Poor sleep quality in adult ADHD

We don’t realize how important sleep is. In a recent review of a new popular science book “Why We Sleep” by Matthew Walker (and you should really check it out) [1] a commentator wrote that our attitude towards sleep reminds her of what ancient Egyptians did just before they mummified a body: they always dumped the brain because they had no idea what it is, so why bother with the mushy pudding inside the skull? (www.tinyurl.com/y85pbmck) It seems that the way we treat sleep today has similar negative consequences for our physical and mental health as if we were thrashing our brains. It certainly doesn’t help to mummify our bodies as lack of sleep can considerably shorten our lifespan [1].

Poor sleep quality disturbs all aspects of cognition and emotion [2] resulting in poor concentration and high sleepiness during the day [3]. If you suffer from ADHD you are very likely know what I’m talking about, regardless how old you are [4, 5].

Sleep problems have long been a part of daily (or rather nightly) struggles of people with ADHD [6]. In fact, it is estimated that more than 50% of adults with ADHD experience sleep concerns [7] and suffer from low sleep quality [8-11]. This makes the burden of ADHD even higher by further lowering the quality of life. Imagine being exhausted by ADHD by day and then not being able to get any rest at night… No wonder poor sleep quality in ADHD results in poor academic performance, negative relations with significant others and higher chances for obesity [12]!

Interestingly, sleep disorders would often produce symptoms mimicking ADHD, so doctors should be extra careful not to confuse ADHD with consequences of these sleep problems [13, 14].

In our recent study involving adults with ADHD (data not yet published) we found that sleep quality is closely related to symptoms of inattention, hyperactivity/ impulsivity and emotional instability and that people with poor sleep quality make a lot of errors and respond much slower in a cognitive task which required concentration.

This means that if you have ADHD and you don’t sleep well, it’s as if you’d have more severe symptoms. And if you don’t have ADHD, lack of quality sleep could essentially make you a bit ADHD.

That’s why, regardless of whether you suffer from ADHD or not, you should do all in your power to make sure you sleep well at night (for useful tips check www.sleepfoundation.org). After all, we will all spend 20-30 years of our lives journeying into slumberland, so let’s make the best of these long and frequent trips – for the sake of our bodies and minds.

 

  1. Walker, M.P., Why we sleep : unlocking the power of sleep and dreams. First Scribner hardcover edition. ed. 2017, New York: Scribner. pages cm.
  2. Krause, A.J., et al., The sleep-deprived human brain. Nat Rev Neurosci, 2017. 18(7): p. 404-418.
  3. Durmer, J.S. and D.F. Dinges, Neurocognitive consequences of sleep deprivation. Semin Neurol, 2005. 25(1): p. 117-29.
  4. Hvolby, A., Associations of sleep disturbance with ADHD: implications for treatment. Attention Deficit and Hyperactivity Disorders, 2015. 7(1): p. 1-18.
  5. Cortese, S., et al., Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry, 2009. 48(9): p. 894-908.
  6. Konofal, E., M. Lecendreux, and S. Cortese, Sleep and ADHD. Sleep Med, 2010. 11(7): p. 652-8.
  7. Yoon, S.Y., U. Jain, and C. Shapiro, Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future. Sleep Med Rev, 2012. 16(4): p. 371-88.
  8. Sobanski, E., et al., Sleep in adults with attention deficit hyperactivity disorder (ADHD) before and during treatment with methylphenidate: a controlled polysomnographic study. Sleep, 2008. 31(3): p. 375-81.
  9. Boonstra, A.M., et al., Hyperactive night and day? Actigraphy studies in adult ADHD: a baseline comparison and the effect of methylphenidate. Sleep, 2007. 30(4): p. 433-42.
  10. Schredl, M., B. Alm, and E. Sobanski, Sleep quality in adult patients with attention deficit hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci, 2007. 257(3): p. 164-8.
  11. Surman, C.B., et al., Association between attention-deficit/hyperactivity disorder and sleep impairment in adulthood: evidence from a large controlled study. J Clin Psychiatry, 2009. 70(11): p. 1523-9.
  12. Um, Y.H., S.C. Hong, and J.H. Jeong, Sleep Problems as Predictors in Attention-Deficit Hyperactivity Disorder: Causal Mechanisms, Consequences and Treatment. Clin Psychopharmacol Neurosci, 2017. 15(1): p. 9-18.
  13. Bioulac, S., J.A. Micoulaud-Franchi, and P. Philip, Excessive daytime sleepiness in patients with ADHD–diagnostic and management strategies. Curr Psychiatry Rep, 2015. 17(8): p. 608.
  14. Oosterloo, M., et al., Possible confusion between primary hypersomnia and adult attention-deficit/hyperactivity disorder. Psychiatry Res, 2006. 143(2-3): p. 293-7.

Come sit on a mat with an artist and a psychiatrist to have a chat about mind wandering, gingerbread men, shark baits, and the interface of normal/abnormal behaviour

By Dr Kai Syng Tan (Leeds College of Art and University College London) and Professor Philip Asherson (Kings College London)

How far is too far?

