THE ADHD PERSONALITY: SENSITIVE AND STUBBORN

        Children with ADHD often are very emotionally sensitive and impulsive.  They get their feelings hurt easily and wear their heart on their sleeves. They are upset by things that are said, the way they are treated, the tone or volume of the voice we use and specific remarks that teachers or friends often innocently make. Because of their lack of attention to social situations they are especially vulnerable to the unkindness of others.

           Who of us has not spent sad times drying their tears, listening to their sad stories and reassuring them against the thoughtlessness of friends and family?   These experiences develop in them a deep empathy for other children and even adults who are going through tough times.  They often have exceptional insight into the problems of others who are drawn to them for their consolation and advice. 

          Traveling through the trials of life on an emotional roller coaster is difficult.  They are pulled off the straight and narrow King’s Highway of The Pilgrim’s Progress not only by every sound they hear or thought they consider but every harsh word or unfair action that they experience.  Clearly they will need to build some emotional toughness. My son hates it when I tell him to get a thicker skin.

       Along with this sensitivity they also have perhaps the worst possible combination character trait – they are stubborn. Here is where many parents automatically begin to nod their heads in rueful agreement and recognition. Psychiatrists call this unholy union “Oppositional Defiant Disorder” but I prefer the more descriptive terms of sensitive and stubborn personality. These children have very strong feelings about what they want and do not want to do and they are happy to strongly express their opinions in no uncertain terms to anyone who questions them. 

     This combination of characteristics (which are completely separate from the additional diagnoses of ADHD or learning differences) are challenging to everyone around the child, but once we get past our frustration we begin to see their extraordinary qualities.  They not only have highly original ideas but the drive to start (but not always finish) their plans.  We appreciate their creativity and sense of purpose. Stubborn people should be more positively defined as determined and persistent.  They strive to complete the work they are interested in and can often find a way regardless of what anyone says.  The idea that no one believes they can accomplish the impossible motivates them like nothing else.       

          Because stubbornness is essential to faith, we find many examples in the Bible.  Jacob wrestled an angel and Abraham had every intention of following through on Jehovah’s command to sacrifice Isaac on the altar.  The determination of Job to not blindly accept the false critical comfort of his “friends” was rewarded by the voice from the whirlwind.  The hard-heartedness of Jonah in refusing to go to Nineveh or the Israelites questioning everything God asked of them changed their lives.  Hard lessons may be necessary but ultimately rewarding.

          Sensitive but stubborn children achieve may not their best in grades, relationships with family and friends, or self-esteem.   Invariably when school and relationships sour, frustration leads to determination to not do their work or cooperate with the rules.   An attitude of disagreement or an atmosphere of resistance becomes more and more firmly ingrained and difficult to alter at home and at school.  It is not our wish to change their personality but rather recognize and redirected it in appropriate directions.  Relentless single-mindedness can be our friend if it is properly harnessed.  It sounds difficult and it is but it is not impossible.

ADHD: THINKING OUTSIDE (& INSIDE) THE BOX

Our child with school difficulties has two essential characteristics: an exquisite sensitivity to their environment (both external and internal) and a corresponding over enthusiastic reaction to those stimuli.  Some experts believe their primary difficulty is a drive to actively seek more and more stimulating situations. They are acutely aware of what is happening around them as well as inside of them and they react quickly and strongly. They leap before they look. They are like lightning rods that instead of harmlessly conducting their white hot energy safely away into the ground instead send it back to the sky and at innocent bystanders leaving unintentional destruction and conflagration.

      We try to minimize the external stimuli by choosing a teacher who is flexible but fair, provides a consistent routine with clear rules and expectations, and immediate rewards coupled with appropriate consequences.  The teacher may sit him in front of the class, give a good deal of eye contact and tap on his desk when he is distracted. She may give him special responsibilities to keep him moving and reward his good behavior.

           At home we try to supervise his interactions with siblings and other children, provide constant discipline from both parents, and avoid wild birthday parties, violent loud cartoons or video games. Tea at his elderly great-aunt’s apartment is not going to happen.  We have seen what over stimulation can do and want to prevent the problem before it starts.  As my mother-in-law states it “You just have to nip it in the bud”.  Good advice but it is hard to catch them (if you can).

     The internal component is somewhat more difficult to get at but has the potential for greater success. We can’t completely control their outside world but we can help them learn how to manage their inner attention, hyperactivity, and impulsivity. We want our child to be less immature, to think carefully, take their time, remember to slow down and finish the job and be kind especially to small animals and stressed parents.  Psychiatrists call this process “internalization”.  As people grow older they eventually come to accept the values and customs of their culture. They become more civilized.  This is the hope and prayer of every parent.

