Understanding ADHD

In the article entitled "Attention Deficit Disorder," I began my discussion of ADD by covering the symptoms, causes, and treatment of the Inattentive Type. I emphasized that the primary problem encountered by children with this type of ADD is the inability to focus and sustain the attention. Often described as distracted, day-dreamy, spacey, and sometimes even lazy, I also noted that these children are for the most part cooperative, quiet, and well liked by teachers. For this reason their problems are often not detected until well into their school years when the problems with inattention become very noticeable. ADHD (Attention Deficit/Hyperactivity Disorder) children, on the other hand, are noticed early in childhood, often in the preschool years and certainly by the time they reach kindergarten and first grade.

Why is this? Because the inability to control one's impulses, and the accompanying disruptive behavior that are the hallmark of ADHD, surface loudly and early in these children's activities and interactions with others. Not only do they have difficulties sustaining attention over time as do ADD children, they have the added problems of hyperactivity and impulsivity. Let's me begin by discussing the three major components of ADHD which are inattention, hyperactivity and impulsivity, and then go on to see how these affect thought processes and behavior.

Inattention

Like the ADD child whose basic problem is the incapacity to focus and sustain attention, the ADHD child has all of the same problems in attending to schoolwork, becoming distracted, and following instructions. In terms of school work, these children often make careless mistakes, do not follow through on instructions, may get homework finished (with prodding), but then not turn it in the next day. They have difficulty organizing and keeping track of school supplies, and simply forget what they have been told. They lose things, have difficulty listening when spoken to, and tend to avoid tasks that require sustained mental effort.

Sustaining Attention

It's not so much that they are unable to pay attention or even to understand what they are told, it's more a problem with being able to sustain their attention long enough to translate instructions into action. They can't seem to keep themselves from wandering mentally toward something that is of greater interest than the task at hand.

Russell Barkley points out most importantly that ADHD children do not have problems with filtering information (1995, p. 30). In other words, they can extract the important information from the irrelevant in a communication. This means that there is not a problem with understanding what is said. The problem is more one of distractibility, particularly when the task at hand is lengthy, boring, repetitious, or uninteresting. Schoolwork almost always falls into the "uninteresting and boring" category, as do lectures from adults, instructions that are complicated and have a number of parts, and tedious activities that offer no immediate rewards.

Need for Stimulation

ADHD children attend best when activity is interesting, novel, fun, and generates a good deal of energy. In fact, we might go so far as to say that ADHD children are "stimulation junkies." They gravitate toward highly stimulating activities that produce sensations of excitement and emotionality. These are usually those activities that are more action oriented and offer immediate rewards. Also, the greater the sensory and emotional stimulation the better. Loud music, colorful toys, big motion outside activities, and action packed video games, all offer the right stimulation.

Immediate Gratification

The last part of the inattention problem has to do with the capacity to delay gratification. As was mentioned above, ADHD children go for tasks and activities that offer immediate rewards. They need something to look forward to on almost a momentary basis. If they have to choose between picking up three toys off the floor rewarded with five minutes of video game time, and doing a number of jobs to earn the money to buy a new favorite video game (at a later time), they will almost always opt for the former. They would rather have the immediate reward even though it has far less value both monetarily and in terms of the pleasure it can offer over time.

Hyperactivity

Inattention is certainly a problem that is noticed in school, but more often hyperactive behavior is what brings the note home from the teacher asking the parents to come in for a conference. This is because the disruptive quality of this behavior and the difficulty in managing it requires an intensive and collaborative effort by teachers and parents together.

Extreme Restlessness

The hyperactivity displayed by these children has two components worth mentioning here. The first one I would call an overall "restlessness" that is supercharged with energy. These kids can't stay seated in class and sometimes leave the room without permission. They talk excessively and loudly, squirm in their chairs, make unnecessary noises liking humming or tapping their pencils, and so on. These are the kids you see running through the grocery store with their mothers chasing after them in despair as others look on with that "can't you keep your child under control" look. Other descriptions often used are things like "being driven by a motor", "bouncing off the walls," "always on the go," "can't sit still," and sometimes simply "hyper." Normal attempts to restrict this kind of behavior often don't work. You might hear a teacher complain that she's moved the child to every possible seat in the classroom, including a seat isolated from the other students, but the child still talks to everyone and regularly disrupts the class.

