ADHD, Addiction, and Mental Health

Welcome to Today's presentation on ADHD, addiction and mental health issues. I am your host, Dr. Donnelly Snipes. In this presentation, we're going to explore the connections and symptom overlaps between adhd, addiction and mental illnesses. And by the way, if you are working on your dissertation or maybe your master's thesis right now, there is very little research out there, comparatively speaking, on the comorbid conditions that present with adhd. So that is an area that is ripe for research if you need a research topic. But I digress. And then we will explore the impact of these symptoms on the individual. In part two on Thursday, we are going to talk about interventions. ADHD is one of the most common psychiatric disorders with a worldwide prevalence of about 5% among children and adolescents. In most adults, 60 to 70% of cases, the ADHD persists into adulthood either as a residual condition or as a full clinical disorder. We need to be cognizant and sensitive to this when we're working with people. If they did have ADHD as a child, it's likely they still have some residual symptoms that may need addressing with cognitive behavioral tools. Medications used to treat adhd, such as methylphenidate amphetamine, indicate a dopamine norepinephrine dysfunction as the neurochemical basis of adhd, as well as a potential target for comorbid anxiety and depression. You remember, dopamine is your perseverance neurochemical. Norepinephrine is involved in energy and focus. You know, they also do many, many other things. But in terms of adhd, that's really what we're looking at here. So with anxiety, you might see dysfunction in norepinephrine, maybe too much. And in depression, you're often going to see low levels of dopamine and norepinephrine. So you're. So you can see how these two disorders or these three disorders could dovetail. The presence of probable ADHD and the severity of ADHD symptoms are related with the severity of insomnia, even after controlling for depression and anxiety. So I thought this study was really interesting because they looked at people who had comorbid mood disorders and adhd and they said, okay, let's control for these mood disorders and look at, let's look at the ADHD and the insomnia. And they found that people with ADHD have more severe symptoms if they have significant insomnia. So the worse their sleep is, the worse their symptoms tend to become. So that is a huge target not only for pharmacological intervention potentially, but Also for cognitive behavioral intervention, a lot of people with ADHD and without adhd, a lot of people have really crappy sleep hygiene. So this is one area that we could actually start to look at. Remember, for example, that caffeine and stimulants tend to stay in your system for quite a while. So the caffeine you drink or the stimulants you have at noon may still be in your system at midnight, which can interfere with your ability to get that good deep sleep. So it's important to work with the person and encourage them to work with their prescribing physician if, for example, they're taking a long acting amphetamine for their adhd. For those of you who aren't familiar with ADHD and even for those who are, we're going to talk about the symptoms or some of the characteristics of people with ADHD as well as the neurological and neurochemical underpinnings of ADHD and comorbid disorders and issues including anxiety, depression, addiction. And here's the surprise for you, giftedness. And my son is gifted, which we mistakenly thought was ADHD only for the longest time, and I believe he has some concurrent adhd. But a lot of his hyperactivity tends to be focused and can be addressed through giftedness interventions. But I digress. In the bottom right corner of this presentation there is a video called Asperger's Disorder and Other Common Misdiagnoses and Dual Diagnoses of gifted children by Dr. James Webb. This is an hour video and y' all know I hate watching videos. I'm sorry for I am not a an auditory learner, so I don't usually get engaged in videos, especially not long ones. This man is extremely engaging and this video is definitely worth watching. If you are a diagnostician or an active clinician, whether you're working with adults or children, it provides a lot of insight and it can also help you provide insight to parents who may have children who are gifted in addition to or. Or whether they or if they have adhd. Great presentation. Really love it. I believe it was the. I can't remember what university it was from. I'm sorry, I don't want to misquote it, but it is free. It's on YouTube. You can watch it. Great presentation and I highly recommend it. It's not super in depth listening, so you can listen to it while you're cooking dinner or something and really get the gist of it. But. So that's an aside. Let's look at some of these characteristics here. People with attention deficit and hyperactivity disorder tend to have difficulty getting organized. That is in large part due to problems in functioning in that frontal cortex area, that executive functioning area. Well, what other things or what other issues have we talked about that result in problems in executive functioning in that frontal cortex? Addiction, anxiety and depression. So