Does your mind wander? What do you picture when you daydream? Where do you go? How far is too far? How often is too often? When does mental restlessness become impairment? What are the boundaries between pathology and normalcy, a healthy brain versus one that is ill, disordered and disorderly? What can a science-art collaborative exploration of mind wandering contribute to, challenge and extend our understanding of wellbeing?

Above: Left: Art invades science, science invades art: Phil and Kai at Monologue Dialogue IV exhibition inside Kai’s installation entitled ‘Crossed wor(l)ds (un-floored) (brain drawing) (2019 itinerary) (after Brexit, Chagall, Billingham, Wes, Savage, 2017)’, The Koppel Project, London (Photography by Richard Wright). Right: Memory Lane, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.

A roving art installation

Drawing on emerging research on how mind wandering relates to Attention Deficit/Hyperactivity Disorder[i], channelling the exuberance of artist Grayson Perry’s legendary tapestries as well as an artist’s lived experience as a mind wandering extraordinaire, We sat on a mat and had a chat and made maps! #MagicCarpet is a new collaboration between artist Dr Kai Syng Tan and molecular psychiatrist Professor Philip Asherson that aims to generate a critical and creative space to explore the boundaries between normal and abnormal behaviour, social and medical models of disability, imagination and pathology, art practice and scientific research, clinician and patient. Under the mentorship of Professor Asherson at the MRC Social, Genetic & Developmental Psychiatry (MRC SGDP) at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), a key aspect of the practice-led research project is how Kai will gate-crash/invade/intrude/immerse herself within the environment of leading researchers in ADHD at King’s College London as a Visiting Researcher. Apart from observing/participating in seminars, Kai will also volunteer for scientific experiments and trials. She will then embed knowledge, questions and interpretations gained in the design of a tapestry. The tapestry will be weaved in Flanders Tapestries in Belgium, which has produced tapestry art by Perry and other contemporary artists. The work ‘takes off’ when people sit on the tapestry, and chat about their mind wandering. Because words may be inadequate or challenging, they also capture their discussions/disagreements/discoveries in the form of maps and drawings (and the point is not how well you draw) that they will co-create. Co-riders of this ‘magic carpet’ include clinicians and researchers from UK Adult ADHD Network (UKAAN), self-taught artists from Submit to Love Studios, of Headway East London, a charity for people affected by brain injury, and as well as students and staff at King’s and elsewhere. Selected maps, as well as commissioned text and developmental sketches, will be documented in a limited-edition publication. A one-day seminar, exhibition and book launch will take place at the iconic Art Workers Guild. Other possible exhibition venues may include the Southbank Centre and IoPPN. Those who cannot experience #MagicCarpet live may enjoy photographs and a short film published on social media.

A space to problematise, debate and make magic 

As Flo Mowlem (April 11) and Dr Martine Hoogman (March 20) pointed out in previous blog posts, while mind wandering – in which attention switches from a current task to unrelated thoughts and feelings[ii] – is a universal human experience, excessive mind-wandering can be unproductive, and could be a key feature of ADHD; while ADHD can pose serious problems, there can be positives, and this is hitherto an under-explored area of research. Indeed, as one of the best example of a continuous trait found in both impaired and excelling individuals, ADHD is an ideal springboard to spark a discourse about the line(s) separating wellness and illness. BBC Horizon’s recent ADHD and me with Rory Bremner did a wonderful job in sparking mainstream interest in ADHD (not least in its controversial analogy of people with ADHD as half-baked gingerbread cakes and hapless victims of shark attacks). The ‘magic’ that #MagicCarpet as a project aims for is not to provide answers but to raise more questions. This is not just during the workshops, but publication, exhibition (if the tapestry and maps are portraitures of the makers’ neurodiversity, they present an interesting counterpoint to the hung portraits of able-bodied males that deck the Edwardian Hall of the Art Workers’ Guild), and beyond. While there are no shortage of melting clocks, cupboards that lead to other worlds and grand pronouncements about human beings’ primal desire for ‘journeys of the mind and body’, without which we ‘rot’ [iii] in the so-called ‘art world’, that mind wandering as a subject area, creative process or tool in the arts seems to be an unchallenged ‘given’ makes it an appealing area of research for Kai as a researcher and practitioner. Her own diagnosis of ADHD, dyslexia and dyspraxia in Autumn 2015 generated questions, not clarity. Where and when does the ADHD/art/personality begin, end or smash into each other? What are the problems and opportunities afforded by conceptualising and making ‘neurodiverse art’? Is this discussion a rehash of the tiresome myth of the ‘mad artist/genius’ (which artists themselves may corroborate, intentionally or inadvertently)? Is neuroscience society’s new tool to ‘otherpeople who do not conform, or does it enlighten and clarify? What can art bring to this conversation? #MagicCarpet is Kai’s process of inquiry/discovery as a woman/artist/curator/researcher. It is also her way to interrogate existing representation of ADHD which she has found to depict as largely only affecting children or adult male criminals, and only as an aberration to be corrected, cured, ironed out, medicated.

