ADD/ADHD | Attention Deficit Hyperactivity Disorder

[ADHD Explained: A 28-Minute Primer] [Understood for learning & attention issues] What we know as ADHD, [Thomas E. Brown, Ph.D. — Associate Director,] [Yale Clinic for Attention and Related Disorders] attention-deficit hyperactivity disorder—or some people still call it “ADD,” attention-deficit disorder— has been recognized by some doctors since way back in 1902. But from 1902 until 1980, it was all about little boys who couldn’t sit still, couldn’t shut up, and were driving everybody nuts. It was just behavior problems. The name of the disorder was changed a number of times. There were different formulations. But it was all about behavior problems. Since 1980, which is when they first changed the name of the disorder to include the words “attention deficit,” we’ve realized that this is not so much a behavior problem but far more a problem with the brain’s management system— its executive functions. And we also learned that there are many people who have ADHD who’ve never had any significant behavior problems. And that even for those who have, that’s usually the least of it. It’s the attention problems that tend to make more trouble for people, particularly as they get a little bit older and more is expected of them for being able to manage themselves. One thing that’s important to be clear about from the very beginning is that ADHD has nothing to do with how smart a person is. There’s some people who have this who are like super, super, super smart. Others, high average, middle average, low average, slow. I treat people for this who are like university professors and doctors and lawyers and big shots in business. A lot of people who are regular folks. Some people have trouble doing the basics. You could be anything along the IQ spectrum and still have ADHD. It has nothing to do with how smart you are. The other thing to know is that this is a problem—a set of problems— that include a wide range of characteristics, and what I’d like to do today is to describe for you some of the characteristics of what we call ADHD, give some examples of them, and then talk a little bit about what we know about what’s involved in the brain in the course of ADHD. One thing that’s important is that people— one of the main things that people with ADHD complain about is trouble staying tuned. That when they’re listening or reading or working on something, they get part of it, but then it sort of drifts off, and then they’re back, and then they drift off, and it drifts off again, and then they’re back. They have difficulty staying tuned. It’s similar, in a way, to the problem you have with a cell phone where you’re in an area where you don’t have good reception. You can get part of it, and then the message keeps fading in and out. The other thing is that they often have a problem with being distracted. Like anybody else, they see and hear things that are going on around them. They have thoughts going through their head. But most people, if they have something they’ve got to focus on, can push that stuff out of the way and focus on what they’ve got to do. People with ADHD— it’s real hard for them to do that. They’ll be sitting in the classroom trying to listen to what’s going on, or perhaps they’ll be in a meeting or sitting down trying to read something or write something, and somebody drops a pencil, and they have to sort of check and see, where did the pencil go? Then they’ll be back on task again for a couple of minutes. Then they’re thinking about some TV show they saw the night before. And then they’re back on task again for a minute, so they’re thinking about some conversation they had with somebody two hours ago. And then they’re back on task again for a few minutes, and then they’re looking out the window like anybody else will from time to time, but they’re likely to sit and watch the squirrel go up the tree a little longer than somebody else and be checking out the traffic and the cloud formation, the guy who’s mowing the lawn. Then they’re back on task again for a few minutes, and they’ll be thinking about what they’re going to do when this is over and how soon is this thing going to be over anyhow. I’ve got things I’ve got to do. And what am I going to have for supper tonight? And I wonder what’s on TV tonight? All these things are coming in all at one time, and it’s almost like you’re trying to watch TV and you’ve got four different stations all coming in at the same time on one channel, and it gets kind of hard to separate the signal from the noise. But the thing that’s puzzling about this, that really makes it very difficult for people to understand, is for people who have ADHD, it’s like that almost all the time, but not always. Everybody I’ve ever seen who has ADD— and that’s a lot of people—has a few things they can do where they have no trouble paying attention, no trouble focusing. Let me give you an example. Sixteen-year-old boy I saw—he was the goaltender for his school’s ice hockey team. And it just happened that the day his parents brought him in to see me was the day after his team had just won the state championship in ice hockey, so they’re bragging a little bit at the beginning about how great he was in the tournament the day before. And apparently he was a very good goalie. They said when he was in there playing hockey, he missed nothing. He knew where the puck was every second