Attention Deficit/

Hyperactivity Disorder

What is AD/HD?
By far, the most commonly diagnosed disorder in
childhood.
Symptoms have to appear before 7, and the
disorder is generally a chronic condition until
adulthood
After puberty, about half of those diagnosed no
longer show symptoms, especially in
hyperactivity/impulsivity
AD/HD appears to be about 80% heritable, more
than bipolar disorder, or schizophrenia, for
example.
There are a variety of possible causes, all of them
related to a problem in frontal lobe functioning.

Whats the
problem?
. . . The person or the context?
Several elements of the ADD mind favor creativity....As mentioned earlier, the term
'attention deficit' is a misnomer. It is a matter of attention inconsistency. While it is true
that the ADD mind wanders when not engaged, it is also the case that the ADD mind
fastens on to its subject fiercely when it is engaged. A child with ADD may sit for
hours meticulously putting together a model airplane. (Hallowell/Ratey)

ADHD traits are a problem when the child is expected to conform to regular routines,
and operate in contexts that favor their weaknesses, not their strengths.
For example, children with AD/HD often excel at Kinesthetic (physically oriented) and
creative pursuits. They are far more likely to be entrepreneurs than accountants.

Farmers vs.
Hunters
Disorder Perspective

ADD as a Natural Adaptive Trait

"The Hunter (Thomas Hartmann)

Distractible.

Constantly monitoring environment

Poor planner, disorganized

and impulsive (makes
snap decisions).

Flexible; ready to change strategy

quickly.

Distorted sense of time:

unaware of how long it
will take to do
something.

Tireless: capable of sustained drives,

but only when "hot on the trail" of
some goal.

Impatient.

Results oriented. Acutely aware of

whether the goal is getting
closer now.

Daydreamer.

Able to easily conceptualize new ideas,

creative

Acts without considering

consequences.

Willing and able to take risks and face

danger.

ADHD and
Cognition
AD/HD is characterized primarily as a problem in
Executive Functioning. This includes a number
of different abilities related to controlling mental
processes and putting a plan into action.
Regulating attention
Selective or focused attention the ability to focus on
something while ignoring other stimuli
Sustained attention focusing on a task over a period of time
Vigilance the ability to notice a particular detail, piece of
information, etc.

Sustained
attention

Planning/responding
to feedback
Planning
Prospective memory the ability to remember
to do something at a future time

Putting a plan into action, remaining flexible

Sequencing/organizing
Managing competing demands, incorporating
feedback from the environment
Inhibition stopping an initial, impulsive
response
Set shifting changing strategies based on
changing circumstances or feedback

Response
Inhibition
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Response
Inhibition
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Switching
Inhibition
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Working Memory
Working memory While not really a
part of EF, this is the ability to hold
information in mind and manipulate it.

VARIETIES.
VARIETIES.

Diagnosing
AD/HD
. . . is in some ways a process of elimination
When someone struggles with a mental health problem,
the attentional system is the first thing to go.
These disorders also have a subsequent effect on
school performance, completion of the tasks of daily
living, etc.
ADHD is sometimes mis-diagnosed in cases of:

Fetal alcohol effects

Brain injury
Anxiety Disorders
Bipolar Disorder
PTSD/Anxiety Disorders
Young children often show anxiety as hyperactivity

Unlike other mental health issues, ADHD is a chronic

condition.

Inattentive
Subtype

Spacey, daydream frequently, disorganized, easily distracted,

inattentive to detail
This lack of vigilance causes the child to forget important items and
responsibilities

Primary deficit in working memory, especially prominent in auditory

processing because of the demands it places on working memory.
Can lead to problems in reading, mathematics due to WM demands.

Problems in auditory attention/vigilance lead child to miss

directions/verbal commands

A significant subset are hypoactive, sluggish, have slow response

speeds.

Easily bored, under-aroused. As maintaining focus is experienced as

arduous and aversive, tend to procrastinate, have trouble with task
completion.

Inattentive
Subtype
Tend to be overly self-conscious
More likely to be introverted, social problems
because too passive, shy, or withdrawn
Internalizing disorders, such as anxiety or
depression, are somewhat more common in
children with ADD than those with ADHD. Reading
and language deficits and problems with mental
mathematical calculations are more commonly
comorbid with ADD than with ADHD.
A significant percentage are not helped by
Methylphenidate, those who are helped by
methylphenidate often do best at low doses.

