Our preschooler'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 practice his letters with me, it
seems like it is torture for him to sit in the chair. Everyone is
distractible, restless, or impulsive some of the time. And for a
preschooler in particular, it's normal to be sometimes forgetful,
lost in the clouds, wild, jumpy, disinterested in routines,
super-playful, silly, or fidgety. The question is, are these
behaviors a problem for the child or for people around him or
Perspectives on ADHD
One way to think about this topic is to
imagine kids - or adults - on a spectrum in terms of three personal
attributes: distractibility, restlessness, and impulsivity. As
distractibility, restlessness, and impulsivity increase, around the
80th percentile - in the upper fifth or so of the
population - we'd start to think about a child being "spirited." As
the intensity of these three characteristics increases further, at
around the 95th percentile we'd start thinking about a
child having Attention Deficit/Hyperactivity Disorder
The topic of ADHD is fairly
controversial these days. There's no controversy about the fact that
individuals range on a spectrum of distractibility, restlessness,
and impulsivity. What is controversial is what that spectrum means -
and what to do about it.
In our view, there are plusses and
minuses to just about any kind of temperament. We think of ADHD as a
normal variation in human temperament, and that humans evolved to
have a variety of temperaments in represented in the
hunter-gatherer groups that our ancestors lived in for millions of
years. Groups whose members had only cautious, conservative
temperaments would not explore and take risks as much as they should
- while groups with only spirited/ADHD members would not be as
prudent and planful as they should be. The groups that would have
the best odds of survival - and passing on their genes - would be
the ones with a mix, a synergy of temperamental types.
So, in a sense, ADHD is normal. That
six-year-old boy running around the playground, getting into a
million things, full of spirit and passion, bored with schoolwork,
driving his parents and teachers crazy . . . .would be on the fast
track to becoming a mighty hunter or explorer - and admired and
successful within his tribe - a hundred thousand years ago. But
today, he's sitting in the principal's office because he just can't
hold it together to sit quietly at a desk for six hours a day.
In short, the "disorder" of ADHD is
really a disorder of fit between perfectly normal - albeit
inattentive, looking-for-action, intense, easily upset, on the move,
impulsive, delightful, make-you-pull-your-hair-out - children and an
environment that places historically unprecedented demands on young
people (and grown-ups, too) to concentrate, sit still, and absorb
streams of abstract material. These modern environments are recent,
in the evolutionary time scale, and humans have not had time to
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. We suggest focusing on the facts (what a concept),
getting a good assessment (see below), and working on practical
Bottom-line: ADHD is a concern, but it
can be taken care of (see our 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.Some Facts about ADHD
Fundamentally, ADHD involves weaknesses
in regulation (of attention, activity, and desires). In a sense,
someone with ADHD is like a big 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,
• 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
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
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
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
• 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."
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
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 our next column I will describe the
care of ADHD. We 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, we recommend four key elements
in the care of ADHD
• Education and understanding
• Community and support
• Holistic physical
• Psychological interventions within the
child and at home and school
Please note that we 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.
We will discuss all this issues in
detail next month!