ADD and ADHD are highly prevalent conditions that manifest with a broad-spectrum of symptoms including but not limited to:
Given the vast array of symptoms that can occur, it is no wonder that standardized care such as psychotropic medications, stimulants, and counseling have poor predictability of success (as low as 5% in some studies). Additionally, the stimulant class of medication can cause undesired side effects.
The reality of the ADD/HD spectrum is that there are many manifestations of brain dysfunction that can occur. With neuroimaging techniques, we have isolated 11 specific issues (or subtypes as we call them) that can drive symptoms consistent with ADD/ADHD. Most people with an ADD/ADHD diagnosis will have anywhere from 2 to 10 of these specific subtypes of issues which causes the situation to become quite complex. This displays the incredible importance of both functional and structural forms of neuroimaging to accurately and objectively assess the organ that is involved in ADD/ADHD development. This allows us to determine the subtype and spectrum for each individual with ADD/ADHD so that we can determine proper care protocols with exceedingly high predictability (as high as 96%). This creates the cutting edge of individualized care for ADD/ADHD.
I am continually astounded that >95% of ADD/HD populations have never completed an MRI, EEG, or other neuroimaging study to assess brain function, especially considering that 22% of ADD/ADHD cases have undiagnosed non-epileptic seizure activity (also known as paroxysmal, non-epileptic seizure (PNES) activity), 26% have undiagnosed developmental trauma, and 15% have undiagnosed communication issues associated with head trauma. The aforementioned subtypes can only be fully assessed and diagnosed using neuroimaging and specialized testing and questionnaires. The unfortunate reality is most people with ADD/ADHD will never have a proper neuroimaging assessment.
At Neurvana Health we specialize in neuroimaging and techniques used in the care of ADD/ADHD. This includes conventional, natural and neuromodulation techniques. The first step in determining what options are best for you are to complete a quantitative EEG and MRI assessment. This allows us to pinpoint the brain regions or functions associated with your specific symptoms and subtype of ADD/HD. From there, we can recommend specific care strategies to significantly ameliorate your symptoms. This almost always includes an integrative approach and can be adjusted based on your comfort level. For example, some people do not wish to embark on conventional psychotherapy or do not wish to use medications, this is something we are always willing to work with.
Listed below are the specific subtypes that drive ADD/ADHD symptoms. Keep in mind when learning about these that they are nearly all reversible and, in some circumstances, where reversal is not possible, management and improvement always are. The reason subtyping causes for ADD/ADHD is so incredibly important is that without knowing the cause we do not know what options will be effective. We are left with guesswork and as you will see, this condition can be too complex for guesswork in most cases. Using protocols that are meant for one subtype on an improper subtype can render a care plan ineffective at best and at worst, it can cause significant side effects and sometimes cause short and long-term problems. We call this iatrogenic illness.
a. This subtype occurs when neurons in certain regions of the brain all fire in a synchronous manner resulting in a temporary “shut-down” of the region it is occurring in. Think of this like flipping off a light switch temporarily. One second it is perfectly light and bright in a room, we can see everything that is present within the room and then suddenly, the light flips off, and everything goes dark. We cannot process or visually see anything in the room and then a few seconds later the lights turn on again. When this type of response occurs in the brain, the area associated with the activity will stop doing what it is supposed to be doing for anywhere from 300 ms to several seconds. This can lead to moments of “blacking out”, seeming completely absent or tuned out, and leads to a complete loss of information and flow state within that period. In 22% of ADD/HD cases this leads to symptoms of inattention, focus difficulties, executive function problems and in some cases emotional outbursts. There are many techniques that can get this activity under control including medications, nutraceuticals, neurofeedback, and other neuromodulation technologies. See below examples of real ADD/HD cases and the seizure-like activity associated with their symptoms:
Figure 1. In the image above, all the activity on the left half of the recording is normal. The right half illustrates paroxysmal absence seizure activity in a patient diagnosed with ADHD. This was resulting in complete absence activity and the resulting effects were complete inattention and difficulty comprehending information. Learning is extremely difficult when this is occurring and unfortunately the typical medications and counseling will not help.
