A Beginner’s Guide to Understanding ADHD
Attention – the ability to focus our mental energy towards a specific stimulus while ignoring other environmental aspects that are not pertinent. In order to function effectively in many environments, we are required to have control over our focus. We must be able to attend to the desired aspects while ignoring distractions and be able to maintain that focus over time.
Most people’s attention is like a dimmer switch. They are able to control the intensity and duration of their attention. For example, they may turn up the intensity when tasks are more challenging, there are more distractions, or when something is very boring. Although this is something that develops over time (a 3-year-old’s ability to stay focused for 30 minutes straight is laughable!), many people are able to effectively adjust their attention dimmer as desired.
This isn’t at all what people with attention difficulties experience. Instead of a dimmer, they have a light switch. Their attention is either turned all the way on or is completely off. As a result, the person with dysregulated attention may have the light switch on when reading a book, drawing, or playing a video game. They become so focused that they fail to pay attention to both external and internal stimuli, such as a parent asking them to do something or basic needs (i.e., hunger). This is known as hyper-focus. These individuals may lose track of time and believe they have only been engaged in the activity for a few minutes when in reality they have been in a state of hyper-focus for hours. When the switch is off, these people are unable to hold their attention to any one aspect and instead are distracted by noises, their own thoughts, and/or physical sensations (the feel of their shirt on their skin or a sense of restless that requires movement as a release). As a result, they float between many tasks, get started on several projects, but accomplish very little. In addition to these challenges, people with an on/off switch have little control of when their switch gets flipped or on what their focus attaches (the video game or the hum of the air vent).
What is Attention-Deficit/Hyperactivity Disorder (ADHD)?
Diagnostic categories have changed over the years. Previously there were two separate labels for those with attention challenges: Attention-Deficit/Hyperactivity Disorder (ADHD) and Attention-Deficit Disorder (ADD). This was designed to separate those who solely experienced inattention from those who experienced hyperactivity. However, we began to realize that attention dysregulation was not as clear cut as those two diagnoses, particularly for those who experienced both inattention and restlessness. Now, regardless of the symptoms, all attention issues are captured under the umbrella term ADHD and then further delineated into three main categories:
ADHD – Predominantly hyperactive/impulsive presentation
ADHD – Predominantly inattentive presentation
ADHD – Combined presentation
There are some similarities across all of the categories. For example, they all require the following features for diagnosis: symptoms occur in multiple settings (home, school, sports teams, church, etc.); symptoms result in significant impairment; and symptoms are developmentally inappropriate. ADHD is considered a neurodevelopmental disorder, meaning that it is seen over the course of the development of an individual’s life. As a result, symptoms must be present prior to the age of 12, even if it is not diagnosed until later in life. However, the symptoms may change over time and the degree of impairment often depends upon the daily tasks required of the individual. For example, the symptoms may be more problematic when in an academic setting or working in a cubical, but be more manageable as an athletic coach or a photographer.
Additionally, children with attention difficulties frequently have weaker scores on tasks tapping working memory and processing speed. Both of these intellectual aspects are necessary to perform well academically. However, they require the ability to attend to specific information upon demand, hold and manipulate information in your mind, and work efficiently within a time frame. This is extremely challenging when the attentional switch is off or turned on but focused on the wrong information.
It is important to understand that children with dysregulated attention are not lazy, rebellious, or defiant. Quite the contrary, these students often have high levels of motivation, want to please others, and have a strong desire to follow the rules. Simply put, their minds are wired differently, causing them to not be present mentally even when they aspire to maintain their focus. In fact, many of them are putting forth extraordinary amounts of efforts to even maintain the little amount of attention others see. What you see is the duck gliding effortlessly along the top of the water, what you don’t realize is the intensity and tenacity with which the duck is kicking their legs to simply stay afloat. This is one of the most challenging aspects for many parents to understand as it can be quite frustrating to have to repeat yourself multiple times or have to wait for a child to re-do an activity due to incorrectly following the directions. We will talk about ways to help manage this a little later in this blog.
Although there are some similarities, each category is slightly different. Let’s dive into them just a little more.
ADHD – Predominantly hyperactive/impulsive presentation
This is likely the type of ADHD that you envision when you here the term ADHD. These kids are often flagged earlier due to their difficulty staying still and tendency to be very talkative. As a result, they are more likely to be a behavioral distraction or problem in the classroom. These are the kids that you might feel exhausted trying to keep up with them because they are bouncing off the walls. Those in this category experience several symptoms related to hyperactivity and impulsivity. For older children and adults, this is often experienced more as a sense of restlessness (they usually learn how to stay in their seat!). These people frequently use counteractive measures to address their restless such as bouncing their knee, doodling during meetings/classes, or tapping a pencil. Whether it is related to biological or societal aspects, this type of attention dysregulation is more likely seen in boys than girls.
