- Hello.
My name is Dr. Sharon Saline.
Today, we're gonna talk about understanding ADHD or ADD,
and executive functioning in children and adolescents.
Welcome!
I'm a clinical psychologist.
I have a private practice in North Hampton, Massachusetts,
and I also consult at schools and clinics
about ADD, ADHD, executive funtioning
and other kinds of learning challenges.
I work with children, adolescents, families,
young adults, some individual adults,
and of course, parents.
Let's start by thinking a little bit about
who do we know, who's in the world at large,
who might have ADHD and what do those people look like?
Have they accomplished anything in their lives?
Are they somebody who just struggles
to get through everyday?
My answer to that would be, "yes and yes."
So let's start by thinking about some people
who you may have heard of who have ADHD.
Terry Bradshaw, Prince Charles, Tom Cruise,
Kirk Douglas, Whoopie Goldberg, Dustin Hoffman,
Bruce Jenner, Magic Johnson, Michael Jordan.
Pablo Picasso is rumored to have had ADD,
as well as Eleanor Roosevelt,
Will Smith, Steven Spielberg, Robin Williams,
Henry Winkler, and Stevie Wonder.
What are some of the prominent myths
in society today about ADHD or ADD?
I guess the first thing I wanna say is
that I'm gonna be using ADHD and ADD interchangeably,
even though they refer to different parts
of the attention deficit diagnosis.
ADHD refers to Attention Deficit with Hyperactivity.
ADD refers to Attention Deficit without Hyperactivity.
Some people can have one.
Some people have the other
and some people have a combined type.
ADHD means being hyperactive.
It is a failure to listen and comply.
People with ADHD have brains that are overactive
and need to calm down.
The myths about ADHD include
that ADHD is a lack of willpower.
People with ADHD can focus well on things
that interest them, so obviously they could focus
on other tasks if they really wanted to.
Medication for ADHD is over-prescribed, risky
and not well-researched.
That, of course, is another myth about ADHD.
We'll look at both of these myths today
and you can decide whether you think
they're real or not.
ADHD is a neurobiological condition
that takes hold during the early years of brain development.
Genetic factors account for 80% of ADHD traits.
ADHD is not simply a deficit of attention
or an excess of motoric hyperactivity.
ADHD is a chronic impairment in activating
and regulating executive functions
appropriately in an effective manner.
It refers to significant deficiencies
in behavioral inhibition, sustained attention,
resistance to distraction
and the regulation of activity levels.
ADHD is a syndrome, a cluster of impairments
in the management system of the brain.
We'll talk a little bit more about that later.
It is not an all or nothing status like pregnancy,
but more like depression.
You can have some impairment
or you can have a lot of impairment.
Estimates are that 6.8 of children
in the United States have ADHD.
Studies around the world show comparable figures.
Fifteen percent of adults with ADHD
are estimated to have a diagnosis and treatment.
The general prevalence is thought to be
about 5 to 10 percent of the population.
ADHD is an inherited medical condition
which seems to be caused by an under-arousal
in the areas of the brain that control mood,
behavior and attention.
The under-arousal is related to a problem in brain cells
that use dopamine and/or norepinephrine to communicate.
Now, this is a little perplexing
because sometimes people think, "How can ADHD
"be a syndrome of under-arousal
"when there's so much motoric activity
"or an inability to keep your attention from wandering?"
We'll talk about that as well.
ADHD is a disorder of now.
A person with ADHD cannot use
what he or she knows and it reflects difficulties
with actual performance, not intelligence.
Edward Hallowell, who is one
of the leading experts on ADHD in the world,
says that people with ADD have special gifts
like creativity, originality, charm,
energy and an unusual sense of humor.
He sees it as a collection of symptoms
of an intriguing mind.
ADHD is a way of being in the world.
But when it impairs people's lives
it becomes a disorder.
The more you emphasize the negative aspects of ADD,
then the more pathology you will see in your clients,
shame, fear, and less vision of possibilities.
In Hallowell's book, "The Seven Habits
"Of Highly Effective Adults," he talks about
how ADHD is like having a brain that's a race car.
He calls it a race car brain.
Your brain goes faster than the average brain
and the trouble is putting brakes on the brain.
You get one idea and you have to act on it.
And then what do you know?
While you're doing that idea you get another idea.
I had a client who had this problem exactly.
He would come home,
actually he came home one day and his wife
and he had planned to do some home renovations.
It was a Saturday afternoon.
He went to exercise and came home
and then they were gonna do some home renovations.
One of the renovations was measuring and replacing
some blinds on a window.
He measured the space for the blinds
and he went to the hardware store.
While he was in the hardware store looking at the blinds
he saw some other things that he liked.
A new screwdriver, perhaps or I forget
maybe it was a hammer.
He started to look at the tools
and then while he was at that tools
he realized that he really wanted to fix the tree house
that the kids had that there was a loose board.
Then he went and he had to get some wood for the board.
Three or four hours later he came home without the blinds,
because he had gotten so distracted from one idea
going to another idea to another idea,
all of which were interesting
and all of which were useful, that he had forgotten
the original purpose of the trip.
What are executive functions?
Executive functions are the management systems of the brain.
They connect, prioritize and integrate
cognitive functions moment by moment.
They integrate memory with what's happening right now.
They are the thinking and doing skills of the brain.
Let's take a minute and pause.
What did you do this morning when you woke up?
Before you, perhaps, left for your day of work,
or sat down here at the computer to watch this class.
How did you wake up?
Did your alarm go off?
Did someone else wake you up?
Did your cat come and meow into your ear?
What did you do when you got out of bed?
How did you decide which things
you had to do first, second, third?
Were you rushing?
Were you calm?
Were you able to figure out what to do first
then next, or were you kind of jumbled and overwhelmed?
Executive function is a term that describes
the directive capacities of the brain
that organize activities like getting yourself up
and out of the house for a day of work or school.
These are the functions of what's called
the pre-frontal cortex.
