Attention problems: what is ADHD and what isn’t?

An article by Kim Rosenthal, MD.

So you’re sitting in a meeting, distracted by the sound of your colleague’s shoe tap-tapping at the ground.  It’s too much.  Sensory overload.  You’re ready to jump up and go for a run, or a fast walk at least, anything to get out of this room and away from the boring lecture your boss insists is vital for your work’s survival.  So far you’ve caught nothing.  Body restless.  Mind restless.  Without thinking, you raise your hand and hear yourself utter a random joke, trying to make light of the matter.  It’s off color.  Everyone stares at you like you’ve offended the gods.  You immediately regret it.  Damn, you think.  That’s my ADHD acting up.

But do you really have ADHD?

Problems with concentration and sitting still don’t necessarily mean you have Attention Deficit Hyperactivity Disorder.  Attention problems and restlessness can exist in many situations and disorders and NOT be ADHD:

• Adjustment to change
• Being overwhelmed
• Anxiety
• Depression
• Psychosis
• Mania
• Substance use disorders (while using and after quitting)
• Cognitive problems
• Boring lectures and meetings
• Being normal

In this article, we’ll talk about ADHD briefly.  We’ll also go over the differences between ADHD and non-ADHD causes of attention and hyperactivity/impulsivity symptoms.

So, what’s ADHD?

Here’s the formal definition: ADHD is a psychiatric disorder associated with debilitating inattention and hyperactivity/impulsivity.

In simpler terms: having ADHD means you can’t concentrate, can’t sit still, and/or tend to act without thinking.

ADHD is a disorder of the brain.  When comparing the brain of someone with the illness versus without, you can find changes in anatomy and activity.  These differences affect the parts of the brain that control attention, judgment, patience, mental gymnastics (juggling information in your mind), ability to respond or NOT respond to stimuli, and inhibition (avoiding impulsivity).

A brain-based disease?  It’s not that easy.  You can’t diagnose someone with ADHD by getting an MRI or PET scan of their brain.  Many people with the disorder don’t show these anatomical differences, and many with non-ADHD conditions do.  People’s brains don’t know they’re supposed to look like ADHD brains, so there’s a lot of variation.

What are the types (or subtypes) of ADHD?

There are two subtypes, although it’s possible to have both.  Here’s a breakdown:

(1) Inattention subtype means that people can’t concentrate. Specific symptoms include:

• Making careless mistakes and doing sloppy work
• Frequently losing stuff (like keys and cell phones)
• Frequently forgetting stuff (like appointments or returning important calls)
• Having difficulty focusing on and following conversations and not seeming to listen when spoken to
• Struggling to complete tasks that require organization
• Not following through on daily responsibilities, like chores around the house
• Avoiding or disliking things that require a lot of attention, like reading, balancing a checkbook, taking a college course, or doing complex work projects
• Being easily distracted by unrelated thoughts or noises in the environment

(2) Hyperactive-impulsive subtype occurs when someone has problems staying calm and quiet AND/OR they tend to react before thinking.  Specific examples include:

• Saying things that are rude or inappropriate without thinking
• Acting recklessly on the spur of the moment
• Fidgeting and squirming a lot, being constantly “on the go,” or feeling restless
• Problems staying seated (like in long meetings)
• Difficulties engaging in leisure activities that require calm behaviors
• Blurting out answers before the question has been completed, or problems taking turns
• Interrupting others or being intrusive in conversations and activities

How is ADHD diagnosed?

First, never diagnose yourself with a mental health disorder based on an article you find online!  If you read through the criteria above and heard yourself say “check” and “check” and “check” to every symptom on the list, make an appointment with a psychiatrist.  They’ll do a thorough evaluation and assess for ADHD, as well as all the other medical and psychiatric conditions that can mimic ADHD.  The provider will probably ask permission to contact a family member or friend (preferably someone who’s known you since childhood) to get more history.  When unsure, psychiatrists and other prescribers refer patients to psychologists for formal testing.

So ADHD involves inattention, hyperactivity, and impulsivity.  How do doctors tell the difference between ADHD and non-ADHD causes of these symptoms?

NORMAL VS ADHD 

Although there are many differences between “normal” concentration problems and ADHD, here are a few pointers to help clarify.

(1) ADHD symptoms don’t come and go. We all have moments of inattention, excessive energy, and poor decision-making, but for people with this disorder, the symptoms are severe and occur almost every day.  Happy, sad, angry, rested, or not rested, the attention problems or hyperactivity/impulsivity are present.  There might be some fluctuation in severity of symptoms, depending on the situation and person, but the problems don’t go away.

(2) Symptoms start before age 12.  According to the psychiatric bible of diagnoses, the DSM 5, symptoms of ADHD must start before the age of twelve.  Even when diagnosed as a grown-up, the person with ADHD has struggled throughout childhood and adolescence because of the disorder.  The sudden emergency of attention problems in an adult is always caused by something else.

(3) The symptoms cause problems with daily functioning. ADHD causes problems in day-to-day life.  Unlike in most people, where the occasional inattention and impulsivity don’t cause much of a ruckus, adults with ADHD tend to struggle with failing relationships and difficulty at work or school.

What are the conditions that mimic ADHD, and how do you tell the difference?

It takes a lot of information-gathering and educated clinical judgment to determine what is what when it comes to mental health issues.

Attention problems related to stress, anxiety, depression, mania, and psychosis tend to disappear when the stress or problem or condition returns to normal.  For example, if a person has problems concentrating because of depression, once the depression is treated, their concentration stabilizes too.  This usually takes time.  Mood improves first, concentration later.

People who use drugs and alcohol heavily experience concentration problems, while using and for some time after they quit.  When they stop using or drinking, their brain eventually improves.  This can take months to years.  It’s unclear whether they can reach baseline.

Providers must also differentiate between young people with cognitive problems like dementia (like Alzheimer’s or traumatic brain injury) or intellectual deficit disorder (IDD, formerly called mental retardation) from ADHD.  In general, people with cognitive problems might have inattention, but these are always accompanied by other difficulties, like memory problems and deficits in self-care (not seen in ADHD).  Unlike ADHD, dementia never starts in childhood.

It is possible to have ADHD and another psychiatric disorder at the same time.  In this case, most psychiatrists try to stabilize the non-ADHD disorder first, depending on the situation.  Usually both conditions need to be treated individually, so you must treat the most acute.

Struggling with ADHD?

Check out Tips for people with ADHD.  If you want more information about the disorder in general, look into this National Alliance of Mental Illness’ web page on Attention Deficit Hyperactivity Disorder.  The link opens in a new page.