#MagicCarpet may also present a template of how art and science can clash and/or create sparks. As an ‘experiment’ which ‘invites us into the epistemological space of the laboratory’ while pointing to ‘ethical and aesthetic territories of novelty, invention, and play’[iv], it contributes to discourses on interdisciplinarity. Research in and with the arts and sciences tends to be siloed, but grand (and not-so-grand) challenges often require crossovers and the pushing of boundaries. The work creates a platform for clinical communities to dialogue with the arts about ADHD. As a leading artist working in the art-science interface argues, ‘not only is medicine capable of providing new material for the gallery space’, art can bring ‘new knowledge into the consulting space’ [v]. Equally important is the opportunity for artists to engineer forays out of comfort zones, in order to learn unfamiliar tools, languages and processes. A mind that does not seek new frontiers is one that is closed and stuck. Kai is thrilled as she is terrified by the extent to which her trespass into the medical world disrupts her assumptions and habits as an artist. Which was why she approached Philip in March 2016. The ensuing cultural clashes, collisions and antagonisms would, hopefully, be jarring, surprising, productive [vi].

Unlimited commission, unlimited possibilities

#MagicCarpet is one of 6 works commissioned by Unlimited in its Main Commissions strand for its 2017 round of awards. Unlimited is an arts commissioning programme that celebrates the work of disabled artists, with funding from Arts Council England, and is delivered by Shape Arts and Artsadmin. While the project is expected to run between Summer 2017 – Autumn 2018, there are possibilities to extend #MagicCarpet intellectually, artistically, pedagogically. An example is to tour the tapestry at various universities and working with the respective disability offices to help raise awareness of ADHD, mindfulness and neurodiversity in its staff and student populations. Another is to incorporate the tapestry as an object-based learning activity for students at MRC SGDP. Evidence relating ADHD with exercise as a preventative treatment is emerging[vii]. This is an area that could be developed into a research project, and relates to Kai’s existing body of work on running as a creative and critical toolkit. A related strand is to work with mobile EEG devices to enable the ADHD brain to create ‘brain drawings’ as the body runs through different places in various parts of the world, which could fit under the Science in Culture flagship of the Arts and Humanities Research Council.

Come ride the magic carpet with us. Share your thoughts, experiments, explorations, recommendations and counterarguments. Let’s see how far we can go (together).


Dr Kai Syng Tan FRSA SFHEA is an artist and curator. Through installation, performance, film, and text, she explores the body and mind in (com)motion. Sitting/slipping between/beyond discipline/form/conceptual frameworks/spaces/places/allegiances, her work is turbocharged by a day-glo palette, hyperactive layering and over-the-top vocabulary. They have appeared at Documenta, Royal Geographical Society, Biennale of Sydney, MOMA, BBC and the Guardian, and are collected by the Museum of London and Fukuoka Art Museum. Currently a Research Fellow at Leeds College of Art, Visiting Fellow at University College London’s Institute of Advanced Studies, Peer Review College Member of the Arts and Humanities Research Council and Director of RUN! RUN! RUN! International Body for Research, Kai completed her PhD at the Slade School of Fine Art, University College London. From Summer 2017 she will also be a Visiting Researcher at SGDP. @kaisyngtan
Professor Philip Asherson, MB,BS, MRCPsych, PhD is Professor of Molecular Psychiatry at the MRC Social, Genetic and Developmental Psychiatry (SGDP) centre at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London in the United Kingdom. Since 1996 when he moved to the IoPPN he has worked closely with Professor Jonna Kuntsi to develop a program of research on clinical, quantitative and molecular genetics of ADHD. In his own work, he has a particular focus on adults with ADHD. Current research projects include investigations of the neural basis of mind wandering in ADHD, clinical trials of prisoners with ADHD, and the impact of ADHD on learning in University students. He is the author and co-author of more than 300 articles and book chapters on ADHD and other neurodevelopmental disorders and traits. @ukaan_org

[i] See for instance Franklin, Michael S., Michael D. Mrazek, Craig L. Anderson, Charlotte Johnston, Jonathan Smallwood, Alan Kingstone, and Jonathan W. Schooler. “Tracking Distraction.” Journal of Attention Disorders 21 (6): 475–86. doi:10.1177/1087054714543494 (2014) and Mowlem, Florence D., Caroline Skirrow, Peter Reid, Stefanos Maltezos, Simrit K. Nijjar, Andrew Merwood, Edward Barker, Ruth Cooper, Jonna Kuntsi, and Philip Asherson. “Validation of the Mind Excessively Wandering Scale and the Relationship of Mind Wandering to Impairment in Adult ADHD.” Journal of Attention Disorders, June, 1087054716651927. doi:10.1177/1087054716651927. (2016).

[ii] Smallwood, Jonathan, and Jonathan W. Schooler. “The Science of Mind Wandering: Empirically Navigating the Stream of Consciousness.” Annual Review of Psychology 66 (January): 487–518. doi:10.1146/annurev-psych-010814-015331. (2015).

[iii] Chatwin, B. Anatomy of Restlessness: Selected Writings 1969-1989. Viking Pr. 100-106 (1996).

