Getting Ahead of ADHD: What Next-Generation Science Says about Treatments That Work - and How You Can Make Them Work for Your Child
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ISBN-13: 9781462524938
Media Type: Paperback
Publisher: Guilford Publications - Inc.
Publication Date: 08-04-2017
Pages: 299
Product Dimensions: 5.90(w) x 8.90(h) x 0.90(d)
Joel T. Nigg, PhD, is Professor of Psychiatry and Behavioral Neuroscience at Oregon Health & Science University. A leading expert on ADHD, he has conducted scientific research and worked with children and their families on diagnostic assessment and treatment planning since the 1990s.
A New Understanding of ADHD You probably know that ADHD means attention-deficit/hyperactivity disorder. And you might have found out online that children with this condition have serious problems paying attention, sitting still, taking their turn, or finishing what they start. This pattern typically starts early in life and remains stable, although some individuals seem to have a slightly later onset and others seem to "recover" in adolescence and adulthood. If your child has been diagnosed with ADHD, the effects are familiar to you. But what is ADHD? Why do so many of the features of children with ADHD not seem like deficits in attention? Why are some kids labeled with ADHD even though they aren't hyperactive? You might be asking yourself, "Why was my child diagnosed with ADHD when his main problem is anger?" Before we delve into the new thinking about what causes ADHD and how this can give you hope for change, it's important to understand how the different manifestations of ADHD are connected. Where experts once saw ADHD as a problem of attention, and then of executive functioning, the picture has evolved again in recent years, and now we can best understand it s as a problem with self-regulation. This shift gives us a perspective that is both more complex and more powerful. Self-regulation involves a half dozen processes or capabilities that, when any one of them doesn't develop properly, can create the appearance of ADHD. Very similar to executive functioning but broader, the capacity of self-regulation helps us understand the breadth of challenges faced by children (and adults) with ADHD as well as the very important variations that occur in the disorder. It also helps us recognize that many of the frustrating behaviors associated with ADHD are just as frustrating to the individuals with ADHD themselves, seeming to occur before they can get a handle on what is going on. However, in children and adults, this frustration can get turned outward, toward blaming others for their own problems. Together, these new perspectives can clear the way for new hope and new solutions to help children with ADHD. What Is Self-Regulation? Self-regulation means the capacity to optimize our behavior, thinking and attention, and emotional experience and expression. Note that we say optimize — self-regulation doesn't just mean the ability to suppress or inhibit an impulse or control an emotional outburst, although that's part of it. It also means the ability to activate — or energize and persist — when needed. So one of the first misconceptions about ADHD is that it's only a deficiency in the ability to inhibit (or that it's really just impulsivity). Now, not being able to inhibit is indeed a core feature of ADHD. Kids with ADHD blurt out what they shouldn't say, have a hard time resisting temptation, and act in ways that they regret. But they also have trouble activating — getting started, initiating, and maintaining effort over time. Both inhibiting and activating are part of regulating. Finally, they have trouble fine-tuning. For example, even in studies in which children are asked to press with steady force on a plate, they have trouble holding consistent pressure — it varies from too high to too low. They go too slowly when they have to go fast, and too fast when they have to go slowly. All of this together is self-regulation. If you think of ADHD as a self-regulating problem, rather than an attention or inhibition problem, it is a bit easier to see the connection between seemingly opposite behaviors. Take ten-year-old Jenny as an example. Her mother reported, with some puzzlement, that "I can see why she has ADHD because she can't focus on her homework for more than two minutes without me standing right there to make her do it. But then she gets so focused on her doll collection that I can't get her to break away from it to do something else. And she can lock on to a video game for hours! So it seems like she can pay attention when she wants to." The explanation for this apparent contradiction is that Jenny cannot optimize her attention. She can't really control it. Instead, her attention controls her. She can't focus on her homework when she needs to. Her attention is captured by her doll collection or the video game, and she can't break away without a struggle. In a way, Jenny isn't entirely free, because she can't put her attention where her ultimate goals would suggest. (Caution — if the only time attention is a problem is when a child is doing schoolwork, it's important to rule out a learning disability.) All of self-regulation is connected. Kids who can't focus their attention also frequently cannot get a handle on behavior. This is why classic ADHD looks like inattention plus impulsivity (and in young children hyperactivity, or in older individuals extreme restlessness). It's also why problems getting a handle on emotions commonly plague kids with ADHD as well. Yet the degree of these different problems varies like a rainbow among kids with ADHD, with different profiles common. What Is Impulsivity? Impulsivity is one consequence of weak self-regulation — in the arena of action. Impulsivity means habitually and nonreflectively responding to the immediate trigger or the immediate payoff, regardless of whether it's ultimately the best choice. The hallmark of dysfunctional impulsivity is inability to adjust how impulsive we are to fit the circumstances. For example, an average adult without ADHD may be quite impulsive and spontaneous at a party with friends, but then be planful and controlled at work or when