ADHD Notes

I ran across some very interesting notes from a lecture on ADHD while searching for something quite different. I’m largely putting them here for my own reference later, but since there was some very sensible stuff here I decided that perhaps others would find the information useful, as well.

~~Dr. Barkley’s ADHD Seminar Notes~~

Dr. Russell Barkley, widely considered to be the leading research psychologist working on ADHD, is Director of Psychology and Professor of Psychiatry and Neurology at the University of Massachusetts Medical Center. He has authored several books on attention deficit disorder, including the classic ‘Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.’ The following notes are from a seminar Barkley presented in Cleveland on 29 April 1994. The seminar was sponsored by the Institute for Adult Development and the Institute for Child & Adolescent Wellness in Beachwood, Ohio.

While compiling these notes, the liberty was taken of replacing such terms as ‘normal’ with ‘average’. For while ADD certainly impairs the ability of people to function with expected efficiency at certain tasks in industrialized societies, it is not to be seen merely as a disorder. Let’s not minimize ADD, but let’s not pathologize it either. Indeed, many psychologists now speak of ADD as an outlier in the spectrum of human neurological variation, and therefore little different from other genetically-determined human traits like hair or eye color, height, intelligence, etc. As Thom Hartmann and Ned Hallowell have advocated, ADD should be seen as much as a gift, and indeed many people with ADD have high intelligence, whether inborn or acquired as a compensating response necessary to function in a complex society. While much of Barkley’s presentation was oriented toward ADD children, the extensions to adult ADD are in most cases straightforward. Note that one does not necessarily have to agree with all of Barkley’s views, (especially with regard to a single cause underlying all ADHD) in order to gain useful information from this essay.

The notes below were not taken from any recording. Notes may be redistributed only if the above commentary is included.

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Russell Barkley seminar on ADHD

Calling ADHD an attention disorder trivializes it; it is not an attention deficit. Barkley is working on a new theory to explain the psychobiology beneath the spectrum of symptoms usually considered to be part of the ADD syndrome. All of these symptoms are observed in ‘normal’ people at one time or another—they differ in people with ADHD by reason of their presence since childhood, their persistence beyond childhood, and their severity.

ADD has in the past been termed post-encephalitic behavioral disorder, brain-injured child disorder, and minimal brain disorder. The hallmark triad of symptoms are:

inattention or inconsistent attention,
hyperactivity
impulsiveness.

Barkley says that ADD has more to do with lost interest than with an inability to concentrate. He estimates that ADD affects 2 million children in the USA, with the condition persisting into adulthood in the chronic form in over 50% of these. Boys are affected at three times the rate. ADD crosses all social barriers, and is present in all ethnic groups and social classes.

Barkley says that it is misleading to speak of three primary characteristics of ADD. Might a single underlying cause account for the wide range of characteristic behaviors? He believes so and points to the persistence of effort as the cornerstone of ADD. Some think ADD arises from a faulty ‘filtering’ mechanism, but this is not the case—it has to do with motivation. As a result, telling children or adults to try harder is futile and should be stopped—rather, the interest of the curriculum (or job, etc.) should be increased to keep ADD children interested and motivated.

ADD is not an attention disorder, but a disorder of impulse control. ADD children do things other kids think of, but don’t actually do. The urge to act is not being inhibited. The first response is the immediate response. People with ADD have trouble resisting the attractiveness of things other than that immediately before them. The observed hyperactivity is not independent from, but born of, the impulse control problem. To be ADD is to be hyper-responsive, not hyperactive. Failure to inhibit is at the core of the problem.

ADD has an early onset. 95% are identified by age 7; the mean is age 4. By this time, ‘normal’ children are learning self-control. All young children are impulsive, but they eventually learn control. 20-30% outgrow the condition. >60% (Barkley thinks it to be 75%) carry the condition in some form into adulthood.

ADD children act better in a one-to-one setting than in groups. They behave better in the presence of fathers than mothers. This is also observed in other children. Barkley thinks that in the mind of the child, the person (parent) who talks loses, the one who acts wins. Mothers tend to talk; fathers tend to act. He suggests that you not try to reason with your children in every situation—ADD is not a failure of reason, neither is it a failure of knowledge.

For the person with ADD, novelty is a reward. They do well with a rich schedule of feedback. Barkley calls them ‘little Ed Kochs’, for the New York City mayor known for asking ‘How’m I doing?’. Tell them how they are doing—they want immediate feedback, for they operate on the level of immediate vs. delayed consequences/rewards. Education is delayed gratification; they want what feels good now. Those with ADD generally do better in the morning (even those who are not ‘morning people’ find it easier to function more close to normal in the morning). Therefore, give them the hard work in the morning, and give them something fun to do later. Its important to realize that symptoms are dependent on the environment; one is not going to see all the problems under all circumstances.