of a fast game. Totally on top of it. The kind of goalie every team wants. Smart kid. Tested way high up in the superior range. Wanted to get good grades. Was hoping to go to medical school. But he was always in trouble with his teachers. And what they’d say to him is, you know, once in a while you’ll say something that shows how smart you are. We’ll be talking about something. You’ll come in with some comment that’s really very perceptive, and it’s quite impressive. But most of the time, you’re out to lunch. You’re looking out the window. You’re staring at the ceiling. You look like you’re half-asleep half the time. You don’t even know what page we’re on. And the question they kept asking him was, “If you can pay attention so well “when you’re playing hockey, how come you can’t pay attention when you’re sitting in class?” Here’s another example. A lot of times parents will bring in kids for me to see, and they say, “You know, “the teacher says this kid can’t pay attention “for more than five minutes. We know that’s not true. “We have watched her play video games. “And she can sit and play those video games “for three hours at a time and not move. “And the teacher said she’s easily distracted. “That’s nonsense. When she’s playing those games, “she’s locked on that screen like a laser, “and the only way you’re going to get her attention is to jump in her face or turn off the TV.” So again, it’s like, you can do it here. Why can’t you do it there? Now, it’s not always sports or video games. There’s some people with ADD— they’re not good at that stuff. They might be into art, and they’re sketching and drawing and really getting into it. Somebody else, when they were little, they’re creating engineering marvels with LEGO blocks. And then when they’re older, they’re taking car engines apart and putting them back together or designing computer networks. But everybody I’ve ever seen who has ADHD has a few things they can do where they have no trouble paying attention, even though on almost everything else, they’ve got a lot of trouble paying attention. And if you ask them about it, you say, “What’s with this? How come “you can do it here and you can’t do it here, here, and here?” Usually what they’ll say is, “It’s easy. “If it’s something I’m interested in, I can pay attention. If not, I can’t.” And most people hear that and they say, “Yeah, right. Congratulations. That’s true for anybody. “Anybody’s going to pay attention better for something they’re interested in than for something they’re not.” Which is true. But here’s the difference. People who don’t have ADHD—if they’ve got something they’ve got to do and they know they’ve got to do it and it’s important, they can usually make themselves pay attention, even if it’s pretty boring, just because they know they have to do it. People with ADD—it is incredibly difficult for them to be able to make themselves pay attention unless the task is something that’s really interesting to them, not because somebody told them it ought to be interesting, but just because it is interesting to them for whatever reasons. Or if they feel like they have a gun to their head and something very unpleasant is going to be happening very fast if they don’t take care of this right here, right now. Under those two conditions, no problem. They can focus very well. Anything else, it’s really difficult for them to focus. But the problem is, this is not something that’s under voluntary control. It makes it look like it’s a problem with willpower. “If you can do it here, why can’t you do it here, here and here?” But it’s not a problem with willpower. It’s a problem with the way the brain is wired. All the characteristics of ADHD, which I’m going to be describing here, are things everybody has trouble with sometimes. It’s just people with ADD have a lot more trouble with it. So in that sense, ADHD is not an all-or-nothing deal like pregnancy, with, either you are pregnant or you’re not pregnant. There’s nothing in between. It’s more like depression, where everybody gets bummed out once in a while. But just because somebody’s unhappy for a couple of days doesn’t mean we’re going to diagnose them as clinically depressed. It’s only when those depressive symptoms are persistent and pervasive and making a lot of trouble for them, we say, “Yep, that’s a depression. We ought to do something about it.” So all the characteristics of ADHD are problems everybody has sometimes. It’s just, with people who have ADD, they just have a lot more difficulty with it more of the time. And the problem is, it is not under voluntary control. It’s not something you can do with willpower. But let me tell you about some of the other things which we see with people with ADHD. One is they often have trouble getting organized and getting started on things. For many, it’s difficulty organizing their stuff—their backpack, their desks, their notebooks, their filing system, their living space— bigger mess than most other people most of the time, unless somebody else is helping them take care of it. Other people have no trouble at all with their stuff. They have a lot of trouble with their time and their work. And what they’ll tell you is, “If I have a bunch of stuff to do “at one time, it’s really hard for me to look at it and say, “‘OK, that should be first. That should be second. That should be third.'” But even when they get their priorities