dealing with more serious matters. A typically developing child without development problems like ADHD may be spontaneous and excitable on a vacation but able to settle in to calm, focused work at school or relaxed calm behavior at dinner. ADHD is characterized by inability to get out of the spontaneous, excitable, or "highly reactive" state, even when the situation calls for it. Because of this problem with self-regulation of action, seven-year-old Dan was in constant trouble at school. When the child next to him stacked some blocks on the table, Dan knocked them down for the thrill of it, before he even thought. Likewise, eighteen-year-old Maria was unhappy with herself. Friday evening she had baked a cake for a friend's birthday party the next day. She was proud of herself for managing to bake the cake. It looked good, so she decided to have a little piece. In fact, it was really good, and before she knew it she had eaten a third of the cake. Now she was really unhappy because she had eaten too much and the cake was not fit to take to the party as a gift. People with ADHD often make others mad, disappoint themselves, and are at risk for addiction, because when they have an idea, feel a desire, or sense a craving, it pours into action almost by itself. They have trouble interrupting the path from internal thought or feeling to action. This is poor action control or poor impulse control. Here's a lighthearted example. In a movie called The Shaggy Dog, the comedian Tim Allen plays a man who sometimes turns into a dog involuntarily. He retains his human awareness — but now has a dog's instincts. As a result, he is ruefully impulsive. He narrates his thoughts during the dog scenes. One incident in the movie perfectly illustrates impulsivity and disinhibition. The humanly aware dog is in his house, where his teenage daughter thinks he is just the family dog. She and her boyfriend are in her bedroom preparing to "make out" on the bed. Disapproving of this, but being a dog, Allen tries to intervene by hanging out in the room and annoying the teenagers. The boyfriend picks up a toy bone to distract the dog. We hear a voice-over by Allen: "That's not going to work. I'm not going to fall for that! No way! I'm staying right here!" The kid then tosses the toy bone out into the hallway, where the shaggy dog immediately bolts for it, and then of course is quickly locked out of the bedroom by the two would-be lovers. In the next voice-over Allen, in a tone of exasperation, says, "I have to quit doing that!" This is impulsivity — doing something for an immediate reward or trigger that defeats one's established goals. Doing, in a sense, the opposite of what one really wants to do. As in this example, dogs are impulsive when seen through human eyes: they react to the immediate moment without regard to any semblance of a long-term goal. In a much more serious vein, we see something similar in addiction. The alcoholic wants to be sober — but he also wants a drink. His immediate impulse and ultimate goal are in conflict. If he takes the drink, he satisfies his immediate craving but defeats his ultimate goal. Similarly, an individual with ADHD as a teen or adult may blurt out an inappropriate insult or flirtatious remark — even after resolving not to do this — and then immediately regret it. A typically developing individual without ADHD may have the same passing thought but suppress it and move on without acting on it. Impulsivity — poor self-regulation of action — often results in a general style that is spontaneous and excitable. When spontaneous and excitable is the best approach, a child or adult with ADHD may do well. This is why some children with ADHD can be a lot of fun at a party or during a break from school. It's why some individuals with ADHD find a niche in the adult world where their style can succeed. I have seen adults, sometimes parents of children with ADHD, who have become salesmen, entertainers, or even entrepreneurs (assisted by organized teammates), working in settings where their active, high-energy, spontaneous style seems to fit and to complement others around them. But because they had ADHD, they could not adapt well to other settings — they struggled or failed in school, failed at jobs that required careful, quiet work, and had interpersonal problems and conflicts from not being able to adjust their tempo and style and not being able to stay organized or manage time. With ADHD, this spontaneous, immediate response style is practically always "on." Whether or not it is the right style for the situation becomes irrelevant. That's just a matter of luck (for a child) or of fortune and insight for an adult. I should add that for some individuals the impulsive aspect of ADHD is severe enough that they never seem to be able to find the right niche. Our modern world doesn't provide enough of the right kind of niche, or their loss of self-regulation is too extreme for almost any niche without a lot of support. They need extra professional help, both as children and as adults. What about ADD? There is one important variation to explain right here — that is why many people ask what "ADD" means. Rhonda brought her eleven-year-old son Tyrone in for an evaluation. She had been told he had ADHD but said, "I just don't see it. Yes, he can't pay attention and he's very spaced out. He zones out whenever I talk to him, and his friends even tease him for being a 'space cadet.' The teacher is concerned that he's not following in class. But he's not hyperactive in the least! Just the opposite! He's laid back, even lazy. He'll sit around the house and not do anything. It doesn't make any sense to call him ADHD!" Rhonda is right: ADHD is not a very helpful term for kids who are not hyperactive. But the picture here makes sense when we think of ADHD as a problem in self-regulation and remember that regulating means optimizing. Some kids with ADHD are not overactive. They are underactive. They seem to be slower than normal, low in energy, even lethargic — yet very inattentive. Some people use the now-discarded term ADD for these children. This is not an official medical term; it is an older term for ADHD. This profile has been called instead sluggish