What is ADHD?
ADHD stands for "Attention Deficit/Hyperactivity Disorder". It refers to a childhood-onset, neurobiological disorder characterized by marked, persistent and maladaptive levels of inattention, impulsivity and hyperactivity, which are age-inappropriate. For a long time, ADHD was believed to be a disorder exclusively characteristic of childhood/adolescence, but scientific evidence has instead shown that it tends to persist throughout life in up to 85% of cases (Barkley et al. 2008; Kessler et al., 2006), causing significant difficulties even into adulthood.
It is estimated that approximately 7% of the child population and 4% of the adult population suffer from it (Faraone et al.2003, Fayyad et. al 2007), but although it is now known that the disorder is also present in adults, only a fraction of them receive proper diagnosis and treatment.
It has been shown that having ADHD makes one vulnerable to other disorders that emerge over the years further complicating the clinical picture: it is recognized that 50% to 87% of ADHD individuals have at least one other disorder in comorbidity, while two or more in 33% of them (Biederman et al. 1993; Adler et al. 2008).
Among these, the most frequent are:
Oppositional Defiant Provocative Disorder (>50%);
Conduct problems and antisocial difficulties (25-45%);
Learning Disorders (25-40%);
Low self-esteem, Depression (25%);
Antisocial Personality (10-25%);
Substance use/abuse (10-25%).
Affected individuals often have low educational attainment, work and relationship difficulties. They frequently change jobs, partners and friendships, are often victims of trauma and road accidents, and more frequently have marriage (separation, divorce) and legal problems.
The Istituto di Neuroscienze provides a specialized outpatient service for the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD).
The Istituto di Neuroscienze was founded by Dr. Stefano Pallanti in 1989 to translate research into care.
Diagnosis and treatment
It remains difficult to recognize ADHD in preschool children (age 3-6 years): many children present a marked hyperactivity, fits of anger, truculence, and predominantly motor aberrations, but most of these will not develop ADHD. It is during elementary school (age 6-12 years), however, that the first diagnosis occurs more frequently, due to a series of symptoms that differentiate the ADHD child from his peers:
obvious presence of cognitive symptoms, such as inattention, easy distractibility, impulsivity;
avoidance of cognitive tasks (particularly copying tasks, or long reading);
low self-esteem, feeling of not being capable;
possible co-presence of oppositional-provocative behavior.
The child with ADHD is distracted, struggles to concentrate, fails to complete initiated actions, avoids activities that require attention, loses significant objects or forgets important activities. Tends to move quickly from one activity to another, fails to wait his/her turn in play and/or group situations. Has difficulty respecting rules, timing and spaces of peers, struggles to stay seated.
In the absence of an identification and diagnosis of ADHD, followed by appropriate intervention, this maladaptive condition will tend to persist into adolescence, in which there will be:
underperformance in school compared to his or her potential ("He/She could do more");
attenuation of motor hyperactivity, replaced by increased internal restlessness;
persistence of attentional, planning and organizational difficulties;
instability in social relationships;
sensation seeking and dangerous conduct;
emotional problems and occurrence of comorbidities with anxiety disorders, depression, substance abuse;
persistence of impulsivity, social maladjustment and family difficulties.
If ADHD has not been diagnosed and properly treated, over the years there will be an increase in difficultiesdue to comorbidities that, by complicating the clinical picture, will need an intervention that sometimes prioritizes ADHD itself.
The initial evaluation of a hyperactive child must be systematic and include a series of cognitive and behavioral tests, which will allow the presence of ADHD to be correctly identified, alternative diagnoses to be ruled out, and the possible presence of associated disorders to be considered. Indeed, other problems frequently coexist with ADHD, such as oppositional behavior, a conduct disorder, or a learning disorder. The diagnostic assessment should therefore establish a hierarchy of difficulties generated by both ADHD and co-occurring disorders, which will influence treatment planning.