frontal cortex issues produce symptoms that are common to a lot of different conditions. And I think it's really important that we recognize this so we adequately and accurately differentially diagnose, as well as identify comorbid diagnoses. Chronic procrastination or trouble getting started. Trouble getting motivated indicates problems in dopamine and norepinephrine. When people aren't motivated, both of these or either of these chemicals can be low. Both of these chemicals are involved in motivation. When people are depressed and they're apathetic, they can be experiencing low levels of dopamine and norepinephrine. When people have addictions, we know that there is a dysfunction in their dopamine system. Many projects going simultaneously. Now, this is more of a behavioral thing, and I had difficulty pinning it down to a chemical or an area. But thinking about people with adhd, they often have a lot of different projects going and often don't think finish a lot of them. But you see that as well with people who are gifted. So you may see people who are gifted get bored. They start a project, they start a model airplane, or they start something, they get bored and they move on. Which takes us to trouble with follow through. And dopamine is our main follow through neurochemical. Not the only one, but it is the main one. So when people don't have enough dopamine, then it can cause problems with helping somebody want to persevere and work all the way through to the end. People with adhd tend to have a tendency to say whatever comes to mind without considering timing or appropriateness. That filter is just not there sometimes. And that is a frontal cortex issue. When you remember that the frontal cortex does not finish developing until about the age of 24, then you can recognize that even for most adolescents and children blurting things out, Having difficulty with the filter occasionally is probably going to be something pretty common, but it tends to be very pronounced in people with adhd. They have difficulty stopping to think before they say something. It's just, it's got to come out. And we see some similar things in people with anxiety. They have such high levels of anxiety, they want to communicate what's going on. And by the way, we're going to talk about how ADHD overlaps with trauma in just a minute. A frequent search for high stimulation and intolerance of boredom indicates a lack of dopamine and norepinephrine. When the person is looking for high stimulation, they're trying to naturally sort of self medicate through doing things that are stimulating and exhilarating. When they're bored, they feel flat, they don't feel right. We see low levels of dopamine and norepinephrine and difficulty with being alone a lot with people who are depressed. With people who have anxiety, they may not search for stimulation, but they may have difficulty if they're not engaged in something because then they are focused on their anxiety. People with ADHD can sometimes get overly involved in goal directed activities. They can be really scattered when they're doing schoolwork or other things. But if there's something that they're interested in, they may have this laser focus and it's like all time disappears. And that also indicates a dysfunction in that dopamine and norepinephrine area. People who are gifted also tend to have a lot of goal directed activity. They don't like being bored. They look for stimulation because their minds are running so quickly and they want something to be able to focus their energy because they know they feel like they're going a whole lot faster than everybody else. My son, when he talks, especially when he was little, he doesn't do it as much anymore, but he would pace around in a circle. He'd be standing there talking to us, talking to my mother, talking to whomever, but he could not sit still and talk at the same time. And the more excited he got, the faster he paced in a circle. And you know, I'd kind of waited for fire to spread out of the floor someday because he was walking so fast. But that is not uncommon in ADHD or in giftedness. People with anxiety or with ADHD tend to have easy distractibility and trouble focusing their attention. This is also true in depression and addiction. We see that, you know, in anxiety, people are easily distractible because they're worried. They're constantly scanning for threats. They're hyper vigilant, so they are hypersensitive to what's going on, which makes it more difficult for them to focus their attention on one thing, like their schoolwork or a movie. People who are depressed are often easily distractible because their dopamine and norepinephrine levels are low. And they're just nothing engages them. Nothing interests them enough to get that dopamine and norepinephrine to kick in and go, let's focus on this. So they're just kind of like blah all over the place. Trouble focusing on proper procedures is another one of those impulsivity, attention deficit issues that goes along with problems in the frontal cortex area of the brain. Impatience, low tolerance of frustration, and emotional dysregulation. Also frontal cortex oriented. But with people who have anxiety, depression and addiction, we also see a fair amount of emotional dysregulation. So we want to pay attention