Insights into ADHD and the future of treatment – A clinician’s perspective

Dr Joris van Neijenhof is Senior Clinician & Neuropsychologist in neurocare’s Netherlands clinics. Having worked with extensively with ADHD clients he shares his motivation, experience and speculations about ADHD treatments for the future.

What inspired you to specialise in ADHD?

ADHD is fascinating because it’s so varied. and there are such a range of underlying processes that contribute to the disorder. It also has the impact to be very debilitating in daily life leaving people at risk for co-morbidities such as substance abuse, depression and anxiety. Supporting people to manage their ADHD can have a significant positive impact on their life.

What has changed in the treatment of ADHD during the past few years?

There seems to be more awareness of the pros and cons of medication, especially seeing that school children have been prescribed up to 4 times more medication in a time span of 10-15 years while the prevalence of ADHD seems to have been quite constant. That shows that ADHD is not on the rise itself, but that we as society deem it more of a problem.

In general, people are more aware of ADHD because of the ease of access to information on the disorder, and we as psychologists are often confronted with patients that have done their homework, which I think on the whole is a good thing. The number of people that come to find out if they have “it” has also steadily increased over the years.

[ADHD] often severely impacts [people’s] self-image, feeling that they fail a lot, being branded the troublesome child or the lazy and tactless friend that forgets appointments, loses stuff and makes a total mess of situations. And this does not even include the trouble that comes from substance abuse and having anxiety and depression.

Dr Joris van Neijenhof, Senior Clinician & Neuropsychologist   

Do we know what causes ADHD?

Well, there are a lot of ideas and overall, it’s considered to be a developmental disorder. What I find difficult with that idea is that all the research into this has not yet shown a definitive and convincing model of what is then actually wrong with the brain. I like the idea that in some people at least, ADHD is a symptom profile caused by an underlying sleep disorder that can be already present from early childhood. It’s a problem with not being able to fall asleep on the appropriate bedtime and therefore incurring chronic sleep deprivation. This in turn will make your forebrain sleepy, which then leads to problems with attention, planning & organisation. You also lose the “brake” on your emotions and behaviour, creating impulsivity and hyperactivity.

This also helps to explain why so many people with ADHD experience emotional problems, often leading to anxiety and depression, and why they are at risk for substance abuse. It’s as if your brain loses the conductor of the orchestra and all the musicians go wild.

What are the signs/symptoms of ADHD and when should you seek treatment?

When you often experience attention lapses, difficulties in planning (for example losing things, missing appointments, always being late), excessive daydreaming and/or have trouble with impulsivity and hyperactive behaviour, and it negatively impacts your life then it would be good to seek out a professional to help you with determining if you suffer from ADHD and what treatment could help you.

How do people live with ADHD – how does it impact their lives?

People often complain of living in a feeling of chaos, never feeling relaxed (always being “on”), not being able to hold jobs. They may fail at school/study and get the brunt of irritation and exasperation from teachers, parents, siblings and friends. This often severely impacts their self-image, feeling that they fail a lot, being branded the troublesome child or the lazy and tactless friend that forgets appointments, loses stuff and makes a total mess of situations. And this does not even include the trouble that comes from substance abuse and having anxiety and depression. To be fair, there can be some positives too: people with ADHD are often credited with being creative, fun, in for a party and they bring a lot of energy. They sometimes find their place in society, for example as artists, and excelling at jobs that need energetic people. So, although ADHD can be negative it’s not always all bad! I have seen examples of people with ADHD who use their intelligence and self-discipline to excel in demanding jobs, while also bringing that creativity and energy that they can exude.

Is it possible to “cure” ADHD or is it only possible to manage its symptoms?

That’s a hard question. I have seen some examples of people getting rid of the major symptoms, to the extent we they were no longer classified as having ADHD. I’ve seen this occur through neurofeedback therapy, and in some cases also with the proper medication. But I think for the majority it’s all about managing their symptoms to a level that they can live (better) with it.

Interestingly if someone still has the symptoms of inattention and hyperactivity, but they don’t feel that they are limited by it in daily life, then we can no longer classify them as having ADHD. The system states that they should have problems in at least 2 domains of life in society. So, two people with exactly the same symptoms and severity still can have different classifications.

What are the typical approaches to treating ADHD?

Medication and integral behavioural approaches, such as life-style training and planning training. There also have been some successes with adjusting diets but the literature on that is often of poor quality and not always convincing.

We think that [Neurofeedback] goes more to solving the core of the problem, while medication seems to be more about suppressing symptoms.

Dr Joris van Neijenhof, Senior Clinician & Neuropsychologist   

What role does medication play in ADHD treatment (both in the past and now)?

Medication has always been the primary treatment option, often prescribed in childhood. We are now learning more about what medication does in (or to) the brain and opinions vary a lot about how it impacts health, how effective it is, and what the long-term side-effects are. There is even now some insight in that it not only ameliorates the primary symptoms but may have a positive effect on sleep too. So, the jury is still out on that one.

What are the benefits of using Neurofeedback for ADHD?

It makes use of the natural activity of the brain and naturally occurring learning processes, so there are no negative side-effects as with medication. We also haveevidence that points towards a better long-term effect than medication. We think that it goes more to solving the core of the problem, while medication seems to be more about suppressing symptoms.

Is there strong evidence that supports the use of Neurofeedback in ADHD?

Yes there is, if you know how to judge the mixed results from the literature. It’s very hard to research neurofeedback and even little tweaks and changes can render the training ineffective. It’s also realistic to state that we are currently still trying to understand how it works, and what the effective components are. The clinical results can be very impressive, and up to 70% of people (children and adolescents) have been seen benefiting from neurofeedback training. This can range from experiencing some improvement to getting nearly rid of the whole symptom profile. It’s hard for clinicians not to be enthusiastic about it.

Are there other “medication free” interventions available?

Yes, a lot of mental health care institutes offer behavioural programs, in which people with ADHD learn to cope with their symptoms. Literature shows that the effects are more on the modest side, but you can gain insight into your ADHD and learn how to better plan and organise. I would be critical of treatments other than that that because I haven’t seen convincing studies that show proof that they work, and you can find a lot of “snake oil” in the market.

What are your expectations and hopes for the future of ADHD treatment?

I hope that neuromodulation techniques such as neurofeedback keep playing their role in helping people with ADHD and sleep problems. I also hope that we learn more about the underlying way it works and how we can tweak it to be even more effective. I think with how our society is evolving, especially with a constant barrage of information, and all the screens that have crept into our lives, attention spans and patience will probably shorten, and this has the potential to makes us all a bit more ADHD.

About Dr. Joris van Neijenhof

Joris van Neijenhof graduated in Neuropsychology and Rehabilitation psychology in 1999 at the Radboud University Nijmegen in the Netherlands. He then proceeded to work as a clinician at the Sint Maartenskliniek, a rehabilitation centre for acquired brain injury in Nijmegen and completed his post-master’s degree in health psychology there. Dr Neijenhof joined the neurocare Group in 2017 where he predominantly works with patients and also functions as head supervisor of post-master psychology trainees. He is proficient in the clinical application of rTMS, neurofeedback and tDCS and is especially interested in the effects of rTMS on neurological disorders like stroke.

In addition to his clinical work, Joris also has extensive experience in teaching at the post-master level. Since 2004, he has worked as a senior lecturer at the Radboud Centre for Social Sciences where he teaches a course in Clinical Neuropsychology.