Common characteristics:
Fidgets with items (bracelets, hair, pencil, scraps of paper)
Moves excessively (squirms in seat, bounces leg, has difficulty staying seated, etc.)
Seems “on the go” (like the Energizer bunny!)
Talks excessively
Is impulsive (acts without thinking, blurts out answers, frequently interrupts)
A sense of restlessness
Has trouble working/playing quietly
Has difficulty staying in one place for an extended period of time
ADHD – Predominantly inattentive presentation
Predominantly inattentive presentation is what is used to describe those who were previously diagnosed with ADD. These individuals are frequently overlooked. Many of these children are very well-behaved, but may be seen as day dreamers. Although they do not disrupt classrooms by bouncing off walls, they may miss important information as their mind wanders outside of the classroom. Just as boys are more likely to experience hyperactivity, girls are more likely to present with this type of attentional issue.
Common characteristics:
Difficulty attending to details
Makes careless mistakes
Struggles to sustain focus for lengthy periods of time
Disorganized
Forgetful
Has difficulty following through (obeying instructions, completing and turning in school assignments, etc.)
Easily distracted
Day dreams; mind wanders
Doesn’t appear to be listening
ADHD – Combined presentation
As you might have guessed from the name, those with a combined presentation experience both inattentive and hyperactive/impulsive symptoms. The combination is unique for each individual, with some experiencing slightly more hyperactive symptoms while others experience more inattentive symptoms. Additionally, some symptoms may be more present depending on the time of day, the specific activity, or the environment the individual is in.
Additional Challenges (executive functioning)
An additional challenge that many individuals with ADHD face is weak executive functioning skills. Executive functioning is an umbrella term to cover a variety of “common sense” skills that people tend to develop over time. These skills include:
Organization: having a structure in place that allows you to know where items are and where things should go (at home, in school, in the car, etc.)
Planning/Prioritizing: determining the steps necessary to complete the task and the best order in which to complete them
Initiating: actively drawing up the energy and engaging in the task
Inhibition: the ability to think before acting (that one second pause before doing something regrettable)
Regulating emotion: the ability to experience an emotion and employ coping strategies to avoid becoming consumed by the emotion
Self-monitoring: awareness of own thoughts and behaviors; the ability to recognize when they are off task, their mind has wandered, or their behavior is problematic (i.e., bouncing in chair is distracting other students)
Multitasking: effectively and intentionally shifting between tasks
Communication: expressing yourself in a clear manner and being flexible enough to provide elaboration or alternate phrasing if not understood initially
Time management: understanding the passage of time (i.e., having a sense of how long you have been engaged in an activity); accurately determining the amount of time required to complete an activity
Often, children will learn these skills by observing others or through trial and error. However, those who struggle with dysregulated attention frequently need more explicit instruction to develop executive functioning.
A great example is learning to pack a bag for a weekend trip. This requires organization (to find your bag, clothes, toiletries), planning (what do you actually need), initiation (actually get started), and inhibition (keep yourself from getting side tracked by the book you found or the text you received). Children with ADHD often have no concept of the process involved in packing. Instead of simply showing them, you need to provide them with the framework you use to guide your packing decisions. For me, I first count how many nights and days I will be gone so that I can have the correct amount of underwear (plus an extra, “just in case!”). I then get my pajamas. Next, I look up the weather so I know what to expect and then select an outfit for each day. While I’m selecting outfits, I also have to keep in mind what activities I will be doing so that I have the appropriate attire (a bathing suit top and shorts doesn’t exactly work for a nice dinner at a steakhouse!). Lastly, I toss in shoes, electronics chargers, and my toiletries. I then run through everything one final time in my head ensuring that my travel motto to make sure that I have all of the things I cannot easily buy (because they are expensive, hard to find, or irreplaceable) has been met.
Do you see how involved a “simple” request of packing a bag for a trip can be? Without my executive functioning skills, I would just be throwing things in a bag and hoping for the best. Children with ADHD frequently need extra support to learn and develop these skills. What other children learn in two steps, these children may need five steps. In our above example, for the first few trips, a parent might provide a list of items for their child to gather. Then, on the next few trips, they may talk their child through the process while having the child be the one to actually gather all of the items (i.e., we are going to be gone 3 nights, so how many pairs of underwear do you need?). After success at that level, the parent may have the child verbalize the process and collect the necessary items for a few trips. And finally, the parent may simply be a checklist for the child after the bag is packed. Do you see just how much more involved a parent is in this process? And this happens across many activities such as, developing study skills, doing laundry, pursuing romantic relationships, and getting ready for the day.
Managing Attention-Deficit/Hyperactivity Disorder (ADHD)
One of the main questions I get when dealing with parents of children who have just been diagnosed with ADHD is whether they should medicate or not medicate. While this is dependent on a multitude of factors and is a highly personal and individual decision, I firmly believe that everyone should understand the options available to them.
