Monthly Archives: August 2014

ADHD – What is it and What can we do about it? I



Why write about ADHD?

I was recently asked to write a paper to contribute to a volume addressing changing trends in child psychiatry. I chose to write about ADHD. I made this choice for many reasons. One reason is that more parents bring their children to me with ADHD as one of their stated concerns than any other problem. Another reason is the evolution of thinking about ADHD has grown to appreciate the complexity of the problem (though back in 1992, Leon Eisenberg warned about the rush to medicate) (Eisenberg, 1992). That makes it interesting. And yet, despite the greater complexity of what is currently known about ADHD, many clinicians still behave as if it were a simple disease entity with a single etiology, and consider medication the first and often the only treatment option. Finally, I think the young child psychiatrists I teach and the parents and teachers I consult to should have access to contemporary knowledge on the subject.

Executive function  

I know I promised to blog more about executive function. I intend to do that. However, my reading about ADHD interrupted my agenda for a good reason. There is a large overlap between ADHD and EFD. That is due in part because there is no clear definition of executive function in the literature. Basically, executive functions refer to the internal processes an individual uses to organize the knowledge he has in the service of accomplishing goals. Problems with executive functioning include difficulty organizing oneself in time and space; initiating and formulating a plan of action to accomplish a goal; maintaining motivation during a goal oriented activity; avoiding distractions while working; and following through to a satisfactory result. You can see the similarities between dysfunction of these processes and ADHD.

I am going to write several installments on the subject of ADHD. They will be somewhat academic and may try the patience of readers who want a quick explanation and a “how to” section, but unfortunately (or fortunately) life isn’t that way. Our children are complicated, and in order to understand them we have to be patient and learn all we can learn about what makes them tick. Here is the beginning.

What is ADHD?

Among many stated claims that are unclear about ADHD, there are three facts are clear.

  1. The first is that the number of children diagnosed with ADHD is growing. Between 2003 and 2011, 2 million more children in the U.S. aged 4 to 17 were diagnosed with ADHD (Visser et al, 2014, p. 34).
  2. The second is that there is a central nervous system basis for ADHD symptoms. This fact is supported by many candidate gene studies that show associations between ADHD and dopamine transporter and dopamine receptor genes (Lou et al, 2004; Bralten et al, 2013), and also by neuroimaging studies that identify functional connectivity abnormalities in particular neural networks in the brain (Konrad et al, 2010; Liston et al, 2011; Levitt et al, 2013).
  3. The third is that a multi-dimensional assessment and treatment approach is far preferable to a rush to medication.

ADHD is characterized by inattentiveness, distractibility, impulsivity, and overactivity. It is certainly not a disease. Many attest to the heterogeneity of ADHD (Jensen, 2000; Musser, 2013; Arnold, 2014). Some even question whether it is a disorder rather than an extreme of temperamental variation (Jensen, 2000, p. 195). This consideration is based on the observation that a significant group of children with ADHD seem to “grow out of” ADHD (Hechtman, 1992), as well as studies that demonstrate the influence of social and school environment on the diagnosis of ADHD (Schneider & Eisenberg, 2006). It does seem likely that the demands our current culture places on children to sit still and pay attention, to manage frequent transitions, and to multi-task, may not be as easy for some “normal” children to accommodate as for others. This kind of consideration has led some to argue for a “dimensional” rather than a “categorical” diagnosis of ADHD (Vande Voort, 2014).

In the next installment I will write about some of the neurodevelopmental findings on ADHD.


Arnold L, Ganocy S, Mount K, Youngstrom E, Frazier T, Fristad M, Horwitz S, Birmaher B, Findling R, Kowatch R, Demeter C, Axelson D, Gill M, Marsh L (2014). Three year latent class trajectories of attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD, JAACAP 53(7):745-760.

