NEURODEVELOPMENTAL DISORDERS

Attention-Deficit / Hyperactivity Disorder

or more commonly known as ADHD

What ADHD is not

ADHD is often a misunderstood condition. It is important to realise that these symptoms, or the manifestations of these brain-based challenges faced by our loved ones with ADHD, are not intentional. Nor are they defects in character or personality. Below are some common beliefs, or myths, surrounding ADHD:

Ψ ADHD is caused by bad parenting.

ADHD is a neurodevelopmental condition and is not caused by bad parenting, although behaviors that arise from ADHD can challenge otherwise effective parenting. Unfortunately, when people see kids being impulsive or not listening to instructions, they assume it is due to a lack of discipline, not realizing that these are signs of a medical condition. That being said, the home environment can influence the symptoms of ADHD to be better or worse.

Ψ Children with ADHD are lazy.

ADHD is not a result of laziness or lack of motivation, but stems from a real difficulty in functioning due to the different ways their brain works. 

The resulting outward behavior such as being unable to sit still in class or finish their homework may seem like they are not trying hard enough, but it is highly likely that they are trying harder than their peers to pay attention.

Ψ People with ADHD can hardly ever focus.

You may think that a boy who can focus on his video-games for long periods of time could not have ADHD. However, children with ADHD usually have problems with focusing their attention on a specific task for long periods of time and this does not include highly engaging or stimulating activities such as a video game. School can be especially challenging as it requires sustained attention over a long period of time and a child with ADHD may have problems adapting to that environment.

Ψ ADHD only affects children and they will outgrow it.

As symptoms of ADHD are typically observable from childhood, people with ADHD tend to be diagnosed as children. However, this does not mean that adults are not affected by the condition. Adults do get diagnosed with ADHD, even if they were not previously diagnosed in childhood. Nevertheless, their symptoms are less apparent. They may have also learnt effective ways to manage or hide their symptoms into adolescence and adulthood. In fact, adult ADHD is believed to be under diagnosed, with an estimated 2% to 5% of adults from ADHD globally. Consider how often you see a grown-up running around uncontrollably and you get the idea—ADHD appears differently in adults.

The main goal when managing ADHD should be to ensure that the individual functions well at every stage of their life (childhood, adolescence or adulthood) rather than to get off medication as soon as possible. Even though symptoms of ADHD may persist till adulthood, many are still able to lead productive lives.

More about ADHD in Adults

Ψ ADHD is a “male” disorder.

ADHD is more commonly diagnosed in males across ages. However, this may be due to how the symptoms are presented between the genders. Males with ADHD are more likely to exhibit symptoms of hyperactivity/ impulsivity, such as running wildly and uncontrollably, making them more likely to stand out. In contrast, females with ADHD are more likely to demonstrate symptoms of inattention, such as spacing out. Thus, they are more likely to be perceived as bored and tend to be underdiagnosed for ADHD.

Ψ People with ADHD are deliberately difficult/ cannot hold onto jobs, meaningful relationships/ lead a “normal life.

People with ADHD tend to have difficulties with processes that taps on executive functioning, such as planning and organisation, prioritising, focusing and sustaining attention, as well as regulating emotions and behaviours. In addition, there is an area in our brain, called the anterior cingulate cortex, which helps us realise when we’re about to do or say something we probably shouldn’t. In people with ADHD, it doesn’t quite work like it’s supposed to.

For someone with ADHD, everything that comes to their attention will get their attention. This makes daily living difficult for people with ADHD.

Nevertheless, the difficulties faced by people with ADHD are not intentional acts, nor are they defects in character or personality. Despite the challenges, people with ADHD can learn coping skills to improve their social, academic and occupational functioning, making it possible for them to secure and maintain jobs, meaningful relationships and satisfaction with life.

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Core dimensions of ADHD

(1) Inattention: The inability to sustain attention, especially so for tasks that are repetitive, structured & less enjoyable. It also involves difficulty in following instructions, resisting distractions, planning and organization.

Examples of inattentive behavior: Daydreamy, spacy, process information slowly, difficulty focusing on tasks, have trouble remembering things & may appear socially withdrawn.

(2) Hyperactivity/Impulsivity: The lack of control of motor behavior, poor sustained inhibition of behavior and the inability to delay a response or gratification. 

