A New Way of Looking at ADHD and ADD
Millions of children, as well as a large number of adults, are diagnosed with attention deficit and hyperactivity disorders. Although estimates vary from 1 percent to 20 percent, most researchers believe that approximately 8 percent or more of children have this disorder. Today, the vast majority of these children and adults are put on medication as the main feature of their treatment. Some children may also receive special accommodation at school, such as sitting in the front row, and they may participate in many types of behavior management programs to limit impulsive or inappropriate behavior. Unfortunately, such programs rarely address the underlying reasons for a child's difficulties with paying attention, focus, and self-control.
Can children and adults with attention deficit disorder (ADD) and attention deficit/hyperactivity disorder (ADHD) overcome these difficulties without pills? The answer is absolutely yes for the vast majority. The key lies in identifying and treating the problems that underlie each child's or adult's inattentiveness. Many parts of the mind and brain contribute to attention. Each individual has his or her own unique profile. Over the past thirty-five years of clinical practice, I have worked with all age groups affected by ADHD and related disorders—from infants, toddlers, and preschoolers to grade schoolers, adolescents, and adults—as well as conducted many research studies. This experience has made it possible to create a program that systematically strengthens the different abilities that contribute to paying attention and enable each of us to regulate ourselves, to focus on problems to be solved, and to follow through.
From this work, my colleagues and I have developed a new way to think about ADHD. It is not a single disorder like strep throat. Contrary to many current beliefs, it does not involve just one part of the brain or mind. Rather, there are many different roads that lead to the symptoms that we call attention deficit disorders and hyperactivity. For example, because some children are overly reactive to sights, sounds, and other sensations, they become highly distractible. Other children are just the opposite. They crave new sights and sounds as well as touch and, therefore, are constantly on the move, going from one thing to another. Still others are so underreactive to sights, sounds, and sensations in general that they withdraw into their imaginations and, for this reason, appear inattentive. Still other children get "lost in the trees" and have difficulty with visualizing the big picture. Planning and sequencing motor actions are yet another problem area for many children with attentional difficulties.
The ways in which these and other patterns characterize a particular child are at the heart of this new way of thinking about ADHD and ADD. They are also at the heart of the intervention program we have created that tailors the approach to each child and family. Intervention is based on understanding not only the nature of the child's problem with attending and the challenges that develop in daily life and school as a consequence, from infancy through childhood and adolescence, but, more important, how the healthy abilities that make focus and attention possible can be encouraged and strengthened. The motor and cognitive exercises and activities we have developed can strengthen the mind, and there is mounting evidence that when we strengthen the mind we also strengthen the physical structure and functioning of the brain as well. Unfortunately, at present the roots of attention disorders are rarely fully addressed. Treatments focus only on reducing the outward signs of the disorder.
The Nature of Attention
There are two ways to think about attention. One is that it's a feature of the human nervous system, and either you can pay attention or you can't, and if you can't, you need one of the stimulant medications such as Ritalin or Adderall or Concerta. The other way to think about attention is that it's a learned process with many components. When a baby in the first months of life turns toward Mommy's voice or looks at Daddy's face and gives a big smile, that's the beginning of attention. When a toddler takes Mommy by the hand to the toy shelf and points up to the bear she wants, that's an active, practical, problem-solving use of attention. When a child is sitting in the classroom listening to the teacher and following her instructions and then raises his hand to ask for an explanation, that's again a very active, dynamic, problem-solving use of attention.
Variations in attention can be expected in early development. As early as two to four months of age, when babies become more capable of turning and focusing to look at Mother's smiling face and listen and coo responsively to Father's happy voice, they can differ in their ability to sustain attention. At eight to twelve months, some may attend only fleetingly rather than in a sustained manner in back-and-forth games such as peek-a-boo or pat-a-cake or when enjoying a shape-sorter game with a parent. A two year old might just move from toy to toy and appear highly distracted even when playing with a favorite doll or truck. Later, a young child may always be on the move, always changing "topics," unable to stick with a conversation or a game. Another pattern of inattention involves spurts of attention and then inattention or intermittent stop-and-go interactions. Some children may focus on favorite toys or one-way forms of entertainment (TV, video games, and so on) but find it hard to shift their attention to people, even when their mother or father is calling them.
Sometimes variations in attention can be related to differing motivation, as when young children may be attentive to books, construction sets, or individual projects but less so when they are expected to attend and participate more actively in activities others choose or when there are ground rules, as in "circle time" at school. Often, the tolerance or expectations of those around them affect whether attention is seen as a problem. For example, a child playing alone for long periods might be considered "independent" and "well behaved" rather than self-absorbed. Adults may think it necessary to change activities every few minutes at preschool or at home because they assume that the attention span is very short in young children.