If you take your hand and you put it
on your forehead like this, it's behind your hand.
It's the right, front part of your brain.
I call it the Oy Vey part of the brain
because when these don't work well, oy vey!
You have some problems.
Executive functions resemble a supervisory system,
composed of multiple parts that then come together
to co-conduct a larger orchestra of conscious perceptions,
thoughts, feelings and actions.
George McCloskey, who has written a lot
about executive functioning, says that, "Executive functions
"are the directive capacities that are responsible
"for a person's ability to engage
"in purposeful, organized, strategic,
"self-regulated, goal-directed processing
"of perceptions, emotions, thoughts and actions."
These executive functions cue
other mental structures in the brain,
such as reasoning, language,
visual-spatial perception and representation.
They are directive processes that give out the commands
but they don't carry them out.
ADHD and executive functioning are inherently linked.
That's what we're gonna talk about a little bit today.
A person can have ADHD and will necessarily
have impairment in his or her executive functions.
Some people can have impairment in their executive functions
and not have ADHD.
I do not have ADHD but I am not great at time management.
I always think things take less time
than they actually do.
So, I've had to actually use backward design
to get myself places on time,
which is what I teach many of my clients to do.
If you have to be somewhere at 12:30,
how long is it gonna take you to drive there?
Okay, 15 minutes.
And then how long is it gonna take you to get dressed
before you go and to give yourself enough time to do that.
And that's something that helps me.
But, that's easy because I'm targeting
one specific problem in my executive functioning.
When you have ADHD, there are several aspects
of your executive function that are impaired simultaneously.
It weakens your effective capacity for learning,
productivity, social understanding and acceptance.
So, ADHD is a mix of a whole lot of things.
What do you think it's like to have ADHD?
Doctor Hallowell has said, "How do you talk to a child
"about having ADHD?"
He's written, "Well, your brain is super-charged.
"It mean, it could go really, really fast.
"The only problem is that sometimes
"it can't put on the brakes,
"and sometimes it needs a special motor oil
"so it won't overheat and break down.
"But with the right motor oil and the right brakes
"it wins lots of races.
"You know how sometimes how you have trouble
"payingg in class," he goes on to say.
"That's because your mind is zipping around
"all over the place.
"You have new ideas all the time and that's great.
"That's why you're gonna have fun all your life
"and do amazing things.
"But, to become a man, you have
"to take care of your race car and that's your brain
"that I'm gonna help you take care of."
What are some of the positive aspects
of having ADHD?
Creativity, passion, intuitive way
of thinking and being in the world,
funny, perfectionistic, fast thinking,
hyper-focus, inattentive, sometimes really sensitive,
push limitations, unusual out of the box thinking.
Often people with ADHD have very original
and unpredictable ways of looking at life
and situations that I find quite endearing
as well as sometimes really amusing.
I have one little girl I worked with,
and she called her ADHD her "bullet brain."
Her bullet brain would take her all around the room.
In my office she'd be upside down on my couch sometimes
or lying on the floor.
That was how her bullet brain worked for her.
Often people with ADHD have unconventional
senses of humor and sometimes don't see
how their humor might affect someone not so kindly.
They can be warm and generous.
They are often fun to be with,
can be good in a crisis, have lots of ideas,
can be a little quirky or eccentric,
and really like to do what they like to do.
Sometimes they look at their ADHD with humor
as well as an endearing quality,
particularly as they learn to accept it.
I've one client who calls his ADHD "ADLS."
Oh, look!
There's a squirrel.
I asked him, what does that mean, exactly?
And he said, "Well, you know, I'm walking a long
"and no matter what I'm doing, if I'm in a conversation,
"or I'm eating or I'm listening to music,
"if I see a squirrel, that's where my attention goes,"
which I found really interesting.
He also calls it sometimes "ADLS, oh, look,
there's a shiny object," because, same thing,
he sees a shiny object and it will distract him.
What are some of the challenging aspects
of having ADHD?
One of the most challenging aspects of having ADHD
is difficulty with transforming great ideas
and desires into action.
There is a chronic underachievement,
a history of being labeled lazy or spacey
or having a bad attitude.
There are significant problems managing money
and financial decisions
and difficulty with time management.
There's an inconsistent performance despite effort.
Often angry or negative moods due to frustration.
Sometimes difficulties can be seen in free play settings
but much clearer in situations
needing sustained attention to what the person perceives
are dull, boring and repetitive tasks.
There's a really poor delay of gratification
so if you have to do something because later on,
in a month, or a year you'll get something from it,
i.e. an A or a high school diploma,
it's very hard to see how the mundane aspects
of what a person is doing now, who has ADHD,
pay off in the end.
It's very hard to distinguish between foreground
and background in terms of sound.
I had a client who basically told me
that in social situations she actually couldn't hear
what people were saying.
And I said, "You mean you can't really hear,
like, you auditorially cannot hear?"
And she said, "No, I can hear them,
"but I can't process.
"It goes so fast and I can't get what they're saying."
She would have to ask her friends to repeat things
and they would get tired of that and irritated with her
and tease her or put her down.
This was very hurtful to her.
But she had no choice because she couldn't
process what was going on,
the speed and the volume.
People with ADHD have real struggle
to get from point A to point B.
They're kind of stuck on surfing a channel
with no remote so they can't actually stop the TV from going
to this next place and this next place.
It just keeps going.
The attention wanders.
I'd like to read you something
from Thomas Brown's book about Attention Deficit Disorder.
It's on your reference list.
This is a good example of a child, named Joey,
and his struggles with ADHD, particularly in the morning,
written by his mother.
"My eight-year old, Joey, is not a bad kid.
"Often, he is charming and funny,
"but he really is a handful for everyday stuff.
"Every night, bedtime is a nightmare
"for at least an hour or two.
"Joey never feels tired and is always arguing to stay up."
"Even when he is really tired,
"it's tough to get him to quit whatever he is doing
"to get him in his PJ's and into bed.
