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Attention Deficit Disorder: A Decade Later

by Jay Einhorn, Ph.D. In the summer of 1992, The Cove Chronicle published my article: “A Look at Attention Deficit Disorder” (the Cove Chronicle is the newsletter of the Cove School, a school for children with learning disabilities, where I am Consulting Clinical Psychologist). Ten years have passed, and recently Vivian Drexler, Cove’s High School Division Head and Transition Coordinator, asked me to provide an update to help teachers, students and parents. The biggest change over the past decade has been in our understanding of the brain functions underlying ADDs (I’m using the term “ADDs” to refer to “attention deficit disorders,” since there are a variety of them). Ten years ago, I wrote: “There is a considerable amount of research to suggest that attentional problems may often be the result of impairments in the frontal lobes of the brain, the parts of the brain just behind the forehead and under the top of the skull.” Today, the concept of the “executive functions” of the brain is being more and more widely researched and discussed and, in fact, seems to include attention within a wider spectrum of frontal and prefrontal brain activity. (Imagine a semicircular hairband going straight over your head from the front of your ears and that’s roughly the division between the frontal and prefrontal parts of the cerebrum, at the top and toward the front of the brain, and the rest.) Executive functions include prioritizing, planning, organizing, sequencing, self-monitoring, self-evaluation and generating adaptive changes in response to internal and external feedback. Attentional self-regulation, that is, selecting what to pay attention to, sustaining that attentional focus for as long as necessary, and inhibiting distractions until that purpose is accomplished unless something more important happens, is part of executive function. We know that these functions, for the most part, are mediated through the frontal and prefrontal lobes, both from injury studies (patients who sustain frontal or prefrontal injuries often show disruptions in self-regulation and other aspects of executive function) and imaging studies (research subjects whose brains are being scanned show increased frontal and prefrontal lobe activity on tasks of executive function). So, attention deficit disorders seem to be part of the executive functions of the brain, which seem to be mainly located in the frontal and prefrontal lobes. But, of course, there’s more to it. For example, the cerebellum, behind the base of the brain, seems to be involved in some aspects of attention and learning, especially in the kind of learning that occurs when new skills that we’ve learned through effort and repetition become automatic. If the new behavior can’t become automatic, we have to keep learning it over and over again, dedicating conscious energy which could be available for other things if the task became subconscious. Thus, impairment in the frontal-cerebellar circuitry may interfere with the transfer of new learning into adaptive habits. Next, there is the idea that there is a spectrum or range of attention styles, and that different attention styles are better or worse adapted for different purposes. Whether or not a person has an attention disorder may depend, in some cases, on whether the match between his or her attentional style and the kind of attention required to succeed in his or her environment is a good or poor one. Some people are very sensitive to changes in their external environment, that is, the world around them, while others are able to maintain a firm focus regardless of what is going on around them. The former type of attention is well suited to hunting, tracking, or making split-second decisions in the commodities market. The latter kind of attention is better suited for academic, philosophical or scientific study. Some people are very sensitive to their internal environment, so that changes in their thoughts and feelings can easily result in a shift in attention focus, while others have be to extremely moved or upset in order to shift their focus from a selected task. For former kind of attention may be better suited for artistic creativity, the latter for business or academics. Of course these are generalizations; the point is that different styles of attention correspond to different talents and aptitudes. (As I revise this, seated in the waiting room of an Illinois vehicle emission testing center, the technician had to call me twice, to get my attention, to tell me that my car was ready. His expression, patient and amused, suggests that most people don’t need the second call.) So, the impression emerging from several areas of research--medical, neuropsychological, biological, educational--is that there is an entire spectrum of attention styles. Most peoples’ attention tends toward the middle two thirds of that spectrum. Those whose attentional style tends toward either pole of the spectrum, who are quite externally or internally reactive but still within the normal range, may be misdiagnosed as having attention problems in an academic environment. These are the children who aren’t “made for school” but who would fit in with the demands of a hunting, farming, trading, or artistic community. Often, such children are more successful in life after school than they were as students. They don’t really have attention disorders so much as they suffer from a mismatch between their style of attention and the demands of school. People with real attention disorders, as psychologist and ADD expert Sam Goldstein emphasized at a recent conference, are those who would be seen as disordered in almost any setting, those whose lives are negatively influenced by their attentional style more or less wherever they are and whatever they are doing. The problem here is one of self-regulation. No matter what environment one is in, one must be able to put one’s mind on a task and get the job done. People who are too hyperactive or distractible to see most tasks through to a successful conclusion are suffering from a problem which is likely to undermine their efforts and goals in any context. Inhibition of impulsivity is an important part of self-regulation, as is emphasized by psychologist