The Challenge of ADHD

“ADHD is like having a Ferrari brain with bicycle brakes.”

-Ned Hallowell, M.D.

It was December of 1990. I was in the early months of my fourth year in private practice and found myself in San Francisco at a training with Dr. Russell Barkley, the author of “Defiant Children, A Clinician’s Manual for Assessment and Parent Training”. It was a two-day workshop, a chance to learn strategies for working with parents of defiant children and earn continuing education units for my psychology license.

The first day focused on “step-by-step procedures to follow in conducting a highly effective, empirically validated program for the clinical training of parents in the management of behavior problem children.” The second day focused on Barkley’s seminal textbook and the professional’s “ADHD Bible,” titled “Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.”

I thought I knew all about ADHD, or what was previously called Attention Deficit Disorder (ADD), with or without hyperactivity. In grad school, my dissertation addressed nutritional treatments of mental illness and I was familiar with the published literature on treating ADHD with the Feingold diet.

But sometimes you don’t know what you don’t know until you know, which is what happened that day. I bought Barkley’s book, came back to Redding and wrote a letter to my colleagues in the community that I was developing an ADHD assessment specialty and would welcome their referrals.

In the years that followed, I attended conferences and seminars with leaders in the field and provided local presentations for parents, teachers and mental health professionals. In the last three decades, I have assessed four or five thousand children, teenagers and adults for ADHD, and mood and anxiety disorders. And in the process developed a variety of metaphors for understanding and explaining the ADHD brain to parents of ADHD children as well as adults who struggle with it.

For example, I suggest that we understand ADHD primarily as a motivation disorder, not an inability to pay attention. ADHD children, teens and adults can often sustain their attention for long periods of time if they are engaged in an activity that is fun or interesting, like playing a video game. However, when they are not interested in something like chores or homework, they are not motivated and it is this lack of motivation that is responsible for the inattention, distractibility, and poor performance we associate with ADHD sufferers.

Many will argue this is a choice, that ADHD children are just lazy or defiant. However, the science is clear and paints another picture. The ADHD brain is different. ADHD is primarily a genetic, neurodevelopmental disorder. Thanks to functional and structural neuroimaging studies (PET, MRI and fMri), researchers understand a great deal about the neurological pathways that lead to the cognitive and behavioral difficulties we associate with ADHD.

I sometimes suggest we imagine a symphony orchestra without a conductor. That is the ADHD brain. The musicians depend on the “executive” with the baton who doesn’t play an instrument but helps all the parts coordinate and harmonize with one another. Without the conductor, the individual parts fail to perform in an organized and coherent fashion. A person with ADHD can be highly intelligent, talented and creative but struggle to attend, listen, organize, plan, persist, remember, regulate emotions and follow through with commitments.

Imagine a gatekeeper in our brains who guards the gate of the mind and decides what is important and what isn’t. In the ADHD brain the gatekeeper fell asleep or wandered off and left the gate open. Impulses are free to charge through the gate. It isn’t always clear which of these impulses is the highest priority. In the ADHD brain, there are numerous green lights telling the person to “go-go-go” while there are few yellow and red lights telling the person “slow” or “no.” This is why the ADHD person is viewed as being disinhibited.

Stimulant medication is described as having a paradoxical effect because it appears to calm the hyperactive child down. In fact, the medication stimulates the brain to inhibit impulses, enabling the person to slow down and focus. The medication wakes up the gatekeeper so she can do her job. It does this by increasing specific neurotransmitter levels in the prefrontal cortex.

A person with ADHD struggles to delay gratification. They are impulsive. They want it now, whatever “it” is. Imagine ten televisions on in the brain on different channels with the volume up while a police scanner searches for the most interesting thought, memory or activity to focus on. The ADHD mind’s default setting is “me—fun/interesting—now” and these individuals struggle when they are required to engage in what they perceive to be boring activities with no immediate reward or payoff. The mind wanders without any awareness it is wandering.

Such persons are dependent on the environment to help them stay on task. They crave structure and require supervision and consistency to stay on track. Children, especially will benefit from small, immediate reinforcement as opposed to distant or delayed reward. ADHD children look at adults as if we want them to clean toilets all day for no pay. Expecting an ADHD child to comply with requests to do their homework or clean their room is providing them with a high cost/no benefit requirement. Something in them rebels. They know what is wanted and when but they struggle to discern why they would want to do such things. This is different from intentional defiance although it can become that. Initially, it is a visceral, intrinsic reaction to avoid the frustration and boredom they feel when engaging in an unrewarding activity.

People with ADHD, when they aren’t daydreaming, prefer to live in the now. This does not mean they are “present” with the people around them. It merely means, they are focused on what is interesting to them in the here and now. The past and future are weak concepts in their minds. Like a reverse polaroid, they have a vivid experience in this moment and it fades. And then another vivid experience that soon fades. Because there isn’t an executive control present to process and integrate these experiences and keep them connected, individuals with ADHD are less likely to learn from and benefit from their life lessons. They have poor working and sequential memory. They repeat mistakes and fail to anticipate consequences.