"He gets loud and stirs up the little ones.
"In the morning, he gets up okay,
"but he is incredibly slow about getting himself dressed
"and ready for school.
"I set out his clothes and ask him to get dressed
"while I'm dressing myself
"and the two younger kids so we can all get out too.
"But, if I don't stay on Joey constantly,
"talking him through every step of the morning routine,
"he'll never make his bus.
"His five-year old brother is more independent.
"Joey always gets involved in playing
"with his Transformer toys and forgets
"what he is supposed to be doing.
"He'll be sitting on the floor in just his underpants
"with one sock on when he needs to be walking out the door
"to catch his bus.
"Then when he finally hears me telling him
"it's too late, he gets upset,
"crying and blaming everyone because he's
"going to miss the bus.
"It's the same routine every day.
"We've tried star charts and all kinds
"of rewards and punishments.
"He just hasn't learned how to be careful about time
"and getting things done so he won't make all of us late."
Other challenging aspects of ADHD include:
trouble reading social cues, difficulty making
and maintaining friends, getting lost
in your own thoughts, self-medicating with drugs
or alcohol or addictive activities
or with high-stimulation activities
such as sky-jumping or snow boarding
on very dangerous terrain, other kinds of high-speed,
high adrenalin activities.
They have trouble sticking with
one activity until it's done.
There's a tendency to change plans or activities
for no obvious reasons, which can be very difficult
if it's a teenager and you need to drive
that teenager places and the plans change
and the teenager continues to try to sort of
have you come here and come there.
That's very frustrating for many parents.
There's impatience with self and with others.
There's a very low tolerance for frustration
for themselves and for others.
In addition, and I think one of the hardest things
for people with ADHD, is there's a difficulty
learning from mistakes.
Research shows that multimodal treatment,
medication and psycho-social interventions
are the most effective forms of treatment
for kids with ADHD.
Let's talk for a minute or two about the history of ADHD.
The treatment was first discovered
by Charles Bradley in 1937.
Bradley was a Rhode Island doctor
who was looking for a medication to alleviate
a post-spinal tap headaches and found that amphetamines
he was using resulted in dramatic, short improvements
in children's learning motivation and behavior.
Previous names for ADHD included brain injured
child syndrome, hyperkinesis, hyper active child syndrome,
and minimal brain dysfunction.
In the 1970's, the understanding
of ADHD dramatically expanded.
Researchers observed that hyperactive children
can also have chronic problems with inattention
and both issues were found to be improved
with stimulant medication.
In 1980, there was a recognition of chronic impairment
of attention with or without hyperactivity
as a psychiatric disorder in the DSM.
It was a term that was
called Attention Deficit Disorder, ADD.
At that point they noted that the disorder
usually starts in childhood but can continue into adulthood.
In 1987, a decision through the American Psychiatric
Disorder tied inattention to hyperactivity
but it neglected the importance
of cognitive impairments and that has led
to some new revisions in the DSM 5.
What is the current definition of ADHD?
The main feature of ADHD is a persistent pattern
of inattention of hyperactivity that is more frequent
and severe than is typically observed in children
or adolescence of a similar level
of development or age.
There are several characteristic symptons
which are included as necessary for the diagnosis.
Some of them involve fidgeting, restlessness,
easily distracted, difficulty following instructions,
not appearing to listen, often losing things,
excessive talking, organizational difficulties,
carelessness and poor attention to detail.
The symptoms need to be present in two or more settings,
such as home and school or home and work.
There are three types of ADHD:
ADHD, Attention Deficit with Hyperactivity,
ADD, Attention Deficit Disorder without hyperactivity,
most often seen in girls but not exclusively,
and ADHD Combined Type, which obviously
is a mixture of those two.
The diagnosis occurs after ruling out
medical and environmental factors.
Inattention has been shown to be connected
to problems with working memory.
The threshold in the current DSM has changed
so that there are six symptoms, before the age of 12,
or five symptoms for people age 17 or older.
ADHD is much more of a biological disorder
than an emotional one.
There are emotional components of it,
but it is fundamentally a biological disorder.
It is also a disorder of metacognition,
self-regulation and motor deficits.
Metacognition is the ability to understand yourself
in the world, to be able to take perspective on yourself,
see what you're doing and how you might
be able to do it differently.
ADHD, as I said earlier, is a performance-based disorder,
which means it involves having trouble doing things
and following them through to their logical end,
not because you don't know what the thing is to do,
but you can't actually manage to do it.
Untreated ADHD often results in academic failure,
peer rejection, poor social adjustment,
behavioral problems, family problems,
which when combined can lead to developmental delays
and psychological difficulties related
to low self-esteem and intense frustration.
ADHD, as I said, isn't a productivity deficit.
It is not an accuracy problem.
Many children who have ADHD actually,
if you hand a child who has ADHD a worksheet,
he or she may get only two or three problems done,
but those two problems would likely be more correct
than a child who has a learning disability,
who may get more work done but
have more difficulty actually with producing correct work.
ADHD kids need behavioral interventions
to cue the skills that they cannot manage
to remember on their own to use
at the points of performance where those skills are needed.
Children with ADHD often develop
secondary emotional problems.
The symptoms of hyperactivity decline often
as a child ages over the elementary years,
but usually the difficulties with inattention
stay consistent over time.
I'd like to say something about this particular issue.
These secondary emotional problems
can be just as crippling as the actual ADHD.
In fact, sometimes more so.
I'll give you an example.
I have a client who basically has ADHD
and for her, writing is extremely difficult.
From the time she was in second or third grade,
she would have writing assignments.
She would see the blank piece of paper
and not only would she have difficulty
organizing her thoughts to figure out
what to put on the paper, but then she actually
had to write it out, which was difficult for her physically,
and embarrassing because while all of her students
were writing things on their blank,
white pieces of paper, hers was empty.
This happened to her day after day,
time after time.
What message do you think she got
about herself after that?
