Understanding ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) may be well-known and the basic aspects of it relatively easily understood, but there are many things that are perhaps not as obvious or easy to understand. The common mental image of an individual with ADHD is a scatter-brained, hyperactive person. However, an individual with ADHD may not be hyper at all, may only appear “scatter-brained” at certain times or in certain situations, or may be better thought of as a “daydreamer.” In addition to the effects that ADHD can have on a person’s ability to complete tasks (due to distractibility) or succeed in school (due to loss of focus), it can also produce dangerous situations while driving, cause difficulty with emotional regulation, result in seemingly aggressive behavior, cause the person to appear “lazy”, and contribute to the likelihood of very bad life decisions. I have outlined some information below to help clear up some common misconceptions about ADHD and some facts that are often unknown to the public.

1) There are different "types" of ADHD all sharing the same basic neurology. We categorize individuals as predominately inattentive, hyperactive/impulsive, or combined. Girls are more likely to be identified as inattentive, boys are more likely to be hyperactive/impulsive or combined. In general, boys are far more likely to be identified with ADHD simply because the hyperactive and impulsive behaviors tend to grab the attention of parents and teachers.

2) The hyperactive/impulsive or combined types tend to have worse outcomes because of the impulsive, outwardly-directed behavior, which gets them in trouble (leading to the label of "problem student") and a history of disciplinary problems following it. A higher rate of disciplinary problems contributes significantly to later problems with unemployment, substance abuse, and criminal behavior.

3) Many parents are afraid of medicating because: a) it will make my child a zombie, or b) my child will become dependent and addicted to drugs later. The truth is that b) is far more likely if the child is not treated, and a) is sometimes due to a contrast in before/after behavior. It is still important to monitor the effects of medication and work closely with your child’s physician to ensure the medication is proving helpful and not having serious side-effects. There are now many medication options and it is possible to get a better match between your child’s brain structure and medication. Discussing possible side-effects with your child’s physician and providing a complete medical history is important in helping the physician make decisions about medication.

4) In ADHD, a part of the brain involved in controlling impulsive behavior, maintaining attention/focus, and managing emotional responses is less active than normal. Therefore, ADHD is treated with stimulant medication to increase activity in a specific area of the brain (the medication is more precise now than in the past). In ADHD the stimulant may appear to have the opposite effect (it is “calming”) because it increases the ability of the child to control impulsive behavior and focus.

5) Similarly, a typical child who is deprived of sleep may appear lethargic and groggy the next day. A child with ADHD, in contrast, may appear even more hyperactive due to further reduction in brain activity (which produces less capacity to regulate impulsive behavior). That is in addition to the typical effects of too little sleep, such as irritability, lack of clear thinking, forgetfulness, and not feeling good.

6) The most obvious characteristics of ADHD are fidgeting, rapid and frequent task switching, poor organization, distractibility, and difficulty with sustained focus (for example, a frequent tendency to say, "huh?" in conversation). However, in diagnosis the less obvious characteristics are at least as important, including: sleep disturbance, racing and incomplete thoughts, obsessive thinking, poor emotional regulation (easy to anger), low frustration tolerance, and a history of no response to behavior interventions. There is also often difficulty producing clear and coherent communication (writing and speech appear disorganized and rambling), difficulty with tasks that demand sustained effort (especially sustained mental effort), a tendency to become extremely sleepy/groggy during repetitive or low-stimulus activities (e.g., driving), and difficulty beginning activities or responding quickly to requests.

Recalling or remembering can be very challenging at times because successfully retrieving information requires maintaining focus until the information has been successfully retrieved. Routines can be very useful in aiding children with ADHD because they reduce the number of things the children must try to remember. Therefore, with a routine in place, a child may be able to simply breeze through a set of activities automatically without giving it any thought, while their mind is otherwise engaged. However, establishing routines can be very challenging because the entire sequence of activities must be successfully completed many times before it becomes routine, and children with ADHD often have difficulty independently completing all steps of tasks. Prompting them and giving them feedback on what they did (emphasizing what they did correctly) is helpful in establishing routines. Initially, routines should be kept short as well (for example, brushing teeth). Eventually, the child can be given longer routines made up of many short routines (for example, getting ready in the morning includes brushing teeth and other activities) after the short routines are already automatic.

 
Just as routines are helpful in reducing memory demands, disruption to routines can produce some serious complications. It is very common for an individual with ADHD to begin forgetting parts of a routine if there is a disruption. For example, perhaps your child normally gets up, gets dressed, eats breakfast, brushes teeth, puts homework in the backpack, picks up the backpack, and then goes to wait on the bus. However, one morning things are slightly different. Maybe that evening there is a special event (such as a family outing or a birthday party). Your child is anticipating this event and thinking of it, and you find that parts of the tooth-brushing routine were left out (supplies are left on the counter instead of put away) and your child forgot to put homework in the backpack. This is a fairly common outcome resulting from a disruption in the routine. It is helpful to be aware of such disruptions and pay extra attention to your child’s completion of routines when disruptions are present. 
 
Because the relationship between attention and memory appears to be so strong, it is very common for children with ADHD to struggle with reading comprehension, especially with longer passages. A child may finish a page of text, and upon reaching the bottom of the page, realize that he/she no longer remembers what was on the page. The child may read quickly and fluently, but as his/her attention wanders, information is simply lost. Asking the child to periodically pause and summarize what was read (perhaps in the margin of the page or on a separate sheet of paper) can greatly help with understanding reading materials and recalling the information later. 
 
Homework can provide a special challenge for children with ADHD because it often requires long periods of constant mental effort. Sustained mental effort is known to be a very challenging (and therefore unenjoyable) task for children with ADHD. Though you certainly want to build up your child’s capacity for sustained mental effort, it would be unreasonable to expect him/her to immediately leap upon the challenge and knock out an hour of homework after struggling with maintaining attention for more than 5 minutes. It would be just the same as expecting someone that has never been a runner to leap up and complete a marathon race (which can be what lengthy homework feels like for a child with ADHD). Instead start with a manageable, but challenging goal for your child. If 5 minutes of sustained focus is easy, but 8 minutes is impossible, then consider setting a timer for 6 or 7 minutes. After the timer goes off, let your child take a short break (such as 2 or 3 minutes) to walk around and get a drink. Then it’s time to go back to doing the homework for another 6 or 7 minutes. To encourage your child to push beyond what is easy or comfortable, you may also want to offer some kind of reward for working longer than the timer is set for. For example, if the child manages to work 1 minute longer than the timer, then he/she can earn 5 minutes of a preferred activity (playing outside, video games, TV time…). Over time, this will build up the child’s ability to complete the “homework marathon.” 
 
Life outcomes for individuals with untreated ADHD are more likely to be bad (lots of "bad decisions" for one thing), including poor academic outcomes, frequent unemployment, drug addiction, and criminal behavior. This also increases the frequency of social and emotional problems (such as depression and social isolation). Encouraging individuals with ADHD to actually seek treatment (which should typically include medication and behavior therapy with psychoeducation) is very helpful. Knowing what to look for is important. A person does not have ADHD just because they're active or just because they're distractible. High levels of stress or anxiety, insufficient sleep, or recent trauma can mimic some of the symptoms of ADHD. Therefore, it must be an enduring pattern, and should include many symptoms (some of which I described above). Also, it should be having a significant impact on their daily functioning ("adverse impact").

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