straight, which often doesn’t happen, they tend to have a lot of difficulty getting started. Another piece of it that you’ll often hear about from people with ADHD is, they’ll say they have a lot of difficulty in regulating their sleep and their alertness and being able to keep up the effort to finish things in a reasonable time. Many complain that they have trouble getting to sleep, and what they’ll tell you is, “I often stay up a lot later “than I really want to or should because I’ve found “if I try to go to bed before I’m really, really exhausted, “I just can’t shut my head off. I just keep thinking of stuff. “And so I stay up late reading, watching TV, “surfing the net, or whatever until I’m just exhausted. “Then I fall asleep fine. But the problem then is I tend “to sleep like a dead person, and I have a hard time “resurrecting myself in the morning. And if I don’t have “somebody around to help me get myself out of bed “in the morning, I’m very likely to be late to whatever it is “I’m supposed to do or possibly sleep through “the whole thing. I just keep hitting the snooze button or just turn the clock off altogether.” During the day they’re usually all right as long as they’re on their feet moving around or talking a lot. But if they have to sit still for very long to listen or to read or do paperwork, the eyelids start getting kind of heavy. Another thing that often happens as a problem with people with ADHD is they have trouble staying with a task, that they may start it reasonably well, but they have a hard time then keeping up the effort to finish it in a reasonable time. I had a track star from the university, a runner, who came into my office one day, and he said, “My mind’s a great sprinter, but it’s a lousy distance runner.” He said, “If the task I have to do is something “you can do in one quick chunk, you just go all out for it “and then you’re done with it, I’m fine. But if it’s “something where you can’t do it in one quick chunk, “it’s a longer-term project, if you have to chip— “keep chipping away at it day after day, that I have “more trouble with. And my approach to that “is either hurry up, slapdash, get the thing done, “or, why don’t we just set this aside and wait until it becomes a little more of an emergency?” Everybody has trouble with deadlines sometimes. People with ADD, it’s almost like they can’t get started until it’s becoming an emergency. Another thing that often persons with ADHD have trouble with is writing. I’m not talking about penmanship, now. I’m talking about taking ideas and putting them into sentences and paragraphs. Because what people say is, often, “I’ve got a lot of ideas for what I should write “for this essay I’m supposed to write “or for this term paper, but it just takes me half of forever “to be able to get the sentences and paragraphs “put together so they make sense. I’m either changing it or it’s just disorganized.” They have difficulty organizing their thoughts and being able to get the words out in a reasonable way. Another piece of this—it’s not part of the official diagnostic criteria for ADHD, but it’s certainly something that a lot of people with ADHD are concerned about and complain about— is that many times they have difficulty managing their emotions. But I need to give you a few examples, because it’s not the same for everybody. Salesman I saw one time came in and he said, “You know, I was in the diner yesterday late afternoon “having a lunch. I’m in a pretty good mood, sitting there “eating my sandwich. The guy in the booth behind me “gets his sandwich. He’s chewing too loud. He’s going chomp, chomp, chomp.” He said, “There was something about that noise “that was driving me nuts. It was as though “a computer virus had gotten into my head “and just gobbled up all the space, “and that’s all I could think about, was that noise. “I’m sitting there with my fists clenched, seriously thinking “about getting up and smacking this guy in the mouth because he was chewing so obnoxiously loud.” He said, “I didn’t do it. I didn’t want to get arrested. “But if I’d been at home, I would have been yelling at somebody or I would have walked out of the room.” He said, “Then it was strange, “because after a few minutes, he’s still making the same noise, but then it didn’t bother me anymore.” He said, “Stuff like that happens to me a lot “where there’ll be some little frustration, the kind of thing “that most people on a scale of frustration would say— “that goes from zero to 10—would say, that’s a zero or a one, maybe a two at the most. For me,” he said, “it can be like a seven or an eight or nine.” He said, “Sometimes I make a big fuss about it. “A lot of times I don’t say anything. But I feel this surge “of anger where I feel like punching somebody or breaking something. And then usually it’s over with.” But he said, “It’s not always that way.” He said, “Day before that, I’m in the office. I’m walking “down the hall. A friend of mine who works “in the other department’s coming around the corner. “He’s walking toward me reading some papers “as he’s walking. And I hadn’t seen him for a long time. “So as we approached each other, I stopped and said, “‘Hey, what’s up? How you doing?’ I figured we’d stop “and chat for a minute. And he looks up, says hi, puts his head down, keeps right on walking.” He said, “Now most people would blow that off “in a minute and figure he was in a hurry. He’s got to get to a meeting or something. We’ll talk later.” He said, “Not me. Happened at lunchtime. I got nothing “done for the rest of the day. I spent all afternoon “thinking to myself, ‘Did I do something to annoy him?’ “Or maybe I did something to offend somebody “in his department and they’re all angry with me. “Or maybe I’m just the kind of person that nobody likes, “and nobody would tell me about it. But I couldn’t get it out of my head.” Other people, it’s not like that. They get an idea in their head of something they want to do or something they want to get or something they want to buy, and all of a sudden that wish takes on such strong urgency that the feeling is, I’ve got to have it now. And it almost doesn’t matter how expensive it is or how inconvenient it’s going to be for them or for somebody else, or whether they’re using time and money now for this that they know they need for something else tomorrow that’s more important. There’s just this relentless push, and they will keep that up until either they get it or they hit a brick wall. But even if they get it, they’re not that happy, because usually by then they’re off on something else they want. Other people, it’s not like that, but they worry a lot. Like one woman talked about how she was driving down the expressway. She’s in the left lane. She said, “I’m in the left lane. “I’ve got the Jersey barrier to my left, an 18-wheeler truck “on my right. We’re cruising about 65 miles an hour, “and this truck starts to pull over a little bit. “He didn’t get in my lane, but it got me thinking about “how big his truck was and how small my car was. “And pretty soon I’m thinking to myself, “what would happen if he didn’t see me and he pulled “over and squished me against the Jersey barrier? “And soon I’m not just thinking about it. I’m running “a very vivid movie in my head, imagining exactly what “it would look like if that truck came over “and smashed into my car, crumpled the car, “sharp pieces of metal were sticking into me, “I’m bleeding to death, the car’s getting dragged “along the Jersey barrier, the truck jackknifes, “cars and trucks behind us are hitting us repeatedly, “there’s this massive traffic jam, takes a long time “to get the rescue squad out to cut me out of the car. “By that time, I’ve bled to death. They have to call “my family and tell them I’m dead. And all this “while I’m trying to drive the car 65 miles an hour down the road.” She said, “Stuff like that happens to me “all the time. There’ll be some little thing, and I think, “what would happen if this happened? “And everything’s going all right, and I’m thinking, “what would happen if this happened or what “would happen if that happened? And pretty soon I’m not just thinking about it. I’m into it.” Now, it’s not like anybody with ADD has all this stuff. But many will have one or some combination of a couple of them. But what they have in common is that computer virus in the head thing, that the emotion, whether it’s the hurt feelings or the being annoyed about something or, “I’ve got to have it now,” or, “What would happen if?”—comes and just sort of gobbles up all the space in their head, and it’s very difficult for them to put it in perspective, to put it to the back of their mind and get on with what they’ve got to do. Another thing that’s very important for people with ADHD is their working memory. If you ask folks who have ADHD, “How’s your memory?” Often they’ll say, “I’ve got the best memory in my family. I can remember stuff nobody else can remember.” And they give you some example about some movie they saw 10 years ago. And they can tell you every detail of the entire storyline of the movie they saw once 10 years ago and haven’t seen it since. Or somebody else will say, “Yeah, I went “to the Super Bowl five years ago. I can still describe for you almost every play they ran during that game.” Or somebody else will say, “I’ve got 450 songs “in my head, all the music, all the lyrics, all the verses that were popular back in the ’70s.” But even though they might be very good about remembering some things like that from a long time ago, if you ask them about something that happened just a couple of minutes ago or yesterday, often they can’t tell you. The problem with memory with ADHD is not with long-term storage memory. It’s with short-term working memory. It’s what you depend on when you go into the other room to get something and you’re standing there scratching your head wondering what in the world you came in here for. Or you’re working on a project. You go downstairs to get something you need for the project, see something else that’s interesting or something else that needs doing. Soon you’re up to your elbows in project number two, having totally forgotten you were in the middle of project number one upstairs and it was kind of important to get it done. Students complain—they’ll be in class. Teacher asks the question. They’ll raise their hand. They’ve got a good answer for it. Teacher calls on somebody else first. You have to wait while this other kid says her shtick. Then the teacher comes back and says, “Yeah, what were you going to say?” It’s like totally clueless. Not only have I forgotten what I was going to say, but what was the question again? Or they’ll read something and understand it perfectly well at the moment that they read it. They read a few more pages, stop for a second, and realize