What happened to her level of anxiety
every time a writing assignment came her way?
This is what I'm talking about
in terms of the every day, small traumas
that occur for these children.
We've talked a little bit about the diagnosis for ADHD.
I just wanna review that.
Currently the DSM 5, the criteria is six symptoms
of either inattentive or hyperactive behavior,
symptoms that are developmentally inappropriate
and have existed for at least six months
and occur across two settings,
result in impairment in major life activities
and are developed by the age of 12,
that cannot be explained by another disorder.
Inattention is a problem of working memory
and executive functioning.
The threshold doesn't work so much for adults
and girls who tend to be identified a little bit later.
One of the reasons the DSM 5 changed the age,
it used to be seven, now it's 12, was to include girls
who are being diagnosed generally more often
from nine and up or in middle school,
when children are expected to function independently
and have frequently several classes
that they have to go to in different places
and different notebooks and have more challenges
to their organizational skills.
Corroboration from key reporters is a necessary
part of the diagnosis so, in general,
if you're trying to diagnose someone for ADHD,
it's good to get information from somebody at school,
for a child as well as a parent.
People themselves frequently under report
about having ADHD, so if you're talking
to someone who's a little bit older, 12, 13,
14, 15, 16 etcetera, those children
might minimize some of their difficulties
and their parents might exaggerate
some of their difficulties, so it's helpful
to have someone outside of the family,
such as a teacher and guidance counselor,
to be filling out some forms, or for you to talk to
before you make the diagnosis.
The fundamental issue in ADHD is chronic, long-term
impairment in the executive functions of the brain;
not a lack of will power, not a lack of commitment,
not a lack of caring.
People with chronic difficulties with attention
have some areas in which they can pay attention and focus,
which makes it very confusing.
For example, why can my son watch Wii for four hours
but can't see down and do 20 minutes of his homework?
It's because he doesn't wanna do his homework, that's why.
Tom Brown says something else.
Tom Brown says when people who do not have ADHD
are faced with something that they know they have to do,
and it's ultimately important to them,
because they can see the goal out there
and they know it has to get done, they'll do it.
They'll buckle down, put the pedal to the metal
and they'll do what they have to do.
When someone has ADHD, they can't do that
unless the consequences of not doing it are so great.
Generally they lack the attention
for a task that is uninteresting to them.
They cannot focus on it.
There are four types of focus; selecting, monitoring,
hyperfocusing and shifting.
Let's look at these.
Selecting is about distractability.
It's the ability to stay on task.
I'm going to choose to continue to do my history reading
even though my cell phone is buzzing.
I'm going to choose to do my math problems
even though I would rather look at Facebook.
Hyperfocusing is the monitoring of focus.
It's over-focusing on something.
I have a client who, when he sits down to write,
he will sit down and he'll sit down for six hours,
produce two or three paragraphs, but he keeps thinking,
"Oh, I have to get this,
"or if I just do this or if I just keep thinking about it
"I'm gonna figure it out.
"I'm gonna figure it out."
He doesn't know how to separate out what he's thinking
into parts that he can actually manage,
chunking of information and production.
Shifting focus, basically being able to change
from one thing to another.
This is very hard for kids with ADHD,
just that process of shifting and changing.
They finally get themselves adjusted to something
and then they have to get themselves
adjusted to something else.
Other general issues for people and kids with ADHD
would be disorganization, an impaired time sense,
so basically you'll see kids who come home
or their parents report they come home
and they're papers are all stuffed in the backpacks
or you open up their notebook and there are papers
and they're not clipped in or they're
sort of shoved in there.
The desks of these kids, frequently, are quite messy.
They have a lot of stuff in there
in no particular order.
There's an impaired time sense.
So, in general, a lack of awareness
of how much time passes in the context of an activity,
an awareness of time, an ability to manage time effectively,
to understand how long things take
or how to project some idea of when something
will be finished and then deal with that.
There's a diminished social competence.
There's a sense that they're missing something socially
that other people aren't.
They feel that.
They feel different.
Frequently they are treated differently
because there's a lot of internal preoccupation,
among these kids, about what they're missing,
or what they're trying to remember.
How do they stay on task?
What are other people doing?
So, there's this inability to sort of
be attuned to what's happening in the social environment
as people who don't have ADHD are able to do.
Many children of high IQ are often low achieving
and inattentive at school when they have ADHD.
There's a discrepancy between their cognitive strengths
and intelligences being assessed in school
and what they produce.
You can have really bright kids with high IQ's
who are barely making it through school.
Often intelligences at school are assessed
through verbal and logical mathematical means,
but these student's strengths may exist
in spatial or kinesthetic areas, which are not assessed.
Sometimes you have a bright kid
whose intelligence or skills is not seen
in the WISC or the WASC or the Wyatt
or the Woodcock-Johnson, but the skills,
the intelligence is there.
If you ask them about puzzle pieces
or how a particular engine might work, something like that.
ADHD kids have difficulty following through
on what they know.
So, for example, a child who has
a written expressive disorder will be able
to talk to you about what he wants to put
in his history paper but can't actually
get it on the paper.
Can't sit down to do the paper.
In these instances I recommend that kids get a software
so that they can talk their thoughts out
which is then transcribed onto the computer
and then they can work with someone
at the school or a tutor or a parent,
if they can tolerate it, to help them
go through what they've written.
Disorganization appears independent of general intelligence.
ADHD kids have knowledge, but they can't apply it
when they need to and perform often according
to the abilities of their intelligence.
ADHD interrupts persistence towards a goal.
This ability to work toward a goal until completion
really matures in someone's mid-20's.
There's a long time of having to be
in goal-directed environments without a skill,
which is why I think it's so important
to think about ADHD as a skill-based deficit
as well as an attention deficit.
Goal-directed persistence,
which is something we're talking about refers to
difficulties resisting distractions or interferences.
Can I continue to have my conversation with you
even though the squirrel just ran across
really fast and up a tree?
