Introduction
The Search for
Stimulation
What Causes ADHD?
Making the Diagnosis
Treatment
Parent
Training for Behavior Management
General
Principles of ADHD Behavior Management
Introduction
I had just completed my evaluation of 11-year-old Timmy.
His parents had brought him to me because of behavior problems and his
teacher’s concern that Timmy was underachieving in school. I determined
that Timmy had attention deficit hyperactivity
disorder, often referred to as ADHD or ADD.
After I inform families of my diagnosis, one frequent
remark parents make is, "We don’t understand how he has attention deficit
disorder; he can pay attention when he wants to." Timmy’s parents then
gave me examples about his being able to sit for hours playing computer
games or watching television. "But he just won’t sit and do his homework."
This is a typical remark from parents. From a parent's point of view, their
son or daughter doesn’t seem to have a disorder; they see a child who just
doesn’t seem to care.
As a child psychiatrist, I welcome parents' questions
and comments. Their questions give me an opportunity to educate them as
to what ADHD is. Lots of people don’t really understand this disorder.
But the better they do understand ADHD, the more likely they will be to
make appropriate decisions on how to guide a child like Timmy.
The
Search for Stimulation
One of the problems in understanding attention deficit
hyperactivity disorder is the limitations of its name. It’s a pretty good
name, better than the earlier names we used, such as "minimal brain dysfunction"
and "hyperkinetic syndrome." Using attention deficit hyperactivity disorder
is better because it reaches closer to the core of the disorder: the difficulty
in sustaining attention to tasks, rather than simply the hyperactivity.
But even this name falls short in helping families understand the disorder,
as in Timmy's case. Saying Timmy has attention deficit hyperactivity disorder
sounds like Timmy has two problems: an inability to pay attention and hyperactivity.
Let's examine the term, taking on the second part of it
first. Hyperactivity is just one symptom. And as with any disorder people
don’t necessarily have all the symptoms. Timmy, for example, is not hyperactive.
Secondly, regarding "attention deficit," Timmy’s parents do not see their
child as having an attention problem, but rather an attitude problem. To
his parents, Timmy seems not to care. If he only had a better attitude,
they reason, he would do his work and he would not get into so much trouble.
Timmy's parents were certain he could pay attention if he wanted to.
If I was in charge of renaming ADHD—and I’m not—I would
call it the "search for stimulation disorder." To explain this, let’s look
at the problem of Timmy’s attention. Timmy has difficulty sticking to tasks
such as homework or other relatively less interesting chores, such as cleaning
up his room. To Timmy’s parents, it wasn't that he couldn't do his chores,
but that he just didn’t want to do them.
Timmy's parents are partially right. Timmy can do things
that he is interested in, but he has trouble with jobs that require more
sustained effort. It’s not because he doesn’t care; it’s because, more
than most other people, he needs to find something interesting for it to
hold his attention.
Timmy searches for stimulation. That often gets him into
trouble because he doesn’t pay attention when he’s supposed to. He turns
to look out of the classroom window when he should be listening to the
teacher. He gets up out of his seat during the middle of a lesson. He annoys
other children when they are trying to listen or do their work. Although
medical scientists do not know exactly what causes ADHD, I can tell you
what I think it is, just as I explained it to Timmy's parents.
What
Causes ADHD?
Most child psychiatrists, including myself, do not believe
the root cause of ADHD is psychological. We believe an abnormality in the
body's nervous system produces the disorder. As I told Timmy’s parents.
This is only a hypothesis, and no one really knows what causes ADHD. But
the nervous system hypothesis has considerable explanatory value, and I
believe something like it does operate in ADHD.
I describe ADHD as a kind of barrier to the nervous system—an
invisible shield that prevents normal levels of stimulation from getting
through. It is as if Timmy had a thick layer around his nervous system:
normal levels of stimulation don't penetrate it. Just as nature hates a
vacuum, so, too, the nervous system hates sensory deprivation. So if Timmy
doesn't get stimulation, he will seek it out. This would explain Timmy’s
excessive need or, perhaps better put, his thirst for any stimulating information
or event. He looks out the classroom window not because he’s lazy or wants
to annoy his teacher or his parents but because he’s looking for something
to hold his interest. He simply finds school work and chores too boring.
