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Tuesday, November 5, 2013

Demystifying ADHD

Attention Deficit/Hyperactivity Disorder, commonly referred to as ADHD, is a disorder that we are getting better at identifying and addressing as research studies and understanding of the brain improve.  But I notice time and again in my work with families that parents have difficulty understanding why it is that their child with ADHD functions as they do: why they can’t manage their belongings, get ready to leave the house on time, complete homework independently, and so on and so on.  A thorough description of the disorder and specificity in the subtype affecting their child (Inattentive Type, Hyperactive Type, Combined Type) is insufficient even when it is thorough and highly detailed. 

It is this one sentence that makes all the difference, one to which parents invariably reply, “Oh, now I get it!”

Individuals with ADHD generally function at a 30% developmental delay in areas of performance that rely on executive functions.

It’s the 30% part that they get. 

Oh, so my 12 year old actually functions like he is eight?,” says a mother. 

“Yes,” I reply. 

“That makes so much sense,” she says, her husband nodding away beside her. 

Now the conversation can really take off:

Me: “So, would you expect an 8-year-old to complete his homework without reminders and guidance?”

Parent: “No, I wouldn’t.”

Me: “Would you expect him to remember to brush his teeth, put his clothes in the hamper, and get his backpack ready for school on his own?”

Parent: “No way.”

And so it goes, through the conversation about cleaning his room, getting ready for school in the morning, leaving his belongings all over the place, remembering to do chores.

ADHD is a disorder of inhibition and self-regulation seen in deficits in executive functioning that cause impairments in an individual’s ability to perform at an age-appropriate level.  One might think of the executive functions as the use of self-directed actions to choose goals and then select, enact, and sustain actions across time in furtherance of those goals.  Individuals with ADHD cannot demonstrate the expected level of skill in selecting goals and then behaving in the manner needed to attain those goals.  Their thinking is predominantly (and at young ages even exclusively) of the now, rather than the later and so working toward a goal (in the future) is quite difficult. 

An understanding of the 30% developmental delay enables adults who work with the youngster to think of his or her chronological age (e.g., 15 years) as well as the ever important executive age (e.g., 10).  In doing so it is easier to set and support expectations that are appropriate to the student’s current ability (as opposed to expectations based predominately on age-based norms).

By its nature, ADHD is a performance disorder, not a problem in the acquisition of knowledge.  The individual’s intelligence is intact as is her knowledge base; she understands what to do.  The problem lays in performance, despite knowing what to do, she cannot do it. 

We must thus think about interventions like this:
  •  What structures does this child need to succeed?
  •  How much guidance must be inherent in those structures?
  •  How do we motivate this particular child?

Those interventions then need to be modified at the point of performance such as the classroom or during the completion of homework, not later.  And appropriate changes in expectations must be made and sustained.

Remember, if your child is operating at a 30% delay in executive functioning, he or she is unable to self-regulate at an age-appropriate level.  Expecting him to is setting him up for frustration and failure.  It’s setting yourself up for the same.  
  • What expectations have you been putting on your child that he is not ready to fulfill?  
  • How have you been reacting when she has failed to meet them?  
  • How is he telling you he feels when he fails to live up to your expectations?
If you would like to learn more about executive functions and practical ways to address their development in the home and classroom, there are many books available for resource. Two that I often recommend to parents in my practice is:  Late, Lost, and Unprepared: A Parent's Guide Guide to Helping Children with Executive Functioning by Joyce Cooper-Kahn & Laurie Deitzel or Smart but Scattered, by Peg Dawson.

Thanks, Jennifer
Jennifer Jackson Holden, Psy.D.
Clinical and Educational Psychologist
Center for Psychological Services
Paoli, Pennsylvania

610-647-6406, ext 3
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