Issue 132: ADHD Deep Dive: Symptoms, Causes, Hidden Links

Welcome to 2025! I hope you had the most wonderful holidays, including some time to rest! We all need a minute to regroup after being completely out of routine for a couple of weeks.

This special Inner Workings double issue is dedicated to ADHD, its symptoms, root causes, and nutritional and integrative interventions. We have something for everyone, whether you experience life through an ADHD lens or support others on their journey. It’s been fun to bring all of this info together in one place!

Today’s first half discusses the definition and symptoms of ADHD, who is diagnosed with it (some surprises here!), common co-occurring diagnoses, and key underlying root contributors. Our next issue in two weeks will present nutritional and lifestyle interventions that really work to ameliorate the symptoms.

This is a complex topic, and I hope that you will reach out to me with your questions or thoughts.

In Wellness, Mary Virginia

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I’ve received a lot of education on supporting adults with ADHD. For these tandem articles on ADHD, I have drawn from research, my trainings with Dr. James Greenblatt and Camille Freeman DCN, MS, RH (AHG), LN and from the deep dive podcast ADHD and How to Improve Focus by Andrew Huberman (The Huberman Lab).
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What is ADHD?

Attention Deficit/Hyperactivity Disorder is a type of neurodivergent (vs typical) brain wiring that results in challenges in activities of daily living. Importantly, the person with ADHD is not being willful: this is really how their brain works. Any combination of the following symptoms might show up in an individual with ADHD:

• Trouble with maintaining attention/focus, aka easily distracted or difficulty staying on task.
• Moving constantly and/or talking incessantly.
• Impulse control, or difficulty restraining themselves from doing or saying something, interrupting, or standing in line.
• Hyperfocus (interruptions are met with frustration or anger).
• Attentional blinks, aka attention dips out briefly and returns. The person might have to use context clues to catch up to current events, and they might miss the info in that span of time altogether.
• Challenges with time perception/time blindness, aka run late, procrastinate, be motivated by deadlines.
• Issues with spatial perception, e.g. “pile” method of filing, but can’t find anything.
• Troubles with working memory in the moment (though can be good at remembering past events).
• Typically emotionally delayed compared to peers (children).
• Sometimes have physical balance or coordination issues.
• Often a night owl.
  

An important point is that those with ADHD can certainly learn new skills, but may not have the necessary focus or connectivity to apply them well. Renowned psychiatrist James Greenblatt notes that ADHD is a “performance disorder, not a skill disorder.” Nor is it an intellectual disorder, even if it interferes with academic performance. Having some combination of these symptoms can make it tough to participate at school or work, and they can be difficult for relationships and carrying out duties.

ADHD hits hard on executive function, the parts of the brain that provide organizational structure and time management along with task completion.

Those with ADHD brains are often intuitive, creative, and quick, and they can have amazing native intelligence. Any given experience for those with ADHD is often wired to emotion. It barely touches or skips past the brain’s executive function areas and goes straight to the emotional/limbic part, which is very close to our primary site of memory storage.

Seeing and processing the world through a unique lens inspires different connections than neurotypical folks. Many remarkable inventors, artists, comedians, and entrepreneurs have had ADHD, but also lawyers, doctors, and business people.

That said, it can interfere enough that even the brightest people sometimes can’t get traction in work or relationships. They struggle to integrate diverse sources of information, and have difficulty imposing useful structures, boundaries, and patterns where needed.

My own experience with ADHD is that there is a spectrum, from somewhat neurodivergent to highly impaired. Regardless, it’s not formally ADHD unless it is diagnosed.

How is ADHD diagnosed?

ADHD is diagnosed when a trained provider clinically confirms 6 or more symptoms in one or more of the domains below in a child <17 years old, or 5 or more in an adult >17 years old.

• Hyperactivity/Impulsivity.
• Inattention.
• Combined Type (some of both of the above).
  

Formally, per the DSM-V (the diagnostic manual on mental health used by clinicians. Read about it here), to be diagnosed with ADHD, symptoms must exist before age 12 in two or more settings (e.g. home and school) and interfere with daily living. As the DSM is always evolving, I’m curious about whether this age qualification will change over time.

While most of us will experience some symptoms that are like those of ADHD, they may be the result of our behaviors (e.g. cell phone use/scrolling or lack of sleep) or other root causes (e.g. traumatic brain injury) and not true ADHD.