A recent review that examined 17 studies conducted from 2001 to 2011 found a 45.1% comorbidity between ADHD and Learning Disability (LD): ADHD children and adolescents thus have a high prevalence of writing disorders, as well as reading and math skills. If these difficulties are not appropriately identified during the assessment and adequately treated, ADHD intervention alone, focused mainly on decreasing hyperactivity and increasing concentration ability, will not achieve the expected improvements.
The Multimodal Approach
In the case of a diagnosis of ADHD, multimodal treatment including a combination of interventions targeting the different areas compromised by the disorder will be indicated.
Although ADHD has an organic nature, it cannot be treated solely by pharmacological intervention. In fact, pharmacological therapy, if considered suitablefor the child, may act on the central symptoms of the disorder (hyperactivity, inattention, and impulsivity) but may not produce improvements on low self-esteem, poor social and interpersonal skills, and school learning difficulties, which will require other modalities of intervention such as coaching and psychoeducation.
Problems related to the ADHD child/adolescent's behavior make it necessary for parents to be involved in the treatment pathway, as the family is a key resource in fostering the emergence of positive behaviors. Unfortunately, parental love alone cannot address all the issues produced by ADHD, and without appropriate supports and strategies they will not be able to change the dysfunctional behaviors of their child with the disorder. Parents will be encouraged and helped to cope with the symptoms of the disorder, and to structure an environment that can foster the child's self-regulation. Parent Training involves individual or group meetings, depending on the preference of those involved, in which they can be:
provided correct information with respect to the child's difficulties and possible treatments;
clarified the goals of the intervention and the objectives to be achieved;
dysfunctional attitudes and interaction modalities identified, and then reworked;
identified the child/adolescent's strengths, so as to increase the frequency of desirable behaviors through reinforcement techniques;
contextualized problematic behaviors, so as to recognize the importance of antecedents and consequences;
illustrated ways in which a predictable environment, with clear and shared rules, can be created to facilitate management of the child/adolescent's behavior;
taught techniques for managing problematic behaviors and problem solving strategies.
The Parent Training intervention can be conducted in individual sessions (where the participation of both parents is preferred) or group sessions. It provides 12 fortnightly meetings lasting about 90 minutes, in which parents will have the opportunity to change their view of their child and of themselves within the parenting relationship, and will be able to transform dysfunctional vicious circles into functional interactions that will increase their child's strengths.
Teacher involvement is an integral and essential part of a therapeutic pathway for the treatment of the child with ADHD. School usually represents the environment in which ADHD dysfunctional behaviors are most likely to manifest as hyperactivity, impulsivity, and inattention impair the child's ability to comply with classroom rules and achieve appreciable academic results consistent with his or her intellectual potential. Teacher Training is an intervention that must be conducted in conjunction with Parent Training and aims to foster self-regulation, self-control, and self-awareness of their own behaviors in the ADHD child/adolescent within the school environment through:
awareness of the difficulties encountered by the ADHD child/adolescent and situations that can be linked to problem behaviors;
the establishment of school rules and routines, including the organization of materials;
the implementation of specific behavior modification techniques within the classroom;
a structuring of lessons and the environment that minimizes the emergence of problem behaviors;
the improvement of teacher-parent communication and the teacher-child relationship, which are challenged by behavior-management difficulties.
Teacher Training is important to achieve improvements in the school behavior and the learning skills of the child/adolescent with ADHD. Three to four meetings can be scheduled during the school year, planned according to the needs of the individual case, or training can be arranged upon request.
Intervention with the child/adolescent
The treatment of ADHD also requires direct therapeutic intervention with the child/adolescent with the goal of improving his or her behavior through a training aimed to:
the teaching of self-control, anger management, problem-solving techniques;
the improvement of impulsive and inappropriate behavior;
the improvement of interpersonal relationships with parents, teachers, siblings, and peers;
the improvement of learning skills;
increasing autonomy and self-esteem.
Interventions in Adulthood
ADHD /ADD in adults is a difficult diagnosis to obtain because it requires complex and multidisciplinary assessments. It is difficult but very important in determining successful treatment in: Depression, Mood and Anxiety Disorders, Eating Disorder, Addictions, Obsessive-Compulsive Disorder (OCD), Learning Disabilities, and Parkinson's Disease. Given the high rates of comorbidity of ADHD with other disorders, only if ADHD/ADD diagnosis is also taken into account the personalized and specific treatment will be successful.