Timmy wants to do well. He wants to make his parents proud of him. But
he just can’t seem to do this, because of his excessive need for stimulation.
In class, Timmy fidgets and is easily distracted. He can’t
maintain focused attention on what is being taught. However, if the teacher
increases the level of stimulation, Timmy can more easily pay attention.
The teacher can get his attention in a variety of ways. She can teach in
a more dramatic or dynamic manner. She can sit him in the front row and
engage him with more frequent eye contact or by directing questions directly
to him. Yelling will certainly get his attention, but I, of course, I don’t
recommend this.
Making
the Diagnosis
Not all children or adults with inattention have ADHD.
For example, inattention can result from low IQ or when kids with high
intelligence are placed in academically unchallenging environments. Some
rebellious children resist tasks that require self-application simply because
of an unwillingness to conform to others' demands. Certain medications
(for example, bronchodilators for asthma or isoniazid for tuberculosis)
can cause inattention, hyperactivity, or impulsivity. So, how do we make
the diagnosis?
I explained to Timmy's parents that ADHD represents a
specific disorder. And because problems may appear to be ADHD, we need
to be careful not to label people with the diagnosis recklessly. ADHD has
a shape, color, and feel that you can learn to recognize. An accurate diagnosis
can usually be made when someone has at least six of nine symptoms from
either one of the following lists:
ADHD, inattentive type
-
Failing to give close attention to details or making careless
mistakes
-
Difficulty sustaining attention in tasks or play activities
-
Not seeming to listen when spoken to directly
-
Not following through on instructions and failing to finish
schoolwork, chores, or duties
-
Difficulty organizing tasks and activities
-
Reluctance to engage in tasks that require sustained mental
effort
-
Losing things (toys, school assignments, pencils, books,
or tools)
-
Being easily distracted by extraneous stimuli
-
Being forgetful
ADHD, hyperactive-impulsive type
-
Fidgeting
-
Being unable to remain seated in the classroom or in other
situations in which remaining seated is expected
-
Running or climbing excessively
-
Difficulty playing or engaging in leisure activities quietly
-
Being on the go as if driven by a motor
-
Talking excessively
-
Blurting out answers before questions have been completed
-
Difficulty awaiting one's turn
-
Interrupting or intruding on others
Many individuals with ADHD have at least six symptoms of
inattention and at least six symptoms of hyperactivity-impulsivity. We
then give them the diagnosis of ADHD, combined type.
Timmy's parents asked me about a test for ADHD. I told
them we make the diagnosis on the basis of history and clinical observation.
Psychological testing and neurological examinations provide no significant
value in establishing the diagnosis of ADHD. They, in fact, contribute
little but additional costs to the diagnosis and treatment. Neurological
evaluation may, however, be used to rule out other neurological disorders.
Though the frequency of neurologic soft signs (mild neurologic abnormalities)
is greater among children with ADHD, their presence does not confirm or
rule out a diagnosis of ADHD since neuropsychological abnormalities are
also found in a fraction of normal children. And psychological testing,
although not diagnostically helpful, can detect the possible coexistence
of learning disabilities.
Treatment
Many people do not appreciate how serious a disorder ADHD
can be. ADHD prevents kids like Timmy from being able to focus attention
on academic work; the frequent results are significant academic underachievement
and poor self-esteem. Furthermore, the impulsivity, short attention span,
and overactivity often make the child’s behavior unacceptable to peers,
resulting in poor socialization and rejection by others because they often
find it too difficult to be with someone with ADHD. In late adolescence,
and in more serious cases, antisocial behavior and an increased risk of
developing
drug and alcohol abuse can follow—partly because of the increased impulsivity
of ADHD and partly because the individual is simply not happy.
Using stimulants to treat ADHD
The fact that medicines such as Ritalin or Dexedrine
can help people with ADHD is both interesting and instructive. Stimulants
are the most effective medications for the disorder. Stimulants?
