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.

1. We can pro­gres­sive­ly redis­trib­ute parts of a thought for use in par­al­lel processing.
2. We can reassem­ble the parts into new mes­sages and events (cre­ativ­i­ty)
3. This is the seed of ver­bal fluency
4. 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?

1. 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.
2. They are required for the orga­ni­za­tion of behav­ior across the span of time.
3. They direct behav­ior toward the future rather than the present.
4. They are aimed at the max­i­miza­tion of future consequences.
5. They allow increased pre­dic­tion and con­trol of the envi­ron­ment (rather than just reac­tion to the environment)
6. 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:

1. defi­cient in self-regulation,
2. impaired in orga­niz­ing their behav­ior toward the future, and
3. 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.

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Above notes were com­piled and edit­ed by Dan Diaz ([email protected])
Mod­i­fied Jan­u­ary 9, 2003