And can I return back to where I was in the conversation
if I look at the squirrel?
Let's talk a little bit about ethnic
and gender differences in ADHD.
The male/female ratio is 3.5 male to 1.
Sixty percent of kids diagnosed with ADHD are male.
There are about two to four percent of elementary-age girls,
six to nine percent of elementary-age boys,
one to two percent of adolescent girls
and one to five-point six adolescent boys.
It's basically found to be in every country
where it's been investigated, including North
and South America, Great Britain, France,
other parts of Europe, Japan, China,
Turkey and the Middle East.
Until recently it was estimated that it was 3.5%
of the childhood population in general.
New data from the CDC, including land line phone interviews
with 76,000 parents, suggests that it's 11%
and that 64% of children between the ages
of four and 17 had received an ADHD diagnosis at some point.
A 16% increase since 2007.
Apparently, two-thirds of these children
take medication and about one-quarter
of adults worldwide take medication.
These statistics are somewhat disturbing
because, first of all, the 76,000 parents
who were interviewed are land line holders,
and many people have cell phones who were
not included in this study.
Secondly, the high increase in the kids
who have ADHD and in medication,
speaks to some of the controversies today
about over-medicating kids with ADHD
and the ease with which some children,
mostly teenagers, are getting medication
such as Adderall and then abusing them.
The CDC did another study that said 15%
of school-age boys and seven percent
of school-age girls have ADHD
and in high school it was 10% of the girls
and 19% of the boys and about one in ten
high school boys takes meds.
Again, recently there were several articles
in the New York Times that talk about the concerns
about the abuse of medication, the lack of follow through
in terms of the prescribers keeping up with
and checking in on their patients.
This is of great concern to me.
I think that medication has to be prescribed carefully,
with sound history taking,
a clear diagnosis and follow through.
One of the questions about these results
are does the diagnosis of abnormal behavior
with minimal proper assessment,
because someone can't sit quietly at a desk.
That somehow sitting quietly at a desk
is considered to be normal.
My question is why?
There are many people who are not desk people,
many professionals who are not desk people.
If we go back and we look at the list
of famous people I read in the beginning who have ADHD,
many of those people do not have desk jobs.
Secondly, the controversy about the CDC study
is related to its methodology
and how that affected the statistical findings.
One thing that I think is worth noting
is that ADHD decreases in both boys and girls
across development as they age.
Recently there was an article by Dr. Madeline Wedge,
in the New York Times about the lower rates
of ADHD in French children because the definintion
is more limited and thus less pathologizing
of what's considered normal behavior.
It's a more holistic, psycho-social approach
which includes nutrition and allergens
and parenting style that relies more
on a frame or structure and consistently informed limits.
In French they call it a (speaking in French).
The kids learn more self control earlier in their lives
and grow up in families with very clear rules
and a family hierarchy.
In our families in the United States,
that's a lot harder.
Number one, because I think that the families
are more disjointed and there is less consistency
between parents about how they're parenting
and an increased reliance on schools to do parenting
for the parents because the parents are working
or they're not able to do it or they never learned how.
In general, in terms of ADHD, girls tend to show
more symptoms of anxiety and depression than boys,
with boys showing more defiant behaviors.
There are no differences found among the genders
across ethnic groups.
In a recent study on parent/child interactions,
the differences across ethnic groups was significant.
Caucasian parents were more likely
to display warmth and positive reinforcement.
African-American parents were more engaged
in active behavior management for their children with ADHD
than Latino parents were for their children of ADHD.
African-American children displayed greater compliance
and less complaining than other groups
and Caucasian children who have ADHD
showed more verbal abuse to their parents.
In other findings, girls showed less severe symptoms
of both inattention and hyperactivity,
impulsivity in school, fewer symptoms
of oppositional defiant disorder,
and greater intellectual deficits
and higher peer rejection.
I think that's quite interesting.
Number one, because girls tend to be diagnosed
later than boys because the ADHD that they have,
the inattentive type, is less bothersome.
It doesn't stand out as much to a teacher
in early elementary school grades.
It's diagnosed later, which basically results
in greater intellectual deficits,
because they miss basic skills earlier on
that they then have to catch up on later.
I worked with a client, she wasn't diagnosed
with ADHD until she was in 10th grade.
Her mother had complained to the school
for several years that her daughter
had reading difficulties
and was not able to pay attention.
Seventh grade, eighth grade, ninth grade;
at the end of ninth grade, she was in a special program
in her school for kids with behavioral difficulties.
The social worker asked me if I would take this child
on as a client, which I did.
She was in detention several times.
She got suspended.
She was having all kinds of behavioral difficulties,
stirring up social activities, drama, lots of drama.
I met with the mom.
I met with the girl.
She was barely passing.
I said to the mom, "There's this history
"of her struggling in school.
"Have you thought about having her tested?"
She said, "I've tried to get her tested for three years.
"No one's followed through.
"I haven't know what to do.
"I would be so grateful if you
"could help me test this child."
So, we worked together, navigated the labyrinth
of paperwork and requests and she was tested
in the fall of her sophomore year,
at which point it was clear
that she was dyslexic and had ADHD.
So, she was placed in a support class.
She was taken out of the behavioral program
so that she could be in the special class
and also because intellectually,
she didn't need to be in a class
with the kind of remediation that was offered
academically in those classes.
She worked very hard.
She made the honor roll in the fall of her junior year.
She was the first person in her family
to ever have made the honor roll.
It was a privilege to work with her
when that occurred and to celebrate her success with her.
In general, girls tend to internalize
the traits of ADD, the forgetfulness,
the difficulty listening, problems with verbal expression
or control, misreading social cues.
It's hard for them because they tend to relate primarily
through verbal connections.
As I said, I talked about another client
who couldn't hear what people were saying to her.
She actually couldn't listen.
She was ostracized.
Girls with ADD have been found to be sexually active earlier
than their peers who don't have ADD.
They show less severe symptoms of hyperactivity,
behavior in school and less impulsivity in school.
