What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is a neurological deficit which affects the prefrontal lobe. This is an area behind the frontal lobe towards the middle of the brain. For many years scientists maintained that ADHD was a form of brain dysfunction but the studies that were cited were based on such small samples that is was hard to accept their validity. Now, thanks to the National Institutes of Health in the U.S., which has spent millions of dollars in this endeavour, there have been some major studies done with very large samples of people, some as high as 1500 in the experimental group, which have shown clearly that there is a difference between the brains of persons with ADHD and those who do not have this disorder. What is also confirming is that whether the studies use MRI, (which look at the anatomical structure of the brain), PET scans, (which look at the metabolic activity in the brain), EEG activity, (which measure brain wave patterns) or evoked potential, (which measure the electrical activity of the brain), all of the studies basically support the same conclusion­ that the prefrontal lobe of the person with ADHD is underfunctioning. In some cases it is significantly smaller and in other cases simply not doing the job as well as it needs to be.

How can we be certain of this conclusion?

When we get replication of studies and the same conclusion drawn from different avenues of asking the question, we can begin to say with some certainty that we know something. One study alone is simply interesting, but it needs to be replicated by other similar studies and reliability and validity come from different studies, looking at the same phenomenon from different avenues, which all point to the same conclusion. This is now the situation we have with ADHD.

What is the function of the prefrontal lobe?

The next question to answer is what does the prefrontal lobe do? This is the area of the brain which deals with self control. It is the "brakes" of the human being. It says "No," "Wait," "Don't Act Now." This is an enormously important ability to have. Because we can inhibit our behaviour, it allows us to consider, ponder and think about our responses, thereby making better choices in life. We can do a mental rehearsal, go over what happened the last time this event happened and decide whether we want to repeat that or change it. It allows us to think about what others have told us, how others have cautioned us. It allows us to consider potential consequences, both good or bad. It allows us to connect with our memory banks of the same and/or similar circumstances and decide how we want to proceed. If, however, we don't stop ourselves, we don't have a chance to connect with all this good information and potential sources of judgement. What happens then is we simply act, impulsively and without forethought, often making poor choices and then paying the consequences.

It is important to note, however, that persons with ADHD are not completely without a pre frontal lobe. If they were devoid of this area completely we'd see highly impulsive, uncontrolled behaviour all the time. This is not what exists. We do have kids who are about two to three years behind in the development of their self control mechanisms. When one is 9 years old and is behaving like a 6 year old this is a noticeable and debilitating difference. Self control is an ability, like most others which is developmental in nature, that is, it develops over time and gets better with age. A child of 4 without ADHD has much less self control than a child of 8. Even as adults our self control is not perfect all the time. When we're tired or stressed, we have lapses in self control. This is why it's an erroneous conclusion to say "Well he can control himself sometimes, therefore he can't have ADHD." On average, a person's self control who has ADHD will be significantly weaker, exercises significantly fewer times than a person without ADHD. Persons with ADHD also improve as they get older, but so do everyone else, hence they never really catch up. Also, by the time they are adults, they have incorporated into their self image so many negative self attributions, such as "lazy," "bad," "obnoxious," and "unlikable" and these seem to stick and don't go away with time.

What can we do about ADHD?

Once you have a good understanding of ADHD you will know what to do to help your child. If you don't know what to do you don't really understand it. Read on.

First of all ADHD is not a skill deficit, it's a performance deficit. Person with ADHD know what they're supposed to do. The kids I see know better than most kids what the rules are. They've probably heard them at least a thousand more times than other kids. The information does exist in their brain. It is not, however, available to them, when they need it. They do not stop themselves long enough to access this information. So they know it when they sit in my office or you talk to them afterwards. What we need to do is put the information, the reminders in front of them, in the environment, so that when they look around they are reminded. We need to think of ways to make the environment function like a pre frontal lobe. Some ideas are:

Yellow sticky notes everywhere

Large ones, small ones, ones with pictures on them, ones with reminders on them, ones with our hand writing, ones with their handwriting, ones from different people in their life, like grandparents, coaches, friends, etc. Instead of telling them over and over and hoping the information gets into their brain and that they will be able to connect with that information in their brain, put it on a post-it note so they will see it. This really does work wonders and most kids find it very loving and helpful.