to where is this coming from, what is motivating or prompting the emotional dysregulation for this particular person. Is it caused by anxiety, is it caused by depression, or. Or is it caused by a whole other issue that is related to ADHD or a combination therein? Impulsivity, either verbally or in actions goes back to what we've been talking about with that frontal cortex. The ability to stop think process before acting is really challenging for a lot of people with ADHD as well as people with addiction. We see a lot of impulse impulsivity in addiction. We also see impulsivity in anxiety and depression because people don't want to feel that way anymore. So they may impulsively act or they may become irritable in situations. We also see a little bit of impulsivity and giftedness or what seems impulsive to us because in their minds, a lot of times we are just going too slow and they are like, come on, catch up. Mood swings, especially when disengaged from a project going back to that emotional dysregulation. People who have anxiety or depression, if they're not focusing on something that's keeping them grounded in the present and they start thinking about what's stressing them out, causing their, triggering their depression or their anxiety, they may have greater mood swings. People with ADHD often tend, because of their low frustration tolerance and their impatience, may have these mood swings and a lot of irritability. When they aren't focused on something, they just, they get impatient. Think about driving five hours with somebody who has ADHD in the car. You know, they would be ready to probably jump out of the car after 45 minutes if they weren't engaged in something. Which is why when you've got somebody who is gifted or, you know, has difficulty, if they're not engaged and they have to endure something for a period, like flying on an airplane, it's good to pack a, what I call a survival bag. Five things maybe that they can have access to that can keep them focused. You know, with children, it may Be coloring books or, you know, little video games or something like that. With older adults, it could be books on tape or whatever works for them. But it's helpful if they know they're going to be engaged in something that's long and boring to have something to engage themselves. Another little side note, and I told you I wasn't going to get into interventions, but I can't help myself. For people with ADHD in staff meetings and you know, you may be one of those people or you may know one of those people who can't stand staff meetings because after about 20 minutes they start fidgeting and they're like, okay, I'm ready to go, I got stuff to do. That can be from anxiety because they feel overwhelmed, or it can be from the ADHD encouraging them to think about bringing things with them. Whenever I would go to lecture classes, you know, I would always, you know, have paper with me so I could draw, so I could make grocery lists, whatever. When I go to places where it's appropriate, I will bring my crocheting with me because I need to be doing something or I have difficulty sitting still. But it's one of those things. You've got to figure out what kinds of projects that are socially appropriate to engage in. In that setting. Physical or cognitive restlessness again relates to the dopamine norepinephrine disruption and can be seen as symptoms of anxiety, depression, addiction, withdrawal, giftedness as well as adhd. Because for whatever reason, you know, whether it's because of anxiety, because of, you know, a need to increase dopamine and norepinephrine because levels are too low, as in ADHD, or because of depression leading to some irritability and restlessness, There may be something going on there. And pretty much all of these people with all of these disorders or any of these disorders may have chronic problems with self esteem. Because a lot of times people don't see them as struggling with challenges. They see them as being oppositional, as disorganized, as irresponsible. Instead of looking at what's causing this, they're looking at the behavior itself and assuming that that person has the same capabilities as everybody else. And it's important to recognize the. Environments and the, what's the word I'm looking for here? The invalidating environments that a lot of people with ADHD may be in. They may be trying their hardest, but they just can't see, seem to get organized. My brother in law was that way, God bless him. You know, he would walk out without his head attached if it wasn't, or without his head, if it wasn't attached. So it's important to recognize that people with ADHD are not doing these behaviors intentionally. So let's talk about ADHD and trauma. And this comes from a PDF that you can pull down from the National Child Traumatic Stress Network. There is significant overlap between ADHD and trauma. We now know, thanks to the Adverse Childhood Experiences Survey, that a lot of people have been exposed to traumas throughout their life or during their life. So trauma is not the exception. It's really, unfortunately, the expectation. Now, does everybody develop trauma, traumatic injury, as I call it, when exposed to trauma? No. Some people can be exposed to trauma and have the support and the resources necessary to cope with