What you'll see more is this kind of dramatic,
problems, interpersonal difficulties, social challenges.
Boys, on the other hand, relate more
through shared activities, as we know,
which makes the difficulties in verbal expression
and reading social cues less pronounced
than it does for girls.
Because girls tend to have these very intense
emotional relationships where they're
talking about things a lot.
ADD girls and their difficulties processing
that information, both auditorially
and expressing themselves verbally,
set them back and away from their peers
in terms of being able to join in.
For boys, where they're bonding occurs more
through shared activities like sports, or Wii,
or watching baseball, or football, or basketball,
or doing computer games, or building things,
the difficulties in verbal expression are less pronounced.
They experience fewer problems in activity-oriented
social situations and their ADD-like, ADHD traits,
such as risk-taking and aggression
are often rewarded and considered part
of being a real guy, you know?
It's part of that's something to be proud of.
ADHD is the most genetically
transmitted diagnosis in psychiatry.
Almost a 50% transmission from parent to child.
This means that if you see a child who has ADHD or ADD,
you can expect that 50% of the time
they have a parent who has ADHD, diagnosed or undiagnosed.
I once worked with a little boy
and he had been tested and he was diagnosed
with ADHD by the psychologist who tested him.
He came to my office.
I met with him.
I met with his parents and it was clear.
We started to talk a little bit about what is ADHD?
I did some educational work with the family.
And the mom said, "That is really interesting.
"Do you have any books I could read?"
So, I loaned her "Driven to Distraction," by Dr. Hollowell.
She took it home.
The next week she came back and she said,
"I have this.
"What do I do?"
We talked.
She decided she wanted to try medication.
She went to the doctor.
She tried medication.
She came back a few weeks later and said,
"I feel like the fog has been lifted,
"that I'm able now when I make my list of 12 things,
"instead of getting one done,
"I actually might get three or four done."
It changed how she parented as well.
She was able to use her life experience
in organizing herself to help her understand
the challenges her son was experiencing
and not being able to organize himself and what they shared
that she could be able to help him learn.
Hyperactivity, remember, is not necessarily
an indicator of ADHD.
About 60% of kids with ADHD are hyperactive,
which means 40% are not.
Children who can be dreamy, forgetful
and sort of spacey are often unrecognized
as potentially having ADHD.
We call that, in my office, attention-wandering.
You're attention kind of wanders to something else.
Both types of ADHD, hyperactive and inattentive,
show similar impairments in vigilance,
processing speed and inhibition.
The hereditary component of ADHD is high
and it's very important when you meet with the family
of a child or teen you're working with,
who has ADHD, to find out if anyone else
in the family has been diagnosed with ADHD,
has attentional issues that may have never
been diagnosed, or had a history of school difficulties.
The history of school difficulties might be reflective
of having an attention issue that was never diagnosed.
Children with ADHD may lag up to 20 to 40%
behind children without the diagnosis
in terms of maturational development.
In general, I use a three-year cutoff.
If I see someone who's nine, who has ADHD,
I expect that their maturity is up to three years delayed
in some areas and in some areas it might be superior
to other kids their age.
For instance, they might have
a very strong ability to process.
They might be able to actually process their feelings
and name their feelings.
The bullet brain girl was able to do that,
but she was behind her peers socially.
She had a lot of trouble making friends,
holding on to friends because she would get frustrated
and impatient with how they were treating her.
Many children with ADHD also have
sensory integration disfunctions
as high as 10 to 20%, which means that they
process information through the senses
ineffectively or very differently than other people.
They're very sensory sensitive.
I have a little girl who I've seen who loves water.
She loves the feel of water
and she'll be in the bathroom putting her finger
up in the faucet to see what happens
when the water goes wherever.
She's nine.
She just loves the feel of water.
She'll wash the walls of the shower.
She'll spend a very long time in the shower
because she's washing the walls
or just experiencing the water on her body.
This infuriates her mother, who does not have ADHD,
but amuses her father who does.
We have to kind of laugh at some of these behaviors
with our clients and figure out how to intervene with them.
It also means that a 10-year old with ADHD,
in a classroom, can act like a seven-year old.
That's important for a teacher to think about
because a teacher is looking at some one
and the child looks like her or she is 10,
but in terms of maturity, he or she might be seven.
In terms of social impairments for kids with ADHD and ADD,
I wanna name a few things.
First of all, there is increased parent/child
conflict and stress.
There's increased hostility, lower parental responsiveness,
sometimes harsh discipline, the punishment
way outweighs the crime.
There's more child noncompliance and dissruption
and a lower sense of parental competence.
There are peer relationship problems
between 50 and 70% of the time.
Sometimes the social impairments can involve
a crisis lifestyle, one crisis after another,
which will, as adults, lead to constant money problems.
In general, the clients I work with,
the teenagers and the young adults who are managing
their fiances on their own, cannot have debit cards.
Debit cards are the death of ADHD young adults,
because they have no record of what they're doing
or any way of following how much they're spending.
As soon as they've gotten rid of their debit cards
and had to actually function a little bit more
on a cash system, writing checks,
they were able to manage their finances more successfully.
There's an extremely high risk for alcohol,
tobacco and substance use, the self-medicating of people
who have ADHD and aren't on a prescribed medication.
Also, the self-medicating might allow them
to be more socially accepted with their peers
than if they weren't doing that.
In terms of specific peer problems,
sometimes what we'll see is less sharing
and cooperation in the younger years,
more anger, bullying, either being the bully
or the victim, a reduced guilt for actions
that they actually do that harm someone else
and a reduced ability to be truly empathic.
Let's talk about the onset and course of ADHD.
Most children with ADHD are identifiable
as being different from typical development
by the ages of three or four.
The average age of onset is about four
and frequently their parents describe them
as very busy or very spacey.
In the elementary years there's noticable
differences from peers and poor sustained attention,
impulsivity, a lack of focus, restlessness,
aggression, a failure to complete work,
disruptive behavior and challenging peer relationships.