The way that I and many of my colleagues who work with children prefer to think about attention is that it's a dynamic, active process involving many parts of the nervous system at the same time. Attention involves taking in sights and sounds and touch; it involves processing information; it involves planning and executing actions. If you can take in information, process and comprehend it, and plan and execute actions based on this information, you can pretty well pay attention. It's not just about sitting still; there are many gifted people who are very active—they're moving around or fidgeting all the time—yet are very successful professors or engineers or doctors or lawyers or chefs and wonderful parents. What determines whether they're what I would call "functionally attentive" (i.e., taking in and mastering their environment) is how well they get all the different abilities just mentioned working smoothly together. When they are, a person is attentive.
If we think about attention that way, it helps explain the variety of problems that I see in my practice. Of the children who come to see me having been diagnosed with ADD or ADHD, a great majority have what we call "motor planning and sequencing" problems. Almost all of them have difficulties with carrying out a many-step action plan in response to either a verbal request or visual information or an implicit demand of the environment, like solving an obstacle course. Other children—not all of them, but some of them—are overreactive to things like touch or sound, so they get overwhelmed and very easily distracted, for example, by another child sitting next to them at school who's making noise. Their overresponsiveness leads them to be less attentive.
Children who are underresponsive or underreactive to sensation—for whom a normal speaking voice won't register or who won't feel you touching them unless you use firm pressure—are also going to appear inattentive. For example, a little boy came to my office the other day, and I talked to him for a good five minutes in a normal tone of voice before he finally looked up from his electronic game and noticed me. I let it go on for a while because I wanted to see how much he could tune out and how underreactive he was. I learned during the session with him that, when I increased the energy in my voice, I could get his attention within a second every time, but if I talked to him in a normal tone of voice, he basically tuned me out. When we went through his history very carefully, it turned out that he was underreactive in a number of his senses.
Sensory-seeking children may or may not be underreactive but are constantly looking for more touch, more sight, more sound, more movement, and so they're going to be very active, distractible, and inattentive—they are the typical children who get diagnosed with ADHD.
Other children diagnosed with ADHD may have a problem with processing and sequencing information. If you say, "I need you to go upstairs, put on your shoes, come back down, and get ready to go outside because we're going out to lunch," he may be able to process only the first part of that sequence—"I need you to go upstairs"—and then he forgets what he's supposed to do. His problem with sequencing information makes it difficult for him to hold on to complex verbal instructions. He's going to seem very inattentive because on the way to his room he gets so distracted by a toy that he forgets why he went up in the first place.
The ability to plan and sequence actions and solve problems is commonly referred to as "executive functioning." It's related to motor planning and sequencing and also to sequencing and problem solving with ideas. A good way to think about executive functioning is that it's the child's ability to take in information through the senses, process that information, and then use that information in a sequence of actions to solve a problem. We notice the last part of executive functioning—the planning and sequencing actions or words—but it depends on the first two steps, as well.
Other problems, such as in visual-spatial processing, can play a part in attention. A child who can't see the big picture goes upstairs to find her shoes but doesn't know how to look systematically because she doesn't have a picture of her room. So she goes and looks near the bed, doesn't see them, and then gets distracted because she doesn't have a mental picture of other places the shoes might be.
From these examples we see that a diagnosis of ADD or ADHD may not be simple at all. The inattention is the outward symptom, but the problem is rooted in these deeper elements, like motor planning and sequencing, overreaction, and visual-spatial difficulties.
There are different theories about the causes of ADHD/ ADD. Some who study the condition have recently claimed that it is simply a normal difference among individuals and may have conferred an evolutionary advantage on individuals who needed to be very active and reactive in their environments. Obviously, being in a classroom where you need to sit at a desk, focus on the teacher, take in everything she is saying, and think about it can be a difficult task if you are a person who notices everything and wants to get up every few minutes and walk around and discover things. Since many more boys are diagnosed with ADHD than girls, this difference has been attributed to our long evolutionary history, that is, men were expected to go out and hunt in a dangerous environment to provide the daily food for the family. In today's industrialized society, there is less and less emphasis on outdoor activities and higher expectations for sitting and focusing and paying attention in a classroom or office. Even recreation or playtime seems to be more passive now—sitting in front of a computer screen and playing video games, for example. Clearly, cultural expectations and opportunities need to be taken into account in the definition of ADHD. As we will discuss more fully later, one of the goals of this book is to help children deal flexibly and appropriately with the demands of different environments, such as being very active and alert to all signals but organized, during sports, dance, or wilderness camping, and more narrowly focused and still when listening to a teacher give a lecture or instructions.