[iv] Callard, F, and Fitzgerald, D. “Medical Humanities.” Where Does It Hurt, 16–17 (2014).

[v] Padfield, D. MASK: MIRROR: MEMBRANE The photograph as a mediating space in clinical and creative pain encounters. University College London. 3 (2013).

[vi] Elsewhere Kai has talked about interdisciplinary collaborations. See Latham, Alan, and Kai Syng Tan. “Running into Each Other: Run! Run! Run! A Festival and a Collaboration.” Cultural Geographies, Cultural Geographies (Sage), doi:10.1177/1474474017702511 (2016).

[vii] Rommel, Anna-Sophie, Jeffrey M. Halperin, Jonathan Mill, Philip Asherson, and Jonna Kuntsi. “Protection from Genetic Diathesis in Attention-Deficit/hyperactivity Disorder: Possible Complementary Roles of Exercise.” Journal of the American Academy of Child and Adolescent Psychiatry 52 (9): 900–910. doi:10.1016/j.jaac.2013.05.018. (2013).

Is an ADHD mind a wandering mind?

This post follows on nicely from a previous one on the positive aspects of ADHD, and it is great to see that this area is receiving more attention. Research in this area is definitely sparse.

Throughout my PhD, I have been keen to conduct research that will be of benefit to those with ADHD, and I believe that finding different ways to look at and frame ADHD speaks to this. Yes, ADHD is associated with functional impairment in many aspects of life and poses a serious problem and difficulty for individuals, such as educational 1,2 and occupational problems 3–6, but I believe that there are also positives to ADHD. Recently our research group interviewed 6 adults with ADHD to try and understand more about the positive aspects of their ADHD, with reports of strengths and flourishing. Perhaps also appreciating and acknowledging the positive elements of ADHD traits could help reduce the stigma attached to mental health disorders.

In relation to occupational functioning, individuals with high levels of ADHD symptoms may excel in the workplace if they are in jobs that take advantage of some of the characteristic features of ADHD, such as the ability to hyper-focus on highly salient tasks or high levels of energy. It may be that individuals with ADHD or high traits of ADHD choose a specific type of job and career that is more suited to their ADHD symptoms. It is highly conceivable that creative professions would be appropriate, and an association between ADHD and creativity has also been described in the literature 7,8 (see Dr Martine Hoogman’s post ‘Is there a positive side to ADHD?’ for information about the association).

Such creativity could stem from the spontaneous generation of internal thoughts, also known as mind wandering, which is when our attention drifts away from our current external environment to internal thoughts and feelings that are unrelated to the current environment. This is something that we can all relate to (whether we have high traits of ADHD or not) – I know I can!! However, it seems that excessive and uncontrolled mind wandering is commonly experienced by adults with ADHD, and they often report symptoms that are very clearly descriptions of mind wandering.

My supervisor Philip Asherson is also a clinician and was noticing more and more that his patients with ADHD were using descriptions of mind wandering to characterise their symptom experience. This led to our research group looking more closely at this phenomenon and developing a new rating scale measure of excessive mind wandering; the Mind Excessively Wandering Scale (MEWS). Using this scale we found that excessive and uncontrolled mind wandering appears to be a common co-occurring feature of adult ADHD that has specific implications for the impairment experienced by individuals in their daily lives 9.

Currently, ADHD is characterised almost entirely at the behavioural level by reports of observed behaviours, but exploring mind wandering in ADHD encompasses a new way of thinking about the psychopathology based on mental phenomena rather than observable behavior. Also, if individuals experiencing ADHD symptoms find it easier to describe these subjective, internal experiences, and if these symptoms also separate those with and without ADHD then it is important to explore these alternative ways of evaluating symptoms. We are not saying get rid of current measures used to diagnose ADHD, but the MEWS could definitely complement these measures and may be more accessible for individuals. After all, the scale is based on actual patient reports of their experience.

wanderWe believe that excessive mind wandering has specific relevance for many outcomes associated with ADHD. However, we do not feel that it should only be viewed as having negative implications. It may confer functional benefit in some circumstances, and an association between mind wandering and creativity has also been described 10. This has led us to believe that it is important to enhance our knowledge and understanding of the role of mind wandering in the long term outcomes of ADHD. The area of mind wandering in ADHD also provides an opportunity to understand more about the positive aspects.

We decided to create an online survey that would help us understand more about how mind wandering and ADHD traits are associated, both the positive and negative aspects. More specifically, we want to learn more about how educational and occupational outcomes, as well as creativity, relate to mind wandering and other ADHD traits. We are collecting responses from both the general population (as ADHD traits are believed to lie on a continuum and are present in everyone to varying extents) and from individuals with a clinical diagnosis of ADHD.

Anyone over 16 years can complete our online survey.