Hyper-Responsiveness

The second component has to do with being overly responsive to situations. Barkley describes this as "behaving too much" or being "hyperresponsive," (1995, p. 37). What he means is that these children are quick to respond, often with a sort of high intensity knee-jerk reaction that doesn't take into account the context of the situation, possible rules that might apply, or consideration of the consequences. These responses are highly emotional and forcefully acted out without the benefit of first thinking through the situation. Another way of understanding it is that ADHD children are very easily emotionally aroused, and they react automatically to their heightened feelings without first filtering them through a process of analysis. I'll explain more about this further on in the article, but for now lets move on to "impulsivity."

Impulsivity

We've actually already alluded to the problems with controlling impulses above. Because of the high emotional response factor, ADHD children don't make decisions based on objectively thinking through a situation, but rather base decisions on their moment to moment feelings and desires. For example, they might blurt out an answer to a question before the question has been fully stated, or they might interrupt others' conversations, sometimes repeatedly even though they've been told to wait their turn.

Emotionally Driven Behavior

ADHD kids act quickly on ideas without considering the consequences, especially if the situation appeals to their need for stimulation and excitement. They seem almost incapable of waiting, and as such are quite demanding and excessive in their drive to act. Parents complain of these children that once they have decided they want something, they will badger them unceasingly to get it now. If a movie is planned for the weekend, they will do their best to get a parent to take them during the week. They will ask repeatedly, offer a number of reasons why they need to go now, try and manipulate the situation, coerce the parent, use guilt if necessary, or if all else fails, whine, cry and/or throw tantrums. The intensity and longevity of the attempts to sway parents is what is so difficult to endure, and often wears them down until they give in.

Socially Disruptive

Impulsivity also plays a negative role in social development. In playing with other children, ADHD children seem unable to share, take turns, give equal time to other children's ideas and desires, and generally be considerate of others. They are likely to grab things out of another child's hands, blurt out something rude or hurtful, or disrupt activities that require delaying a response such as playing a board game. They badger their friends in the same way they badger their parents, and quite often are seen as selfish and annoying. Unfortunately, most of these children want to have friends and participate as part of the group, but they form negative relationships with other children as a result of their pushy, disruptive behavior.

Barkley's "New Theory About ADHD"

Russell Barkley offers a unique view of ADHD that is very helpful in understanding the mechanisms that underlie the problems of inattention, hyperactivity and impulsivity. He believes that the real root problem is an impairment of "behavioral inhibition," (1995, p. 43). In other words, ADHD children do not seem to be able to inhibit their urges to "act" in the same way as other children of a similar age can. The way this plays out is that when the child needs to focus on or attend to something, he is unable to inhibit his urges to shift his attention to something that is more interesting or rewarding. It's not so much that he has a short attention span, but he has a "short interest span," (p. 43).

Likewise, hyperactive behavior and the tendency to impulsively act out an emotional response are again the result of not being able to inhibit the urge to respond or gain immediate gratification. Barkley points out that as children mature, they naturally develop the ability to delay responses and impulses, and to focus on instructions and activities that have low interest value. The ADHD child does not mature in the same way and is in fact much more like the normal younger child.

Parents of ADHD children often complain that their child seems unable to carry out the basic age appropriate tasks that their younger children have already mastered. If you follow these kids all the way through school and into college, the same pattern of lagging behind developmentally seems to hold.

Dr. Barkley expands his theory of ADHD by borrowing from Dr. Jacob Bronowski who has a lot to tell us about how our methods of communication are different from those of other animals, especially the primates. In fact, a distinguishing factor between humans and primates is the ability to "impose a delay between a signal, a message, or an event that we experience and our reaction or response to it," (1995, p. 45). We can take in a message, impose a period of waiting while we process it, and inhibit our response until we have deliberately decided what our response should be. Further, this capacity to inhibit the urge to respond allows us to process the message in four ways: (1) we can split the experience or message into both the emotional and informational components, (2) place the experience within time by connecting it to past experiences and thereby creating a sense of the future; (3) talk to ourselves as a means of facilitating the process and controlling our responses; and (4) break the information down into parts so that we can then put it back together in a new and synthesized message with which we respond (p. 45).