their eyes have gone over every word and they haven’t got the foggiest idea of what they just read. Or—this really bothers them—they’ll study for a test the night before the test. They’ll go over it and, quiz them, they’ve got it. They go into class the next day thinking they’re going to get a good grade on this, and all of a sudden the big chunk of what they knew the night before has evaporated. Can’t pull it out of their head when they need it. But then a few hours, a few days later, something jogs their memory and it’s all back again. It’s not that they didn’t have it. It’s they couldn’t retrieve it when they needed it. Or you’re getting ready to go someplace. You think of five things you need to take with you. Half an hour later, you’re walking out the door. You got one of them. Can’t remember the other four to save your life. It’s where you have to hold one thing in your mind while you’re doing something else. That’s the kind of memory problem that people with ADHD complain about. Another part of this is managing action. You know, it’s certainly true that there are some people who, even as adults, are very restless and antsy. It’s like they always have to have some part of them in motion. And there are some who are very quick to jump into things, even as adults. And certainly there are many kids who have this sort of thing. But the fact is, many people with ADHD have difficulty slowing down when they need to slow down and speeding up when they need to speed up. Often they have difficulty in monitoring their actions. They’ll sometimes speak out of turn and not take into account what the effects are going to be of talking out and saying what they’re saying. Or they’ll jump into something without thinking about, “What’s going to happen if I do this?” But all these things I’m talking about—the problems with memory, the problems with difficulty in controlling actions, the problems with regulating emotions, the problems with regulating alertness and sleep, the problems with being able to focus and shift focus when you need to—all these things constitute the range of difficulties that people with ADHD complain about. And remember, all of these are things everybody has trouble with sometimes. It’s just that people with ADD have a lot more trouble with them. So the question is not, does it ever happen, but how much does it happen? How much does it interfere with the person’s being able to do the things they have to do in their daily life? Now, how does it happen? Why is it that some people have this—so much more difficulty with these things than other people do? The evidence shows that it seems to be mostly inherited. Out of every four people diagnosed with ADHD, one of them has a mom or dad who’s got it, whether they know it or not. They never used to diagnose this very well. Even today, it gets missed a lot. The other three, if they don’t have a parent who has it, usually they have a grandparent or an uncle or an aunt or a cousin or a brother or sister. One of their relatives will have it. Although often, it’s not recognized. There are some people who have this where you can see it from early childhood. There are some others where you don’t see it much in the early years of their schooling, but then when they begin to move into middle school and they don’t have that one teacher who can help to keep things organized for them, now all of a sudden they’ve got to keep track of what’s going on in several different classes and homework for different courses and moving around from one class to another. They have a lot more difficulty managing it. There’s some whose parents are so effective in building a scaffolding around them that you don’t even see the problem until they get up into high school where their parents are not that much aware of what they need to do, or they may move out of the house and move off to college or get involved in some work where the parents can’t help them, and you begin to see then that they have a lot of trouble organizing themselves and doing what they need to do. So we don’t always see this in early childhood. Sometimes it doesn’t really appear until adolescence or early adulthood. But the fact is that those are usually the hardest times, I would say probably for most, middle school, high school, first couple of years of college or going out in to the work world. Those are the times when most people with ADHD have the most difficulty with it. Because those are the times when you have the widest range of tasks you have to do with the least opportunity to escape from the ones you’re not that good at. If you’re lucky, as you move on, you can focus more on the things you’re good at and let somebody else do the other stuff that you’re not that good at. And some people function quite well that way. But the fact is, these are problems that can cause a lot of difficulty, not just in school, but in the way people get along with other members of their family, the way people manage their social relationships and the way they manage their jobs. And what we need to do is to be able to design a way of helping them to work with their strengths and working around their difficulties. But I think in order to be able to really appreciate this fully, it’s important to understand what’s going on in the brain that underlies these difficulties, which I’ve just been describing. The brain is about two and a half pounds. About that big. In