Attention Desirable Holiday Destination

Here is a bit of information about AD/HD

AD/HD means different things to different people

• To teachers ..This child takes all my attention.
  

• To parents .. What have I done to deserve this?

• To sibs.. It’s not fair, the whole family has to revolve around my brother/sister, I get no attention/praise

• To themselves…. Unhappy, low self-esteem

• To the uninitiated.. If that was my child, I’d ...!

• To the label makers – DSM - IV
  inattention, impulsivity sometimes also hyperactivity

Impulsivity

• Tendency to act in quick but often inaccurate manner
  (multiple choice, racing through sheets of maths or comprehension question, insisting they’ve checked it all )

• Acting without thinking
  (does not consider the consequences, i.e.runs onto road without looking)

• Prefers small, immediate reward rather than wait for larger, but delayed reward – research shows the ability to wait for two sweets, instead of one immediately, at the age of 4 predicts fairly well the impulsive adult personality

• Responding before a task is fully understood or sufficient information available – eg - answering before the question is finished

• Failure to withhold inappropriate responses
  - difficulty waiting for turn
  - calling out in class

The executive functions

• Are based on the frontal regions and their connections which help to plans, organise, modulate and integrate our behaviour. People who have head injuries here often suffer from Executive dysfunction, which gives disordered attention, poor memory, inefficient problem-solving, inability to self-monitor or organise things, and poor inhibition over impulses.

• In fact the growth of the executive functions can be seen as growing – up!

• The connections between the frontal lobe and sub-cortical regions involved in executive function are heavily myelinated (insulation of the connection to make them fast) and complete myelination sometimes doesn’t take place until early adulthood. A good metaphor is our "stop and go" system is the brake and accelerator or attentional thermostat.

So there is a faulty "stop - continue - go" switch

• From the frontal lobes to the limbic system (basal ganglia) which regulates arousal, attention and inhibition.

• Slower arousal means it takes time to start paying attention and there is less ability to put in much effort so attention is not sustained. This makes the child very distractible

• They work without an overall goal to guide them so each part of the task seems separate and what they do between distractions !

• Shifting to a new taskis hard.

• They will feel easily overwhelmed when faced with several tasks and can’t organise or prioeitize them.

• This reluctance to expend effort means everything is left until the last moment.

• Getting up in the morning is hard,

Less a problem of attention than Intention?

• Parent’s say “but he/she can concentrate for hours on dinosaurs/game-boys and things they are interested in. It’s just that they can’t raise the motivation to attend to routine, familiar, or academic tasks as opposed to novelty or volitional activities. They seem to get a “brain lock”.

• Research shows the frontal lobes of ADD diagnosed people get “stuck” in a low frequency, high amplitude brain wave – called theta. The whole sleep/wake cycle is affected. In fact the child has nearly always been a poor sleeper right from birth – still aroused at night time when everyone else is exhausted. (research shows this) and sleepy in the daytime, so they are not responsive to the normal circaidian rhythm clues that biological life responds to (night/day). Not only the onset, but also the length of the normal sleep stages is disturbed.. So much of the time they are, physiologically speaking, like people who are jet-lagged and their arousal/alertness level fluctuates.

• Given that in some stages of sleep and dreaming we consolidate our learning this has a pretty bad effects on their learning and memory.

• Immune system functioning is also affected.

Arousal instability also affects emotions

• These children tend to have poor emotional control and weak social skills because the same problem of impulsivity and inattention affects interpretation of their own emotions as well as their social communication. So the same deficits that cause poor problem-solving also cause social problems.

• The impulsivity, unpredictability, difficulty in suppressing responses, lack of foresight,, uneven motivation, failure to remember and keep confidences, all beyond “just a boy”, “just growing-up”, “just a teenager” explanation. They also tend to have little insight into their own or others’ motivations. This is still an executive function problem, no self-monitoring or feedbback

• This is often exacerbated by speech difficulties – word finding problems, stammering and the fact that much communication at home involves “NO”, “STOP IT” etc. So they have low-self esteem which becomes more apparent as child becomes older, especially if they have a high I.Q.

Working memory is part of executive functionning

• So deficiencies here mean not remembering rules, so social nuances that indicate the need for a change of behaviour and executing the change is difficult

• Children learn to use language to regulate behaviour, increasingly internalised, describe and reflect on experience, moral reasoning, self- questioning/ correcting, i.e. mentally rehearsing plans, strategies, generalising from the specific to the whole – they develop meta rules to serve as guide-lines for living but this is delayed in AD/HD …so they can’t see the overall end

• They have difficulty hearing/remembering directions/facts – or be able to hold parts of a problem in mind to break it down into a manageable one, so just give up. They can’t prioritise well, because this means holding two concepts in mind to compare to pick out the main point Similarly a sense of time is often missing because they can’t hold events in mind, so have trouble in recalling the past or learning from mistakes, consequences/obstacles

Inattentive AD/HD

• There is a primarily inattentive type of AD/HD, which has different neurochemical underpinnings, probably more a noradrenalin or acetylcholine deficit than the impulsive dopamine deficiency syndrome.