In short, humans are able to stand back from an experience, analyze it, compare it to previous experiences, foresee the consequences of different responses, and then synthesize all of this to produce an outgoing message or response. This is often referred to as "executive function." Moreover, it is the ability to delay and inhibit behavior that is the starting point of the entire process. Let's look at how each of these manifests in the behavior of ADHD children.

Separating Emotions from Information

What's implied here is the ability to break an experience into both its subjective and objective components. What is the personal meaning versus the facts of the situation? Is what we are feeling actually in response to the reality of the situation, or are we overreacting or incorrectly assessing what is really going on? By imposing a delay, we create some emotional space that allows our thinking capacity to emerge and help us calmly and objectively analyze the experience in order to formulate a proper response. Those with ADHD very often are not able to create that space because they cannot delay or inhibit their response. They are instead hyperresponsive to their own emotions and tend to act (or act out) without any analysis.

Gaining a Sense of Past and Future

The ability to delay a response slows time down in such a way that a situation or experience can be kept actively alive in the mind long after the event has passed (1995, p. 46). This allows us to study and evaluate the experience, compare it to past experiences, and place it within the context of our personal history. More importantly, it enables us learn from our past experiences as well as hypothetically consider our future actions. The "now" is placed in the larger picture of personal time.

People with ADHD have difficulty in building this larger historical view. Without the capacity to adequately delay responses, past and future get lost in the emotional "now" driven by the need for stimulation. It's no wonder that the same mistakes are made repeatedly, or that the payoffs that come from long-term pursuits allude these folks. The inability to orient oneself to the future coupled with the need for immediate gratification can have dire results, particularly if the avenues of stimulation and gratification become self-destructive as in the case of school failure, substance abuse, careless driving, and so forth.

Talking to Ourselves to Control Behavior

When we are able to delay responses, we allow ourselves time to talk ourselves through the experience and examine possible responses. This kind of self directed speech is called "internalized speech," (1995, p. 49). Dr. Bronowski explains that internalized speech is different from social speech or speech used to communicate something to someone else. Talking to ourselves, or internalized speech, is an "instrument of reflection and exploration" (p. 49) to hypothetically construct verbal responses. We practice how we are going to respond by verbalizing the possibilities to ourselves before we act on them. It has been found that ADHD children have very little self-directed speech. In fact there are a number of treatment programs that have focused on teaching these children how to develop and make use of internalized speech.

Synthesizing Information

The last skill related to the ability to delay and inhibit behavior has to do with the capacity to break incoming messages into smaller components so that we can thoroughly analyze them and then recombine them into a response that incorporates all of the aspects of our experience. This may sound somewhat complicated, but most of us do it automatically. We hear something, analyze it from a number of perspectives that incorporate both the subjective and objective elements, and through a process of synthesis we formulate a response that hits the mark so to speak. The response takes into considerations past experience and future possibilities, as well as the information imparted in the present.

The more successful we become at this whole process, the better we are at problem solving. Again, all of this is dependent on the ability to delay responses, inhibit behavior, and impose a waiting period for processing.

The Brain Connection

The ability to inhibit behavior, which is as we have determined the root problem for those with ADHD, is facilitated in the frontal region of the brain in an area called the orbital-frontal cortex. This is the area of the brain that is directly linked to the capacity to sustain attention, inhibit behavior, plan for the future, and control impulses. It is also the area of the brain that is far more developed in humans as compared to primates.

There are a number of studies that have linked underactivity in this area of the brain among children with ADHD as compared to non-ADHD children. This is why stimulant medications help. They speed up the processes in this area of the brain, and the results are a greater ability to focus and attend, delay responses, and control behavior. The slower brain activity might also explain why ADHD children have such a high need for stimulation. These children sometimes are much better able to do homework with a radio on, or to sleep for that matter, because the stimulation from the music actually has the effect of speeding up the functions performed in the orbital-frontal cortex, and hence serves to calm and focus the mind.

All of this has implications for finding ways to best help these children harness their intensity and drive toward productive activities as well as methods to compensate for deficits. I've discussed this more thoroughly in the article entitled "Managing Your ADHD Child." For now, it's good to keep in mind that "stimulation" is a key component to both understanding and assisting children with ADHD. Any effective behavioral program will necessarily need to incorporate the need for stimulation as a key component in developing strategies that will work.

_{Barkley, Russell A. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York: The Guilford Press, 1995.}