Friday, March 09, 2007

ADHD: The basics and the controversies

ADHD: The basics and the controversies

Attention "Deficit," however, is a terrible name. Most people with ADHD report that their attention is not deficit, it is excessive. People with ADHD describe that they are drawn to all the stimuli around them equally and simultaneously. They are like jugglers who give fleeting attention to each ball in the air. Nothing gets sustained, undivided involvement.

TAKE HOME MESSAGE #1: For persons with ADHD, the ability to maintain attention and impulse control is determined by one factor-- if the task is interesting, desired, or challenging, the individual with ADHD has no problem with distractibility or impulsivity. If, on the other hand, the task is boring, it is a neurologic impossibility to stay on task. Interest and challenge only determine the ability to function, not importance. This "interest based performance" is coming to be the hallmark diagnostic symptom of the disorder and the key to successful management once medication treatment has been established.

The swings of attention can be profound from states of "zoned out" dissociation to a condition known as hyperfocus. As many as 40 percent of adolescents and adults with ADHD can enter what appears to be an altered state of consciousness while doing activities which they consider particularly intriguing. During a hyperfocus the person performs at almost 100 percent efficiency, does not notice the passage of time, does not become tired or hungry, and has virtually 100 percent comprehension and retention of what he reads.

This inconsistency of performance based on interest leaves the impression that the ability to function is under the control of the ADHD patient who is just being lazy or uncooperative. We used to use a trick question with the parents of children brought in for assessment of ADHD. We asked them what their child's favorite TV program was in the smug belief that a truly ADHD child would not sit long enough to have a favorite program. Now we understand that more than half of children and adults have the ability to become deeply and productively involved in tasks that interest and challenge them, only to fall apart when they become bored.

Many people would also like to drop the term "disorder" because ADHD seems to convey a large number of positive traits along with the distractibility and impulsivity. People with ADHD usually have much higher than average intelligence, although they commonly express frustration at not being able to demonstrate it consistently. They tend to be very creative and inventive. Sometimes this presents as being artistic, musical, or inventive, but almost always it manifests itself in intuitive problem solving. People with ADHD can often pull together the threads in complex problems to develop ingenious solutions that no one else would ever see. People with ADHD are also described as having "relentless determination" whenever they do hook into a challenge. Finally, people with ADHD tend to be affable, likable people who often have a quick and zany sense of humor. They tend to have a close, tight group of friends and family who describe them as being "high maintenance but high reward" individuals.


The 579 children in the study were selected because they had "screaming ADHD" that was unmistakable. These children were randomly divided into four treatment groups:

1. Just stimulant class medication that was fine-tuned to the needs of each unique child
2. Just intensive behavior management
3. Both medication and intensive behavior management
4. A community treatment group to see what was happening in the real world

At the end of 24 months the results were striking. The two groups that received medication did exceptionally well. The group that got both medication and intensive behavioral therapy did no better than the children who received only medication. The group that got behavioral treatment alone did improve but much less than those who received medication. Surprisingly, when the follow-up assessments were done three months after the intensive behavioral therapy had ended, no evidence could be found that the therapy had ever occurred. Just as with medication treatment, when the behavioral treatment ended, so did the benefits. This also was consistent with what was so commonly seen in the real world…families would become hyper-structured in order to help an ADHD child succeed, but the child would flounder as soon as she left the family to try to make it out in the real world that was not structured for her. The group that did by far the worst was the community treatment group.

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