In the case of a diagnosis of ADHD, a multimodal treatment will be indicated, comprising a combination of pharmacological and non-pharmacological treatments, such as cognitive behavioral therapy and specific training programs, aimed to get the individual to develop effective strategies to minimize the negative impact of the disorder in daily life.
Since ADHD impacts differently on each person, what is most effective for most patients is a combination of individualized, needs-centered treatments, comprising the following interventions.
An individual diagnosed with ADHD should be informed about the effects of the disorder. Part of the treatment involves the development of an individualized understanding of how ADHD affects one's life on a day-to-day basis.
Many individuals show significat improvements with the pharmacological treatment provided for the disorder. Naturally, pharmacological intervention and the appropriate treatment regimen are discussed and decided by mutual agreement between the physician and the patient.
Although ADHD is a neurobiological disorder, it carries with it other disorders such as Depressed Mood, Anxiety, or Substance Abuse. While medication can improve ADHD symptomatology, many people continue to experience problems in changing dysfunctional behavioral patterns learned in the past, such as those related to procrastination and poor time management skills. Cognitive behavioral therapy (CBT) emerges as an important part in the treatment of people with ADHD, along with counseling and psychoeducation sessions. In addition, couples or family therapy sessions can be helpful in improving interpersonal communication and reducing conflict.
Specifically, the psychosocial treatment aims to:
Improve time management and organizational skills;
Discover how to reduce impulsive behavior;
Develop better problem-solving skills;
Cope with academic and social problems;
Discover ways to improve relationships with family, colleagues, and friends;
Develop strategies to control temperament, manage anger, frustration, and stress.
Depending on the specific needs of the individual, information regarding alternative treatments will be provided, providing updated data from scientific research.
The Istituto di Neuroscienze collaborates with the referring National Association in order to provide:
up-to-date scientific information on available new medicines and possible acquisition modalities;
psychoeducational interventions and family support;
organization of specific trainings for the different professionals involved in the diagnosis, treatment and support of the ADHD patient and his/her family;
research activities on the impact of ADHD on the affected individual and the repercussions on his or her daily life, as well as on the benefits of early and accurate multimodal intervention on the individual in therapy;
integrated therapeutic interventions, with cognitive-behavioral training, social skills education, problem solving and stress-management;
participation in the planning of summer activities aimed at young adults, involving the presence of appropriately trained staff.
Study Skills Training is a specific intervention aimed at strengthening those skills that are impaired due to ADHD, and is indicated for students who have problems in structuring, planning, and organizing study activities.
The training can be conducted in individual or group sessions, and is composed of 8 meetings in which problem areas will be addressed and techniques and strategies useful for furthering the educational and/or professional path will be taught.
Further Insights on STUDY SKILLS TRAINING FOR STUDENTS
Research has well documented how the difficulties produced by ADHD impair study skills to such an extent that most affected individuals do not complete their education, do not continue their studies after high school graduation, or drop out of college (Barkley, 1998; Barkley & Murphy, 2006; Fayyad et al. 2007).
The transition from high school to college is a particularly delicate time, especially if children leave the parental home: the freedom to take or not take classes, the much free time available, the lack of the constant tests that used to be there in high school, and the new friendships make it easy to lose track of the time that passes in the run-up to exams.
Despite having average or above-average intelligence (Barkley, 1994), ADHD students struggle with a number of difficulties that jeopardize their success in education and career:
Inability/loss of concentration: they fail to listen to all the content of lectures, become distracted, and get lost in their own thoughts;
Inability to organize, plan and manage time: they tend to procrastinate on tasks to be done until the last minute, lose necessary materials, fail to organize their appointments, fail to meet commitments/deadlines;
Difficulty integrating information: they often get lost in irrelevant details losing the sense of what they are studying, and they easily forget the content they have studied;
Lack of motivation: they are unable to motivate themselves to study if the topic is not interesting to them, if the activities are monotonous and repetitive, and they tend to give up when faced with tasks that require sustained effort.