To read the Information Sheet and complete the survey, go to:

tinyurl.com/mindwander

 

As an aside – but very related to this area – I believe it is important to acknowledge that ADHD traits were undoubtedly of benefit in our evolutionary past. For example, traits of risk taking, novelty seeking, and impulsivity were likely to be indicators of success back in the days of hunter gatherers. Yet, now we often view them as detrimental behaviours which I think speaks to current societal norms. The nature of our current culture and society is in many ways becoming more constrained. To give an example, the structure of the current education system, including the formal setting of the classroom and increased standardised testing, is not going to suit everyone and is likely to highlight and emphasise inattentive and hyperactive or impulsive traits which previously would not have been seen as so problematic.

Also, in schools the tendency is to not place as much emphasis on ‘creative’ subjects and professions as we do on ‘academic’ (in the narrow sense) subjects which can lead those who flourish in these areas feeling marginalised. Such subjects as art and sport are undoubtedly important and if individuals’ strengths lie within these domains this should be fostered and not discouraged or seen as less of an achievement. Especially if it enables those who may be functionally impaired due to a mental health condition experience reduced impairment and increased well-being.

Perhaps we can frame ADHD differently, not only viewing it as negative disorder associated with impairment, but recognising that is can also bring about positive traits such as creativity. It is important to understand more about the potential positive characteristics of ADHD and how individuals may use their symptoms to their advantage in some contexts. Our world would certainly be a very different place without the creative professions – artists, sportspeople, and musicians are an integral part of our society and everyone’s’ lives! (not to say they all have ADHD, but many do or have high ADHD traits).

 

Please feel free to share the survey with others, and tweeting would be greatly appreciated!!

@FloMowlem

Florence Mowlem, PhD student at the SGDP, King’s College London florence.d.mowlem@kcl.ac.uk

 

References:

  1. Frazier, T. W., Youngstrom, E. A., Glutting, J. J. & Watkins, M. W. ADHD and Achievement: 40, 49–65 (2007).
  2. Loe, I. M. & Feldman, H. M. Academic and Educational Outcomes of Children With ADHD. 32, 643–654 (2007).
  3. Biederman, J. et al. Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. J. Clin. Psychiatry 67, 524–540 (2006).
  4. Murphy, K. & Barkley, R. a. Attention deficit hyperactivity disorder adults: comorbidities and adaptive impairments. Compr. Psychiatry 37, 393–401 (1996).
  5. Kuriyan, A. B. et al. Young adult educational and vocational outcomes of children diagnosed with ADHD. J. Abnorm. Child Psychol. 41, 27–41 (2013).
  6. Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P. & LaPadula, M. Adult outcome of hyperactive boys: Educational achievement, occupational rank, and psychiatric status. Arch. Gen. Psychiatry 50, 565–576 (1993).
  7. White, H. a. & Shah, P. Creative style and achievement in adults with attention-deficit/hyperactivity disorder. Pers. Individ. Dif. 50, 673–677 (2011).
  8. White, H. a. & Shah, P. Uninhibited imaginations: Creativity in adults with Attention-Deficit/Hyperactivity Disorder. Pers. Individ. Dif. 40, 1121–1131 (2006).
  9. Mowlem, F. D. et al. Validation of the Mind Excessively Wandering Scale and the relationship of mind wandering to impairment in adult ADHD. Joural Atten. Disord. (2016). doi:10.1177/1087054716651927
  10. Baird, B. et al. Inspired by distraction: mind wandering facilitates creative incubation. Psychol. Sci. 23, 1117–22 (2012).

Is there a positive side to having ADHD?

If you are searching for positive aspects of ADHD on the web, you will find a lot of websites claiming all kinds of positive sides to having ADHD, such as being more creative, able to hyperfocus, or being more spontaneous. However, if you try to back up this information by scientific evidence, you will be disappointed. Up to now, research in ADHD has almost exclusively focused on cognitive and behavioral deficits in people with the disorder. With ADHD being a disabling disorder, this may not be surprising on the one side. On the other, however, scientific research in several other target groups, shows there is indeed evidence pointing in the direction of a positive side of neurodevelopmental disorders and traits associated with ADHD. Take for example creativity: for disorders such as bipolar disorder and schizophrenia, strong links with creativity have been observed in large samples1, and these disorders overlap phenotypically (e.g. through impulsivity) and genetically with ADHD. Also, creative people are often risk-takers and novelty seekers, as are people with ADHD20. From genetic studies, we can also derive suggestive evidence for a possible link between ADHD and creativity. groenebrainlampwebsiteMHThe dopamine receptor D4 gene (DRD4), also sometimes called the ‘adventure gene’, is a candidate ADHD risk gene identified by meta-analysis2 but has also been associated with increased divergent thinking3. Further evidence comes from brain imaging studies, showing brain regions involved in creative thinking, temporal and frontal lobe4, 5, to overlap regions implicated in ADHD (Hoogman et al. in prep & e.g.6).

What is already known about creativity and ADHD?

