Tagged: ADHD

How fast is your child’s thinking?

Core Abilities

I am posting again on my infant 360 degree appraisal series. Core abilities include ‎memory, ‎attention span, processing speed and impulse control. These are factors that affect ability in all other areas. Deficits in core ability will detrimentally affect ability on the other aspects of function. In this post I will cover processing speed and impulsivity.

Processing speed

Processing speed in the brain is exactly the same as the processing speed of your computer. Some computers are just faster than others. If your computer downloads a movie instantly, while others are still buffering, you can imagine who has the advantage. I remember as a child marveling at my older sister’s ability to do sums in her head while I was still scrambling around for fingers and toes to count.  That’s the advantage of processing speed; she was doing the same thing that I was, but just faster and more efficiently and keeping her socks on. Processing speed improves with age in an individual, but there is clearly variation in processing speed between individuals.

Processing speed is all about “how fast” someone can do things. Therefore, in order to test it, you need to know that the child is able to do what you are asking them to do. Tasks chosen should therefore generally be easy. Clinically one measure of processing speed used is a sheet of paper with different symbols on. The child is timed to cross out all the symbols of a particular shape. The score is then based on time taken with a penalty for any false positives (crossed out shapes that were not the specified shape) and false negatives (the correct shape was not crossed out). The task can be varied in difficulty by having all the symbols look very different or very similar. If you are experimentally minded and have an older infant (3 years upwards), you can easily replicate that test at home to gain an idea of processing speed. Here are handy sheets that you can print and use if you are so inclined: Processing Speed Test. Go on, you know you want to, and share with your friends (to find out what their kids score – whilst feigning disinterest of course).

Other simple ways to test processing speed, particularly of younger children include sorting. Sorting items by colour can be mastered easily by an infant and if you time this you can get an idea of the processing speed (again factoring in accuracy). Equally, the time it takes to push shapes through a shape sorter can be used, although this is more of a test for visio-spatial skills, motor skills and processing speed; rather than processing speed alone. Children with good visio-spatial skills and processing speed will be able to do this task quicker. Children that adopt a trial and error approach to the shape-sorter, will get there eventually, but they will be outclassed time wise by someone who is able to process in their head which shape is likely to fit through which hole. Spatial ability is known to predict performance in mathematics and eventual expertise in science, technology and engineering (Tosto, 2014). By the time Lil Bro was one year old, we had acquired so many hand me down toys that we had several shape sorters. The first had only 3 shapes (square, circle and triangle), the second had 10 shapes and the third had about 24 shapes including complex trapeziums and parallelograms. If you are sad like me, you can monitor development through progression of progressively harder shape sorters.

Impulse control/ response inhibition


It is very easy to observe a child’s impulse control, or largely, lack of it! Most adults are able to control their immediate urge to do something to hold out for a greater reward or avoid punishment. For instance, most of us are able to save money in order to buy something big and we are able to wait our turn rather than push into a queue to avoid being told off. Most toddlers are not able to do this, so if you put a new “toy” in front of them, they will try and grab it even if you tell them not to. Try drinking a glass of wine while holding an alert one to two year old in your lap. Good luck.

Sometime between toddler-dom and adulthood, the ability to control impulses develops and strengthens. The earlier that a child develops impulse control, the better they will be perceived, as this will mean that they will be less likely to do things like touch things that they shouldn’t, shout out in class, push in to queues, interrupt other people talking and running across the road without looking. People tend to like children better if they don’t do these things.

You can easily observe your child’s ability to control impulses by taking them into a fancy department store or if you are more daring a china shop. Immediately, you will be telling your child not to touch anything then you can see how long they last. If you really want to test them, you can mix it up a bit. Say “If you don’t touch anything, I’ll buy you some chocolate on the way out” and see if they fare better, or you can up the ante on the temptation and take them to a sweet shop and expect them not to touch! That would be very cruel indeed.

Cruel though is what child psychologists and psychiatrists are in the pursuit of answers, and they actually do this test in the research labs with a cupcake which cannot be eaten despite being left directly in front of the child, on the promise that they will get two cupcakes for leaving it alone. As expected, older children find this easier. This test is very easily replicable at home for anyone who wishes to be so mean (or who has plenty of cupcakes to be eaten)!


Core-ability training

Like for attention, where repeated episodes of bringing back to task and encouraging goal-oriented attention can increase ‎attention span, so too can processing speed, memory and impulse control be improved. The suggested activities for assessing processing speed, memory, impulse control and attention can also be played in order to train infants on these core abilities.

brain growth

This back of an envelope sketch shows a graph of human brain growth and decline. During infancy the brain is going through massive growth with the child building circuits and connections in the brain in response to its environment at a rapid rate. It is thought that training at this stage in development is likely to physically affect brain development (the interconnections between different parts of the brain) and have larger impact than training at any other time in life. Similarly, continued mental activity (such as playing chess) at the other end of the lifespan can slow the inevitable brain decline in old age by strengthening connections so they are not lost.

There is growing scientific interest in obtaining evidence that attention span and impulse control can be trained. Research into ADHD treatment and prevention are moving towards computer games, aimed at toddlers that will train attention to goal oriented activity (Wass, 2011). Potentially, future ADHD prevention will involve computer-based intervention at infancy rather than medication in childhood. Why wait for a computer game to be developed to do this when parental interaction is much more fun and rewarding. In actuality, many parents are doing this already, only they are doing it instinctively when trying to interact with their child on an activity – encouraging, supporting and helping a child stay focused to complete something fun. Now you can carry on doing these things with the smug knowledge that you are not just passing the time, or playing a game, but also potentially physically improving your child’s brain.

Tosto et al.(2014) Why do spatial abilities predict mathematical performance? Developmental Science (Dev Sci), On-line ahead of print.

Wass et al., Training Attentional Control in Infancy, Current Biology (2011), 21, 1-5.

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.


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