Examples of hyperactive behaviors: Often fidgeting, squirming, running, finds it difficult to stay in their seats, excessively energetic & talkative

Examples of impulsive behaviors: Impatient, blurting out inappropriate comments, unable to engage in turn-taking & often interrupt others’ conversations/activities

3 subtypes related to ADHD

(1) Predominantly inattentive presentation: Display primarily inattentive behaviors. This used to be commonly known as Attention Deficit Disorder (ADD).

(2) Predominantly hyperactive/impulsive presentation: Display primary hyperactive and impulsive behavior.

(3) Combined presentation: Display both inattentive and hyperactive behaviors. This is the most common type of ADHD.

Key symptoms defining inattention and hyperactivity-impulsivity respectively.

ADHD vs Autism Spectrum Disorder (ASD)

Some may confuse ADHD with Autism Spectrum Disorder (ASD). This is not surprising, as some of the symptoms between these two disorders overlap. However, there are key differences between the two.

The table below highlights these main differences.

Addressing Childhood ADHD

When a child has been diagnosed with ADHD, parents usually have concerns about how best to aid their child. It is recommended that parents work closely with others who are involved in their child’s life - teachers, healthcare providers, therapists & other family members to ensure their child receives the best management plan. There are 2 primary methods of helping children manage their ADHD.

1. Stimulant medication - Stimulants may be effective in areas such as increasing sustained attention, persistence in work and impulse control. However, for children younger than 6 years old, medication is not recommended. Instead, the American Academy of Pediatrics (AAP) recommends parent training in behavior management first.

   Medication can affect children differently and some may experience side effects such as reduced appetite and sleeping problems. Hence, medication is a tool, not a cure and is more likely to be effective when combined with other management plans.

2. Behavioral Parent Training (BPT) - An evidence based therapy approach where parents are taught positive reinforcements in order to improve their child’s behavior. Parents are taught to use more effective discipline methods through the manipulation of antecedents (rules & instructions) and consequences (e.g. rewards & time-outs) 

This has been shown to effectively reduce disruptive child behavior and parent-child conflicts. Furthermore, it enhances parenting skills for parents and helps to promote prosocial & self-regulating behaviors.

Effective Strategies for children with ADHD

Ψ Self-monitoring behavior
As children with ADHD have difficulties in executive functioning such as decision-making and impulse control, this may lead to many unwanted behaviors in the classroom. Self-monitoring techniques can help a child be more aware of their behaviors and improve over time. Read more about self-monitoring behavior and how to implement it here.

Ψ Token Economy
A token economy is a positive reinforcement strategy for building up and maintaining appropriate performance and behavior, be it at home or in a classroom setting. In a token economy, if a child acts or behaves in a certain way, they will be able to trade in their tokens for a reward or a privilege. Read more about a token economy and how to effectively implement it here.

How to help your child with ADHD
 

To achieve positive changes in all settings, children with ADHD need a sense of consistency. They are more likely to be successful in completing tasks when the tasks occur in predictable patterns and settings. This way, they will know what to expect and what is expected of them. Some tips that may help with your child’s behaviour:

1. Create a routine & follow it. It is important to establish a time and place for everything to help a child understand & follow instructions. Create simple & predictable routines for meal times, homework, play time & bed time.
   

2. Be clear & specific when talking to your child.  Try to use clear & brief instructions when you need them to do something. 
   

3. Use a reward system. Use a chart to monitor goals & track positive behavior, then let your child know when they have done something well by praising them or rewarding them in other ways. Make sure the goals are realistic, as small victories are worth celebrating.
   

4. Create positive experiences. Children with ADHD may find certain situations very stressful. Finding out & encouraging them to be involved in things they do well (e.g. sports, music, art) can help create positive experiences for your child.
   

5. Provide a healthy lifestyle. Having enough rest, eating nutritious food & regularly exercising are important and can help prevent ADHD symptoms from getting worse.

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ADHD in adults is less apparent and less talked about. Even though symptoms of inattention and/or hyperactivity and impulsivity still exist, its presentation is different in adults:

Ψ lacking focus: distractedness, carelessness, difficulty finishing tasks
Ψ disorganisation: poor time management, forgetfulness
Ψ “hurried behaviours”: foot-tapping, pen-tapping, speeding, switch rapidly between tasks
Ψ tendency to be bored or restless, with low mood when they are under-stimulated
Ψ racing thoughts or feelings with difficulty winding down even when tired
Ψ poor impulse control: impulse buying, interrupting conversations, substance abuse

For a person with ADHD, everything that comes to their attention will get their attention.

You can see how this may be a problem in modern life.