The scientist/philosopher Jacob Bronowski wrote in ‘The Ascent of Man’ that the most crucial event in the evolution of the human species was the appearance of the ability to wait—a trait crucial for human function. Barkley sees four aspects to this ability to wait.

1. A sense of time

The human mind can keep an event in short-term memory. The mind can freeze time by holding on to an event which has passed. Barkley’s theory of the neuropsychology of ADD predicts that people with ADD will have poorer short-term memory than average individuals. If you can hold something in short-term memory you can analyze it. This ability is crucial for mental calculations, analysis, reflection. Humans can use their minds as time machines, as vehicles in which to travel between the present, past and future. Other animals cannot sustain an image in their minds. We call the ability to refer back and forth between past and present hindsight. If however, you don’t wait, you don’t reflect, and therefore cannot benefit as well from the wisdom of hindsight.

We are the only species in the fourth dimension: time. This sense develops between 7 and 8 years of age. Conversation at this age begins to deal with anticipation, forethought, planning. Other kinds learn to ignore stimuli which may distract from the task at hand. In contrast, the ADD child doesn’t respond until the event crosses their window. They don’t respond until hit by the train of time. They don’t deal with things until necessary.

2. Objectivity

Once you learn to wait, you can stop an emotional response while you examine it. This is emotion vs. objectivity. If you don’t wait, you will continue to be emotional, and will have difficulty separating emotion from objectivity. It’s facts vs. feelings. Those with ADD are more emotional over the entire spectrum, from happy to sad; they feel their emotions more intensely than average people.

Objectivity is required to serve goal-directed behavior. Perspicacity is the kindling of motivation. Motivation is an emotion. The normal attitude with an unpleasant task is that you ‘stick with it’, as there is a reward at the end. In ADD, the reward must be in the task itself, not after it. Most children can kindle motivation, the ADD child has to find it in what he is doing at the time—he has trouble kindling motivation to do an unpleasant task.

3. Reflection

Humans can turn language on themselves. We call it reflection, and its the bedrock of self-control. Internalized language develops at 3-4 years of age; it is, therefore, no surprise that ADD is typically first noticed at this age. Speech becomes a means for self-control. You can talk to yourself in order to control yourself. This predicts disorganized internal speech in those with ADD. This was actually seen in research done 10 years ago, but it was ignored because it didn’t fit into the prevailing paradigm.

The prediction is that those with ADD will seem younger than their chronological age; they will seem more child-like than their non-ADD peers. That is why ADD children are so ‘chatty’ and why much of their conversation deals with the present, and not the future.

4. Reconstitution

The ability to hold a thought allows you to take it apart and reassemble it in new ways, leading to the observation of new relationships which were not apparent before. We can take nature apart and put it back together as we please. This has several consequences.

We can progressively redistribute parts of a thought for use in parallel processing.
We can reassemble the parts into new messages and events (creativity)
This is the seed of verbal fluency
This leads to a unique world view

It is harder for ADD children to explain things. They don’t get to the point: they talk around the point.

Note that ADD children and adults are not lacking the four aspects of the ability to wait—they are in there, but we often can’t see their consequences. Put a child on the proper medication and all four aspects of the ability to wait return—it was there all along. People with ADD do not lack the ability to wait, they have difficulty drawing upon it.

What are the purposes of the aspects of the ability to wait?

They are related to self-control. Average children are self- regulated, yet they are more free than the ADD child, who being more dependent on his environment, actually operates on the basis of less free will.
They are required for the organization of behavior across the span of time.
They direct behavior toward the future rather than the present.
They are aimed at the maximization of future consequences.
They allow increased prediction and control of the environment (rather than just reaction to the environment)
They permit us to conform the environment to our goals.

ADD is a disorder of response inhibition and executive function, of the ability to wait. This predicts that those with ADD will be:

deficient in self-regulation,
impaired in organizing their behavior toward the future, and
diminished in social effectiveness and adaptation.

Evaluation of suggested causes

There are some psychosocial theories (not widely accepted).
Underactivity in the forebrain (the classic Zametkin studies), i.e., reduced circulation in the prefrontal lobe and striatum, but this may be a consequence rather than a cause of the ADD. The areas affected are thought to be involved in response, attention and sensitivity to reward.
Food/diet. That sugar is somehow involved is part of the folklore.

Co-morbidities: Defiance, oppositional behavior, argumentative. 20-30% have learning disabilities, 30% have delayed motor skill development.