Think of dolphins who jump through hoops in order to be fed fish. The ADHD brain understands this. It is called point of performance training. Since these children lack rule-governed behavior, we reward them at the time they perform the desired behavior. Token economies work. Barkley’s book, “Your Defiant Child, Eight Steps to Better Behavior” utilizes a system whereby children earn points or poker chips for desired behaviors which they can use to “purchase” rewarding activities. The promise of reward is much more effective at motivating children (and animals) than is the threat of punishment.

Other popular books by Barkley include “Taking Charge of ADHD” and “Taking Charge of Adult ADHD.” When I first trained with Dr. Barkley, research into ADHD adults was in its infancy. We now know that 50 to 80 percent of children diagnosed with ADHD will continue to struggle with the disorder as teenagers and 35 to 65 percent will still be impaired by it as adults. Studies tell us that 5 to 7 percent of children have ADHD while 3 to 5 percent of adults meet criteria for ADHD. It is estimated that approximately half of all children with ADHD are not diagnosed or treated.

Individuals with ADHD are more likely to struggle in school, with driving, with substance abuse, in social situations and occupational functioning. ADHD children fail to advance to the next grade in school more often, experience more suspensions and expulsions, drop out of school at a higher rate, have lower grades and GPAs and are less likely to attend and graduate from college. As adults, they change jobs more often, are fired more frequently, have more automobile crashes, more speeding tickets and more license suspensions.

Treatment for ADHD often includes stimulant medication which is successful in 80 to 90 percent of cases. Studies show that the benefits of medication include increased attention, concentration, compliance, effort and amount and accuracy of school work produced. It is also associated with decreases in the following: activity levels, impulsivity, negative behaviors, physical and verbal hostility and the need for punishment from others. Stimulant medication is also associated with improvement in working memory, verbal fluency, organization, handwriting, coordination, self-esteem, emotional control and peer relations. Side effects can include insomnia and decreased appetite.

Before medication is prescribed, a thorough, comprehensive assessment is essential. Also, I usually recommend parents of ADHD children implement behavior management systems before they resort to medication. Both parents should be on board in favor of medication before it is prescribed.

There are several areas of concern with an ADHD child: academic performance, behavioral self-control (impulsivity), peer-relations, self-esteem and relations with teachers and parents. If one or more of these areas is significantly, negatively impacted despite non-medical, structured behavior management programs, medication should be considered as a possible intervention. Treatment of ADHD with stimulant medication has been extensively studied and is considered to be safe and effective.

I often urge adults with ADHD and parents of ADHD children to learn as much as they can about the disorder from reputable sites such as chadd.org, add.org, additudemag.com, russellbarkley.org and drhallowell.com.

 

 

Douglas Craig
Doug Craig graduated from college in Ohio with a journalism degree and got married during the Carter administration. He graduated from graduate school with a doctorate in Psychology, got divorced, moved to Redding, re-married and started his private practice during the Reagan administration. He had his kids during the first Bush administration. Since then he has done nothing noteworthy besides write a little poetry, survive a motorcycle crash, buy and sell an electric car, raise his kids, manage to stay married and maintain his practice for almost 30 years. He believes in magic and is a Dawes fan.
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10 Responses

  1. Avatar Bruce Vojtecky says:

    Dr. Craig, you just described my life. Unfortunately the only cures available for me early were lock him up. My childhood friends were Jack Abbott and Gary Gilmore and a host of other not so famous murderers, rapists and criminals. My life did not change until I came to Redding and a change of environment. Good article Dr. Craig.

  2. My favorite sentence: “ADHD children look at adults as if we want them to clean toilets all day for no pay. ”

    Thank you, Dr. Craig, for taking on such a complex topic, and teaching us in a way that makes it easier to comprehend. (Confession: I think I am on the ADHD spectrum. This column explains a lot.)

  3. Avatar Christian Gardinier says:

    Hey Doug! Here, Here! Always had it and still do. Thing is a double edge sword, sloppy on details because we see the BIG PICTURE and don’t have time for boring, people and activities that don’t! Creative vs Disorganization. Wish our society would take some responsibility for the over 8000,000 tv- radio channels, IPhones, tablets, let alone 50 billion website stimulation we get as kids (and adults) that helps ADHA wire up STAY STRONG! Speed wakes up the brain’s traffic cop so we can manage, sort and send information to where it needs to go. BUT, big problem with speed, (oh, I mean Adderall, Concerta love that name, Dexedrine, hey amphetamine Annie, keep on trucking…) is that it’s a bit addictive if you know what I mean…? (What in our culture and environment needs to change as much as we do?) But, many of our Mental Health Clients, they just love that Adderall stuff! DANGER Will Roberson! Now if I can just find my car keys, and remember how to get to where I need to be by 7:30…. Oh well, late already but that Huffpost thing on tRump and Kim Jong Un! Another cup of coffee? Can you believe that……….

  4. Avatar Eleanor Townsend says:

    Valuable article, Doug. Your analogies really help with at least understanding this complex condition. Thanks.

  5. Adrienne Jacoby Adrienne Jacoby says:

    Where, or where was this information 40 years ago when I so desperately needed it . . . . and still do!!?? 40 years ago I keps hearing, “Oh, he’ll outgrow it!” . . . . NOT!!!