Learning disabilities can emerge in the areas
of reading, spelling, math, handwriting and language.
In terms of the genetic rate of ADHD,
if one parent has ADHD, there's a 30% chance
of a child having it.
If two parents have ADHD, there's a 50% chance.
Fifty seven percent of adults with ADHD
have at least one child with ADHD
and the likelihood that a second child
will have it is 33%.
I'm gonna say that again.
Fifty seven percent of adults with ADHD
will have at least one child with ADHD,
and the likelihood that they'll have a second child
with ADHD is 33%.
Where hereditary isn't a factor,
difficulties during pregnancy can be a factor,
prenatal exposure to drugs, alcohol
or tobacco, premature delivery, high lead levels
and post-natal injury to the pre-frontal lobe regions
of the brain, this part of the brain.
Research does not support ideas
that ADHD comes from watching too much television,
eating too much sugar, food additives or poor parenting.
When there is childhood hyperactivity,
can't sit still, always on the go,
climbing and running, that can become adult restlessness,
can't stay focused on something, fidgety, impatient.
When a child is physically impulsive,
doing things that result in injury
or difficulty waiting for his turn,
that can become verbal impulsivity,
saying the wrong thing, speaking out of turn.
When a child is inattentive, has problems
paying attention in class or completing school work,
it often remains as an adult, difficulty
concentrating at work and problems completing things.
Fifty percent of ADHD persists into adulthood.
Five to ten percent of children with ADHD outgrow it.
Children with ADHD have trouble
with many aspects of self-management.
That will include brushing their teeth,
getting dressed, putting their books in their backpack,
remembering to take their lunch,
the list goes on and on.
They get injured more than other kids
and they tend to be more reckless
and restless than the average child of their age.
Parents are often on high alert
when they have a child like this,
often trying to anticipate and protect the child.
These parents report chronic stress,
more than 83% of other parents,
and can be more negative to the child
because of this stress and
the chronic anxiety that goes with it.
In preschool, what we'll see in terms of onset
is excessive activity, noncompliance,
difficulty with toilet training,
some delay in academic readiness,
very, very busy, high levels of parental distress
that continue on through elementary school and high school.
In general, with kids with ADHD and even ADD,
you can see a high level of noncompliance.
In general, the common time when people seek
an evaluation for a child with ADHD
is between the ages of maybe eight and fifteen.
Between the ages of three and five,
if the child is very hyperactive and impulsive,
sometimes someone will bring their child
for an evaluation, but in my experience,
that's kind of rare.
Most people do not want their child diagnosed
with ADHD at five.
I have worked with a kindergartner
who was diagnosed that way.
In this particular family she had an older sibling
who was diagnosed with ADD.
The mom saw it and she said, "I think this is
"what's going on."
The girl was having a number of difficulties at school,
including difficulties with peers,
difficulties sitting still,
unable to attend to circle time
and the mom basically took the child to the doctor.
He said, "Let's try a low dose of Concerta,"
which they did, and she improved dramatically.
Toward the end of the primary grades,
around third or fourth grade, due to problems
in maintaining concentration and completing
school work assignments, or having difficulties
with reading, writing, math, etcetera,
kids will be brought in for an evaluation
or an evaluation will be requested through the school.
During the middle school years,
particularly as kids have to transition
into much more sort of self-management,
and there will be a spike in oppositionality,
school failure, a lack of motivation,
depression, discipline issues, anxiety,
that will also be another wave of kids
who seek an evaluation.
In high school, the evaluations tend to occur
after repeated academic failure and behavioral problems.
If it hasn't been caught up til then,
I always wonder what happened.
Sometimes with girls it doesn't get caught up
til then because they sort of slide under the radar
and then it's clear that they're
not doing well in high school and it comes to the fore.
After high school and early college years,
sometimes kids make it through high school
because they have the scaffolding from their parents
and the guidance counselor, that they can sort of
hold it together well enough to get through high school
and then they go off to college on their own
and the no longer have those support systems.
So they fall apart and at that point
they seek an evaluation.
I think it's worth noting that 87% of children with ADHD
have at least one other disorder
and 67% have at least two.
Up to 32% of kids with ADHD fail to finish high school.
They often refuse to accept responsibility
for doing routine chores, obeying house rules,
and they demonstrate extremely poor
problem solving techniques.
They experiment with drugs and alcohol.
Family conflicts are likely to increase
and there's a greater likelihood of car accidents
and speeding tickets.
I'd like to talk about the neurological factors
related to ADHD.
Put your hands together like this.
This is the size of a human brain.
Now I know you're thinking, "My brain is '
"bigger than this, Sharon.
"You must be crazy."
But actually the human brain weighs about three pounds,
has about 100 billion neurons or more
and is about this big.
It manages itself and the whole body
through a series of excitatory
and inhibitory chemical processes.
Do you remember that was from chemistry in high school?
The brain is an electrical system
in which chemicals regulate the communication
of messages from one neuron to another.
The corpus callosum is a part of the brain
that's right down the middle of your head
and it further facilitates the integration
of details, sequences and contexts.
In people with ADHD, this corpus callosum is smaller.
This corpus callosum links both sides of your brain.
The frontal lobes figure out what
is worth paying attention to
and what is worth doing.
This is impaired in people who have ADHD.
What is worth paying attention to and what is worth doing.
That's what the frontal lobes do
and that's where the seat of the impairment is
for people with ADHD.
People with ADHD show a pattern of underarousal
in the cerebral cortex and slower brain waves.
In kids with ADHD and executive functioning challenges
the parents act as the frontal lobes
for longer than for typical kids.
Let me give you an example.
If you have a child who's three
as a parent you will say to that child,
"Sam, we're gonna go to the grocery store.
