David M. Callahan, Ph.D.
Providing Psychological Services to
Cape Cod and Southeastern Massachusetts
Understanding ADHD
Many people believe that the diagnosis of Attention Deficit Hyperactivity Disorder has become a way to excuse misbehavior on the part of children. While there are certainly cases in which children have been identified incorrectly as having attentional disorders whose primary difficulty is behavioral, my experience suggests that it is far more frequent that there are children whose attentional difficulties are mislabeled solely as behavioral difficulties. Obviously, these two factors interact, but it is important for parents, educators and clinicians to understand that Attention Deficit Hyperactivity Disorder is not the result of willfulness behavior on the part of children. Instead, specific neurological difficulties contribute to diminished capacities for self-control and focusing that greatly increase the probability of problematic behaviors.
The vast majority of correctly identified cases of Attention Deficit Hyperactivity Disorder share a very specific common characteristic: underactivity in the prefrontal region of the brain which controls focus and attention, planning, organization, self-control and a host of other capacities required for the management of one’s behaviors, often referred to as “executive functioning.” This underfunctioning in that portion of the brain is clearly demonstrable on brain scans showing levels of activity in specific brain regions. Individuals with Attention Deficit Hyperactivity Disorder show less active prefrontal regions relative to the typical person when at rest. However, when asked to focus, the prefrontal regions of individuals with ADHD often show reduced activity, whereas other individuals show increased activity in those regions. In essence, the harder the person with ADHD attempts to focus, the less effectively that he can, as attempts to concentrate actually result in diminished effectiveness.
Underactive prefrontal regions of the brain are not incapable of attention. Instead, they are much more effective at what I would describe as “diffuse attention.” In essence, the level of activity in the prefrontal region is an index of the extent of which ones attentional “spotlight” is able to focus on a small area. Individuals with highly active prefrontal regions can function very specifically on small elements of the environment, whereas people with lower prefrontal regions tend to focus on the environment as a whole. One analogy that I believe is useful to consider is that this is likely a carryover from being a “hunter’s brain.” Picture a hunter wandering the woods searching for game, essentially “in tune with nature.” In such a circumstance, the ability to focus on a broad range of inputs simultaneously is very adaptive. Unfortunately, a brain working in that modality is far less effective in managing more circumscribed tasks, such as attempting to focus on a math teacher.
The reason why stimulant medication is often extremely effective in ADHD is that it essentially “wakes up the sleepy brain.” Whereas in a typical resting or even concentrating state, a person with ADHD will have tremendous difficulty focusing specifically due to underactivity in prefrontal regions, stimulants essentially increase that activity. In doing so, there is a shift from a broad spotlight to a more focused spotlight that is able to place attention and focus on a single activity much more effectively.
Behavioral difficulties associated with ADHD are often the result of children having difficulty focusing sufficiently on tasks that they perceive as understimulating or boring. Thus, they engage in hyperactive behaviors to increase their arousal level. At times, individuals will actually engage in problematic behaviors due to needing to increase their stimulation level. While an individual with ADHD may appear hyperactive and overaroused, the activity level is probably better seen as an attempt to increase one’s arousal level to a normal state. It is easier to entertain oneself through mischief than through “sitting still, listening and using your words,” instructions often directed toward children with ADHD that prove to be very challenging for them to implement.
Medication should certainly not be perceived as a cure-all for attentional difficulties, as they do not in any way rewire the brain or “cure” these difficulties. Instead, medication is often a very effective way to help manage those issues. There are, of course, problems with medication at times. The major side effects to stimulants seem to be appetite disturbance and sleep difficulty, each of which can be managed to some extent by adjusting the timing and content of one’s breakfast and the timing of medication such that it is no longer active later in the day. Different children respond very differently to medications; it often takes time and some experimentation to find the appropriate medication and timing for such intervention. The long-term side effects of stimulants generally are considered to be fairly minimal. Alternative interventions have been attempted including modification of diet, use of relaxation techniques and biofeedback, Yoga and other brain-based interventions, such as brain integration therapy. I would not encourage the use of such interventions as an alternative to medication. My experiences suggest that pharmacology is often dramatically effective and far more likely to be a benefit than those other interventions. I often encourage parents to consider those interventions as a first attempt, but with the understanding that medication remains a viable option should those prove ineffective.
Attentional difficulties do tend to run in families, with often a fairly consistent finding of family history of such difficulties in relatives. While far more common in males, ADHD is also evident in girls with a fair amount of frequency as well. Females are much less likely to be identified as having difficulties, as they are far more likely to be inattentive and “spacy,” whereas boys are more likely to be distractible and overly hyperactive, and thus far more likely to engage in behavioral difficulties that draw attention to themselves. Each of those presentations likely shares the same underlying neurology in the prefrontal cortex, but disposition related to levels of estrogen and testosterone contribute quite a bit to the different behavioral presentation.
I have often heard teachers or parents describe the use of medication as “a crutch” for children who have significant attentional difficulties. While I always encourage my patients to learn better strategies for self-motivation, problem solving and study skills, I believe that it is often unfair to withhold interventions that could be quite beneficial to a given child. Remembering that this is indeed a specific neurological condition that has been demonstrated across a broad range of physiological studies, one must address the question of whether withholding effective treatment is akin to withholding insulin from a diabetic. While ADHD is not life threatening, the behavioral and learning difficulties associated with untreated ADHD contribute to tremendous emotional and behavioral difficulties in children in adolescence. Notably, most of the research suggests that persons with ADHD who go untreated without medication are far more likely to develop drug problems than those who are treated with medication, likely due to a tendency to self-medicate as one moves into adolescence. Again, this certainly is not a cure-all, and medication interventions for individuals with ADHD should best be accompanied with either psychotherapy or skill building that will increase their effectiveness in approaching their daily lives, but time has shown that ADHD does often respond very well to pharmacology.
There are a percentage of youngsters for which stimulant medication proves difficult to tolerate. Alternative medications such as Strattera are often used in that situation, with at times very strong benefits, but with less reliable outcomes. Children are sometimes treated with beta blockers such as guanfacine (aka Tenex and Intuniv), again with some benefits, but less reliably so than for stimulants. Pediatricians are often comfortable with simpler cases of attentional difficulties. In situations where there are possible coexisting conditions such as mood disorders or anxiety disorders, consultation with a pediatric neurologist or psychiatrist is often necessary.