there, you’ve got 100 billion neurons. Those are the cells that make up most of the brain tissue. It’s hard for most people to imagine a number as big as 100 billion, but here’s a way you can do it. Think about pixels on a TV screen. Imagine a 17-inch TV screen or monitor screen for your computer. On that screen, you’d have about 200,000 pixels. Now imagine if we then went to the Freedom Tower in New York. It’s almost 100 floors high. And take 17-inch monitor screens and set them side by side, bottom to top, all the way up one side, all the way around, so this entire building is totally covered with 17-inch TV sets, and turn them all on, and add up all those pixels on all those screens in that entire, huge building. You would then have enough pixels, if you added them all together, to show how many neurons one person has in their brain. Now, these neurons—they’re very, very tiny. You have to look at them under a microscope. But they come in different sizes and shapes, but they all work on a branches-and-twigs system, something like this. And if you isolate any one of them, you’d find that there are over 1,000 places where it’s connecting and interacting with the ones around it. But the thing that’s amazing about it is, the whole system works on low-voltage electrical impulses, and it is not wired together for anybody. That’s true for those with ADHD. It’s true for every one of the rest of us. They are not directly connected. Let me show you what it looks like. If you can imagine these tiny, tiny connections that are so small you need a microscope to see them. Look like a couple of mushroom heads butted up against each other. And then there’s a space between them which is thinner than a piece of tissue paper. So when there’s something that’s coming in from the brain, electrical impulses traveling along here, it has to jump this gap like a spark plug. And there are little receptor buttons on the other side here that it has to connect with. And if it comes in strong enough … ccckkkoo. It goes on to the next connection and moves on from there to wherever it needs to go. If it doesn’t, it just fizzles here. But the other thing we have here is there are little bubbles on the side. This is where they’re coming from. This is where the chemicals are manufactured. The brain makes 50 different chemicals to help carry messages back and forth. And there are two of them that control most of the things that I’ve been describing in ADHD. So what’s happening when that electrical impulse comes is it releases microdots of that chemical. That’s what crosses the gap and hits these receptors. It works like a spark plug. And then if it hits the right threshold, it moves on. And then on this side, there’s some little cells that work like little vacuum cleaners that go scha-week and suck back the chemicals and reload the system. Otherwise, it would be just locked open all the time. We think what happens with people who have ADHD is their brains make these chemicals the same way everybody else’s brain does. But they simply do not release and reload them effectively. And the other thing we know is that for eight out of 10 people who have ADHD, if you give them the right amount of the right medicine, the system can work better. For some, it’s huge how much it helps. For others, it’s substantial, but it’s not huge. For others, it helps a little but not that much. And two out of 10 it doesn’t work at all. But the fact is, though this is indeed a chemical problem, the medicines we have for ADHD cure nothing. It’s not like you have a strep throat, you take an antibiotic, and it knocks out the infection. It’s more like my eyeglasses. I have a problem with my eyes. I can’t see well. If it I’m looking at typewriter-size print, it just looks blurry to me. If I put these on, I can read it as well as anybody can. Take them off, I’m right back where I started. The glasses do not fix my eyes. They just help me see when I’ve got them on. And the same thing is true of the medicines we use for treating ADHD. But it’s also important to recognize that medication is just one aspect of the treatment that’s important for somebody with ADHD. And there are many ways in which we help people with ADHD by helping them to learn skills, by helping them to use some technology and strategies to be able to deal with whatever they have to deal with in school or on the job or in their family and social relationships. And it’s most effective to be able to first of all have a very good evaluation, to understand exactly which problems with ADHD this particular person has and then to have the team of—if it’s a child— the child and the parent, and the doctor, in consultation with the educators and teachers that are working with them—to try to assess what are the strengths of this child. That’s our beginning point. What are the difficulties? And what plan can we put together which will allow us to be able to build on those strengths and help the child or the adult learn about ways of dealing more effectively with their difficulties so that they can succeed and reach their full potential. [More to Explore on Understood] [Video: How Is ADHD Diagnosed?] [ADHD and Emotions: What You Need to Know] [5 Things Not to Say to Your Child About ADHD] [How ADHD Affects Kids’ Sleep—] [and What You Can Do] [Understood | for learning & attention issues] [U |]

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