How to understand ADHD as the Search for Stimulation   Leave a comment

The Search for Stimulation: How to Understand Attention Deficit/Hyperactivity Disorder
I had just completed my evaluation of 11 year-old Timmy. His parents had brought him to me because of behavior problems and the teacher’s complaint that he was “underachieving” in school. Timmy, I explained, has attention deficit hyperactivity disorder, often referred to as “AD/HD” or even “ADD.” After I inform families of my diagnosis, I welcome their questions and comments. One frequent remark parents make is, “I don’t understand how he has attention deficit disorder; he can pay attention when he wants to.” Timmy’s parents then gave me examples such as his being able to sit for hours playing computer games or that he can watch television for extended periods. “But he just won’t sit and do his homework.” From his parents’ point of view, Timmy doesn’t seem to have a disorder. They see in Timmy a child who just doesn’t seem to care.

I particularly like parents’ questions because they give me an opportunity to educate them as to what AD/HD is. Lots of people don’t really understand the disorder. But the better they do understand, the more likely they will be to make appropriate decisions on how to handle a child like Timmy.

The Search for Stimulation
One of the problems in understanding the disorder is the limitations of its name, attention deficit hyperactivity disorder. It’s a pretty good name, better than the earlier names we used such as “minimal brain dysfunction” and “hyperkinetic syndrome.” “Attention deficit hyperactivity disorder” is a better name because it reaches closer to the core of the condition, the difficulty in sustaining attention to tasks, rather than simply the hyperactivity. However, if I were in charge of re-naming AD/HD – and I’m not – I would call it the ” search for stimulation disorder (SSD)”

The term, “attention deficit hyperactivity disorder,” sounds like Timmy has two problems: 1) an inability to pay attention and 2) hyperactivity. 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 and regarding inattentiveness, Timmy’s parents do not see him as having difficulty with attention. He seemed to them simply to have an attitude problem. He seemed not to “care.” If he only had a better attitude, they reasoned, he would do his work and he would not get into so much trouble. They were certain he could pay attention “if he wanted to.”

Let’s look at the problem of Timmy’s attention. He has difficulty sticking to tasks such as homework or other relatively less interesting chores such as cleaning up his room. But it seemed to Timmy’s parents that he just didn’t want to do these things, not that he couldn’t do them.

Well his parents are right, partially. 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 he needs something he finds interesting in order 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 AD/HD, I’m going to explain what I think it is, just as I explained it to Timmy’s parents.

Most child psychiatrists, including myself, do not believe the root cause of AD/HD is psychological. We believe an abnormality in the physical nervous system produces the disorder. The following is the explanation I gave Timmy’s parents. I told them it is only an hypothesis and that no one really knows what causes AD/HD. But the hypothesis has considerable explanatory value, and I believe something like it does operate in AD/HD.

“The Invisible Shield”
I describe AD/HD as a kind of barrier to the nervous system – an “invisible shield” that prevents normal levels of stimulation from getting through. As though Timmy has 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. Timmy needs stimulation, and if he doesn’t get it, he will seek it out. This would explain Timmy’s seemingly excessive need for excitement. Perhaps better put, he has a thirst for any stimulating information or event. He responds to stimulation. He looks out the classroom window not because he’s lazy or wants to annoy his teacher and his parents but because he’s looking for something to hold his interest. He simply finds school work and chores too boring. He wants to do well. He would like to make his parents proud. But Timmy just can’t seem to do it because he has an excessively need for stimulation.

Timmy fidgets and is easily distracted. He can’t maintain focused attention on the what the teacher says. However, if she increases the level of stimulation, it gets through and 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 more frequently with eye contact or questions she directs at him. She can even yell at him. Yelling will get his attention. But I don’t recommend that one.

The Search for Stimulation, An Explanation for the Effectiveness of Stimulant Medication
The fact that medicines such as Ritalin or Dexedrine can help people with AD/HD is itself 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 AD/HD more “hyper”; and stimulants make them better. How can we explain this curiosity?

