What is ADHD?

Planes ADHD

ADHD stands for attention deficit hyperactivity disorder. When I tell people that I am an ADHD specialist,  the next question is usually, “What is ADHD anyway?”. It then turns out that the common conception of an ADHD child is of a naughty boy running around the place, and that the common misconception of treatment is of medication to “calm the kid down” or “sedate him”. So to set the record straight, ADHD is primarily a brain disorder that makes focused attention difficult. The hyperactivity is secondary. It is caused partly by genetic factors, and partly by environmental factors. The environmental factors that are important are usually those around pregnancy, birth and early infancy.

I could talk about symptoms and signs, dopamine receptors, synaptic disruption in the fronto-striatal pathways, but you can get that information from any google search. I don’t think that that will help you understand ADHD or its treatment. So instead, I am going to talk about air traffic control. It’s a long analogy, I apologise, but if you bear with me, you will understand more than most medical students about ADHD and its treatment.

You are watching planes at Heathrow airport. The planes are not behaving as they should for some reason. Pilots are circling the landing strips at random, flying very fast at times and almost crashing in an uncontrolled manner. Sometimes multiple planes are attempting to land at once and sometimes planes are adjusting direction and altitude quickly to avert a crash. There doesn’t seem to be any order and the planes will cause a major accident if they don’t slow down. Your first instinct to solve this problem may be to tell all the pilots to reduce their speed. “Pilots, stop being so ‘hyperactive’, slow down!” Sure, that has stopped the pilots whizzing around causing accidents, but it hasn’t improved their ability to land planes. Now, they are slowly and lethargically circling the airport at random. They don’t crash because they are going so slowly, but they don’t do much else either, they don’t know where and when to land.

If you were to go to the air traffic control room and see what was actually happening, you would come up with a better solution. At air traffic control, what you find is that half the staff have disappeared (there is an economic downturn you know), and the remaining staff have been replaced by pimple faced 16 year olds. Each child is looking at 6 screens with two head phones on with pilots shouting at them “Tell me what I do now? What do you want me to do now?” Most of the kids are completely overwhelmed, and banging their heads against the wall. Some are up to the challenge and attempting to land planes, others are shouting random orders based on knee jerk reactions.

Now what is your solution?

From this vantage point, you can clearly see that the pilot’s speed is not the issue. What is the issue is that the control room is ineffective. It is under resourced and has not been taught how to deal with multiple demands on attention and how to organise the information it is getting in order to achieve a goal.

There are 3 options:

1)      Re-employ the senior management of the air traffic control room to train the 16 year olds in air traffic control. This will take time, money and a lot of effort. You are still in effect operating with only half the staff, but with time, the senior managers will be able to train the 16 year olds, identify their strengths and weaknesses, motivate and organise them into a team that can effectively manage to land planes, forever. The managers must be committed, able to deal with frustration and most of all, not give up.

2)      Call in the cheap immigrant labour from Planet Zog. They will arrive en masse in the morning; land all the planes for you and then blast off in their space ship again at night for next to no money. They only speak Zog, so they cannot train your staff. They also like to pass wind and can make life slightly unpleasant while they are around.

3)      Do nothing. Let the situation “muddle through”. There can be two outcomes for this strategy. The 16 year olds may learn slowly from experience and mature into men and women with greater experience and knowledge to be able to land planes on their own. They might crash a few planes, but at the end, emerge mature and competent. Alternatively, the 16 year olds may lose hope. They crash a few planes. Initially by accident. They get lambasted by the press “You useless people, you good for nothing kids. Why can’t you even land a plane?” They crash a few more planes. They decide this is kind of fun, and deliberately crash planes.

Hopefully this will help you to understand that ADHD is primarily a brain disorder, not an “energy” disorder. The control room is the brain, the staff are neural circuitry. The focus in ADHD should be on “Attention deficit”, not the “hyperactivity”.

In ADHD the brain is under functioning, it is unable to organise or prioritise the stimuli it is being constantly fed. It cannot attend to one thought, or follow through on one action, because it is constantly distracted by other thoughts and stimuli. The result is endless non-goal oriented activity; purposeless movement; hyperactivity. Activity itself is not a problem. Endless goal-oriented activity, purposeful movement to multiple demands is multi-tasking, is productivity. Sedation is not the solution. This will slow the brain and body down so that damage will not be caused, but nothing will be actively achieved either. The solutions are:

1)      Behavioural management training. This can only realistically be done by parents (with training and support from teachers and psychiatrists/ psychologists). Done well, it can train the child to function at an appropriate level, and motivate them to attend. It is labour intensive, takes time and is expensive. It requires a lot of work and dedication from parents, but can offer long term change. In a randomised clinical trial of behavioural management training against medication, behavioural management produced equal results to medication, few side effects and with longer lasting effects (MTA, 1999). This is why NICE (National Institute of Clinical Excellence in the UK) guidelines suggest behavioural management as first line treatment for ADHD. Unfortunately, much of what the NHS is currently providing in terms of “behavioural management training for ADHD” (if it is even provided) does not match the behavioural management training given in the clinical trial. In pragmatic studies (studies using real life clinics, and unselected patients rather than well-funded research teams with patients recruited for commitment) there is little evidence for benefit of behavioural management. The problem? Cost and parental resources.

2)      Medication. This is typically in the form of a stimulant, which stimulates the brain to work. Most of us are already taking a brain stimulant everyday to help with our functioning on a daily basis. Caffeine. Caffeine is in the same class of drugs as methylphenidate (the main ADHD medication), cocaine and amphetamines. Methylphenidate does not cause highs or addiction at doses prescribed in children for ADHD treatment. It can be abused which is why it is a prescription only medication and prescribers will not prescribe it to children whose parents are known drug users. Medication is a cheap and fast solution, but once the medication is stopped, the benefits are also gone. It can sometimes be a good strategy to use medication to allow children to begin participation in behavioural management training. Some children will experience side effects. The tolerability of the side effects is variable between individuals. About 30% of children will not respond to methylphenidate. Good clinicians can get good outcomes from medication prescribing. Bad clinicians; are bad clinicians.