Figure 2. In the image above we see the left highlighted section atypical spike-wave activity occurring in the left prefrontal regions. This was causing executive function problems, memory retrieval issues, focus issues and significant difficulties regulating mood and emotional responses. This person was prone to angry outbursts and reported episodes of depression along with difficulties managing substance use. This response was improved, and all his ADHD symptoms significantly improved.
a. Inflammatory subtypes show up in extremely non-specific ways in the brain. Simply speaking, inflammatory compounds (typically from the immune system however external compounds can have an effect as well) have a specific effect on cells in the brain called “glial cells”. Glial cells are widespread, complex cells in the brain that play the role of electrician, power linemen, and garbage men in the brain. They oversee whether signals in brain cells are turned on or off (using gliotransmitters), whether we wire new pathways (learning, motivation, inhibition), and whether our brain inflames or repairs and regenerates. They also play a role in the glymphatic system that acts as a waste removal system that is particularly active at night while we sleep. If glial cells are receiving signals to inflame, regions associated with this signal will flip into a sort of “sleepy” state. This means that any areas affected by large amounts of inflammatory activity will be more “asleep” than they are “awake”. The symptoms of this are dependent on the areas affected but include ALL symptoms of ADD/ADHD. This is again why a quantitative EEG is so important. This subtype is by far the most complex mainly because we must identify the source of inflammation so we can properly repair this activity. The number 1 problem that needs to be ruled out and repaired in instances like this are sleep issues. Sleep and circadian rhythm problems (not waking up and going to sleep at consistent times) are a strong causative factor for this subtype. The second most common cause is something called chronic inflammatory response syndrome (CIRS) which is when something triggers an inflammatory response (such as a virus or exposure to mold) and the response does not shut off, even after the trigger is gone. Other causes for this include microbiome imbalances (gut-related bacterial imbalances), toxicity, infections, and improper light exposure/lack of sunlight. Figure
Figure 2. This image shows elevated glial cell activity (typically associated with low-grade inflammation) that was causing this patient’s brain to be more “asleep” in the left parietal and occipital regions of the brain. Symptoms of this were difficulties learning, comprehending, and focusing. Memory retrieval was impacted, and he suffered from complaints of anxiety, irritability, and daydreaming.
a. The cerebellum is a unique part of the human brain. It plays a role in balance and coordination of all signals traveling throughout the brain. This means it plays a role in physical balance, cognition, learning, and emotional regulation. Think of it like the conductor of an orchestra or a timing belt in the engine of a car. It orchestrates and times the sending of signals to ensure the brain functions optimally. Symptoms of issues within the cerebellum include focus issues, anxiousness, difficulties learning/comprehending, slowed processing speed, balance/coordination issues, disorientation/dizziness, and mood swings. This area is the most predominantly affected by concussions and sub-concussive injuries. I frequently see problems in the cerebellum when there were whiplash or other head/neck injuries in the past. Sometimes this is even correlated to the time of onset of the ADHD symptoms for patients.
Figure 3. This image is an example of cerebellar communication issues (red square). When these blue lines are visible it is indicative of cerebellar regions not communicating to the brain well which can, in some cases, result in symptoms of ADHD.
Figure 4. Another example of cerebellar communication issues (red square)
a. The basal ganglia and thalamus are regions within the midbrain that play a role in processing of signals (much like a processor in a computer). The basal ganglia regions also play a role in how fast or slow or brain idles (called alpha peak frequency). ADD/HD patients can have a slow, fast, or normal idling rate depending on the subtype. It is important to measure this to optimize care and management plans. Brains that idle too slowly tend to experience fatigue, drowsiness, brain fog, poor memory retrieval, inattention, and tendencies to daydream or dissociate. Brains that idle fast tend to display hyperactivity, anxiety, sleep issues, distractibility, agitation, and mood swings. These fast-idling subtypes typically respond worse to pharmaceutical approaches to ADHD which include stimulants.
Figure 5. The image above shows significant impairment of the thalamus and regions surrounding the basal ganglia (as indicated by red circles/squares). This was leading to symptoms and issues with learning, memory consolidation, attention, and processing speed which translated to difficulties with schoolwork, studying and severe test anxiety.
a. Metabolic rates within the brain are essential to proper function. Metabolism is synonymous with energy. This subtype occurs when certain regions within the brain do not meet the energy requirements to function optimally. Like the inflammatory subtype, it will cause sluggishness within the areas affected. The most commonly affected areas are the prefrontal lobes which are involved in attention, focus, executive function (planning/organizing) and emotional regulation. Any area affected by a metabolic or energy issue will function more poorly, and it will lead to symptoms. Causes of metabolic dysfunction include airway obstruction (apnea/hypopnea), cell danger responses (danger responses from the cells), poor nutrition including nutritional deficiencies, thyroid function issues, and neuropeptide deficiencies (typically caused by head injury). Metabolic dysfunction typically presents with mental fatigue, brain fog, and sluggishness but it can also cause mood swings. This subtype also tends to respond well to stimulants and drugs such as modafinil.