The idea of an invisible barrier around the nervous system might explain this unexpected finding. A tranquilizer, tranquilizes Timmy and “thickens” that barrier, allowing even less stimulation to get through. Then Timmy feels an even greater craving for stimulation. He might, thus, become hyperactive or more distractible. Perhaps stimulants work in AD/HD because they don’t tranquilize. Instead they stimulate the nervous system, perhaps leaving Timmy less thirsty for outside stimulation and better able to focus his attention.

Making the Diagnosis
Not all children or adults with inattention have AD/HD. For example, low IQ can produce inattention. Inattention may also occur when kids with high intelligence are placed in academically under stimulating environments. Some oppositional children resist tasks that require self-application simply because of an unwillingness to conform to others’ demands. Certain medication (for example, bronchodilators or isoniazid) can cause inattention, hyperactivity, or impulsivity. So, how do we make the diagnosis?

I explained to Timmy’s parents that AD/HD represents a specific disorder. We should not recklessly label people with the diagnosis. AD/HD has a “shape”, “color”, and “feel”. The diagnosis is made when someone has at least six of nine symptoms from either one of the following lists:

AD/HD, 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

AD/HD, 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 his turn

● interrupting or intruding on others

Many individuals with AD/HD have at least six symptoms of inattention and at least six symptoms of hyperactivity-impulsivity. We give them the diagnosis ofAD/HD, combined type.

Role of Physical and Psychological Tests
Timmy’s parents asked me about a test for AD/HD. 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 AD/HD. They, in fact, contribute little but additional cost to the process. 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 AD/HD, their presence does not confirm or refute the diagnosis since neuropsychological abnormalities are also found in a fraction of normal children. Psychological testing has not been shown to be diagnostically helpful. It can, however, be useful for detecting the possible coexistence of learning disabilities.

Treatment
Risks of Not Treating
AD/HD prevents kids like Timmy from being able to focus attention on academic work and typically causes significant academic underachievement. Many people do not appreciate how serious a disorder AD/HD can be. Frequent complications are 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 the child or adolescent with AD/HD. In late adolescence and in more serious cases, antisocial behavior and an increased risk of developing drug and alcohol abuse follow – partly because of the increased impulsivity of AD/HD and partly because the individual is simply not happy.

The Benefits of Medication
50 – 70% of AD/HD children and adults respond with significant clinical benefit to treatment with stimulants. The nature of this improvement can be profound and is often not appreciated by those unfamiliar with the treatment responsiveness of AD/HD. These medications often result in functioning at a level better than any the patient has ever experienced before.

Children and adults with AD/HD are not “drugged” into compliant, complacent behavior. Numerous studies report stimulants to improve all of the core symptoms of AD/HD (the hyperactivity, inattention, and impulsivity). Treated with stimulants they 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.

Non-medication Treatment
Behavior management can be extremely important. It is essential to understand, however, that medication is the only intervention that will actually change the individual. 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 the parents to cope with but not change the underlying behavioral dysfunction caused by AD/HD. Behavior management techniques will 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 AD/HD Behavior Management

● AD/HD is a biological deficit in persistence of effort, attention, and inhibition. AD/HD individuals typically also exhibit a reduced sensitivity to behavioral consequences. These characteristics are not the result of laziness or moral weakness.

● Use immediate consequences. Occasional praise a few times a day works for normal children and adolescents, but AD/HD individuals require very frequent feedback. They 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.

● Give frequent feedback. The adult may find this tiring, but frequency is necessary in order to change patterns of behavior that have developed in the AD/HD individual over time. Adults need to remember to observe for behavior for which to give feedback.

● Employ powerful consequences. For the AD/HD 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 doing something he or she shouldn’t be doing. 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 3 rewards (positive feedback) for every punishment (negative feedback).

● Maintain perspective. Remember, you are dealing with a handicapped individual. Forgive both yourself and your child when inevitable failures occur. But don’t give up.

Posted October 25, 2013 by Les Linet MD

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