Creativity tests can be divided into tasks that measure divergent thinking (such as the alternative or unusual uses task and the Torrance test of creative thinking), and tasks that measure convergent thinking (e.g. the remote associations task). Also, questionnaires that relate to creative achievement are used to acquire information about ones creative abilities (e.g. the creative achievement questionnaire). A handful of studies has linked ADHD (symptoms) with creative performance. These studies had a maximum sample size of 90. Healey and colleagues showed that among creative children, ADHD symptoms were higher than in less creative children7. Another study, by White and Shah, found increased divergent thinking in ADHD college students as compared with non-ADHD college students8. And also higher creative achievement was found in ADHD9. Additional studies did not find a relationship between ADHD (symptoms) and creativity. For example, in a study by Aliabadi and colleagues, there was no difference on a figural Torrance test of creative thinking, and patients performed worse on fluency and flexibility11.

Another way of looking at potential links between creativity and ADHD is by using possible proxies of creativity, e.g. having a creative profession. Investigating the Swedish population registries in this way did not result in evidence for more creative professions among people with ADHD than among others12. This might be due to the categorization of creative professions (writers, painter, dancers, scientists), as this might be too broad. Also, people with ADHD are often unemployed, which would lead to an underrepresentation of people with ADHD in these studies.

So (what now)…?

Patients consistently claim a link between creativity in ADHD, but this link has not been the subject of large-scaled studies that are indispensable to define such a potential link scientifically. The one large, proxy-based study of creativity and ADHD, did not find a link between both12. Should we stop there? I don’t think so. Following the demand of patients to know more about creativity in ADHD as well as the promising findings of several small-sampled studies, I think that it does deserve our attention to not only focus on the deficits of ADHD. Finding answers on this subject might reduce stigma in ADHD, as we know from previous work that more knowledge about a disorder will create understanding and lessen prejudice13. In addition, it also has the potential to help patients cope with their disorder and support them in making choices education- and career-wise.

Therefore, we are currently making a first attempt to study creativity in our adult ADHD clinical study (IMPACT2-NL) by testing creative performance on divergent and convergent thinking tasks and by administering a creative achievement questionnaire. To be able to relate creative performance to the known cognitive deficits of ADHD, we will also assess those. In addition, we will also collect brain imaging and genetic data to gain knowledge on the underlying neural mechanisms. We are also working on reaching out to other ongoing studies to add creativity tasks to their testing batteries.

It goes without saying that ADHD is a debilitating disorder. However, we feel that if there is a chance that some positive sides of ADHD exist, they deserve to be studied.

 

Dr. Martine Hoogman, senior postdoc and PI of IMpACT2-NL

impactlogo

 

 

References

  1. Thys, E., Sabbe, B. & De Hert, M. Creativity and psychopathology: a systematic review. Psychopathology 47, 141-147 (2014).
  2. Gizer, I., Ficks, C. & Waldman, I. Candidate gene studies of ADHD: a meta-analytic review. Hum Genet 126, 51-90 (2009).
  3. Mayseless, N., Uzefovsky, F., Shalev, I., Ebstein, R.P. & Shamay-Tsoory, S.G. The association between creativity and 7R polymorphism in the dopamine receptor D4 gene (DRD4). Front Hum Neurosci 7, 502 (2013).
  4. Cousijn, J., Koolschijn, P.C., Zanolie, K., Kleibeuker, S.W. & Crone, E.A. The relation between gray matter morphology and divergent thinking in adolescents and young adults. PLoS One 9, e114619 (2014).
  5. Dietrich, A. & Kanso, R. A review of EEG, ERP, and neuroimaging studies of creativity and insight. Psychol Bull 136, 822-848 (2010).
  6. Shaw, P., et al. Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proc Natl Acad Sci U S A 104, 19649-19654 (2007).
  7. Healey, D. & Rucklidge, J.J. An investigation into the relationship among ADHD symptomatology, creativity, and neuropsychological functioning in children. Child Neuropsychol 12, 421-438 (2006).
  8. White, H. & Shah, P. Uninhibited imaginations: Creativity in adults with Attention-Deficit/Hyperactivity Disorder. Personality and individual differences 40, 1121-1131 (2006).
  9. White, H.A. & Shah, P. Creative style and achievement in adults with attention-deficit/hyperactivity disorder. Personality and Individual Differences 50, 673-677 (2011).
  10. Healey, D. & Rucklidge, J.J. An exploration into the creative abilities of children with ADHD. J Atten Disord 8, 88-95 (2005).
  11. Aliabadi, B., Davari-Ashtiani, R., Khademi, M. & Arabgol, F. Comparison of Creativity between Children with and without Attention Deficit Hyperactivity Disorder: A Case-Control Study. Iran J Psychiatry 11, 99-103 (2016).
  12. Kyaga, S., et al. Mental illness, suicide and creativity: 40-year prospective total population study. J Psychiatr Res 47, 83-90 (2013).
  13. Mueller, A.K., Fuermaier, A.B., Koerts, J. & Tucha, L. Stigma in attention deficit hyperactivity disorder. Atten Defic Hyperact Disord 4, 101-114 (2012).

DOES ADHD MEDICATION CHANGE THE DEVELOPING BRAIN?

Treating children with ADHD medication is hotly debated. It’s shown to be effective in reducing ADHD symptoms, but what are the long-term effects on developing brains? We asked an expert.