In addition, ADHD students often fail to wake up on time, arrive late to classes or skip them due to their inability to sit for long periods of time. Lack of awareness related to the effects of ADHD on one's behavior fosters lowered self-esteem, which can result in dropping out of school.
Students with ADHD very often know "what to do," but not "how and when." Therefore, they require help offered by an ADHD expert.
Academic coaching is a personalized intervention that aims to facilitate school/university success, and allows:
Acquisition of the most functional study method;
Improvement of social and communication skills;
Decreased absences and increased participation in school/university activities;
Increased sense of efficacy and competence;
Increased autonomy and sense of responsibility.
Adults, ADHD and Work
Adults with ADHD can have many difficulties at work, just as they had them in school when they were children. Some may have successful careers, while others struggle daily with a variety of issues, which may differ depending on the individual and the type of profession and job task.
At the Istituto di Neuroscienze, it is possible to request individualized intervention aimed at improving those conditions and behaviors that impair work effectiveness and interaction with the employer and/or colleagues, not allowing the full expression of one's potential and resulting in lowered self-esteem.
Adults with ADHD at work struggle daily with difficulties generated by:
The main symptoms of ADHD, such as impulsivity, inattention and easy distractibility, hyperactivity;
Tendency to boredom, especially in monotonous and repetitive activities;
Poor sense of time, resulting in delays and failure to meet deadlines;
Difficulty in managing complex projects;
Order in the work environment and organization of materials needed for activities;
Social and relational difficulties.
The Job Coaching Program includes 8 meetings, of which the first 4 are weekly and the next 4 are fortnightly, and includes:
Learning strategies for prioritization and effective use of time;
Improving memory skills;
Strengthening decision-making skills;
Improving interpersonal skills and communication skills in the work environment;
Learning techniques for managing negative emotions and controlling anger;
Increased self-esteem, self-efficacy and motivation.
Women with ADHD, Family and Work
Recently, ADHD in females has received considerable attention, as research has shown an underestimation of the disorder in the female sex, due to a difference in presentation compared to males: females are twice as likely to have ADD, without the "disruptive" symptoms that cause them to seek help. However, scientific evidence shows that both sexes are affected by the disorder with the same degree of severity, and suffer the same disabling consequences.
Women with ADHD who have not been diagnosed in childhood may come to consultation after one of her children has been diagnosed with ADHD, and recognizing in the diagnoser's descriptions many of their own behavioral patterns.
Some women with ADHD seek intervention because their lives are "out of control," chaotic, they have financial problems, difficulties in managing work, childcare, home organization, keeping track of all family commitments and various errands to run. Other women manage to successfully hide their ADHD, but continually struggle to carry on with their lives by going so far as to work nights and sacrificing free time in an attempt to "get organized." Whether in the case where the ADHD woman's life is in utter chaos or where she is able to hide her difficulties, both often describe themselves as "exhausted," "stressed," and "overburdened."
ADHD women frequently experience Dysphoric Mood, Anxiety Disorders and Depression, often have eating problems and low self-esteem.
It is often for depressive or stress symptoms that undiagnosed women seek specialist care; in the event that ADHD is not recognized and treated, chronicity of secondary disorders is possible (Kooij, 2013).
Women with ADHD can benefit from several interventions:
Parent training ― In most families, the mother has a primary role: she is responsible for cleaning and managing the home environment, and organizing family activities. These are all tasks that require attention, concentration, organization, and planning, and ADHD impairs all of these skills, making the role of mother much more difficult than in non-ADHD women. Given the strong genetic component of the disorder, if then the woman with ADHD has a child with the same disorder, then the daily challenges will be many more. In this case, parent training will provide for supplementing the ADHD child's behavior management program with training aimed at strengthening parenting competence and simplifying activities for managing the home environment.