and ADD expert Russell Barclay. In order to keep my attention focused as I write this article, I have to inhibit distractions both from outside my office, such as people walking by and chatting, cars passing, and smells from the spice shop and bakery nearby (did you notice the change of scene from the emissions testing center? ). Potential distractions also arise from within myself, such as the urge to go into the kitchen and snack, run across the street to Hogeye Music to get new strings, or ruminate on the various emotional and relationship issues which are always going on in anyone’s life. I have to keep my mind on this project, and not others, such as the several client evaluation reports which are waiting to be written, although there may be connections between this topic and those reports. When I’m interrupted, for example by a telephone call, I have to refocus on the task when the conversation is over, rather than allowing my attention to flow into a new direction. There seem to be different channels or pathways in the brain that are dedicated to inhibit external versus internal stimuli, which results in a couple of different kinds of attention disorder, and also has implications for medication. Some people, as I’ve indicated, seem to be more distracted by events happening around them. They seem to be more hyperactive, because they respond to what happens in their environment. This kind of attention disorder seems to be more responsive to medication by stimulants. The current clinical assumption is that the stimulants cause the release of a neurotransmitter, dopamine, which is undersupplied in those neural pathways in the brain that are responsible for inhibiting external stimuli. By some process which is theorized but not yet known, the stimulant is selectively absorbed by the undersupplied inhibitory pathways, resulting in the paradoxical response of hyperactive children and adults to stimulants: they slow down. (For shorthand purposes, and somewhat ironically, I refer to stimulants for hyperactivity as, “brake fluid.”) On the other hand, stimulants don’t seem to help people with the internally distractible type of attention deficit disorder all that much, but antidepressant/anti anxiety medications, such as SSRI (selective serotonin reuptake inhibitors) and tricyclics do. This leads to the assumption that the pathways in the brain that inhibit internal distractibility from our own thoughts and feelings are chemically different in their method of operation than the ones that inhibit external distractibility. It may be that the antidepressant-antianxiety medications fortify undersupplied internally focused inhibitory tracts, like stimulants for undersupplied externally focused inhibitory tracts are thought to. It also may be that, by causing a general numbing of emotion (a sensation which is reported by many people taking such medications) antidepressant-antianxiety medications simply “turn down the volume” of the inner world, so to speak, allowing the person to maintain a more consistent focus. Medication can be part of the answer, and is often a necessary one, for persons with attention deficit disorders, but behavioral interventions are necessary as well. A recent U.S. Government study of children with ADDs indicates that medication, together with cognitive behavioral therapy, including parent training, is more helpful than medication or therapy alone. Medication alone did seem to be more effective for more children than psychotherapy alone, but not as valuable as both together. (The quality of therapy is always an invisible but powerful variable, since, assuming that the diagnosis is correct, medication is always the same, but therapy varies in subtle but crucial ways that cannot be easily measured--or, perhaps, measured at all. See my earlier article on Mutual Attunement in Psychotherapy.) Its important to remember that medication is not a panacea. It rarely resolves the problems of ADDs completely, usually causes side effects--sometimes quite uncomfortable or severe ones--and generally loses potency over time, as the body accommodates to it. Personal learning, for both the child with ADD and his parents, is necessary to help in ways that medication can’t. “Personal learning” refers to the child and her parents learning about ADDs and understanding how that information applies to them, and to their acquiring skills to observe, evaluate and change their behavior. It can take place in psychotherapy, and always does when therapy is effective, as well as through self-help groups like CHADD (www.chadd.org), and from the work of experts such as Russell Barclay (my search found no dedicated web page but lots of references on other web pages), Sam Goldstein (www.samgoldstein.com), and Edward Hallowell (www.drhallowell.com). Personal learning is vital to help keep the amount of medication to the necessary minimum, and to place keys to self-control in the hands of the child and his parents. There is an analogy between teaching a child with an ADD to manage herself, and teaching a dyslexic child to read. In remedial tutoring, the dyslexic learns methods which she can use to compensate for her problem in reading. The person with attention disorders, or his parents and teachers, use behavioral methods to compensate for the attention disorders. Tracking, prompting, planning, time-out and time-in strategies, relaxation, exercise, and structured reflection, are all behavioral methods that can help individuals cope with attention disorders. Let’s consider each one, briefly. Persons with ADDs often miss homework deadlines and arrive late to appointments or forget them altogether. They don’t keep good track of what they have to do, when it has to be done by, or where they have to be in the future. Tracking methods, such as assignment notebooks, homework logs, calendars, or electronic organizers, can play a vital role in helping persons with ADDs to be organized about what’s due and when. Some children with ADDs can’t keep track of what they should even with an assignment notebook, homework log, or calendar, so they need the concerted cooperation of teachers and parents to make sure that their tracking is up to date. Parents and teachers often make a well-meaning mistake by expecting the child to be able to keep up his own tracking system