Lots of consistent feedback

What keeps most of us on track is feedback and reinforcement. This is where behaviour charts come in. Any kind of chart system where you use stickers or points to acknowledge good behaviour keeps us on track. What I say to parents who say behaviour charts don't work is that the whole world is on a point system. Tell the corporate world behaviour charts don't work. If they don't work, why have they put us all on point systems­ air miles, bonus points, etc. Holiday Inn now has all their employees on a star system for compliments. The employees say they love it. They don't work because parents give up on them too quickly. (See any of Russell Barkley's books for helping children with ADHD for more help setting up behaviour charts.)

Schools are notoriously bad places for persons with ADHD who need lots of feedback, daily, sometimes hourly. Most classrooms have too many students and one student may have to wait days before he/she gets any feedback from the teacher. Tests are taken and it's often weeks before it's returned with the mark. Projects take weeks and then it's weeks before they are graded. Time is the enemy for the kid with ADHD. They live in the moment, in the present. He/she needs feedback now. So we encourage teachers to set up daily report cards where kids get a check mark or a sticker four or five times a day. It takes literally a few seconds and the child knows whether or not he's on the right track in certain key goal areas that have been decided upon. This can go home and then the parents also know to what extent the child has been on track.

We know kids with ADHD need lots of feedback from studies done which look at which professions persons with ADHD do better in as adults. They do well in professions that are rich in feedback. Jobs like commissioned sales, where you know clearly at the end of the day how you did; jobs like making things with your hands where you know whether you did well because it fits or it works or it doesn't. They also do well in sports, which are rich in immediate feedback. If you shoot a basketball towards the hoop, you know if you did it well, because it goes in. If not, you know what correction to make. Actually sports, which are action-oriented and rich in feedback, are often the forte' for kids with ADHD. If you're a more thoughtful kind of person, thinking about the past or the future, you get penalized in sports for thinking too much and not being ready for the next play. Kids with ADHD who are coordinated often gravitate to action sports. We need to take a lesson from this.

Stimulation and action

There's a reason why kids with ADHD need stimulant medication. They do better with stimulation. This seems to activate the brain, giving the prefrontal lobe a chance to work optimally. They need to be busy and they need their environment to change and not be boring.

Structure

External structures also keep us on track. Having a place for our books, for each item of clothing. What is structure but a place for everything (and everything then goes in it's place) and a time for everything (and things get done in their time). It's not a bad idea, no matter what the age, to label drawers, in big bold letters, to show what they're for. This way, it's much more likely the things that belong in those places will end up there. Remember, don't expect that even though this information is in the brain that it will be accessed at the time when the item is being put away. In fact, it's much more likely the item will be put away if the eye sees the label staring them in the face. And when you make a schedule, it needs to be advertised, put up on the wall, on the mirror, in the gym bag, everywhere you can think of. Be bold!

Externalize

Externalize, Externalize, Externalize as much as you can. Eternalize the information­ Put it on oak tag, on placards, on mirrors, etc. Externalize the sources of motivation. Put reminders up of what they will get if they reach their goals, if they earn the points, if they get the stickers. Advertize, Advertize, Advertize. Don't expect memory to do it all.

Make it fun!

Life doesn't have to be tedious or constantly a chore. Have fun with this and it's more likely that it will happen and then even if it doesn't you still had fun, so you can't lose.

Medication

Medication does help a large percentage of kids and persons with ADHD. Unfortunately the medications available at this point are fairly gross in that they work on the whole brain and not just the prefrontal lobe, hence we end up with side effects such as insomnia and appetite loss. These can be worked around. The medications are not as bad as some aspects of the media have portrayed it. In fact, the medications used are relatively safe. Unlike antibiotics there has not been one reported death from stimulant medications for ADHD. They are relatively quick acting, that is in and out of the system within four hours, and non addictive. In my role as consultant at the children's mental health centre I have seen hundreds of kids on medication and listened to thousands of parents talk about their experience. They may not always like how the medication affects their child but none have complained that it was difficult to get their children off. I do think the medication is often worth trying, if you've had a proper assessment and diagnosis, to see if it works for your child. There is really no down side to trying it. But medication alone will probably not result in the kinds of results most parents are looking for. For long term results you need to have proper administration and dosage of medication, a good understanding of the disorder so that you can make the proper accommodations in the environment.

I hope this has been helpful. Please, let me know about your experiences with any of the ideas mentioned here or strategies that have worked for you that might be useful to others.

- Doc Robin

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