it just fine, thank you. Other people may not have that. So they develop long standing issues as a result of that trauma. But the overlap between trauma and adhd, difficulty concentrating and learning. In school, the person with trauma tends to be hypervigilant. They're scanning, they don't feel safe, so they have a hard time focusing on what's going on. They have a hard time sleeping at night often. So it means that they're probably exhausted and having difficulty concentrating because of that adenosine buildup and that lack of sleep. In adhd, people have difficulty sustaining attention and struggle to follow instructions. In our American classrooms that are based primarily in many places on sort of lecture based learning and some integration with a textbook, it may be difficult for students to sustain attention while the teacher is up there lecturing and writing on the whiteboard. So we do want to recognize that if we have a student, a youth, or even an adult who presents with difficulty concentrating and functioning in school or work, we want to consider, is it from ADHD or from trauma? They're easily distracted. Hyper vigilance from trauma, or just difficulty because they don't have enough dopamine and norepinephrine to help them focus. So their attention is drawn. I had a friend in my graduate class who did a presentation on ADHD one time. She is an adult with ADHD and she was giving her presentation and as she was talking she had somebody turn on a radio. And that continued. And we all thought it was a little annoying because we didn't see what she was getting at at that point. And she kept talking and then she had somebody start flicking the lights on and off, on and off, on and off. So the radio is going, that's flicking on and off. And she's talking. And then she has a third person start shuffling papers around over in the corner sort of noisily. And by this point, we're all starting to look around and not be able to focus on what she's saying. And, you know, once she gets the entire class kind of irritated, she. She stops all of it and she says, this is what sitting in a classroom is like for me because it's difficult for me to filter out stimuli. So everything, every movement, every sound, every flicker of the lights can be distracting to me. And that was an important take home message because you don't really notice until you're paying attention how many different distractions there are. When my son was little, you know, he was homeschooled, and the room that he would work in had a window. And we ended up having to pull the blinds when he was working because he would be distracted by the birds that would be pecking on the windowsill outside of his room. And, you know, there was just nothing more we could do about that. So when he was studying, we had to have the blinds drawn. But figuring out again, what is causing this easy distractibility. Is it trauma and fear and unsafeness? Or is it an inability to filter out stimuli? Fidgeting or squirming, Sorry, I jumped to the wrong thing. Often doesn't seem to listen. People with trauma are often so focused on trying to stay safe that they may not hear what you're talking about. Their HPA axis is activated. They're in a persistent low level, if nothing else, state of fight or flee because they don't feel safe, which means they're focused on survival. When we're focused on survival, when we've experienced a trauma or stress, we have difficulty hearing things and actually processing them because our brain is focused over here, even if we're trying to listen and pay attention. Disorganization. People who have experienced trauma often are so concerned about other things that they have a hard time focusing long enough to figure out, okay, what do I need to pack in my gym bag? What do I need to have in my school bag or my briefcase to go to this meeting or to go to work today? So disorganization can be a big issue because the person with trauma is more focused on survival than packing a bag. In adhd, the disorganization goes along with distractibility. The person may sit down and start trying to figure out what they need to do, but they don't take the time. They're too impulsive, so they get a paperback and they shove it into their backpack instead of filing it in the correct folder so they can become disorganized. And forget where they've left stuff. Hyperactivity and restlessness are also common in trauma. We see a lot of hyper vigilance and irritability. People are sort of wound up in that fight or flight phase. So it looks more like hyperactivity. They're easily startled and they can be somewhat restless because they're scanning, they're constantly scanning. People with ADHD similarly can be hyperactive. Not everybody with attention deficit disorder has hyperactivity. Some of them have the inattentive subtype. So you also could see, and it's not on here with the inattentive subtype, which is actually more common in girls than in boys. Dissociation in trauma, the dissociation could be caused by a sense of unsafeness and, you know, dissociating for that reason. In add inattentive subtype, the person tends to drift off. They tend to start daydreaming. So it seems like they're, they're not paying attention. So we want to look at those things as well. And as I said, difficulty