Heredity is the best explanation of the facts. 25% of fathers and 17-25% of mothers have the condition. There is a 40% chance that one of the parents has ADD. A 35% chance that one other child in the family has it. A 95% chance that a twin will have it. Can have multiple causes: anything affecting frontal lobe development, including smoking and drinking during pregnancy, but most overwhelming majority of cases due to inheritance.

The neurochemical balances which lead to the syndrome of symptoms we call ADD should not be seen only as a pathology, but a genetic characteristic like height, weight, and intelligence, which can have outliers. Variations in height and weight are accepted are seen as natural until we see someone who is extremely tall, short, large or thin. People with ADD are ‘neurochemical outliers’ who are more easily noticed in western industrialized societies.

With adolescents and young adults the absolute level of symptoms declines relative to childhood, but 70-80% are fully ADD. The brain is not fully formed until the late 20’s or early 30’s. Barkley suggests that while people with ADD continues to improve with age, their level of self- regulatory behaviors is 30% below that of their non-ADD peers. As a guideline he suggests that one subtract 30% from someone’s chronological age to get an estimate of their self-regulatory behavioral maturity. As a result, Barkley recommends breaking down assignments into manageable chunks.

ADD teens have four times the auto accidents when they start driving. He says that using the guideline above, 16 year olds have the self- regulatory behavioral maturity of 12 year olds, which suggests one delay their driver training. [ I don’t know whether this applies to successfully medicated 16 year olds as well ]. The above information is not meant to stigmatize these children, but to better help them. 35% never finish high school.

Adults with ADD suffer from poor school/work performance related to

deficient sustained attention, reading, paperwork, etc.
easily bored by tedious material
poor organization, planning, anticipation
procrastination until deadlines imminent
trouble working in confined spaces
grabbing opportunity
impulsive decision making style
cannot work well independently
don’t listen to directions
frequent impulsive job changes
often demoralized
putting aside things for now

On the positive side:

sometimes people worry over nothing
people sometimes conjecture a future which never happens

Sometimes the gut response is the best response. People with ADD are often passionate in a world lacking in passion. They experience a wider bandwidth of the spectrum of emotions—including anger and love. Many people appreciate the arts because they bring back emotion that’s been lost. Perhaps talking to yourself all the time isn’t good. You can incubate fear and negative emotion from too much self-talk. Some people are very successful because they take risks.

On diet fads:

Megavitamins/orthomolecular stuff (kid’s lives are not ready for this)
Sensory integration therapy (not developed for ADD)
Chiropractic (utter nonsense)

Take home lesson: don’t extend anything beyond what it was meant for.

On other therapies:

Ocular/auditory exercises (ridiculous)
EMG biofeedback/relaxation (muscular biofeedback) and neurofeedback
(costs $3-6 k/yr results are not lasting)
Cognitive therapy (not always best as ADD is not a skill or knowledge deficit)

ADD is a problem of doing what you know to do. Time is not given for common sense one has to emerge. What we want for people with ADD is for them to perform what they already know. The hope is that they will be able to do it with less prompting/reward necessary. The self-control is in there, but it’s difficult to call upon it. a person has to be ready for treatment. 1988-90: Church of Scientology launches its campaign against Ritalin, which Barkley calls ‘safer than aspirin.’

Teach compensating skills—long term therapy is not usually necessary.

How to be an effective ADD parent or ADD adult:

Become an executive. Do not abdicate responsibility. Professionals can help but you have to make the final call. Stay informed so you can call the shots.
Be scientific. Read widely to discover the truth in a world of fad therapies. Truth has several characteristics. Truth emerges from available information. Truth converges from many sources. Experiment. Maybe this and that will work. Don’t get stuck. Don’t think that this medicine has to work this or that way.
Be principled—centered. When you act, follow the rules—don’t be reactive. The ‘7 Habits of Highly Effective People’ work well with ADD:
1. Be proactive—take charge and stop whining. Cut the crap. Go ahead and grieve, but get through it and accept things as they are. Grief should lead to acceptance. You can then go about changing things proactively.
2. Begin with the end in mind. Think about your funeral—what would you like them to say? This is an excellent idea for any situation. How do you want this to turn out? Keep that in mind and it will help you persevere. If you see the end you will know what to do.
3. Put first things first. You cant do it all at once. Prioritize. Is having your kid make his bed all that important? Making a bed is not a great predictor of success—tidiness is not all that important; spending quality time with your family is.
4. Think win/win. What will they get out of this? Make sure the person you interact with feels they have won something.
5. First understand, then be understood. What is on their mind? Listen, then take your perspective into account.
6. Synergize. More gets done when working together—how can you both get things done together?
7. Find renewal. Look for sources of satisfaction, note them, and return to them on occasion. Your kids don’t need or want you to be a martyr. ADD people don’t like being around martyrs. So take care of yourself and get refreshed.