  6. Avatar Teresa says:

    Dr. Craig, Diagnosed as an adult I have tried numerous meds and found nothing that made any difference. My son (now 27) is so effected I don’t know how he found his way out of his bedroom each day! Here is my chief complaint, every group, every Dr. etc. wants to hand me a book to help me learn how to deal with my own and then his issues. Hmmm… I don’t read—I HAVE ADD!!! It frustrates me to tears! If I could make sense out of a book I probably wouldn’t struggle every step, every day of my life!! My brain is so tired.

  7. Joanne Snyder Joanne Snyder says:

    What I’m really impressed by is that you came to the study of this disorder after having done a dissertation addressing nutritional treatments for mental illness. You have looked at mental anomalies from a nutritional as well as a nurological angle, so you have a better picture than most. Thanks for sharing this knowledge. Many people (generally not the ones with ADHD children) believe that all of the issues of this disorder can be cured by diet alone, and that medication is unnecessary.

  8. Avatar Linda Rasmussen says:

    Thank you Doug for keeping ADD in the public forum. “Farrari brain with bicycle brakes” , what a good analogy. In the future I hope to see articles about ADD in adults. ADD impacts a person and their family for life. It doesn’t go away.

  9. Douglas Craig Douglas Craig says:

    Thanks everyone for the positive comments. I appreciate it.

    Regarding ADHD medication and addiction potential, I have not seen this as a general problem in my practice. I will attempt to explain this. First, when we picture a person who is addicted to a drug, they are highly motivated to obtain and consume it. However, with ADHD children, they usually will not remember to take the medicine unless they are reminded. And it is common for teenagers to refuse to take the medication for various reasons associated with defiance, autonomy and resistance to adult authority and control. This does not look like addiction. In the last 30 years, I worked with one ADHD adult who had a history of addictive behavior (mostly opiates) who convinced his prescribing physician that he was unique and needed a higher than normal dose of his stimulant and a more frequent dosing schedule. He was the exception, not the rule. I also worked with an ADHD adult who before he was diagnosed with ADHD, used methamphetamine in a very scheduled manner to self-medicate and had a long, successful career, was a responsible father and husband. Again, the exception, not the rule. Finally, I evaluated two teens who were clearly abusing their ADHD medication (and who I later learned were friends). In 30 years of working with this population, these are the exceptions.

    There is some evidence that ADHD teens and adults who are not properly diagnosed and treated are more likely to abuse substances “as a way of relaxing or calming the mental restlessness they often experience,” according to Dr. Kevin Murphy, President of the Adult ADHD Clinic Of Central Massachusetts in Northborough, Massachusetts, Associate Professor of Psychiatry at UMASS Medical School, and Associate Research Professor in the Department of Psychiatry at SUNY Upstate Medical University in Syracuse. Primary “drugs” of choice are usually alcohol and marijuana. About one-third of patient’s at Murphy’s clinic “met criteria for substance abuse or dependence at some point in their lives.” Most seemed “to be self-medicating in an attempt to cope with their underlying ADHD symptoms.”

    Once treated with stimulant medication, there is often not only a decrease in ADHD symptoms, but also a decrease in substance abuse. According to Dr. Daniel Connor, Chief of the Division of Child and Adolescent Psychiatry at UConn Health, an academic medical center connected to the University of Connecticut schools of Medicine and Dental Medicine, all evidence suggests that ADHD individuals abuse substances due to their ADHD, not because they are prescribed ADHD medication.

    One of the most extensive studies of ADHD ever conducted “found no association between stimulant medication and risk for substance abuse in adolescents at 8-year followup.” There is no evidence that prescribing stimulant medication to children increases “risk for later adult substance use disorder.” It is true, of course, that among adolescents and college-aged adults not diagnosed with ADHD, we often see improper use (abuse) of stimulants and other illicit drugs.

    The American Academy of Pediatrics recommends stimulant medication with behavior therapy as the “preferred treatment” for teens with ADHD. Studies show that individuals with ADHD are much better drivers when they take their stimulant medication and are much less likely to be involved in automobile crashes.

    Regarding books on ADHD, I agree with Teresa, that the audience for these books often do not have the attention span to focus on and benefit from them. Again medication can help. Also audio-books work for some people and YouTube videos for others. Some benefit by working with an ADHD “coach” (similar to a therapist) who helps the client tailor specific strategies for coping with their particular challenges.

    Finally, Hal’s comment reminds me of a book written by Thom Hartman (Adult ADHD: How to Succeed as a Hunter in a Farmer’s World). And a study that found that African tribal hunters with the ADHD gene were more nourished (better hunters) than those without the gene. And African tribal farmers with the ADHD gene were less well nourished than those without the gene. In other words, having ADHD seemed to be an evolutionary adaptation conferring an advantage for the hunter-gatherer cultures but became a deficiency as cultures developed into more agricultural-based societies. Our culture is not friendly to individuals with ADHD. For example, Dr. Michael Gordon once stated that if the President were to appoint a commission to design a hell for ADHD students, it would look like our classrooms.

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