Bralten J, Franke B, Waldman I, Rommelse N, Hartman C, Asherson P, Banaschewski T, Ebstein R, Gill M, Miranda A, Oades R, Roeyers H, Rothenberger A, Sergeant J, OOsterlann , Sonuga-Barke E, Steinhausen H , Faraone S, Buitelaar J, Arias-Vasquez A (2013), Candidate genetic pathways for Attention-Deficit/Hyperactivity Disorder (ADHD) show association to hyperactive symptoms in children with ADHD, JAACAP, 52(11):1204–1212.

Eisenberg L (1972). The clinical use of stimulant drugs in children, Pediatrics 49:709-715.

Hechtman L (1992). Long-term outcome in attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North Am 1:553-565.

Jensen PS. Commentary: The NIH ADHD consensus statement: win, lose, ordraw? J Am Acad Child Adolesc Psychiatry 2000; 39: 194-197.

Konrad K, Eickhoff SB. Is the ADHD brain wired differently? A review on structural and functional connectivity in attention deficit hyperactivity disorder. Hum Brain Mapp. 2010;31:904-916.

Lawrence K, Levitt J, Loo S, Ly R, Yee V, O’Neill, Alger J, Narr K (2013). White matter microstructure in subjects with Attention Deficit Hyperactivity disorder and their siblings, JAACAP, 52(4):431-440.

Lou, H. C., Rosa, P., Pryds, O., Karrebaek, H., Lunding, J., Cumming, P., & Gjedde, A. (2004). ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology, 46, 179–83.

Liston C, Malter Cohen M, Teslovich T, Levenson D, Casey BJ. Atypical prefrontal connectivity in attention-deficit/hyperactivity disorder: pathway to disease or pathological end point? Biol Psychiatry. 2011;69:1168-1177.

Musser E, Galloway-Long H, Frick P, Nigg J (2013). Emotion regulation and heterogeneity in Attention-Deficit Hyperactivity Disorder, JAACAP, 52(2):163-171.

Vande Voort J, He J-P, Jameson N, Merikangas K (2014) Impact of the DSM-5 Attention-Deficit Hyperactivity Disorder age-of-onset criterion in the US adolescent population, JAACAP, 53(7):736-744.

Visser S, Danielson M, Bitsko R, Holbrook J, Kogan M, Ghandour R, Perou R, Blumberg S (2014). Trends in the parent-report of health of health care provider-diagnosed and medicated Attention Deficit/Hyperactivity Disorder: United States, 2003-2011, JAACAP, 53(1):34–46.





El Salvador: Executive Functioning Part II


School Observations:

We visited the three private schools attended by the children in the home. Whereas they all bore the stamp of Salvadoran educational philosophy, they were very different. The most strikingly different was the Laura Lehtinen school recently started in San Salvador. This school for children with learning disabilities was remarkable for the high teacher/student ratio and the skill of the teacher we observed. The child we were observing, “Tomas”, had demonstrated slow development from infancy and had always struggled in school. In his last school, he was very unhappy. In this new school, his contentment was obvious.

Tomas’ classroom had 8 children, though only 4 were present during the lesson we observed, the others apparently in an adjacent room with another teacher. The teacher in Tomas’ room worked individually with a student for about 10 minutes, then moved her chair and began work with another. As she attended to each student, she periodically turned to redirect another student who had strayed from his or her academic agenda or who needed immediate attention. She had great patience and tolerance for Tomas’ behavior – which included frequent departures from his seat and making little dancing or hopping movements – and she gave him many affirmations for correct answers.

An important focus of my school observations is the playground. In Tomas’ school, both teachers were present for the entire playground activity – an unusual and welcome observation, since so much can be learned on the playground, and opportunities to support that learning are so frequently missed. The atmosphere on the playground was relaxed and pleasant. Tomas needed to be redirected once when he strayed into territory outside the bounds, but otherwise he enjoyed himself watching some of the older boys and playing with a girl classmate. Although Tomas’ difficulty following through with an agenda was apparent in his playground games as well as in the classroom, his ease in making social connections and his friendly manner seemed to mitigate his many abrupt departures from the game.