Hyperactive/Impulsive
Combined Subtype

Hyperactive, always on the go, impulsive

Primary problem in response inhibition

Often insufficiently self-conscious

Social problems because too assertive and impulsive: butt in, take
things belonging to others, fail to wait their turn, and act without first
considering the feelings of others

Tend to be extroverted, sensation seeking

Externalizing behaviors, such as conduct disorder, aggressivity,

disruptive behavior, and even oppositional defiant disorder are far
more commonly comorbid with Hyperactive/Impulsive Subtype than
with Inattentive Subtype

Respond positively to Ritalin in moderate to high doses.

Interventions

Interventions
Behavioral interventions can work, but their
effectiveness will be limited.
Generally, medication has to be explored

Ultimately, the child and family need to recognize

that ADHD is managed and coped with, not cured
This means that the childs limitations, and a
certain amount of problem behaviors, have to be
accepted.
How can I get them to remember to hang up their towel
when theyre done with it?
You cant.
You can hold them responsible for picking it up, after the
fact.

Interventions
Inhibition
Children with inhibition problems lack an internal
dialogue that allows them to use language to
manage emotions and self-manage their behavior.
Strategies for inhibition training
Emotional labeling, followed by concrete affect regulation
strategies
Breathing, motor movement

Repetition of desired behavior

Priming through transitions
Games

Card slap
Jenga
Tower building
Control panel
Shape game

Interventions
Hyperactivity
As inhibition is difficult, reward systems can be
useful to motivate behavior, in addition frequent
facilitation.
Care has to be taken to prevent the child from
experiencing self-esteem problems, or creating a power
struggle. The most important ingredient is patience.

Generally, some activity is necessary or even

useful
Allow time for outside, gross motor play
Limit time on-task, utilize frequent breaks
Allow some fidgeting, or provide materials for sensory
stimulation (pipe-cleaners, moldable wax, t-stools, etc)

Studying/
performance

People with ADHD are attracted to, interested in, and pay
attention to things that are novel or interesting
These things increase arousal and are able to achieve
salience, they get noticed and remembered
The are also able to hold attention
Often, things that are interesting will hold attention to the
point of creating a hyper focus with these things,
people with ADHD may have trouble not focusing on
them.

Interventions Memory

The child and family cannot depend on the child to remember the things
they need to remember (from their items to their assignments).
They also will not remember to complete future tasks (deficits in
prospective memory).
Rely on external systems (visual schedules, lists, etc) to hold information
and prompt for activities.

The child is taught to use the systems, and to capture information as

soon as it becomes salient.
Use Visual systems

Everything in a glance
Color code and organize
Outline trees/concept maps
3-D representations

Checklists

Initially, this is completed by caregivers, but subsequently taken over by the

child
For older children/adults, PDAs can be invaluable

As the child gets used to the things that have been presented visually, they will
lose salience and fade away. Visual systems must be re-invented to re-create
salience.

Ritualize, schedule

While the child may often work on autopilot, this can be used to the parents
advantage

Interventions
Inattention

Task completion
Work before play
Do the thing they like least, first. This will increase arousal; theyll work harder to
get to the rewarding activity

Insure that theyve actually processed the direction

Repeating what you said does not equal understanding

Break directives into smaller commands, avoid chains

Increase arousal by increasing:

Imminence/challenge

Encourage!
Break the task into smaller pieces
Set a time limit and race against it
Set a goal for completion
Sprint, dont marathon - limit the amount of time they spend on a task to a specific limit,
study or work for a series of short spurts

Novelty
Change locations
Change seating arrangements (study standing, walking, working)

Change input method

Convert to audio
Go from book to flashcards
Quiz to insure retention

Interventions
Inattention
Increase arousal (contd)
Psychomotor activity/ take up an input system

Drum
Tap feet
Chew gum
Eat/drink
Get a rocking chair
Sit on a yoga ball
Listen to rhythmic music (no words!)
Squeeze ball
Bounce a ball

Eliminate all other inputs

Remove yourself from anything interesting or arousing
Study on a blank desk

Thats all, folks.