Who is diagnosed with ADHD?

Research is only recently evolving out of the realm of white males, and this is super important. For example, children of color, especially boys, are more likely to be diagnosed with Oppositional Defiant Disorder, where white children receive the ADHD diagnosis more often - but they present with the same symptoms. Updated research inspires more accurate diagnoses, allowing more appropriate interventions. The new research is also resulting in some diagnoses being made later in life.

There has been an overall increase of one million diagnoses of ADHD since 2016.

Children
These days 5-10% of U.S. kids ages 3-17 are diagnosed with ADHD, and 40-60% of those children maintain it into adulthood.

Adults
75% of adults now diagnosed did not have the diagnosis as a child. Only 11% of adults are receiving treatment for it.

Girls and Women
Girls and women typically present with distractibility and Inattentive Type vs Hyperactive, and this can cause their diagnosis to be missed altogether. It can make them feel stupid where they are actually just wired differently. Therefore, girls and women will establish coping strategies that mask their symptoms and allow them to be successful in spite of the struggle. But the struggle is real.

To this point, here’s one surprise category of individuals that experience ADHD symptoms at an elevated rate: perimenopausal and menopausal women. In my clinic and by the reports of my colleagues, women often report a spike in symptoms of ADHD that can be prominent enough to warrant a new diagnosis. This is a result of the drop in estrogen that has a modulating effect on the brain areas of focus/attention, reward, motivation, and executive function. Likely these women have had ADHD their whole lives, but it was only in menopause that they no longer felt they could manage it well.

Co-Occurring Conditions

Children and adults with ADHD might experience co-occurring brain and mental health conditions (also called co-morbid). For me, the overlap between Autism Spectrum Disorder (ASD) and ADHD is especially fascinating. Not surprisingly given the challenges and brain wiring, anxiety and ADHD often walk hand in hand. Remember that 40-60% of children with ADHD maintain it into adulthood, and what you see in childhood will filter into adulthood. Here are the most prominent co-occurring diagnoses:

What are the roots of ADHD?

ADHD, like many other illnesses, does not have a single root cause. Anyone with the diagnosis will need a complete evaluation to grasp the most likely contributing factors for their unique physiology and biochemistry. This will let the practitioner personalize interventions to be most effective.

That said, common to those who suffer ADHD is that they have fewer dopamine receptors in the brain or may not be producing adequate dopamine at the right time, or both. Dopamine is the neurochemical of motivation, reward, focus, and attention. Interestingly, it’s also involved in physical movement. If it were a symphony conductor, dopamine would be assuring sounds and silences in the right moments of the music. Those with ADHD are hitting the notes and silences at the wrong time, which causes the “music” to become very confusing and out of sync with themselves and the world around them (credit to Andrew Huberman for the metaphor).

The dopamine pathway can be disrupted by a number of things, and various contributors can trigger, worsen, or mimic ADHD symptoms:

• Genes: 75% of those with ADHD have one or more genetic variations that increase the risk of having it.
• Environmental triggers: toxins, air pollution, lead exposure (even small amounts), prenatal exposure to tobacco, alcohol, and even (possibly) SSRI and SNRI psychotropic drugs.
• Neurobiology: an imbalance in catecholamine synthesis and metabolism (dopamine, epinephrine, norepinephrine).
• Digestive disorders and/or dysbiosis (an imbalance in the gut microbiome): a contributor, but it’s complicated.
• Candida: yeast in the gut and/or elsewhere.
• Food and environmental allergies.
• Food sensitivities.
• Autoimmune disease, most especially Celiac disease.
• Thyroid dysfunction.
• Additional need for nutrients: essential fatty acids (esp. DHA), iron, fat soluble vitamins A, D, E, K, folate (vitamin B9), other B vitamins, and calcium, magnesium, and other electrolytes.
• Sleep disturbances: 70% of kids with ADHD have sleep challenges that may be triggered by delayed circadian rhythms, an overlap with restless legs or sleep apnea, difficulty winding down, emotional dysregulation, or even timing of their stimulant medications.
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Stay Tuned!

Now that you know all about ADHD, come back in a couple of weeks when I publish my next Inner Workings! I will discuss assessments. I will follow that with non-medical interventions that can really support those with ADHD to function more successfully in their day to day lives.
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