sleeping, when you've experienced trauma, and if you can't get to the point where you feel safe, it can make it more difficult to sleep. People with adhd, especially with hyperactivity, may have more difficulty settling down in order to get to sleep. And sometimes the medications, if they're taken at the wrong time of day, can make it more difficult for them to sleep. So we do want to explore, in all people that present with ADHD and mood disorders, we do want to explore for a history of trauma. ADHD and mood disorders have similar neurobiological differences in the prefrontal cortex, which is responsible for attention, behavior selection, and emotion. They also have abnormalities in dopamine and norepinephrine signaling. And it depends on the person, you know, where that problem may be. They are, they've hypothesized in some articles that it may not be that the person doesn't make enough dopamine or norepinephrine. It may be that getting the nerve signals transmitted the signaling. There may be a breakdown in that system. The National Comorbidity Survey reported that adults with ADHD are three times more likely to develop major depressive disorder and six times more likely to develop persistent depressive disorder. So let's think about this for a minute. You know, people with ADHD have disruptions in their dopamine and norepinephrine signaling. People with depression tend to have low levels of dopamine and norepinephrine and, and sometimes serotonin so that kind of makes sense. But let's look at some other things that may complicate the picture. If you have a person who has had ADHD for a while and been in an invalidating environment in which their caregivers and loved ones and friends are frequently getting angry with them because of their inattention and disorganization, disorganization and, you know, other ADHD symptoms, then they may feel rejected, they may feel hopeless, they may feel helpless, which can contribute to the, to the development of depression. You know, think about being in an environment where you're doing your dagum very best and it just never seems to be good enough for anybody. At a certain point, you may start feeling overwhelmed and helpless and develop a sense of learned helplessness. Rates of ADHD in people with bipolar disorder are between 9.5 and 21.2%. So in people with bipolar, we look at a group with a primary diagnosis of bipolar disorder and about 10 to 20% of those people are also going to have ADHD. Thinking about bipolar, you've got mania, hypomania and depression or persistent depressive disorder. And those things look a lot alike, a lot like some of the ADHD symptoms. Hypomania can look a lot like adhd. In people with adhd, you just take people with a primary dose diagnosis of ADHD. About 5 to 47% of them have bipolar disorder. Now it's just kind of an interesting semantic look. The take home message from this is there is a significant proportion of people with ADHD that have comorbid bipolar disorder. Characteristics of the manic or elevated phase of bipolar disorder that overlap with ADHD include restlessness, talkativeness, distractibility, fidgeting and seeking. Those high intensity activities, things that will be sort of thrill provoking. Prevalence rates of depression in individuals with ADHD are between 19 and 53%. And comorbid ADHD in individuals with depression, 9 to 16, 16%. Again, the take home message. A significant proportion of people with ADHD may also have depression and they may also have anxiety. You can have all three of them. Factors that were significantly predictive of undetected ADHD include the number of SSRIs previously tried that failed to attenuate symptoms. If somebody goes into the doctor and they present their symptoms and the doctor says, oh, it sounds like you're anxious or it sounds like you're depressed, Here, let me give you a selective serotonin reuptake inhibitor. Well, that's all well and good because as serotonin is altered, it's going to slightly alter levels of norepinephrine and dopamine, but likely not enough. So if somebody has been on multiple different SSRIs and not achieved substantial relief, and especially of symptoms that are characteristic of ADHD and or anxiety, it may be important to start looking to see whether the person has underlying adhd. I remember one client that I worked with in the residential program, bless her heart, she had a significant history of relapse. She'd relapsed a bunch of times. That follow through, that ability to follow instructions, that ability to persevere and keep doing something, you know, day after day, hour after hour, was that follow through was something she really had difficulty with. And she also had a lot of difficulty interacting with others in the group setting because she had difficulty taking her turn and she was impulsive, intended to speak her mind quite clearly. There was no filter there. And she had been diagnosed as bipolar and with an addiction, which. Okay, but we also, you know, as I started seeing those symptoms, it also became apparent to me that there was a probability that there was undetected ADHD there. And lo and behold, you know, we got her reevaluated and they did find ADHD or they did agree that there was an ADHD diagnosis there. But for her, she had struggled so much and she felt like