Figure 6. Surface EEG activity that shows metabolic problems within the brain with elevated alpha frequency power (red circles)
a. This subtype is highly prevalent within ADD/ADHD populations. It can, but does not ALWAYS occur when emotional, psychological, birth, mental, cultural, or other forms of non-physical trauma occur. The adverse childhood experience studies that were first published in 1999 illuminated the widespread effects early childhood and developmental trauma had on mental health. The main effects of these types of non-physical traumas are on a system within the brain called the limbic system. Think of the limbic system as a ‘threat detection’ system within the brain. Its main role is in keeping us safe from threats physically and emotionally. When the limbic system detects a threat, it mounts a ‘threat response’ or ‘danger response’ in the form of stress. This may be low-grade types of stress such as internalized anxiety, sweating, nervous stomach, or other visceral reactions. It may also be a more intense threat response which induces anger, mood swings, panic attacks, sweating and blood pressure changes. In some cases, we are so overwhelmed our nervous system shuts down, so to speak, and causes hopelessness, helplessness, depression, feeling overwhelmed, fatigue, dissociation, derealization and occasionally events of fainting (syncope). In specific cases of persistent trauma, the brain relates many different events, circumstances, feelings, and sensations to trauma and mounts a danger or shut-down response. When this occurs, it presents with typical symptoms of ADD/ADHD with a focus around symptoms of poorly regulated emotional responses and mood swings. At Neurvana we call this “limbic hijacking”. Like previous subtypes, certain regions within the brain can be “hi-jacked” by this limbic system, rendering them less efficient and more poorly functioning. Symptoms can vary greatly depending on the areas affected but quite often presents as ADD/ADHD. Approaches to this subtype include neurofeedback/neuromodulation techniques, trauma-based psychotherapy approaches, and Brainspotting or EMDR. It is important to note that medications often have the opposite effects to what they are supposed to in these cases, for example, stimulants causing more distractibility, hyperactivity, and mood swings.
Figure 7. An example of “limbic hi-jacking occurring in frontal and prefrontal regions (red circle) and throughout the rest of the brain both on the left and right sides of the brain (image on right). Symptoms included difficulties regulating mood, depressive episodes, mental fatigue, brain fog, inattention, poor focus, memory retrieval problems, impulsivity, emotional reactivity, and substance abuse.
a. This is a more newly recognized subtype of ADD/ADHD and occurs when an infection (traditionally Strep A during pregnancy) triggers an autoimmune reaction (when the immune system attacks our own body) to proteins that help regulate dopamine, norepinephrine (noradrenalin), and epinephrine (adrenalin). It is important to note that there are many more causes for this other than Strep infections; this even includes the SARS-CoV-2 virus associated with COVID-19. The symptom onset of this is typically associated with dramatic and abrupt changes in behavior, mood swings, temper tantrums, defiant behaviors sometimes resulting in aggression, anxiety responses, hyperactivity, distractibility, and inattention.
b. The diagnosis of PANS/PANDAS is determined with antibody testing via a panel called the Cunningham Panel by Moleculara Labs. It can also be diagnosed by enlargement of the hippocampus (a brain region associated with memory) in a quantitative MRI, both of which are done at Neurvana Health™
Figure 8. The above diagram illustrates test results from an ADHD patient that had a sudden, abrupt triggering of symptoms at age 11. We later determined the cause to be triggered by a virus and have since been able to mitigate symptoms. The Ca/Calmodulin Protein Kinase II antibody will cause issues regulating release of adrenalin/noradrenalin and cause these levels to build up. When this happens irrational mood swings and anxiety is very commonly triggered.
a. The brain functions in terms of functional units called networks. They contain hubs and connections that drive function. Think of the hubs like cities and airports and how airways and highways connect cities throughout the world. There are dozens of networks like this in the brain operating every second of every day. We shift in and out of different networks depending on what our brain needs to do, like the way a car shifts in and out of different gears as it speeds up and slows down. What happens to our brain networks due to various issues (usually trauma-related) is that they either get stuck and are unable to shift out OR we are unable to shift into certain gears well leading to us ‘grinding our gears’ in the brain. When certain networks do this, it can lead to MANY of the symptoms of ADD/ADHD. Examples of these networks are attention-dorsal, attention-emotional, attention-ventral, DTI-frontal parietal, salience, DTI-frontal temporal, default mode network and many more. Quantitative EEG can show us exactly what networks are shifting properly and what networks are not. These are problems that can typically be fixed by behavioral interventions as well as neurofeedback/neuromodulation.
