By Abi Angus & Ellie Mulcahy
Part one of this blog explored what ADHD looks like, debunking misconceptions around diagnosis and showing how research on brain structure helps us to understand differences.
In part two, we explore some of the brain differences linked to ADHD and unpick further misconceptions around gender. We set out how this can impact on the identification, treatment and support.
As discussed in part one, myths around the causes and validity of ADHD are still fairly widespread, with some people believing that the symptoms of ADHD are caused by parenting and not by neurological differences.
Recent research has confirmed previous findings that the volume of several important brain regions is smaller in the brains of people with ADHD. While this has no effect on overall intelligence, the functions of these regions are closely linked to the things which people with ADHD find challenging, such as motivation, emotional regulation and reward. Studies have also found differences in the blood flow and connections to the prefrontal cortex, the area of the brain responsible for executive functions, in the brains of people with ADHD.
Differences in neurotransmitters, the chemicals which carry messages throughout the brain and the nervous system, have been observed in people with ADHD, with three key neurotransmitters identified as contributing:
- Dopamine: this is the neurotransmitter responsible for motivation as it’s a key part of the ‘reward circuit’. In people with ADHD, dopamine is removed before it has had the chance to take effect. This results in increased impulsivity and a reduction in motivation; when dopamine is not able to take effect people will not feel the ‘reward’ that comes from completing a task and therefore struggle to maintain concentration.
- Norepinephrine: linked to attention and the ability to retrieve memories, norepinephrine also plays an important role in how the prefrontal cortex responds to incoming information.
- Serotonin: often referred to as ‘the feel good’ neurotransmitter, serotonin is important to a huge number of functions from sleeping and waking up, to learning, to feeling happy. However, too much or too little serotonin can reduce impulse control and result in inattention and aggression an inability to focus.
While there is some debate regarding the causality of the structural and chemical differences in the brains of people with ADHD, it’s clear that young people with ADHD cannot simply ‘snap out of it’ or ‘behave better’ if only they were parented differently; neurological findings show that people with ADHD process stimuli and experience the world differently.
ADHD and gender
A quick google brings up countless articles stating that ADHD is more common in boys, backed up by research showing a 6:1 ratio of boys to girls diagnosed with ADHD in childhood.
However, when looking at ADHD in adults there is a far smaller disparity, with a ratio of 1.6:1 men to women. This suggests that ADHD is not as gendered as it may at first appear, with misconceptions around both the variety of symptoms and the range of ways ADHD can present leading to underdiagnosis in girls.
While research has shown that gender doesn’t affect how people experience symptoms of ADHD, the behaviour presented by people experiencing those symptoms can vary. Studies suggest that in school, boys are more likely to receive praise for taking risks whereas girls are more likely to be praised for behaving ‘properly’, because teachers have gendered expectations of boys’ and girls’ behaviour.
As a result, boys with ADHD are more likely to display behaviour that fits with common understandings of symptoms, such as hyperactivity that impacts on ability to stay seated in classroom settings, whereas girls facing difficulties in school are more likely to withdraw rather than display challenging and disruptive behaviour.
As it’s often disruptive behaviour that results in a young person receiving support or being assessed for additional needs, girls needing extra support can often slip under the radar.
Navigating a world built for neurotypical people can be challenging for those who are ‘wired differently’ and facing these challenges everyday can impact on mental health. People with ADHD are more likely to experience other psychiatric conditions, and again, there are gendered differences here. Boys with ADHD are more likely than the general population to receive a diagnosis of conduct disorder, meaning they struggle to regulate their responses to situations, often resulting in challenging and, at times, violent behaviour. Whereas in girls with ADHD, anxiety and depression are more common. For women, it’s often through seeking support for these other conditions in adulthood that ADHD is identified, resulting in a diagnosis that can give context and explanation to difficulties faced throughout school and adult life.
Some people are able to manage their ADHD symptoms through strategies for making and maintaining healthy routines. This can help ‘make up for’ difficulties with planning, structuring and completing tasks. Exercise and a healthy diet are also credited as supporting people with ADHD to manage, although these are likely to benefit everyone regardless of whether they have ADHD.
However, for some people, ADHD symptoms can significantly impact on their ability to carry out day-to-day tasks. Medication and/or talking therapy may then be required to manage these difficulties.
In recent years concern has been raised over the number of children receiving medication to manage ADHD symptoms, however a Freedom of Information request made by the Guardian in 2018 revealed that while around 5.3% of children have a diagnosis of ADHD, just 1.5% of boys and 0.35% of girls aged between 6 and 17 years were prescribed medication used to treat ADHD in 2017. Similarly, American research on adults with ADHD found that the majority of adults with a diagnosis were not being treated for their symptoms; just 15% of male and 9% of female participants received medication and under 10% received counselling.
Understanding support needs
Within educational, home and work environments, there are a number of adjustments that can be made to support those who struggle with attention, impulsivity and hyperactivity. Strategies designed to minimise challenging behaviours and encourage conformity while failing to explore the specific difficulties faced by an individual with ADHD are unlikely to be effective. However, by understanding the challenges faced by people with ADHD and how these difficulties can impact on behaviour, strategies can be designed to ‘play to the strengths’ of those who are neurodiverse while providing support in areas that do not come naturally.
For example, breaking projects down into smaller tasks and providing rewards for each stage of completion can support a person with ADHD to manage a project that may at first seem daunting, while also making up for any differences in the natural release of dopamine that provides a ‘reward’ when a neurotypical person completes a task.
Viewing ADHD as a neurological difference therefore allows us to understand ‘challenging’ behaviour as a way to communicate support needs that arise from making sense of a world that isn’t always straightforward for those who are wired differently.
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