such a failure because she had relapsed so many times because she had difficulty making friends. Most of the clinicians really didn't like working with her because she was impulsive and she would interrupt and seem to be disruptive a lot of the time. But once we put it into perspective, it became so much clearer. And the way that staff started interfacing with her was so much different and empowering for her in many ways because she started learning skills and tools to be able to deal with some of her ADHD behaviors in addition to, you know, they added more medication. But my point is highlighting the fact that undiagnosed ADHD can have very deleterious consequences not only for self esteem, but also for recovery from other things, including depression, anxiety and addiction. Rates of anxiety disorders in individuals with ADHD approach 50%. Anxiety disorders in ADHD have similar neurobiological deficits in in the prefrontal cortex related to quote, cool processing and deficits in top down regulation. So cool processing is down regulation, re regulating that symptom after it becomes, after the excitatory neurochemicals are secreted, that HPA axis is kicked off. Cool processing is when the rest and digest response kicks in and re regulates the person emotionally. And people with anxiety disorders and ADHD tend to have problems with reregulation. Addiction is approximately twice as common in individuals with adhd. Makes sense. They have problems. Both groups have deficits or problems in the, in the dopamine processing areas, the dopamine signaling areas. So people with addiction are often seeking that dopamine and endogenous opioid rush that they get from the substances. They're seeking the self medication of that or the euphoria, if you will. And people with adhd, since they do have a dysfunction in their dopamine processing, are more susceptible. They're more at risk for addictive behaviors. However, the research has shown, pharmacologically speaking, early intervention in ADHD with stimulant medications like methylphenidate, dexmethylphenidate is actually reduces the likelihood of later addictive behaviors. So if the person is provided the medication in childhood, adolescence, in order to learn how to cope with the symptoms that they have, then they are less likely to seek alternative forms of self medication later in life. That's a good thing. There was a hypothesis for a while that taking powerful stimulants in adolescence could lead to later addictive behaviors. But they found again the opposite is true. And my hypothesis is that medicating it when the behaviors first started prevented the development or minimizes the development of depressive and anxiety related symptoms as it relates to self esteem, self acceptance and relationship issues, etc. As well as learning how to organize and manage impulsivity and feel adequately stimulated but not overstimulated and manage emotions without substances. If they can learn how to develop develop those skills in as they're growing up, as that prefrontal cortex is developing, then they are helping create a healthy prefrontal cortex executive functioning system. So theoretically, when they get into adulthood, the symptoms will not be as intense. Individuals with ADHD experience neuropsychological difficulties associated with inhibition, memory, executive functioning, decision making, emotional dysregulation and time management. All of those are areas that we are going to talk about on Thursday for intervention that we can help people with environmental, behavioral and cognitive interventions. Adult ADHD has been associated with poorer driving and and a higher incidence of traffic, citations and motor vehicle accidents. Well, that's actually not too surprising. Think about how bored you get when you're driving sometimes or you're thinking of six different things and really not focusing as much on the road as you should. Well, intensify that by maybe the factor of 10. Because people with ADHD have difficulty filtering out extraneous stimuli you can see how it can be challenging for them to focus when they are driving. ADHD for the reasons that we already discussed often has negative consequences for an individual's self esteem that can, you know, so they have the diagnosis of adhd. But a low self esteem is also associated with depression and anxiety symptoms, especially fear of rejection. And a sense of being isolated can lead to difficulty in interpersonal relationships because the person with ADHD who hasn't learned how to take turns in conversations, who hasn't gotten organized, may tend to forget things. You know, we had plans at 5 o'. Clock, oh, I forgot. It is. It can be really challenging living with somebody with ADHD if you don't recognize it because you. A lot of times people feel like they're being irresponsible and you know, in reality that's just. They don't remember things the same way that everybody else does. So it may be important to have alarms and push notifications set on mobile devices and things like that to address those issues, encourage them to write things down, provide prompts. People with ADHD, interestingly enough, are also underemployed. Adults with ADHD are 42% less likely to be employed full time as were adults without adhd. And a lot of this has to do