3)      Do nothing. Attention levels in the general population increases with age (see my post on attention), and this is no different in children with ADHD. By late adolescence, some children’s attention will have improved to the extent that they no longer fall under the category of having ADHD. By late adolescence the requirement to attend school and formally pay attention for long periods of time is over, and many adolescents with ADHD choose occupations and pastimes that require less focused attention. Thus, their relative attention deficits have less impact on their lives. Only around a third of children progress from childhood ADHD to adult ADHD. However, there is also high downside risk related to the “do nothing” option. We know, that a significant proportion of the “do nothing” group end up being marginalised from school, singled out and scapegoated by parents and teachers and bullied by peers. The impact of these experiences is highly damaging to children and can lead to additional mental health and social problems with more serious consequences than just inattention. ADHD is related to higher rates of conduct disorder, depression, personality disorder, drug abuse and criminality.

Treating ADHD, by whichever method, is not really about “calming children down” as is commonly perceived. It is about allowing potential to be achieved and preventing conduct disorder, depression, personality disorder, drug abuse and criminality.

I know that ADHD is a highly emotive topic for many, so please feel free to air your views.

References:

The MTA Cooperative Group (1999) A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. 56:1073-1086

11 comments

  1. Pingback: What is ADHD? | ADD from a "grown-ups" perspective
  2. maddfree

    Interesting post. Your traffic control analogy was fun to read. 🙂 I have ADD and believe my son to have it too. Be interesting to read more of your insights.

  3. Vin

    This helped me understand ADHD better than I have in the last ten years of working with kids. I would love to hear more on the behavioural management techniques you would recommend.

    • Holan

      Thank you, I will definitely be posting more on ADHD, learning difficulties and Autistic Spectrum Disorders as these are my specialties. Follow by email to ensure you don’t miss the posts!

  4. hyperpolymath

    Yes, I think this is good, although (as someone with hyperkinetic disorder, which is fairly close), I do feel this is a bit pessimistic. To some extent I agree, and it is nice to see a new analogy that presents the notion in a different way, but I would argue that to some extent what you are saying here is quite true of a lot of people’s experiences of growing up without a disorder. We wouldn’t medicate perhaps, but the work of our parents in responding to the challenges of parenting, and how we approach things that we find difficult – isolate the things that are important (or not), for better or worse, etc. – are things we all face.

    I think one of the things I experienced growing up which I never really understood was how experts were better than other people at their expert ‘things’. It is only quite recently that I’ve really started to see the difference in thinking between me and others (or at least I think I am). When I was growing up I thought that being an expert past a point would mean you would get worse at your job, and it lead to distrusts of a lot of experts and also a much more ‘portfolio’ nature to my adult life.

    When I was doing new things and really concentrating on them it seemed that I was doing them better and better the more I practiced them. It required a lot of attention, perhaps more than my peers, but I could see and feel myself getting better. But when I started getting to a stage where I felt that it was becoming more unconscious, I remember that that was when things started going wrong. I would start to make a mess of things and make lots of mistakes. I went back to the task and I’d try again and again to do it right, but because it was automatic now and I found it difficult to break down and put together, I got sloppier and sloppier. This was where I became really frustrated. I would write something for instance (because that is really automatic), think it was fine. Come back to it, proofread it, think it was fine. Hand it in and think it was fine, then get comments back about where I might have started a sentence and gone off track or just stopped it mid flow. I would look at it and think, how could I have missed that, when it was so obvious. Even writing this (and I’m on dex) I’m thinking, hmm, maybe I’ve done this here too). So it affects me in that way.

    Getting older has not so much been about me getting over it (medicine does help a lot) but built my self-awareness around what my limitations are. Perhaps this is why I am now working as a lecturer, because in this environment there is much more tolerance of flex than in others. I always remember thinking when I was on a plan, I hope the (real) air traffic controller has only been doing his job for a medium amount of time because who knows what will happen if he is really experienced!

    • Holan

      Thanks J. I know the analogy could not cover everything, but didn’t want to stretch it too far. Glad that at least it wasn’t totally out of the ball park of your experience. Motivation has been shown in brain scans to rectify the deficit in ADHD in specific tasks. See stuff by my colleague Phil Asherson. So your experiences seem to reflect this. When something is new and exciting, you will be able to focus better, once it becomes mundane, that rectification becomes lost. What I love about modern science is that you can see this actually happening before your eyes on MRI scans in experiments! (Ok I admit I haven’t but I saw Phil’s great slides of his scans).

      You are right that behavioural intervention is just glorified parenting. Often, you feel a real chump for stating the obvious when delivering behavioural management. It was not until having my own kids that I realised that for most people, myself included, in the heat of the situation best practice can go out of the window. This has less impact on children who are not vulnerable, but in children who have difficulties, being on top of your parenting is really important and can make a big difference, that’s why behavioural management exists, to remind and support parents of best practice and structure it in a way that it becomes routine and consistent. It is not some amazing new formula or unique strategy. It is pretty much all about the reward chart….

      Sorry if it read pessimistic, it didn’t intend to be, I have had many success stories. Maybe instead of saying 30% progress to adult ADHD, I should say 70% no longer have ADHD in adulthood. Does that help?

  5. Pingback: Happy 6 month Birthday! | shrink GROWS kids
  6. Maria

    As a parent of a child affected by ADHD some practical tips for aiding the development of coping strategies in the 7-9 age group would be very useful. Topic for another blog?

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