Tag Archives: executive functioning

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.

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).
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).
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.

References

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.

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“Los Momentos Magicos”: A poster at WAIMH

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This is one of the two posters I presented at WAIMH (World Association of Infant Mental Health) this past week in Edinburgh.

“Los Momentos Magicos”: A Practical Model for Child Mental Health Professionals to Volunteer by Supporting Caregivers in Institutions in Developing Countries.

“Los momentos magicos” refers to small interactions between caregiver and child that when repeated multiple times can have a lasting positive effect. This hopeful perspective is important for caregivers of children in institutions in developing countries, many of whom carry the scars of early neglect and abuse. Through her experiences in visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers (CG) of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.

Weekly Skypes:

Example of Notes from Skype Sessions with Director of Caregivers (DCG) – In a meeting with the teachers, DCG felt frustrated when the teachers implied that the children were neglected. The teacher said the children do well in school but do not bring in their homework. The teacher was concerned that they were hanging out with kids at school who were a negative influence. DCG has told them that they can be friends with these kids, but when they see them involved in problem behavior they should walk away. I suggest – because this has been successful in the past – the possibility of a community meeting in which the other children at the home are invited to brainstorm how to stay out of trouble and how to deal with other kids who are getting into trouble at school. DCG says that is a good idea. She will try it and let me know how it went. We talk about how much responsibility to expect from a 10-yo with his homework. A CG is leaving, and we talk about how to prepare the children for this loss – which children will be most affected, how they might express their distress, how to say good bye.

El Salvador Workshops:

Workshops take place in the orphanage during a weekday, when the children are in school. They begin with coffee and pastry, and there is a break for lunch, sponsored by the workshop leaders. The format is a power point presentation with accompanying video. Following a consultation model, the workshops focus on the caregivers’ chief concerns, underscored by the consistent message of the importance of the relationship. Videotapes of caregivers engaging in interaction with children are used to illustrate successful caregiving techniques, while also demonstrating how the caregiver’s ability to imagine the mind of the child is crucial. Discussion is encouraged throughout the presentation. After the first workshop, examples of the caregivers’ evaluations included, “It is good what you said, but now you should tell the children to do what we tell them to do.” Examples of evaluations after subsequent workshops included, “ I learned that it’s important to get down to a child’s level and listen to him, before I set a limit.” And “How to have a better relationship with a child and how to understand his situation.”

North India Workshop

Workshop to 80 nursing students at mission hospital in No India. Subject: Supporting the First Relationship.

Using Nugent’s book, Your Baby is Speaking to You ( 2011), Harrison and Gregory emphasized three points: (1) Babies are speaking to their mothers; (2) Mothers can listen to their babies; and (3) Nurses can help mothers listen to their babies in a way that can influence the future health and well being of the children. We stressed the importance of making the mother feel competent to understand the communications of her own baby. To illustrate these points, Ginger played the role of the mother, and I played the role of the nurse. As usual, eliciting the help of the translator added another dimension of cultural richness and respect to the consultation process.

South India Consultation to Teachers at School

Again followed consultative model focusing on teachers’ questions about students. Using data from teacher and child interview to answer the questions. For example, (1) Why does he not attend school regularly? (2) How can we make school more interesting to him and motivate his learning?

Child was observed in the classroom and child and teacher were interviewed. Data from observation and interviews were used to answer the questions:

(1) There is the feeling in the family that he will be the brother who stays home and keeps the farm. He is also afraid of family discord and wants to protect family from fighting. He does not see the practical reason for studying. He also has some learning problems – working memory, auditory processing, executive functioning. (Include explanations of executive functioning, working memory, auditory processing).

(2) Story problems about farming (math) – buying selling, ratios of the fields, making calculations on the spot to determine prices and make sure venders are not cheating.

Auditory processing support – when possible, give him important factual information parsed in chunks separated by few seconds pause, with repetition of information afterwards.

Building working memory – tasks that require remembering longer and longer bits of information over time (addresses, phone numbers, “telephone games” of hearing information from one person who repeats it to the next person, etc., drills, repetition, and rote memorization for basic facts, making up his own acronyms for information that is hard to retain.

Strengthening executive functioning –practicing organization of homework, building predictable routines, checking homework lists to make sure everything is done and in its place, going over tests and assignments afterwards to identify errors and to understand how to avoid those errors in the future.