How ADHD medication influences the brain in the short-term has been widely studied, but many children with ADHD take medication over several years. The effects of long-term ADHD medication treatment on the developing brain have been less researched. Lizanne Schweren conducted her PhD research on this very topic, with a focus on stimulants, the most commonly prescribed ADHD medication. We sat down with Lizanne and asked her a few questions:

Photo by en:User:Sponge

What are stimulants?

Stimulants are drugs that activate the body, including the brain. Stimulants are sometimes referred to as “uppers”, as their effects tend to be energizing and pleasant. The best-known prescribed stimulant to treat ADHD is methylphenidate. For 70-80% of children, as well as adults, methylphenidate reduces their ADHD symptoms and helps them concentrate.

What happens in the brain directly after taking stimulants?

Methylphenidate blocks the reuptake of dopamine within the synaptic cleft, the gap between pre- and postsynaptic cells. Dopamine transmits neural signals from one cell to the next, and does so until the presynaptic cell transports dopamine back for recycling. By blocking presynaptic reuptake, more dopamine is left in the synapse and more signal is transmitted.

Children with ADHD often take stimulants for several years. What effect does this have on their brains?

People with ADHD, their brains look subtly different from people without ADHD. Previous studies had suggested that after long-term stimulant treatment, these differences may become smaller or even disappear. However, in my own research we found subtle differences in brain structurebetween those with and those without ADHD, regardless of treatment history. This suggests that the treatment does not in fact change the way the brain develops structurally.

Photo by amenclinicsphoto ac 

As opposed to structural differences, we did find differences in brain activation patterns when comparing children who differed in the age of onset of ADHD as well as stimulant dosage. During an fMRI experiment, the group who began taking stimulants at a young age and at a higher dose, was more likely to show activation in brain regions important for cognitive control (dorsal anterior cingulate cortex, and supplementary motor area), compared to children who took stimulants at an older age and at a lower dose. All children were off their medication during the experiment. We think that people with ADHD, who often act impulsively, may benefit from activations in these brain regions.

What do these long-term effects of stimulants on the brain mean for children with ADHD? And for clinicians prescribing stimulants?

While neuroscientists were hoping for positive – normalizing – long-term effects of stimulant treatment on the brain, parents and clinicians have mostly been concerned about potential negative consequences. For them, the fact that we found no evidence of structural brain changes associated with stimulant treatment is probably a relief. Moreover, we showed that long-term stimulant treatment does not result in better clinical outcomes. Most often symptoms of ADHD decrease during adolescence, and these improvements happen whether the child took stimulants or not. For clinicians working with patients and their parents, it is important to communicate that stimulants may temporarily improve symptoms of ADHD but they do not alter outcomes in the long-term.

 

Lizanne’s research is based on data linked to the Donders Institute: the NeuroIMAGE sample.

We want to thank Lizanne for the interview with the Donders Wonders.

Her thesis can be found here.

 

Interview conducted by Corina Greven.

Blog written by Corina Greven.

Blog edited by: Marisha Manahova.

Featured image by Jonathan Rolande.

 

This blog was originally published on www.blog.donders.ru.nl. This is the official blog of the Donders Institute on brains and science.

donders_banner_bilingual

Subcortical brain volumes in ADHD: the ENIGMA ADHD study

Many neuroimaging studies in ADHD have been published, each with its own contribution to science. However, brain imaging studies are expensive and therefore the sample size of studies is often small, which could result in not finding effects that are actually there. Also, different methods are used, which makes it difficult to compare studies. This results in inconsistent findings and still many uncertainties about the neurobiology of ADHD. To address these issues we founded the ENIGMA-ADHD consortium. Here, many experts in the field are united to share their expertise and their data. This way we can reanalyze existing data in large meta-and mega-analyses to try to get as close as possible to finding true effects in the brain. Our first paper was published last week in The Lancet Psychiatry and received a lot of press.

Summary of the results

We studied volume differences of 7 subcortical brain regions in >1.700 people with and >1.500 without the ADHD diagnosis from 23 collaborating institutes, with and age range of 4-63 years. We found smaller volumes for the amygdala, areas in the striatum (accumbens, caudate nucleus and putamen) and the hippocampus. The effects were small, in the order of 1 %. The differences were most pronounced in children with ADHD, differences in adults were not significant. We also studied the effects of presence of co-morbid disorders and the use of stimulants, but no effects were found. Neither did we find a correlation between the severity of ADHD (number of symptoms) and the brain volumes. Our effects are similar in size when comparing them to other psychiatric disorders such as depression (1). Compared to previous meta-analysis on brain structure in ADHD, our amygdala, accumbens and hippocampus findings are new. The amygdala finding is interesting as this structure in the brain is involved in emotion regulation and connected with many other parts of the brain. Emotional regulation problems are often mentioned in ADHD, but have not been the subject of many studies yet.

What does it mean?

…or equally important, what does it not mean: it does not mean that we can diagnose patients based on their brain scan. Effects are small and we can only identify the differences if we study large groups of patients. Neither can we say anything about cause or consequence, which was not the aim of our study. Also we need to be cautious about interpreting the age findings as this was a cross-sectional study, longitudinal studies should confirm our results.