Yes, medication does change an individual’s behavior. For some, this is very helpful, as their behavior is interfering with their ability to learn and interact with their peers. Medication tends to best address the hyperactive symptoms, allowing individuals to stay in their seat and reducing behaviors seen as problematic. However, some individuals with inattentive symptoms note vast improvement when taking medication.
One of the great things about medication is that it works quickly. It is effective from the first day taken with no need to build up in a person’s system. This means that, even though dosage and type of medication is a trial and error process, we know fairly immediately what difference it will make. However, this also means that the medication wears off quickly. Some children find that they need a booster dose at the end of the school day, especially at the high school level when a high degree of focus is needed to complete homework and study for exams. Another important note is that, since there is no build up, a child can take medication sporadically. In other words, the child may take medication only on school days and not on weekends or over the summer. Some older students may decide to take medication only on days that are longer, more challenging, or for test days. This allows you to tailor the medication to your needs and values.
Some people experience side effects from taking medication. Common ones include a lack of appetite and a sense of feeling numb or operating in a fog (like a zombie). Side effects typically indicate a need to change dosage or medication, or that medication is not a great option.
Most people know of stimulant medications used to treat ADHD (Ritalin, Adderall, Vyvanse). However, for those who struggle with or are prone to anxiety, stimulant medication can increase their anxiety symptoms (chest tightness, shortness of breath, heart racing). Therefore, non-stimulant options, such as Straterra, Wellbutrin, and Intuniv may be a better fit.
Sometimes, medication is necessary to help reduce how hard a child has to work to maintain their “normal” level of functioning (think back to our duck example). Providing medication can allow the child an opportunity to use that energy that had been put towards constantly focusing and re-focusing towards their academic and social success. This may also allow your child the opportunity to develop the skills and strategies necessary to manage their fluctuating attention so that medication is no longer necessary. If the light switch is turned off, then the child is not available for learning and is not getting the essential information.
ADHD can also be managed through the development of skills and strategies. Examples include: learning to go back and check their work for careless errors; using timers to learn to be more in control of when their brain takes a break (setting a timer to work for 2 minutes and then take a 30 second break with the goal of extending the time between breaks); increasing awareness of when their mind has wandered off; using agendas to keep track of assignments; color-coding; and using a pencil or ruler to help with tracking when reading. These students also benefit from accommodations to provide extra support throughout their academic career.
Examples of possible accommodations:
Extended time
Placement with teachers who use multi-sensory teaching approaches
Access to teachers’ notes (or a copy of a peer’s notes)
Preferential scheduling to coincide with medication effectiveness and to ensure appropriate fit with teachers;
Opportunities for one-on-one instruction
Testing in a distraction-reduced setting
Providing opportunities for study time and homework completion at school
Strategic seating in the classroom away from distractions and in close proximity to the teacher
Allowing opportunities for seat breaks in view of her restlessness (this may also include other appropriate “brain breaks” such as snacks, meditation, or short bursts of exercise)
Permission to mark answers on test booklets rather than using Scantron forms
Permission to use a fidget or stress ball to help with focusing
Daily verification of agenda to ensure student has all assignments and tests written down
Access to audiobooks (the opportunity to move while learning can be extremely beneficial for some children)
Permission to record classes to ensure student is receiving all information
Opportunities for test corrections to ensure child understands errors
Access to study guides and tutorials
Opportunities for repetition of material
Breaking down written assignments and larger projects into more manageable parts, with consistent check-ins
Requiring the use of scratch paper on math assignments to minimize careless errors (may also include the use of graph paper to ensure proper organization and lining up of numerals for problems)
Close monitoring by a mentor or advisor
Completion of a study skills or academic strategies course
Additional Resources
ADHD
Books:
Driven to Distraction – Hallowell/Ratey
Answers to Distraction – Hallowell/Ratey
Taking Charge of ADHD – Russell Barkley
Websites:
www.impactadhd.com – tips/tools, groups, education
www.chadd.org – national resource on ADHD
www.helpguide.org – covers a variety of topics but provides parenting tips
Executive Functioning
Websites:
https://childmind.org/article/helping-kids-who-struggle-with-executive-functions/
https://www.beyondbooksmart.com – has lots of info and provides executive functioning coaching services
www.thestudypro.com – focuses on developing study skills; has lots of info on executive functioning
http://efpractice.com – speech-language pathologists who work within the realm of executive functioning
http://www.understood.org – lots of info to understand basics of executive functioning; provides some tips to help improve executive functioning skills
If you believe you or your child is struggling with symptoms of ADHD, please contact us for a free consultation to discuss a possible evaluation to definitively diagnose any dysregulated attention and determine any necessary accommodations.