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FAMILY MATTERS
Rick Hanson, Ph.D. © 1995 - 2002
Inattention, Restlessness, and Impulsive Behavior
Dear Dr. Hanson,
Our third-grader's teacher has been hinting that he might be "hyperactive." She says it's hard for him to sit still, he talks a lot without raising his hand, and he's distracted by any little thing. At home, I have to constantly remind him to do things; he says he just forgets. He can play Nintendo for hours, but if he is supposed to write something for school, it seems like it is torture for him to sit in the chair.
Lately there has been a growing awareness of "attention deficit/hyperactivity disorder" (ADHD) in the popular media. For example, Time magazine had a cover story on ADHD just a few months ago. I will describe ADHD in this column and in my next column discuss what parents can do about it.
Description
All children, and most adults, are distractible, restless, and impulsive some of the time. A diagnosis of ADHD depends on the quantity, intensity, and duration of ADHD characteristics.
There is a range of difficulty with focusing attention and controlling one's body and impulses. At one end of the spectrum, individuals have high capacities for focus and self-regulation. In the middle, people have normal abilities. Then we move into the territory of "spirited children." Finally, at some point on the continuum, there is a zone of mild to moderate to severe problems that are sufficient to warrant a diagnosis of ADHD.
Fundamentally, ADHD involves deficits in regulation (of attention, activity, and desires). Someone with ADHD is like a car with bicycle brakes. If the car is moving slowly or uphill, things work OK. If the car is moving quickly and/or the road is downhill, there's a problem.
There are three types of ADHD
- (A) Inattentive, distractible, hyperfocused, daydreamy: inconsistency in attention.
- (B) Impulsive, restless, hyperactive
- Combined (A and B)
ADHD can vary in intensity from mild to moderate to severe. It can appear inconsistently, and in some settings more than others. It can change during a child's development.
Common estimates are that approximately 5 to 10 percent of children have ADHD. This means that a typical class will have one to four children with ADHD. Boys are diagnosed with ADHD more than girls, although girls are probably underdiagnosed because their type of ADHD is often more daydreamy and less problematic for parents and teachers. ADHD often persists into adulthood, particularly inattention and impulsiveness.
ADHD is biologically based and studies have revealed a genetic link. It is not a character defect or personality flaw or motivated effort to drive parents and teachers crazy! A child's environment can help or aggravate ADHD, but not create it.
There are many positive aspects typically associated with ADHD. These include high energy and enthusiasm, and above average intelligence, intuition, and creativity. People with ADHD are often lively and likable individuals. They are typically results-oriented, with a bottom-line focus.
Unfortunately, there are often aspects of ADHD that are problematic for children, parents, and teachers:
- Inaccurate (often negative) opinions of self, others, and situations. Fix on one aspect of something, losing the big picture. Often misread social cues.
- Forgetfulness. Poor organization. Rush through tasks. Procrastination and poor follow-through.
- Want immediate rewards. Low tolerance of frustration or boredom. Impatient.
- Intense kids who like high intensity situations. Get aroused ("hyped") real easily; "hair-trigger gas pedals."
- Emotions on the surface. Easily hurt. Unstable moods. Background sense of unease, insecurity, or worry.
Other concerns are frequently associated with ADHD and are often the focus of parents and teachers. They include behavior problems, low self-esteem, underachievement at school, problems with peers, and risky behavior. These issues can mask underlying ADHD. Painfully, children with ADHD are often the target of physical and emotional abuse by parents and caregivers.
Children with ADHD can be termed "stupid," "retarded," "lazy," or "flaky." They can become the target and presumed culprit for family discord or classroom problems. A stressful and upsetting BIG STRUGGLE often revolves around a child with ADHD. It is important to allow the person with ADHD to step out of the "problem role." The reactions of others can unwittingly maintain ADHD behaviors.
In a recent popular book about ADHD, Driven to Distraction, the author commented: "The picture of a young child who starts out well and then gradually sees his school performance tail off while teachers grow increasingly moralistic in their explanations should always suggest the possibility of ADHD."
Perspectives
ADHD involves a poor fit between the individual and environments which require sitting still for long periods of time and sustaining attention to often uninteresting material. These environments are recent, in the evolutionary time scale, and humans have not had time to adapt. People with ADHD need a big pasture in which to roam.
Some feel that ADHD has been long under-diagnosed. Others feel that children's inability to pay attention, focus on their work, and control their bodies and impulses is usually due to psychological issues, including lax parenting. All kinds of secondary issues can get mixed up in the question of whether a child has ADHD: school district politics, fears of stigmatizing a child, moralistic views of child development, social agendas about "good old-fashioned parental discipline," etc. I suggest focusing on the facts (what a concept), getting a good assessment (see below), and working on practical issues.
Bottom-line: ADHD is a concern, but it can be taken care of (see my next column). Unlike progressively worsening conditions like multiple sclerosis, ADHD usually gets better over the course of an individual's development and often disappears entirely by adulthood.
Assessment
The first step when ADHD is suspected should be assessment by a licensed psychotherapist and/or physician. School districts can sometimes help. A good assessment involves consultations with teachers and parents, review of school records, and observation of the child in natural settings. The most reliable diagnostic tool is the individual's history. There is no single "test" for ADHD. ADHD should never be ruled out on the basis of testing or doctor's office visits alone!
Sometimes other issues are primary and produce ADHD-like symptoms. Psychological issues include anxiety, depression, significant separation from parents, and family discord. Biological issues include intense allergies, chronic infections, seizure disorders, and hyperthyroidism. These other possibilities should always be ruled out through investigation by the applicable licensed professional.
ADHD and learning difficulties are statistically associated and can mask and exacerbate each other. If diagnosis is still unclear after assessment, address the ADHD and then see what learning disabilities remain; ADHD is the more general factor.
Care of ADHD
In my next column I will describe the care of ADHD. I use the word "care" instead of "treatment" because it is important to remember that there is a whole person suffering a condition not of his or her choosing.
In sum, I recommend four key elements in the care of ADHD
- Education and understanding
- Community and support
- Holistic physical interventions
- Psychological interventions within the child and at home and school
Please note that I have not mentioned Ritalin, which many people consider equivalent to a diagnosis of ADHD. Sometimes a fifth element -- medication -- may sometimes be called for in the care of a child, but only after the first four elements above have been thoroughly explored. I will discuss these issues in detail next month.
(Rick Hanson is a clinical psychologist, Jan Hanson is an acupuncturist/nutritionist, and they are raising two children, ages 11 and 14. You can email Rick or Jan with questions or comments at
drrh@mindspring.com;
unfortunately, a personal reply may not always be possible.)
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