           And so we teach our children well to behave and make the right decision. We reinforce the good behaviors by rewards and give the opposite with natural consequences.  Despite our best efforts some of our children seem to take a lot longer to learn these lessons even though they provide the multiple learning opportunities time and time again.  The frustration level for us rises quickly as the same sad scenes get replayed over and over again with diminishing returns but increasing anger, tears and guilt.

          Improvement depends on addressing both internal and external issues. My patient with a fever might lower his temperature and feel better sitting in an air-conditioned room, drinking cool water, wearing light pajamas next to a giant fan. He might finally make it to 98.6 degrees if I add some Tylenol as well. The combination of inside and outside strategies can get us back to “normal”.

          Goals to measure of therapeutic success in child with ADHD are more difficult to define. We don’t have a thermometer for that, but we have some ideas for next time.

HYPERACTIVE AND INNATTENIVE: Speeding without a map in sunglasses

     Because ADHD is classified as a behavioral diagnosis we will need to identify the three essential characteristics of ADHD; Hyperactivity, inattention, and impulsivity. Not all of these criteria need to be present at the same time, although it is probably impossible to really have ADHD you have a normal attention span.  The diagnosis also requires that these characteristics be seen from an early age (even before delivery some mother say!), present in multiple settings (at least at home and school but often at church, scouts, dance, basketball practice, birthday parties and grandmother’s house), different from their peers (usually longer lasting and severe), and causing impairment. These behaviors sadly create havoc in both academic and social arenas.

     Hyperactivity is exactly what it sounds like.  These kids are on the go, bouncing off the walls, swinging from the chandeliers, “as if driven by a motor (see American Psychiatric Association DSM IV criteria for full descriptions).  The energizer bunny is their team mascot.  They just keep going and going and going and going.  On a positive note even extreme hyperactivity tends to decrease with age.  Over time the physical component slows down as the brain matures, particularly in the area called the basal ganglia.  Fidgeting and other fine motor activity, however, often continues unabated throughout life.  Their keys are jangling, gum is clicking, and toes are tapping even when they are trying to sit as still as possible and doing their best to listen to you.  These children are like cars whose accelerators are stuck racing down the hill towards the cliff while they fiddle with the satellite radio.

     ADHD carries in the name the hallmark of inattention or distractibility.  This may include vigilance, freedom from distractibility, processing speed, working memory or even motivation. Neuropsychological tests can help to measure these qualities which have their origin in the chemical processes of the brain. The scientific research in this area will deserve its own discussion in the future.  Dr Joel T. Nigg presents a comprehensive discussion of this topic in his book “What Causes ADHD?” 

   The brain based defect actually appears to be in the control or modulation of attention.  It is obvious that at times children with ADHD concentrate so completely on some things, particularly those that interest or challenge them, that their problem seems more like selective or over–attention. It is not that they cannot pay attention, but more that they pay attention to everything: the sounds of the refrigerator or overhead lights, the TV downstairs, the pattern or the floor or even their own thoughts. The problem is not distraction but more one of  attraction to whatever they can see, hear, feel or smell. They live in a world of overstimulation and over-reaction.

          The impulsivity associated with ADHD (leaping before they look) includes difficulty with sequential memory or emotional mood swings.  More on this next time.

GOOAAALLLSSS!!!!

During the World Cup soccer matches, a goal would always set off wild celebrations on the field and in the stands. All the team effort to kick, run, defend and block paid off in scoring a goal, increasing the likelihood of winning the game and ultimately the winner’s trophy. Setting goals is also important for parents if they expect to solve their ADHD child’s problems. We as parents basically want our children to consistently reach their best potential in school, relationships, and self esteem. Keeping these goals in mind is an important problem-solving strategy to help clarify the problem and direct the treatment.

When I see a new patient my last question for the parent is “What is your main concern?” Almost everyone correctly takes a moment to think carefully before they answer. If they have difficultly putting their thoughts into words I ask more specifically about their goals for their child or what behaviors they would like to change. I write this on the front of their chart to remind us on every visit of what our team is trying to accomplish.

I recently had a mother give me this list concerning her son. It is a heartfelt summary of the hopes we all have for our ADHD children.

1.    To know and help with what is really wrong with him, even if it is autism

2.    To sit down at a meal at home or in a restaurant with him and have him eat without arguing

3.    For him to feel safe and know he is loved

4.    For him to be able to make friends his own age

5.    For him to do well in school – academic and behavior

6.    For him to be able to sleep without nightmares or getting up so many times through the night

7.    To have one day without him misbehaving

8.    For him to listen and understand what I’m trying to explain to him

The path to successful treatment of ADHD starts when the family can begin to clearly and truthfully describe their expectations of a brighter future. The next step is to put a parent team of experts together that can work to reach that magical moment of rejoicing and screaming “GOOOAAALLL!”