Intuitively, we might think that, if we were going to use a medication
to help a hyperactive child, we would want to use a tranquilizer, not a
stimulant. We might expect a stimulant to make the condition worse since
the child is already hyper. The clinical fact, however, is that tranquilizers
make kids and adults with ADHD more hyper; and stimulants make them better.
How can we explain this curiosity?
Again, the idea of the invisible shield around the nervous
system might explain this unexpected finding. A tranquilizer sedates Timmy
and thickens this barrier, allowing even less stimulation to get through.
As a result, Timmy feels an even greater craving for stimulation, and he
might become hyperactive or more distractible. Perhaps then, stimulants
work for ADHD because they don’t tranquilize. Instead they stimulate the
nervous system, leaving Timmy less thirsty for outside stimulation and
better able to focus his attention.
Of all children and adults diagnosed with ADHD, 50 percent
to 70 percent respond to treatment with stimulants with significant clinical
benefit. Their improvement can be profound and is often not appreciated
by those unfamiliar with the treatment responsiveness of ADHD. These medications
often result in functioning at a level better than any the patient has
ever experienced before.
Children and adults with ADHD are not drugged into compliant,
complacent behavior. Numerous studies report stimulants that improve all
of the core symptoms of ADHD (the hyperactivity, inattention, and impulsivity).
Treated with stimulants, people with ADHD are alert and responsive and
have at their disposal greater options for skilled adaptive behavior and
greater flexibility for behavioral choices. Left untreated, they are distracted,
impulsive, disorganized, too easily overwhelmed by stresses, and hot tempered.
Behavior management
Behavior management can be extremely important. It is
essential to understand, however, that medication is the only intervention
that will actually reduce the individual's symptoms. Without medication,
only the environment—not the individual—can be changed. Behavior management
means changing the environment so that the inattentive and impulsive individual
can function better.
Parent
Training for Behavior Management
Sometimes quite helpful, behavior management can be taught
to parents in order to enable them to more effectively manage the child's
day-to-day behavior. Altogether, however, it should be remembered that
behavior management is a way of helping parents cope with but not change
the underlying behavioral dysfunction caused by ADHD. Behavior management
techniques involve a decreased emphasis on blaming the individual and increased
emphasis on changing the child's environment in order that the individual
function better. Only medication can change the central symptoms of the
disorder.
General
Principles of ADHD Behavior Management
-
ADHD is a biological deficit in persistence of effort,
attention, and inhibition. ADHD individuals typically also exhibit a reduced
sensitivity to behavioral consequences. These characteristics are not the
result of laziness or moral weakness.
-
Give immediate and frequent feedback. Occasional praise a
few times a day works for normal children and adolescents, but ADHD individuals
require frequent feedback. The adult may find this tiring, but frequency
is necessary in order to change patterns of behavior that have developed
in the ADHD individual over time. Adults need to remember to look for behavior
for which to give feedback. Children are much less influenced by general
rules than by immediate consequences. Positive feedback may take the form
of praise or material rewards, but it should be clear, specific, and occur
as close to the moment of the behavior as possible.
-
Use nonverbal rewards. For the ADHD individual verbal praise
is rarely sufficiently potent by itself. The addition of physical affection,
privileges, and material rewards increases the effectiveness of positive
feedback.
-
Rewarding is not the same as bribing or spoiling. Bribery
(or spoiling) is giving an incentive to someone for not doing something
he or she shouldn't. Rewarding is giving an incentive for desirable behavior.
-
Start with rewards before punishments. First, redefine the
problem behavior into a desirable alternative. Then reward it consistently
for a week or two before beginning any punishment for undesirable behavior.
Punishment, if necessary, should be mild and very selective—only for a
specific negative behavior, not for everything that is offensive. The ratio
should be three rewards (positive feedback) for every punishment (negative
feedback).
-
Maintain perspective. Remember, you are dealing with an individual
who in many ways is handicapped. Forgive both yourself and your child when
inevitable failures occur. But don't give up.
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