So what can we say about our results? We have been trying to understand what ADHD is for a long time now and we use multiple levels of research to find answers to our questions. We study behavior, cognition, genetics, environmental factors and also the structure and functioning of the brain. This results in pieces of the puzzle which together should make up the picture of ADHD. The results of our study contribute to a better characterization of the neurobiology underlying the disorder by showing the amygdala, the striatal regions and the hippocampus to be implicated in ADHD. Further research into the associations with for example behavior and also the meaning of the size of the effects should give us more information on what our results actually mean.

What next?

So far we only studied 7 brain regions, and next we want to focus on the thickness and surface area of the cortex. We are also setting up a DTI study within the framework of ENIGMA-ADHD. Our dataset is open to anyone who wants to work with the data and comes up with a good idea. Currently a handful of researchers are working on side projects such as making prediction models and using machine learning algorithms. Others study subparts of particular brain regions (cerebellum). In the meantime we keep growing as a working group, welcoming new institutes at any time. We have grown to 34 participating sites with data of over 4000 participants. We especially encourage cohorts with older ADHD participants, as coverage of this age range is limited in our dataset.

enigma_300dpi

For more information about ENIGMA-ADHD please visit our website http://enigma.usc.edu/ongoing/enigma-adhd-working-group/ or contact Martine Hoogman martine.hoogman (at) radboudumc.nl

 

  1. Schmaal L, Veltman DJ, van Erp TG, et al. Subcortical brain alterations in major depressive disorder: findings from the ENIGMA Major Depressive Disorder working group. Mol Psychiatry. 2015.

 

Mindfulness for children with ADHD – is that possible?!

International research shows that mindfulness can improve attention and self-control. This has already been shown for people without ADHD, and the initial results from research in children with ADHD are promising.

Many parents of children with attention-deficit hyperactivity disorder (ADHD) are looking for alternative treatments that do not involve ADHD medication. Mindfulness (paying attention without judgement) is becoming an increasingly popular training in Western societies, and is already successfully used in the treatment of depression and anxiety in adults. But may mindfulness also work as an intervention for ADHD? Especially in the case of children with ADHD who have difficulties with concentration, you may wonder whether they are able to pay enough attention for mindfulness training.

6035280806_b70fc7e2e0_bImage from: Sebastien Wiertz

What is mindfulness precisely?

Mindfulness involves paying attention in a particular way:

  • On purpose (meaning it involves effort)
  • To the present moment
  • Without judgement

With mindfulness you can learn to become aware of your body, emotions and thoughts. You learn to notice impulses, but to not immediately react to them.

An example: A boy sits in the classroom. His mind starts to wander away from the teacher towards his weekend activities which he is excited to share with his classmate. He deliberately notices feeling excited (awareness) and the urge to turn around to speak to his friend (impulse). He lets the sensation pass through him without judgement (non-judgement/ non-reactivity). He purposefully brings his attention back to the teacher.

Mindfulness for children with ADHD – is that possible?!

In many ways, mindfulness training seems an ideal intervention for ADHD. Children with ADHD have difficulties with paying attention, hyperactivity and regulating their impulses. In short, they experience problems around self-control. Research from non-ADHD populations shows that mindfulness training improves people’s self-control by increasing attention control, emotion regulation and self-awareness.

In addition, evidence suggests that mindfulness training alters the structure and function of brain areas involved in self-control, such as the anterior cingulate cortex, prefrontal cortex, posterior cingulate cortex, striatum, insula and amygdala. Several of the brain areas implicated in mindfulness overlap with those for ADHD. However, is mindfulness training feasible in children with ADHD?

 

3238035260_06613cf1c3_o

Image from: Todd Fahrner

The MindChamp project

A handful of Dutch studies have shown that mindfulness training clearly is feasible for children with ADHD. For this work, children with ADHD and their parents underwent the MYmind programme: 8 weekly mindfulness sessions of 1.5 hours. The training is adapted to the needs of families of ADHD, for example using shorter and more playful exercises. The studies showed that mindfulness training reduces ADHD symptoms, improves self-control and reduces parenting stress. However, the studies were small and used a less rigorous (non-randomised) design.

Research linked to the Donders Institute is taking this to the next level with the MindChamp project: Mindfulness for Children with ADHD and Mindful Parenting. This larger, randomised-controlled trial uses the MYmind mindfulness programme, and is based at Karakter Child and Adolescent Psychiatry, in collaboration with the Radboud Centre for Mindfulness and UvA Minds. Recruitment for the project is ongoing (children with ADHD aged 8-16 years), and the first results can be expected in 2018. The hope is that positive research results will allow more families with ADHD access to the intervention.

Links:

More information about MindChamp here

Questions about MindChamp? Email mindchamp@karakter.com

MindChamp is part of the MiND project. It is funded by a Marie Sklodowska-Curie grant and the Netherlands Foundation for Mental Health.

Blog written by Corina Greven.

Editor: Marisha Manahova.

Featured image by: papermoons

This blog was originally published on www.blog.donders.ru.nl. This is the official blog of the Donders Institute on brains and science.

donders_banner_bilingual