There are also strong views among many that the causes of ADHD involve specific biological pathways. Neuroscience research currently suggests that the frontal lobes of the brain are involved in ADHD—particularly the prefrontal cortex—and that fundamental difficulties in many of the executive functions (for example, sequencing and planning) are, in a sense, "housed" in the prefrontal cortex and the frontal lobes. Other researchers suggest the cerebellum is involved as well. Such research is ongoing. Whatever direction it takes, children with this diagnosis will benefit from a careful analysis of their particular profiles and attention to the strengths and weaknesses that underlie their hyperactivity or inattention. In the chapters that follow, we've outlined the ways to put together such a program.
A Comprehensive Approach
The program that we are going to describe for ADHD and ADD and all other kinds of attention problems, including ones that may not even fit the full criteria for ADHD or ADD, will focus on strengthening each of the separate abilities that support attention, focus, and concentration. This approach doesn't require medication. There is a subgroup of children and adults who benefit from medication, but there is much that can be done before medication is considered. I always do a six- to twelve-month trial of a comprehensive approach in my practice before considering a referral to a psychopharmacology expert for a medication consultation, and I would suggest that this trial is the most important first step. It doesn't rule out the use of medication, but by implementing a comprehensive approach to ADHD and ADD, it becomes clear that there are a lot of children who don't require a "pill" at all. If medication is indicated at some point as part of our comprehensive approach, it's likely to be a lesser dose and of a lesser duration. If we are able to strengthen some of the abilities related to attention but the child still has some difficulties, then medication at a lesser dose and for a shorter period of time may prove helpful until these other abilities become strong enough for the child to maintain full focus and attention.
One of my concerns regarding the use of medication, in addition to the well-known potential side effects, such as agitation, sleep problems, or weight gain, is that many children experience a constriction in their emotional range, in their perceptions. Their creativity or sense of humor may not be as great. Although they can focus more, the medication narrows their horizons. This isn't to say that some children won't still require medication—some will. However, as a general rule I recommend working on strengthening the underlying core issues for at least six to twelve months and seeing how much progress we make before considering medication. If we are beginning to make progress in the first six months in these core issues and we see a better ability to attend and focus, then we have a child whose development is proceeding in a healthier fashion.
Seven Key Goals
In the following chapters, we will discuss each of the elements of a comprehensive intervention approach to ADD and ADHD in greater detail. Below is a brief overview.
1. Strengthening Motor Functioning. Here we work on the child's fundamental ability to use his nervous system and control his body in a healthy, age-appropriate way. This would include balancing, coordination, movement, integrating left and right body parts, hand-eye coordination, fine and gross motor skills, and the like.
2. Helping the Child Plan and Sequence Actions and Thoughts. As I mentioned earlier, almost all children with attention problems have difficulties in sequencing. It's hard for these children to play a treasure-hunt game with a series of clues or to negotiate an obstacle course that involves sequencing many motor actions in a row. Later, they may not be able to follow complex directions in writing an essay. What we call motor planning and sequencing, and sequencing in general, involves verbal sequencing, too, as well as responding to visual cues and visual sequencing.
3. Modulating a Child's Response to Sensations. Many children with ADHD or ADD have challenges in the way they process sensations. Some are sensory craving, while others are sensory overreactive—at least in one or another modality—and are constantly distracted by the stimuli in their environment. Some children may be overreactive to the movement of their own bodies so that moving in space on a swing may overstimulate them, or they may require a lot of jumping, spinning, swinging, and dancing. So this goal involves working with children's unique profiles, helping them find adaptive ways to respond to sensation and stay calm and focused.
4. Reflective Thinking. The fourth goal involves helping children progress up the developmental ladder in terms of their ability to think. We help a child progress from thinking with actions all the way to reflective thinking. A reflective thinker can say, "Gee, this task is hard for me. I had better give myself some reminders." Reflective thinking allows people to know their own strengths and weaknesses and to plan ahead accordingly. This ability enables concentration, focus, and attention in all tasks of home and school.
5. Building Self-Confidence. For many who have felt helpless to control their attention and activity level, anxiety can cause them to be even more distractible and forgetful. When anxious about an assignment or homework, it's easy to play ostrich. As one child told me, "I just put it out of my mind and don't think about it; I just think about the tree outside. I think about what I'm doing now. I don't think about tomorrow. I don't think about the test." Problems in following instructions and paying attention can make a child feel guilty and incompetent, and any comprehensive approach must help a child feel effective and in control.
6. Improving Family Dynamics.
Family dynamics play a large role, certainly in emotional coping, but also in the way we master each of these other abilities. Take, for example, reflective thinking: When a child is three or four years old and says, "Mommy, I want to go out," and Mommy says yes or no, it doesn't encourage thinking. But if Mommy or Daddy says, "Why do you want to go out?" all of a sudden the child has to give a logical answer. She might say, "Because I want to play." "Well, why do you want to play outside rather than inside?" "Because the slide is outside." Some families do this naturally, and some don't. So the family component will be important here.