before he’s ready to do so, thus creating a hole into which he falls. We should encourage children to be as independent as they can be, but when they’re not yet ready to keep track independently, teachers can help by informing parents of assignments as they are given (e-mail helps to make this manageable for overworked teachers), parents can help by making sure that those assignments are done, and teachers and parents together can keep track of the assignment notebook or other tracking method to make sure that it’s complete. For adults, and for children who can keep a good tracking system but then forget to use it, it may be necessary to establish a routine in which the tracking system is checked each day, at regular times. For those with attention deficits, a little bit of constructive compulsivity in compensation can be a good thing. Prompting means reminding persons with ADDs what to focus on. Parents prompt their children by reminding them to do their homework, to check their assignment notebook or other tracking system, to plan to do something. Children and adults can benefit from what I call the “constructive nagging” of parents, therapists, or spouses, about what they have to remember to focus on, as long as they understand that the purpose is to help, not to put down, and the prompting is offered without any negative attitude. When prompting, remember the lesson about communication that Harold Balikov told me: 90% of the message is in the attitude . Planning is necessary once tracking is done. Children have to plan how much time a homework assignment will take to complete. Adults have to plan how much time a project will take, or how long it will take to travel from one place to another for an appointment. Persons with ADDs often don’t plan, and so find themselves without enough time to complete an assignment or project, or get to an appointment on time, even if they remember it. Writing preparation time into the tracking system can be very helpful. Thus, an adult can write not only the time of his appointment, but the time that he has to leave for it, in his calendar. A child can write not only his assignment and when it’s due, but when he’s going to work on it, in his assignment notebook. Time-outs are often very useful for children with ADDs when their self-regulatory abilities become flooded. It can be very helpful for a student to leave a class for three, five or ten minutes, just to reset his attention. This should be seen as positive self-regulation, not blameworthy or a punishment. A teacher can simply say, “John, you could use a time out to get ready to begin learning,” or “Go to (the designated time-out room) and come back when you feel you’re ready to get to work on today’s lesson.” Or, a student can tell the teacher that he needs a time-out. Children will often use these appropriately and not abuse them, though the potential for manipulation is there, and improper use of time-outs has to be watched for. If the child has become emotionally upset, the time-out may need to be extended, as it takes longer--half an hour or so--to recover from emotional flooding than it does from attentional flooding. Well-meaning teachers. parents and spouses sometimes make the mistake of insisting the child or adult stay involved in a discussion of whatever he’s done wrong when he’s too agitated to participate in the conversation. Taking a time-out first, to cool down and refocus, can make a world of difference, and it isn’t avoidance as long as the matter is eventually discussed as thoroughly as it needs to be. What I’m calling “time-in” strategies can be useful to help persons with ADDs engage their executive functions. Time-in involves giving timed cues to help them prepare for a change in mental focus and behavior whose time is approaching. For example, when a parent or teacher tells a child to change a behavior, counting down (from 3 or 5, for example), can help the child to prepare his mind to make the change. If a class or task change approaches that a student finds disruptive, he can be cued at intervals prior to the transition to mentally rehearse a strategy he’s learned to make the transition easier. A similar strategy can be used to help a person with an ADD get ready to leave home on time. Deep relaxation can support executive functions against being overwhelmed by emotional turbulence, by reducing the level of agitation that the person experiences. “Relaxation training” sounds like a contradiction in terms, but it isn’t. Most of us don’t know how to relax deeply; we think we’re relaxed when we’re watching television, but our bodies maintain patterns of chronic tension until we release them. There are various methods of relaxation, and, like anything else, different methods work better for different people. Relaxation has to be practiced regularly for it to become effective in supporting self-regulation. Regular exercise has all kinds of therapeutic benefits, and can help persons with ADDs to reduce stress and enhance self-efficacy and self-esteem. If there was a pill that could deliver the benefits of regular exercise, we’d all be taking it. Because exercise is a behavior and not a pill, we tend to overlook it. Research shows that exercise works more or less as well as medication for relieving mild to moderate depression, and I suspect that it also relieves anger, and the associated emotions of frustration and annoyance. Structured reflection means taking time to look back on what has happened to us, and how we’ve responded to it. The regular practice of structured reflection helps increase our ability to self-monitor, evaluate, and adaptively change our behavior--that is, learn--in response to the various challenges with which life presents us. Psychotherapy encourages structured reflection, by helping clients to reflect on their experiences and reactions. Parents can help children review their day, either from start to finish, or focusing on one or more important parts, before going to sleep (or, if a child finds this stimulating rather than restful, at another time than bedtime). Keeping a diary or journal can support structured reflection, as long as there is a reflective focus and not just a venting of emotion. Forms to support structured reflection can easily be developed, for example, to help students focus on the