Figure 9. This displays a network analysis that was assessed through quantitative EEG. This person suffered from ADHD with main complaints of ruminations (overthinking), distractibility, impulsivity, and poor focus. This was due to the default mode network (overthinking) and salience networks (internalized attention) being overactivated or “stuck” on. Once this was reversed the patient reported significant improvements in symptoms.
a. Structural changes in the brain include presence of cysts, tumors and growth of other abnormal cells that impede the proper functioning of the brain. This subtype also includes very subtle microscopic changes that can occur from previous head injuries, edema, and even something called atrophy. Atrophy is a fancy way of saying “reduction in volume” in a certain region. Most of the time atrophy is incredibly subtle and thus can only be diagnosed with a computerized analysis of a specifically high-resolution MRI. These assessments are called quantitative MRI’s and allow us to see changes within the brain that cannot be seen by the human eye when evaluating an MRI. Radiologists are only successful in identifying low-grade atrophy or edema less than 5% of the time. There are many regions that are important in ADD/ADHD when it comes to structure. Most of them have already been mentioned and include the basal ganglia (caudate, putamen, pallidum), thalamus, cerebellum, hippocampus, and amygdala. If these areas reduce or increase in size compared to normal, they can create symptoms of ADD/ADHD. The image below illustrates a patient with ADD/ADHD that shows reduction in size of several areas within his brain. This patient suffered from tinnitus (ringing in the ears), anxiety, focus issues, distractibility, and ruminations (overthinking). Most of this was driven because the reduction of the caudate is basically like cutting the brakes in a car. It causes the brain to get stuck on and overthink repeatedly. This particular patient felt he had OCD-like tendencies because he would constantly repeat events and have difficulties “letting go”. This causes the overactivation of internalized forms of attention (being stuck in one’s head) and shuts down the ability to focus on things externally such as learning, listening to someone speak, reading, etc.
Figure 10. The numbers above illustrate % volume of various brain regions. Green numbers indicate enlargements while red indicate atrophy (shrinking). Notable regions causing the patient’s symptoms include the caudate and the amygdala. Both atrophy and enlargement are reversible to a substantial degree, opposite to old schools of thought. Reversing these issues will lead to an improvement in symptoms of ADD/ADHD.
a. This subtype is not well diagnosed at our clinic. It includes changes of the upper cervical
region of the neck as well as dental misalignments (also called occlusions) that can create
airway obstruction. Usually both of these issues cause an energy or metabolic
dysfunction subtype BUT can sometimes go unrecognized by EEG and MRI. It is
important to consult with a structural dentist and a NUCCA-certified chiropractic
doctor if you have concerns related to ADD/ADHD and the following symptoms:
a. Neurotransmitter imbalances are the imbalances that occur when our brain chemicals
that modulate/regulate our brain function are not balanced causing the brain to not
function properly. Some well-known neurotransmitters include dopamine, serotonin,
noradrenalin, adrenalin, GABA, and glutamate. Neurotransmitters act as modulators to
change the “vibe” of the brain. Think of them as tuning into different genres of music
such as hip hop, punk, blues, country, and rock. Each has its own “vibe” or “energy” to
it. It could also be compared to lyrical vs non-lyrical music. Neurotransmitters or
neuromodulators tune our brain in a similar way and these different chemicals play a
role in activating certain brain circuits that have different functions. There are dozens of
these chemicals. The main neurotransmitters that can be affected in ADD/ADHD
include:
b. All the above neurotransmitters can be assessed with a 24-hour urine test and all of these can be influenced by nutraceuticals, nootropics, and medications to achieve optimum benefits for those with ADD/ADHD.
These 11 subtypes sum up the causes for symptoms of ADD/ADHD. In our experience we have found resolving these subtypes, either one at a time or simultaneously, improves and often resolves symptoms associated with ADD/ADHD. We continue to learn more each day, but brain science is already right at our fingertips.
If you are interested in consulting with Neurvana™ Health regarding possible or confirmed ADD/ADHD, you can book a 30-minute complimentary consult with a health advisor at the following link: https://neurvanahealth.com/book-consult/
