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The Search for Stimulation: Understanding 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 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.

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

• 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.