• They can be seen as opposites in some ways although both stem from neurochemical and brainwave deficiencies

INATTENTIVE	IMPULSIVE - HYPERACTIVE
Quiet, shy, avoids attention	egotistical, show-off
Underassertive, over-polite,	demanding, blame
Obedient, docile	intrusive, rebellious, bossy
Dreamy, drifts off	“in your face”
Slow, procrasinates	too quick, inaccurate
Tired, everything an effort	flitting, distractible
Bonds but doesn’t easily attract friends	attracts other,don’t bond
internalises... anxious, perfectionist, slow	externalises

Developmental picture of AD/HD

• Infancy;
  difficult temperament, out-of-sync, poor sleeping/eating, colicky, temper tantrums, crying, high levels of activity or passivity, disinhibition

• Age 3 yrs;
  50% of children with AD/HD will have behavioural symptoms; overactivity, short attention span, noncompliance, exasperated parents Nursery – motor over-activity/frequent change activity, so developmental delay in impulse control

• Age 6 yrs;
  90% of children with AD/HD will have been identified by teachers as showing behavioural problems in keeping on-task, keeping class rules, ability to “settle” , social/emotional immaturity, peer problems

Developmental picture - 2

• Primary school age;
  Underachievement in literacy/numeracy, disruptive /dreamy, increased problems when less structured e.g. assembly

• Secondary school age;
  Turns from neighbours on doorstep at the age of 5 to police on the doorstep by 11 or 12!
  
  But aggression and impulsivity may decrease as they are more able to choose the activity they will become involved it.

Developmental - 3

• Young adult;
  Usually there is a better adjustment to work than school, there will be some residual restlessness and low self-esteem, but much depends now on what job market can provide, type of friends they have and whether they live in a critical or stimulating, tolerant environment.

• Adult AD/HD;
  It is not usually true that a child will “grow out it”. ADD often continues and changes into feelings of under-achievement, that something missing, and these frustrated adults often feel they should be happier, wealthier, have more competence, status , etc. Their listening is still usually poor but they become improved “lookers”, notice more. So whether they become a visionary tycoon or drifting drop-out (sometimes both at different stages of life) depends on opportunities but wherever they are the grass will usually be greener on the other side! So long term plans can be changed on impulse.

Causes

• Research suggests there is a high genetic component (up to 80%) but sometimes early traumatic experience can give a similar picture

• Prolonged stress, long term abuse and insecure attachment can alter neurology. When stress hormones flood the system constantly the child becomes hypervigilant, (dopamine, serotonin down) misperceives threat, can’t cope with stress or empathise with others, stumble into conflicts more emotionally literate children can avoid, so fail to develop healthy relationships, become impulsive , aggressive, socially withdrawn

Attention-genic

• Some authorities suggested that an increasingly rapid fire, changeable, zapping culture is a causative factor and behaviour that in the past would have been desirable (hunting and soldering) is now more of a liability in our increasingly conforming culture.

Comorbidities that alter the picture

• Dyslexia (dyspraxia, dyscalculia, dysgraphia)

• Giftedness

• Asperger’s syndrome

• Obsessional Compulsive Disorder

• Tics/ tourette’s syndrome

• Oppositional defiant and conduct disorder

• Depression, anxiety, bi-polar disorder

• Sleep disorder

• CAPD
  
  All at least partly Dopamine mediated (Which help us focus and keep our timing)

6 AD/DH Subtypes

According to Daniel Amen in his “Healing ADD” book, there are actually 6 subtypes, all with different brainwave patterns

• 1. Classic – inattentive, disorganised, hyperactive/restless, impulsive

• 2. Inattentive – easily distracted with low attention span, but not hyperactive. Instead,sluggish or apathetic

• 3. Overfocussed ADD Excessive worrying, argumentative, compulsive

• 4. Temporal lobe ADD –quick temper and rage, periods or panic and fear, mildly paranoid

• 5. Limbic ADD – moodiness, low energy, socially isolated, chronic low-grade depression, feelings hopelessness

• 6. “Ring of fire” – angry, aggressive, sensitive to noise, light, touch, often inflexible, experiencing periods of mean unpredictable behaviour, grandiose thinking

Psychological strategies to help

• Behavioural Reward system
  e.g. token economy, charts, schedules, prizes, praise and ignoring the undesirable.

• Cognitive monitoring
  Timetables to tick every few minutes with questions like "am I paying attention?"
  (There are specialist devices to assist with this).

• Verbal skills
  e.g. Teaching verbal labelling to solve problems, encouraging self-talk
  " was there another way I could have done it".

• Social skills
  Turn taking and empathy exercises, role-play and anger management groups.

• Problem-solving/thinking skills
  A problem solving repertoire, identifying a problem and the steps to a solution.

Thinking skills

• Problem-sensitivity
  knowing what could be a problem

• Alternative thinking
  what else could you have done

• Causal thinking
  awareness that people act in predictable ways (getting in the game)

• Consequential thinking
  main reason for lack of social skills – impulsivity/foresight/