ADHD: Niet één maat past bij alle omstandighedenmaart 3, 2020
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ADHD is expressed in many different ways
ADHD is not a one-size fits all condition. This is because ADHD taps into a more general process called self-regulation. Self-regulation affects everything from how we deploy our attention, to whether we are impulsive, to how we manage our emotions.
Some children with ADHD also have a tendency to depression or anger. Their struggle with self-regulation means they have a harder time handling those emotions than someone without ADHD. They are impulsive, inattentive, and prone to anger-control problems. Other children with ADHD have a tendency to be exuberant and outgoing—and risk taking. They have a harder time regulating these impulses than someone without ADHD, and so they go to extremes.
Another kind of difference is in energy level. Some types of self-regulation problems lead to a problem inhibiting behavior—so some individuals with ADHD are very active and impulsive. Others lead to a problem activating behavior—so a child or adult has a sluggish tempo and struggles to initiate their activity when they should. Some individuals are both impulsive and sluggish—their energy waxes and wanes. This is another sign of difficulty in regulation.
A final example is attention. You may have noticed that a child with ADHD cannot focus on homework or conversation, yet can be absorbed for hours in a video game—and then cannot handle transitioning away. These two kinds of attention problem—under focus and over focus—have the same root. They are both problems with self-regulation of attention. On the one hand, they can’t focus when they should. On the other hand, their attention is captured readily by captivating stimuli like a video game, and it’s hard to break away.
Likewise, even though it’s usually impossible to trace the cause of ADHD in a specific child, we know that at a population level, ADHD has many contributing causes and risk factors. It is certainly influenced by genetic predisposition, but also by perinatal problems, maternal and paternal health, early social experiences, diet (at least in some cases), and exposure to pollutants. The mix of causes and influences may vary in important ways within the population we think of as having ADHD.
We increasingly are able to see reliable and distinct clinical profiles of the sort mentioned above. We are also beginning to see different levels of genetic risk. Distinct brain imaging profiles are starting to emerge and will eventually be verified. It seems highly likely that there are likely several ways to have ADHD and several forms of it. Science is still finding out how to describe these variations in a way that is most accurate in the clinic.
The upshot: personalize your plan
With this in mind, it is important to personalize the action plan for yourself or your child with ADHD. Your plan should take into account the best practices and best evidence for ADHD as a whole, yes. But that likely will not be enough (except for a lucky few!). Most people will also need to carefully take into account what is distinctive about your child’s temperament and background. Putting together what you know about yourself or your child and family, and what a professional knows about ADHD overall, can enable a personalized approach suited to your situation. Unfortunately, we aren’t yet at the point where genetic testing can predict which medication or treatment is right (the day is coming, but hold on to your wallet for the moment). Yet, careful evaluation can get close. For example, stimulant medication works well for ADHD—but it works better if a parent-child relationship also becomes more positive through counseling. If a child with ADHD is also quite anxious, then counseling greatly improves the outcome. An angry child may respond better to rewards than to harsh punishment. An exuberant child may need more social outlets. These refinements await further studies to confirm the best matching approach.
Ultimately, we hope to discover the right prediction models to know which personalized plan is right for each child. Until then, it is a matter of combining best professional advice with some individual trial and error and common sense. The key: recognize that what works for one child with ADHD may not apply to another child with ADHD. More than one variation exists.
Nigg, J. T. (2018). Getting ahead of ADHD: What next-generation science says about treatments that work—and how you can make them work for your child. Guilford Press. See chapter 2 for more on this article’s topic.
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Costa Dias TG, Iyer SP, Carpenter SD, Cary RP, Wilson VB, Mitchel SH, Nigg, JT, Fair DA (2015). Characterizing heterogeneity in children with and without ADHD based on reward system connectivity. Journal of Developmental Cognitive Neuroscience. Feb 11, 2015, p 155-174. https://www.sciencedirect.com/science/article/pii/S1878929315000158
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Karalunas SL, Gustafsson HC, Fair D, Musser ED, Nigg JT. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychol Assess. 31(2):236-247. doi: 10.1037/pas0000664. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6345612/
Nigg JT, Karalunas SL, Gustafsson HC, Bhatt P, Ryabinin P, Mooney MA, Faraone SV, Fair DA, Wilmot B. (in press) Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD. J Child Psychol Psychiatry. 2019 Oct 12. doi: 10.1111/jcpp.13132. https://onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13132