especially with people with undiagnosed ADHD having difficulty in the work environment. They are not. They don't know they have an issue for which they can ask for reasonable accommodations. So they are not able to advocate for themselves. Early optimal treatment of ADHD can potentially prevent the later development of psychiatric comorbidities. If we help people see early on, that will help parents see early on that these are unique characteristics of junior. You know, let's just embrace junior as junior is right now. Let's embrace the reality of what is instead of thinking about what should be or what could be what is, and help parents learn to adapt the environment. Caregivers learn to adapt the environment and encourage them to advocate for their youth with teachers in school in order to make sure that the youth has the most optimal environment possible. Not every school system has all the resources that you would love them to have, but they have as many modifications as possible to make their environment supportive of learning. So those are things that we can do in order to help the child feel safe, feel accepted, feel respected, and feel empowered and capable in their life. So three key questions that clinicians can ask to screen for undiagnosed ADHD in complicated patients. And you know, this is more for if you're seeing an adult like Some of the ones that I talked about that have maybe been struggling with following through on their treatment plans, they seem resistant to treatment or they come for a while and they drop out and then they come back for a while. If you look at their behavior in terms of follow through and organization and motivation, you may start to see that this person might have adhd. They may have some dysfunction in that frontal cortex, dopamine, norepinephrine areas, low birth weight, prenatal exposure to drugs and early childhood trauma are all risk factors for the development of later childhood adhd. That prefrontal cortex, remember when your brain is developing, it's extremely malleable, kind of like a clay jar is before it goes into the kiln. And when it's exposed and head trauma, when it's exposed to head trauma or any kind of chemicals that could harm the brain or just low birth weight or prematurity, any of those things make the brain more susceptible to injury. So we do want to recognize this and screen for people who might be at higher risk. You know, adding to these questions, you can ask people, you know, do you know if you were born, if you had a low birth weight when you were born, if you were five pounds or under? So three key questions that we can ask to screen for undiagnosed adhd. Have you had consistent problems with attention and distractibility most of your life? So not just the last five years, but most of your life? Have your current complaints like difficulty in relationships, emotional dysregulation, difficulty with organization, have they been present for the last 10 or 20 years? ADHD is not something that just pops up in adulthood. ADHD is something that we start seeing in childhood, definitely by adolescence, when children are having to be more organized and control their impulses. So we start seeing it in school age children, and then it very well may persist into late life. And the third question, what were you like in the classroom as a child? You know, were you the one that was climbing over desks and having behavioral problems? What were you like in the classroom? And likewise, what are you like in the workspace now? Now, if their symptoms did not seem to present until adulthood, then you may want to start looking more at anxiety based issues. But a lot of times people with a history of adult ADHD or with ADHD who have been undiagnosed, they have been doing their very best to try to get along in a neurotypical world when they may be neuro atypical. And it can be a relief for some to find out that hey, there is help out there. It's not just grin and bear it and, you know, try to become more organized and get yelled at all the time. So we do want to explore ADHD as an option or as a comorbid condition in patients who present with ADHD like symptoms, even if they, you know, don't seem to think that they're adhd. You know, it can't hurt to screen and, you know, just kind of figure out for yourself might we need to look at this in order to improve the treatment outcome. ADHD and many disorders have similar symptoms and common neurological and neurochemical causes, including dysfunction in the frontal cortex and the dopamine and norepinephrine systems. Treatment strategies should address behavioral manifestations to improve self esteem, work school functioning and interpersonal skills, and explore root causes of symptoms to ensure adequate differential diagnosis and comorbid diagnosis of mental health issues including trauma, depression and bipolar disorder. Part two Like I told you on Thursday, Part two of this presentation will cover cognitive, behavioral and and environmental interventions to help the person with adhd. Are there any questions? Alrighty everybody. I appreciate you being here with me today and being part of this training and I will see you on Thursday. You. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. 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