A simple illustration of this, shared by Jessica McCabe of HowToADHD, is of someone going to the bookshop to buy a particular novel. A person without ADHD would usually enter the store, buy the novel and leave—all in a span of, say, 20 minutes. By contrast, someone with ADHD might enter the store, become distracted by a cookbook with a captivating cover design, start reading the book, decide to join a cooking class, buy a spice rack and leave the store without buying the novel they wanted in the first place. 5 days later, the novel remains on the store’s shelf.

ADHD hides in plain sight

Adults have also found ways to engage in “compensatory behaviours” in order to blend into society. Some of these compensatory behaviours involve setting up very rigid and detailed systems and routines. They may even plan for every eventuality and contingency to reduce impulsive decision making, forgetfulness and make up for their inability to manage and perceive time well.

Others may constantly change tasks and routines to keep themselves engaged and from getting bored and restless.

Some hide their attentional problems by preferring to meet only one or two persons at any one time, making it easier to focus on only a few friends at any one time. Others, however, may prefer only socialising in large groups so as to divert attention away from their behavioural disinhibitions.

Some compensatory behaviours can be harmful while others can have negative consequences in the long run. For instance, high-achieving adults with ADHD may develop rigid perfectionism as a coping mechanism. Having spent their lives being told they’re “careless”, “wasting their potential” or need to “try harder”, they overcompensate with a paralysing need to be perfect. They often waste a lot of time on unnecessary details and set standards so high that they never feel satisfied with themselves or their work.

Another consequence of compensatory behaviours in high-achieving adults with ADHD may be the Imposter Syndrome or the struggle to recognise their achievements. They constantly feel like frauds due to having to work harder than everyone else to achieve the same results. They usually keep this part of themselves hidden resulting in shame and guilt and an irrational fear of being “found out”.

Addressing Adult ADHD

ADHD may be incurable, but it is highly manageable.

In view of the struggles they faced, as described above, it is crucial that adults with ADHD receive help and support. While there is no cure for ADHD, it is highly manageable – which means that it is highly responsive to therapy.

Pills don’t teach you skills

There has been a variety of stimulant and non-stimulant drugs developed that are effective in alleviating ADHD symptoms. However, they may work differently for different people and may not effectively address every symptom. They are also do not address an important non-pharmaceutical component of addressing ADHD - the social skills and tools necessary to allow them to work with their ADHD brains rather than against it. This is why the best management plan for adults with ADHD involves a transdisciplinary approach comprising medication, psychotherapy, and psychoeducation.

Cognitive Behavioural Therapy or CBT is a common therapeutic modality used in managing ADHD. CBT can help to address specific symptoms, dysfunctional thoughts or emotions or behaviours that are disrupting everyday functioning while cultivating healthier ones.

ADHD also frequently co-exists with other DSM conditions, especially mood and anxiety disorders, Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) and/or substance use disorders. If this is the case, your clinician will first attend to the more severe condition.

Psychoeducation is the process by which a psychologist provides relevant information and coping strategies about a mental health condition to help them individuals and their families cope with the condition.

Support, not Enable

One of the most helpful things you can do for your loved one with ADHD is to try and understand their struggles without judgement.

Remember that they are not forgetting things, making careless or reckless mistakes, losing focus, having an emotional meltdown, etc. on purpose or because they are lazy or spiteful. ADHD is not an excuse but an explanation for these behaviours. As a parent or loved one, it is also important to realise that it is not because you are doing something wrong either.

What your loved one may need support with may differ from another person with ADHD, so communicate with them and ask them what they need and how you can help. For example, you can be their accountability partner and help them make progress towards their goals and commitments, keeping them in check and giving them honest feedback along the way.

Be mindful when offering help to not demoralise them in the process. For example, saying things like, “Your room is a mess, as usual. I’ll help you clean it up because you can’t do anything right.” It is common for someone with ADHD to have self-esteem issues after years of frustration from struggling with things other people may consider simple. They thrive on encouragement while demoralisation might make them give up. Therefore, try to notice and appreciate their efforts more rather than pointing out their failures. If you or they are feeling frustrated or emotions are running high, step away and come back when everyone has calmed down.

At the same time do not enable them by trying to do, fix or control everything for them. It will just lead to resentfulness towards your loved one with ADHD or feelings of incompetence in themselves. People with ADHD are known to be passionate, creative, enthusiastic, intuitive people. Be your loved one’s advocate and help the world see them the way you do.

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