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More on Executive Function:

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Executive functioning (EF) is a real “lumper”, as in “lumper or splitter”, term. That is, it refers to a very broad class of skills that we use to get through the day at home, at school, and at work. Not only that, but for executive functioning to work well, all these skills have to be coordinated with one another. It is conceptually confusing to try to collapse all this complexity into one “thing”, but since it is frequently used to describe children, we will use it here too. EFD has a big overlap with ADHD, as you might imagine.

EF is used to help plan, organize, make decisions, and shift between situations or thoughts (make transitions), control emotions and impulsivity, and learn from past experience. It includes cognitive processes referred to as “working memory”, in which facts that are needed to solve problems – in academic tasks, social situations, or tasks of living, such as what is involved in getting ready in the morning – are kept accessible for use when necessary. A figurative image that is often used for working memory is facts on a shelf in the front of the brain, so that if a child is trying to solve a math problem, she may need to be able to find the multiplication tables right away and not stumble as she tries to retrieve them. Or if he is in a tricky social situation, he may need to recall a fact about another boy he wants to play with – such as that this boy does not like to be called a certain nickname – if he wants to make a good connection.

A child with EF difficulty, “executive function disorder” (a term I dislike because of the word “disorder” since there is no discrete “disorder”), has difficulty with organizing his life. He often has difficulty with handwriting (visual motor integration), trouble managing the multiple transitions of his daily life (getting ready in the morning, going from one activity in school to another, managing the bedtime routine), making sense of the complex social communications of the playground, inhibiting impulses (“using your words instead of your body”). Children with this type of difficulty also often have trouble with team sports in which you have to coordinate with multiple other players as well as manage your own body.

What can you to help your child who struggles with executive function problems? Well, to begin with, consider not that you are helping him “compensate” for deficits (which may be true in the immediate situation, of course) but rather that you are “growing his brain”. You are helping him to develop more robust capacities than he has, and you are doing that by making it possible for him to use his less developed capacities in a less demanding situation (so that he can be successful) and practice them over and over so that they can become stronger and more versatile. You are helping him build good habits. You are helping him expand his repertoire of competencies. You are helping him grow his brain.

You would like to ensure success through these considerations:

1. Context – The first thing to do is to identify the contexts in which your child can most easily succeed. Some kids can regulate themselves well in a highly structured setting such as many school classrooms. Others require the reduced stimulation of a small group of children. Some may be able to sustain attention on a simple, structured task such as simple Lego kits or simple academic worksheets, but get frustrated and fall apart with less structured writing assignments or more complex Lego kits. It is common for some kids to do well on tasks requiring information that the child has learned well by practice but be unable to grasp novel concepts easily. Often children with these challenges are more vulnerable to physical or emotional distress interfering with their concentration – a cold or a conflict with a friend. Recognizing the context means you are empathizing with your child, which is at the core of successful parenting of a challenging child.
2. Take Your Time – No matter how much hurry you are in, slow down. Rushing will make everybody anxious and make matters much worse.
3. Break it Down– Then break down the information you want the child to learn into small enough pieces that he can take it in. Directions should be simple (“First, hang your coat on the hook.”); beware of multi-step directions (“Hang your coat on the hook and put your boots, and then come into the kitchen to have your snack.”). Or, teach morning routine in pieces, such as (1) use the toilet; (2) brush your teeth; (3) wash your hands and face; (4) put on your clothes; (5) come down to breakfast.
4. Make Checklists – Help your child by making checklists. Often these children get so preoccupied by making the first decision, that they cannot even start working on the task they have decided on. Setting out the requisite tasks in order ahead of time can make all the difference in a smooth transition. Checking off all the steps can create an experience of mastery. It is also helpful to do as many of the tasks involved in transitions ahead of time, such as laying out the clothes for the next morning the night before, putting everything in the backpack, making the lunch.
5. Write it Down (or Make Pictures) – For younger children, it is helpful to make a schedule strip of Velcro with words, or pictures (depending on the maturity of the child) to document the child’s daily routine. For older children, weekly planners are very useful.
6. Routines are Your Best Friend – Routines establish a comforting predictability that ease tension by making transitions easier. When children know what is coming, the momentum of the schedule can carry them into activities that they would otherwise refuse. Routines help you practice, and practice is essential to building a bigger repertoire.
7. Rewards – I think of rewards – stickers, treats, or special time with parents – not as bribes but as acknowledgement for an accomplishment hard won. Especially for kids with attention problems, rewards given quickly after a good effort can promote motivation.

Photo by Ginger Gregory

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