Overcoming ADHD

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.

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.

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.

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.

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.