although there are many treatment options available for ADHD, they often only address one or two of the root causes of the condition. Stimulant medications focus on the biochemistry of the brain. Behavioral training focuses on parent-child-social interactions. Counseling usually focuses on coping with the stress of living with ADHD and conditions which often come along with it, such as anxiety and substance use disorder. Functional, integrative, and holistic care tends to focus on dietary and environmental exposures to substances and stimuli which can disrupt healthy brain function.

Concussions are often overlooked in ADHD treatment

 Individuals with ADHD are at higher risk than the general population for injuries due to inattentiveness, impulsivity, and/or hyperactivity⁶. It is likely that these accidents lead to increased rates of head trauma, although this hasn’t been well researched. One of the few studies available estimates that boys with severe ADHD are nearly twice as likely to experience a mTBI (mild traumatic brain injury) ⁷. To make things worse, Individuals with ADHD who experience an mTBI are more severely affected than those without the condition⁵.

Two thirds of individuals with ADHD experience a mental, emotional, or behavior disorder². Healthy individuals who experience a mTBI are much more likely to develop ADHD, anxiety disorders, and other mental challenges in the months following the injury⁵. Each of these conditions increase the odds of developing the other and amplify the impacts they have on health. Brain injury, depression, anxiety, and ADHD are leading causes of disability in the USA which can have lifelong impacts. Together, these conditions dramatically increase the chances of developing substance use disorder which can lead to overdose and death⁷.

Treatment options:

 Approximately two-thirds of diagnosed children are taking prescription ADHD medication². In my practice, I strongly recommend genetic testing before beginning pharmaceutical treatment. This helps individuals and families find the medication which is most likely to benefit the patient at the beginning of the journey. About half of children are receiving behavioral treatment and/or counseling support for ADHD and less than one third of children are receiving both². In isolation, these treatments only address a few of the multiple factors. Few individuals are receiving nutritional interventions, supplemental support, assessment of environmental factors, and other supportive therapies proven to reduce ADHD symptoms and improve function. There are few clinics which offer integrated treatment of ADHD and mTBI.

 A comprehensive and integrated approach to ADHD with mTBI include a combination of:

• Genetic Testing
• Lifestyle, dietary and environmental modification
• Counseling and behavioral therapy
• Medication management
• Supplemental and/or IV support of healthy brain function and neurotransmitter levels
• Hyperbaric Oxygen Therapy
• Neurofeedback and/or Biofeedback
• Neurological Rehabilitation and Physical Medicine

No single modality, medicine, supplement, or profession is sufficient to fully treat the complexity of ADHD. The multiple factors contributing to ADHD are unique, so each patient’s treatment plan should be tailored to their needs and history. I’ve found this combination of therapies to be extremely effective even in complex and severe cases. Naturopathic Doctors are trained to treat the whole person and treat the cause. As part of a multidisciplinary team, they   integrate the best of both conventional medicine and alternative treatments. If you or someone you love has been struggling to find comprehensive care for their ADHD, reach out to an ND in your area to experience a full spectrum approach to this condition.

Bibliography:

• S. Department of Health and Human Services. (n.d.). Attention-deficit/hyperactivity disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd
• Centers for Disease Control and Prevention. (2022, August 9). Data and statistics about ADHD. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/data.html
• Chung, W., Jiang, S. F., Paksarian, D., Nikolaidis, A., Castellanos, F. X., Merikangas, K. R., & Milham, M. P. (2019). Trends in the prevalence and incidence of attention-deficit/hyperactivity disorder among adults and children of different racial and ethnic groups. JAMA network open, 2(11), e1914344-e1914344.
• Richards, L. M. E. (2013). It is time for a more integrated bio-psycho-social approach to ADHD. Clinical child psychology and psychiatry, 18(4), 483-503.S. Department of Health and Human Services. (n.d.-a). Attention-deficit/hyperactivity disorder (ADHD). National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd
• Bonfield, C. M., Lam, S., Lin, Y., & Greene, S. (2013). The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury. Journal of Neurosurgery: Pediatrics, 12(2), 97-102.Adeyemo, B. O., Biederman, J., Zafonte, R., Kagan, E., Spencer, T. J., Uchida, M., … & Faraone, S. V. (2014). Mild traumatic brain injury and ADHD: a systematic review of the literature and meta-analysis. Journal of attention disorders, 18(7), 576-584.
• Karic, S., DesRosiers, M., Mizrahi, B., Zevallos, J., Rodriguez, P., & Barengo, N. C. (2019). The association between attention deficit hyperactivity disorder severity and risk of mild traumatic brain injury in children with attention deficit hyperactivity disorder in the United States of America: A cross‐sectional study of data from the National Survey of Children with Special Health Care Needs. Child: Care, Health and Development, 45(5), 688-693.Wilens, 2011
• Wilens, T. E., Martelon, M., Joshi, G., Bateman, C., Fried, R., Petty, C., & Biederman, J. (2011). Does ADHD predict substance-use disorders? A 10-year follow-up study of young adults with ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 50(6), 543-553.