Support groups ― ADHD women's problems emerge early and seem to increase with increasing age, due to the pressing and increasing demands associated with their social role. ADHD women have generally lower self-esteem than men with the same disorder, and often feel a sense of shame when comparing themselves to non-ADHD women. Group meetings can provide a therapeutic experience, providing a place where the woman with ADHD can feel understood and accepted by other women, and at the same time learn to better manage her life.
ADHD Coaching ― ADHD coaching enables the identification of the most challenging conditions for women with ADHD, and work on emotional, relational, and work conflict issues. By identifying sources of stress in daily life, ADHD women will be able to learn useful strategies to manage them effectively, thus lowering their stress level. They can also improve their lifestyle, learning to plan moments devoted to self-care without guilt, and to relax by engaging in activities that are enjoyable but neglected due to previous disorganization.
Coaching will focus on the following goals:
Formation of a more positive and effective self-image, reducing thoughts related to guilt and inferiority;
Reorganization of daily activities in order of priority, optimizing time and resources at hand;
Learning techniques for stress reduction and management;
Managing negative emotions and conflicts;
Gaining greater skills in organizing, planning and dividing work;
Increased awareness of one's own needs, greater self-care and adoption of a healthier and more balanced lifestyle;
Learning constructive communication skills that enable one to understand the views of others and have one's own understood without misunderstanding.
Coaching is a path of personal development aimed at everyone, but it is crucial for adults with ADHD.
Check out the Mindfulness course organized by professionals from the Istituto di Neuroscienze to learn how to manage emotions, increase awareness, calm the mind and increase your bodily and mental well-being.
It is not medications (or machines) that cure. Along with the right choice of medications, it is crucial to individualise the treatment through the choice of a minimum therapeutic dose defined specifically for each person. Learn more about the pharmacological therapies offered by the Istituto di Neuroscienze.
ADHD is a disorder characterized by attention difficulties combined with hyperactivity and impulsivity.
In adults it frequently remains unnoticed by clinical evaluation, to the extent that it is underdiagnosed. The symptoms that patients complain of are often related to problems with inattention, difficulties in interpersonal relationships, with couples, at work, etc.; however, there are many people who are unaware of their condition.
The most common ADHD symptoms in adults are:
Poor dexterity and repeated errors;
Mood disorders/substance abuse.
Patients may often report an excessive tendency to focus on irrelevant details or develop repetitive or compulsive attempts to control the dysfunction.
Diagnosis is complex: clinical evaluations associated with the use of neuropsychological testing are required, to be supplemented by the collection of information obtained from family members.
If you have detected the presence of some of the features contained in the above description, or if you are interested in checking for their presence, you can take the short test below.
Instructions for the completion of the adult questionnaire
This test allows you to check whether the characteristic symptoms of ADHD are present. To answer the questionnaire, indicate the answer that best describes/represents your condition over the past six months. Only one answer is required for each question.
1. Do you experience problems in finalizing the final details of a project when its most complex parts have already been completed?
E) Very often
2. Do you find it difficult to sort things and objects while you are doing a task that requires organization?
E) Very often
3. Do you have trouble remembering appointments and deadlines?
E) Very often
4. When you are doing a task that requires a lot of reasoning, do you avoid facing it or delay starting it?
E) Very often
5. Do you find yourself fidgeting and twisting your hands or feet when you have to sit for a long time?
E) Very often
6. Do you ever feel overly active or compelled to do something as if you were being moved by a motor ("automatically")?
E) Very often
If you predominantly selected answers ranging from C to E on the questionnaire, you may need to see a professional for a specialist visit.
In 2018, Dr. Stefano Pallanti established at the Stanford University (CA, USA) the Adult ADHD Program applying "Precision Medicine." Back in 1998, Dr. Pallanti founded the first Adult ADHD Program in Europe.
They edited the Italian edition of the assessment tool for ADHD in adults: BAARS-IV (Barkley Adult ADHD Rating Scale-IV).
Dr. Pallanti and Dr. Luana Salerno are also the Italian referees of DIVA 2.0 (Diagnostic Interview for ADHD in Adults) and members of the European Adult ADHD Network.