classes they were in today, or times when they misbehaved or became particularly upset. Of course, all these methods are helpful for people without ADDs, and you don’t have to have ADDs to use any of them. We can all benefit from help with our executive functions. Neuropsychologist Elkhonon Goldberg, author of “The Executive Brain: Frontal Lobes and Civilization,” sees civilization as evolving through the cultivation of frontal lobe functions, which cultures can support or undermine. I think that this idea is both fascinating and important, and could lead to our being able to appreciate and criticize cultures, including organizations as well as societies, from the point of view of how they support, restrict, or undermine various brain functions in their members. (www.elkhonongoldbeg.com). The promise of biofeedback in treating ADDs was another topic which I touched on in my 1992 article. Unfortunately, there’s not much more to say now than there was then. It’s very appealing to think that persons with ADDs could learn to alter their brain function through EEG (electroencephalogram) biofeedback; this would be the brain altering itself without the risks and side effects of medications. But it remains controversial. It is discussed on the CHADD website, in its section on “Assessing Complimentary and/or Controversial Interventions,” where it states: “While the theory underlying EEG biofeedback as a treatment for AD/HD, is consistent with what is known about low levels of arousal in frontal brain areas in individuals with AD/HD, its effectiveness is not demonstrated at this time. Several studies have produced impressive results, but these studies are seriously flawed by the use of small numbers of children with ambiguous diagnoses, and the lack of appropriate control groups...” I have discussed EEG biofeedback, also called “neurofeedback,” with parents of very hyperactive children who were unable to continue taking medication because of side effects, or when asked about an alternative to medication. I continue to see it as promising, but strongly suspect that careful selection of children who can benefit along with tailoring of treatment to the needs of individual children by alert and innovative clinicians will emerge as key elements in its effectiveness. That is, neurofeedback, I suspect, is going to end up looking more like psychotherapy than medication. Psychiatrist Daniel Amen claims to have developed a method of specifically diagnosing different ADDs using SPECT, a way of studying brain activity. His identification of a number of different types of ADD tends to reflect the clinical experience of many practitioners that ADD occurs in different forms in different people. I expect that this will provide a fertile area for research. However, Dr. Amen’s claims are also controversial because they haven’t been replicated by mainstream researchers and clinicians, but are presented as if they were already verified. Both Dr. Amen and proponents of neurofeedback (EEGspectrum.com) offer the defense that mainstream science and clinical practice have often been critical of breakthroughs. This is true, but yet not a satisfying rebuttal, since anyone, no matter how unfounded his procedure, could make it. It helps to remember, as a balance against our fascination with technology and belief that there is a technical solution for every problem, that EEG and SPECT, exciting as they are in their ability to provide us with information about brain function, are relatively primitive instruments compared with the complexity of operation of the brain. They are windows into the brain, but still very limited and distorting ones. Today, as a decade ago, the clinical judgement of informed professionals remains the basis for diagnosis. Computerized tests which claim to “assess attention” are over-hyped; attention is too complex a process to be measured in that way, though such tests can sometimes provide useful information contributing to a diagnosis. Psychologist Sam Goldstein, during his talk at the 2002 Learning Disabilities Association conference in Denver, warned his audience to look past the titles of such “tests” to what they actually measure. Shared symptoms and co-morbidity are two factors that complicate diagnosis. People with ADDs may be impulsive, distractible, and have difficulty concentrating and following through on projects, but so do lots of people who don’t have ADDs. Conditions such as depression, anxiety, personality problems and disorders, and post traumatic stress disorder, may all result in such symptoms. Often, too, persons with ADDs also have verbal or nonverbal learning disabilities, and/or emotional and personality problems which complicate their diagnosis, education and treatment. So there is a need for differential diagnosis to try to sort out what is really causing the problem, because the treatment depends on the diagnosis. This can only be done through careful observation over time. Within the last year or so, I’ve diagnosed four adults with ADDs who had been diagnosed with learning disabilities as children but their ADDs had not been noticed. Of three of these adults, whom I’ve continued to work with in therapy after evaluation, two are responding positively to low doses of stimulant medication and using methods to compensate behaviorally, and one is coping with behavioral methods alone. Similarly, there are lots of people diagnosed with ADD who also have undiagnosed learning disabilities. Sometimes the diagnostician is only looking for one thing or the other. The main problem, in my opinion, aside from lack of adequate training of evaluators, is that the time allotted for diagnostic evaluations is often too brief to allow a comprehensive look at the person. There’s really no short-cut to good diagnosis. A columnist for a major newspaper terminated an interview with me because I couldn’t supply a list of people with ADHD but without other learning disabilities whom she could interview, or a ten-item checklist with which her readers could diagnose themselves. Well, sorry. I expect that we’ll know more in another ten years! Note: Special thanks to Vivian Drexler for editorial review of an early draft of this column, and to Dr. Jo-Ann Hoeppner for reviewing a later draft. It’s a better column for their help, and any errors are my own.