cognitive tempo, referring to children who are spaced out, experience frequent mind wandering, and easily get tired. They are prone to depression and anxiety, although not all of them develop those problems. While this is not yet an official diagnostic label, we're seeing more and more data supporting its existence, and we're likely to see increasing interest in it. Such children have a different self-regulation problem: poor activation. They can't get activation up to where it belongs — cannot initiate or raise their level of activity. They are too low and slow, even when it is not useful. Like impulsive and overactive children, they have poor self-regulation of their action but on the opposite side. You might be able to relate to this by thinking of those times you wanted to go exercise but just couldn't get yourself out the door or wanted to get out of bed on a rainy morning but just couldn't summon the necessary willpower. While experts continue to explore whether these sluggish children have a variant of ADHD or a distinct condition, for our purposes we can follow current practice and see these children as a different but related variation of the "self-regulation disorder" that, for historical reasons, is called ADHD. So at this point you can see that poor self-regulation can mean that inattention is overfocused or underfocused. Poor self-regulation of action means that action can be habitually impulsive and spontaneous, without the ability to inhibit. It can also be habitually underactive and slow, without the ability to activate. These both fall under the umbrella of inability to optimize to the situation. Why Is My Child So Anxious and So Angry? Is That Part of ADHD? Perhaps the most important insight about self-r egulation from recent science is that, because self-regulation is all connected, children with ADHD typically have problems regulating their emotion, too. This symptom still confuses many parents, and also confuses many clinicians because they have not connected it to a "global self-regulation disorder." I was asked to consult on the case of Mike, an eight-year-old boy with ADHD. Mike was inattentive and impulsive. But what bothered his parents, and made his doctor unsure of the diagnosis, was that Mike seemed so moody. He could be confident and outgoing. But as soon as he was told he had lost a privilege due to poor behavior, he might start to cry. When he had to sit still at a desk and work, he might work for a few minutes, then he would shout, "I can't stand this!" at the top of his lungs. When it was time to go to the doctor, he worried about it all day long. "What if he gives me a shot? What time are we going? Will it take very long?" He had trouble sleeping the night before and had a tantrum when it was time to get in the car. Assuming that sitting for the schoolwork was nothing unusual; assuming the doctor is not too mean; assuming Mike is not actually depressed (an important rule-out for children who are moody and have tantrums), all of this is part of poor self-regulation of emotion, and part of the ADHD syndrome — even though not part of the official diagnostic criteria. Mike's emotions are all over the place, and he cannot get a handle on them. He overreacts emotionally to everything — at least that's how it seems to other people. In fact, he may be having emotions that are fairly typical — many children are disappointed when they lose a privilege, restless when they have to sit too long at a desk, or a little nervous when they go to the doctor. But Mike's emotions are more intense and not regulated. It's as if there is no governor on the system. His emotions take over, and he seems unable to regulate them very well. This seeming emotionality may not be a separate emotional disorder. It may simply be part of the ADHD syndrome — a syndrome of poor self-regulation. ADHD includes self-regulation of attention, of action, and of emotions. This is very different from depression, which is a problem of regulation of mood (often outside the realm of self-control), and anxiety, a problem of self-regulation of anxious thoughts. In a primary mood disorder, we are facing a particular imbalance in regulation of positive affect (in the case of depression), or negative affect (worry or fear, in the case of anxiety). In the case of ADHD, we face a general breakdown in self-regulation of action as well as cognition and often, secondarily, of emotion. When it comes to emotion, we again see significant variation. Recent research from my laboratory and those of my colleagues, published in 2014 and 2015, suggests that ADHD has subgroups in terms of emotional style, with different physiological responses and different brain imaging responses. Yet all the groups have similar degrees of ADHD symptoms. One group seems to have pretty typical emotional responses. These kids might be spacey, inattentive, and maybe not overactive. Their emotions are low key and they don't get super angry or super amped up. They are similar to the inattentive, underactive children we described above. However, there are exceptions — some of these emotionally typical children also have the full ADHD syndrome. Somehow, their emotional regulation came together even though they haven't yet been able to regulate their attention or action. Read an Excerpt
Getting Ahead of ADHD
What Next-Generation Science Says about Treatments That Work - and How You Can Make Them Work for Your Child
By Joel T. Nigg The Guilford Press
Copyright © 2017 The Guilford Press
All rights reserved.
ISBN: 978-1-4625-2493-8
CHAPTER 1
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Table of Contents
Introduction
1. A New Understanding of ADHD
2. Epigenetics: The End of the Nature-versus-Nurture Debate
3. Food and ADHD: Old Controversies and New Clarity
4. Exercise, Sleep, and ADHD: New Insights on Brain Growth
5. Technology and ADHD: Latest Findings on the Peril and the Promise
6. Environmental Chemicals and ADHD: Sorting Alarm from Prudent Caution
7. Adversity, Stress, Trauma, and ADHD: Finding Sanctuary
8. Getting Professional Help: Traditional and Alternative Treatments for ADHD
9. Tying It All Together
Resources
References
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