"Let's get your shoes on,"
and Sam will walk with you, hopefully,
sit, you'll put the shoes on, you'll tie the shoes,
you'll get the jacket, you'll help Sam
put his arms through the jacket unless Sam
can do it himself, you'll walk with Sam to the car,
he'll climb in the car, you'll buckle his car seat
and you'll go to the grocery store.
You've taught Sam that you put your shoes on,
you tie your shoes, then you get your coat,
then you put your coat on, then you go to the car.
That's a sequence.
It's a plan of action.
It gets you from point A, the kitchen, to point B,
the car on the way to point C, the grocery store.
The parent is acting as Sam's frontal lobes.
As Sam matures, he understands that when the mom says,
"Sam, we need to go to the grocery store,
"get your shoes," he goes,
he puts his shoes on, he gets his coat
and they go to the car,
or he might go to the car by himself,
or his mom will say, "Sam, I'll meet you in the car.
"We're going to the grocery store,"
and then he'll know to put his shoes on and his coat.
So, there are all these steps
that parents teach their children.
They do this.
It's called scaffolding,
helps them with the frontal lobe development.
If you are a parent who has ADHD,
that frontal lobe development for you was delayed
and for your child is delayed.
So, if you, as a parent, are a little bit scattered
and don't always remember that you do the shoes
and the jacket and the car, blah, blah, blah,
then your child isn't gonna necessarily learn
how to do that.
If you are a parent who does not have ADHD,
then you will be teaching your child this
and if the child has ADHD, it's gonna take longer
to learn that sequence.
If you look at the brain structures involved
in the executive functions, there are many
parts of the brain that have to deal
with this part of our functioning.
The working memory circuits in the prefrontal cortex.
Again, this is the prefrontal cortex,
so the working memory, which is impaired
in pretty much everyone who has ADHD,
working memories are converted into long-term memories
in what's called the hippocampus.
Risks and rewards are identified mostly through
the amygdala and the dopamine circuits,
which start in the ventral tegmental area,
alertness from the networks of the locus coeruleus
and the reticular formation.
Alertness is, "Okay, let's stay with this.
"Let's get up in the morning."
Cerebellum fine tunes cognition.
If we look at individual neurons
that form the structure of an individual neuron,
there are two major transmitters
associated with ADHD.
Two neurotransmitters associated with ADHD.
Dopamine, which highlights important stimuli,
signals possible reward situations,
creates conditions under which sensations
are recognized as pleasurable, and norepinephrine,
associated with sleep and alertness in the cerebellum.
Reduced norepineprhine is associated with inattention,
drowsiness, and sleep.
Other neurological factors: dopamine
will enhance the level of interest a person
attaches to something.
People who release dopamine at a lower rate
can find it more difficult to work up excitement
about something that they don't naturally find appealing.
Dopamine highlights significant stimuli.
The limbic regions of the brain assign
emotional importance to something,
so if there's information coming into the brain
and the dopamine highlights that it's important,
then the limbic system will assign an emotional importance
to it and to internal ideals and plans.
These networks immediately evaluate
what may be interesting, dangerous or rewarding
and transmit this information using dopamine,
getting the brain to act or notice something important.
Dopamine is a key to motivation
and when there is a deficiency the brain tends not
to experience motivation to work,
even for rewards that might be desirable.
Dopamine creates the conditions under which
sensations are identified as pleasurable.
In ADHD brains, dopamine pathways allow too much dopamine
to be reabsorbed by the next cell
with not enough dopamine transmitted
or received by nearby cells,
sometimes as much as 70% more than in people
who do not have ADHD.
Also there are approximately 16% fewer brain cells
that are receiving dopamine, receptor sights.
These differences result in underactivity
or underarousal in the brain.
Norepinephrine, the other major neurotransmitter
involved in ADHD impairment and in the functioning
of the frontal lobes, activates areas of the brain
involved in attention, concentration, behavioral contol
and social judgement, as well as alertness.
The lack of distribution of norepinephrine
is associated with inattention, drowsiness, and sleep.
The combination of what's happening with the dopamine levels
and the norepinephrine levels result
in the complex disorder we know as ADHD.
As we are speaking now
or probably as I'm speaking and you're listening,
the research on ADHD is changing.
The ability to do blood tests or brain tests
for ADHD is changing.
When that becomes available,
when it becomes easily available
for people to figure out what brain chemicals
are off so that they can take a medication
to help with the production and management of that chemical,
medication as it's prescribed today,
will be completely transformed.
People with ADHD make dopamine and norepinephrine normally,
but their brains do not release and reload
those neurotransmitters effectively
in areas of the brain that manage executive functions.
Let me say that again because it's really important
and I wanna make sure you understand it.
People with ADHD make dopamine and norepinephrine normally,
but their brains do not release and reload
these neurotransmitters effectively
in the areas of the brain that manage executive functions.
The medications for ADHD do not create neurotransmitters
but they facilitate their release
and delay their reuptake
along critically important networks.
There is more dopamine or norepinephrine floating around
that's going to different cells
that are responsible for the executive functions
that are inherently impaired in people with ADHD
through the medication.
In puberty, for everyone, brain volume
rapidly increases in size and number of neural networks,
so there's this process that goes on,
particularly in the frontal lobes and the cerebellum,
which is back here.
There's this burst of growth and activity
followed by something called pruning,
which results in the brain being more efficient.
It's kind of a use it or lose it model.
So, you have a burst of activity
and then if you're not using things,
the brain will sort of prune it away
so that what you have is faster and more efficient.
The prefrontal lobes, right here,
and the circuits that support executive funtioning
are not fully developed until after puberty,
actually until age 25.
Parents, as I said earlier, are the frontal lobes
from birth and then they decrease over time.
When someone takes medication,
the medication allows the transmission
of the chemical reactions to flow more smoothly.
The medication lasts a particular amount of time,
depending on what you're taking.
If you're taking a stimulant,
when that medication leaves the body,
the facilitation of these processes stop.
It's similar to wearing glasses.
You put the glasses on, they work.
You take them off, they don't work.
It's like that with the medication,
the stimulant medication.