The other two schools were also good schools with dedicated teachers and lively playground activities. One was more academically rigorous than the other and had smaller classes. In this school, the teachers were able to engage their students in the material they were teaching to an impressive degree. We focused on several children from the home in this school. One, a handsome boy of 13, was often distracted by the attentions of the girls sitting near him. Another, a 10-yo girl, seemed focused on filling in the answers in her workbook instead of listening to the teacher. Liz and I took careful notes and returned to the home to discuss our impressions.



El Salvador – Testing for Executive Functioning

playing game

A few weeks ago I returned from El Salvador. It was a wonderful trip because we got a lot done and we also enjoyed the time we had with our friends there. (The names of the caregivers and the children in the orphanage will be changed to protect their confidentiality.) I usually over-prepare for the workshop before my arrival. I am rewarded for all that hard work by discovering that the caregivers are really focused on another subject, and I must do the presentation all over again. This time I decided I would be smarter and wait to prepare the power point until the day before. My traveling companion and colleague for this trip was Elizabeth Tedesco, a talented preschool teacher at the Cambridge Ellis School in Cambridge. I came to discover that she was a pleasant and comfortable companion, a hard worker, a great observer, and an all around terrific collaborator.

Our general plan was to assess the children for executive function – in an informal way, since neither Liz nor I are psychologists. I had been doing some thinking after my India trip – and also considering my skypes with Rachel – I decided that school problems were the most important focus for us right now. The commonest problem facing the children in both places seemed to be executive function problems (EFD) – organization, initiation, follow through. It made sense to me that this would be the case, because in addition to all the reasons my middle class child patients have EFD, children in the low SES population of developing countries may have the additional risk factors of malnutrition, poor health care, neglect, and trauma. That means, according to Perry’s developmental model of the brain (Perry & Dobson, 2008, the infrastructure is weak and regardless of how intelligent the child’s thinking brain is, he or she will not be able to assimilate and integrate information and produce good schoolwork.

A colleague told me about Betsy Kammerer’s work to develop an assessment tool in Africa, and I called her (Kammerer, Isquith, & Lundy, 2013). Betsy is working mostly with very young children, but she agreed with me that assessing for EFD would be most cost effective, given the likelihood that the children in our population would have this problem, and also given that there are strategies designed to help them. She also wondered whether the children in our population might be culturally unprepared to take a test themselves and thought that it might be better to give questionnaires to caregivers. She recommended the BRIEF assessment tool as an easy to do questionnaire for parents and teachers. She cautioned me about the importance of a good translation. When I looked up the BRIEF, it said that a Spanish translation was coming out soon, but I couldn’t wait, so I asked Liz and “Mona” (the education director at the children’s home) to take a try. Liz translated the parent questionnaire and Mona got a native Salvadoran friend to do the teacher questionnaire. Then Liz checked her parent questionnaire against the Salvadoran one, since the items are almost all the same in the two questionnaires. Liz and I were excited to get to work.

This time we flew through Atlanta. In Atlanta, the scene changed from middle class white American travelers, including business people, no upgrades available to first class, to the San Salvador gate. There the culture already is different. People are traveling mostly in families. First class has empty seats. The trip was pleasant and uneventful. When we arrived in San Salvador and entered the arrival lounge and immigration, the tropical air swallowed us in a hot humid blanket. Birds squawked in the palm trees. We had arrived. The director of child care (“Sarah”) met us outside immigration. We drove in the red pick up truck to the orphanage to see it in its new location, and then we headed to our first school observation.

Kammerer B, Isquith P, Lundy S (2013).  Approaches to assessment of very young children in Africa in the context of HIV, in M Boivin & Giordani (eds), Specialty Topic in Pediatric Neuropsychology, Neuropsychology of Children in Africa, Perspectives on Risk and Resilience, Springer.

Perry B, Hambrick E (2008), The neurosequential model of therapeutics,, Vol. 17, No. 3, pp 39-43.