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 AND THE “OUTSIDE” WORLD

      The best practical example of the interplay of external and internal stimuli and response is to think of the ADHD child in the school setting.  We, along with the teacher (and believe it or not the child himself) would like him to stay in their seat, listen carefully, and not talk loudly to his neighbors or suddenly blurt out the often wrong answers.  At school our child lives in a real “outside” world that causes problems for his “inside” world sensitive and reactive personality.  The unpredictable day-to-day changes in his environment or in himself cause the seemingly inexplicable variation we see in his performance.

      For instance, there are days when all the noisy boys are absent from class, the teacher is in a good mood and is teaching a subject that the child loves (such as dinosaurs or gladiators).  Perhaps the lesson involves hands-on activities such as building a volcano or feeding Christians to the lions and rewards right answers with a handful of fake molten lava (just kidding – although you know he would love it!) or more likely plastic golden coins.  They have a wonderful day and often outperform his classmates in creativity, enthusiasm and leadership.  

          The next day, however, all the noisy boys are back, a student or substitute teacher who is unfamiliar with the routines and student personalities  is wading for the first time through a difficult math or social studies unit in a monotone lecture (“What is the capital of Djibouti?  Anyone? Anyone?....”), They may not have been warned that our child should sit in the front row, rather than the window.  As fate would have it the window is open and there is a class at recess playing basketball, tag and kickball. And now his world if filled with swirling images and sounds, random thoughts and new ideas, tangents and intangibles but the lecture is unheard, notes forgotten and homework assignments missed completely.  The other children have similar difficulties paying attention because of these distractions, but nowhere near the degree of impairment for our ADHD child. 

     Although we are only too well aware of this situation, reviewing it now can help us understand why the hallmark of ADHD is variability. It seems strange that at times they can demonstrate laser-like focus on certain topics (like video games) yet drive us crazy at the kitchen table trying to complete a simple fill-in-the-blank worksheet.  That is very different from our earlier medical example of strep throat.  Although the symptoms of fever and pain may worsen or improve over days, the patient is not totally healthy one minute and deathly ill the next.  But this inconsistency is classic for ADHD.

          Obviously our best chance to get our child on track will require adjustments to both inside and outside worlds.

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.

LET THE GAMES BEGIN - ADHD and Videogames

      One example of this attention dysregulation that deserve special comment is the fascination that boys often have for video games.  One of the reasons they can play for hours is because the Nintendo demands interaction on many levels.  There is a colorful, rapid-paced animation, loud sound effects and dramatic theme music, multiple buttons and levers requiring fine motor coordination while possibly receiving jolting vibrations from the controller itself.  Add to all this a mysterious quest with seemingly endless trails and worlds to discover while being constantly rewarded with objects or new skills or weapons and the allure of games makes perfect sense.

           As we know too well, the real world is often confusing to children with ADHD and their best efforts are not rewarded.  The problem is that these games are not the real world and probably do little to prepare children for our twin goals of academic and social success.  They are addicting to us as well because our child is finally quiet and is not irritating his sister, running around the room or loudly refusing to do his homework.  As the game system develop better graphics and unlimited capability through internet connections the addiction potential multiples and more and more time and energy may be devoted to them. 

          We need to teach our children moderation in all their activities whether it be TV watching, eating, practicing or playing sports or other activities such as dance or gymnastics , or going to church or playing video games.  It may be true that the games increase fine motor coordination or self-esteem because of the “expertise” they develop but it is surely a small gain at a huge price.  There is evidence that despite their devotion to their “DS” those children with ADHD score lower than their peers because they still have deficits in attention, distractibility and impulsivity.  Let the games begin but control them with reason and let them end just as frequently.

     It is helpful to think of distractibility as a mental rather than physical hyperactivity.  It seems that these minds of these children are working just as fast as their bodies.  Thoughts come and go with blazing speed and travel on “to boldly go where no man has gone before”.  They make a thousand journeys of one step but never arrive anywhere.  They multitask but never achieve anything.  It is difficult for them to screen things out or ignore the noise around them then to focus and complete the task at hand. 

          The problem is not that they cannot pay attention, but that they pay attention to everything. They listen to the sounds outside the door, the buses going buy, the overhead lights humming or air-conditioning, the patterns in the floor and their own thoughts.  One mother recently told me that her only chance with her son was to hold his head in both hands, come down to eye level with him and slowly repeat one phrase at a time.  Even then he would take off with a new idea or observation that seemed very important to him but had little to do with the job that needed to be done.  I thought had finally reached my son when he kept the eye contact going after my heartfelt instruction but was brought back to earth when he said “Do you know I can see myself in your glasses especially when your eyes get so big when you yell?”  So much for my parenting techniques.  We want to speak the truth in love but don’t know the specifics on how to do it.

A DAY IN THE LIFE

The mother of my new 7 y/o patient confided to me that she simply did not believe the complaints her daughter’s 2^nd grade teacher had about her classroom behavior until she decided to see for herself. The following is her verbatim list of what her daughter did over one three hour afternoon, including lunch and music class. (By the way, her teacher later commented that this had been one of her “better days”.)

• Smacked papers hung in hallway (when her teacher got onto her, she said she didn’t do it)
• Played with egg from desk (it was a part of a project) – 2x
• Played with hair bow
• Up to pencil sharpener – 3x
• Feet not on floor – 10x
• Dropped pencil – 3x
• Put jacket on – 2x
• Took jacket off – 3x
• Not paying attention – 9x
• Looked at book instead of listening
• Wrote on chair and desk
• Stood up – 18x
• Tattled
• Clapping hands
• Shoes not on feet – 4x
• Did not raise hand when teacher asked who was not allowed
• Fingers in mouth – 3x
• Laughing
• Saying random words (“hun”, “mom”, “oww”) at inappropriate times
• Skipping to the pencil sharpener
• Asked to go to the bathroom – 3x
• Dropped book
• Talked out of turn – 7x
• Dancing at desk
• Raised hand to tell a story after teacher said “No more stories”
• Didn’t put lunchbox up
• Looked at reading test while teacher explained block project
• Scooted seat across floor
• Didn’t know what area and perimeter was even though teacher explained it 3x
• Hitting and playing with Cameron
• Didn’t clap to show she was paying attention

In Music Class

• Whistling – 4x
• Singing while the teacher was talking
• Hit a boy
• Hands in mouth
• Hair in mouth
• Yelled at boy to sit down
• Rude to teacher (about teacher’s voice)
• Singing after told to be quiet
• Shouted out answer without raising hand – 3x
• Did not sing
• Scooted seat – 2x
• Shoes not on foot – 3x
• Stood up – 6x
• Kicking feet up
• Did not stand when told too
• Clap hands
• Played with friends shoe
• Tattled
• Sung too loud – almost to the point of screaming.

It is funny and sad and scary all at the same time. We want to keep her spark, but prevent her wildfire from spreading out of control. The only way to help her get all this under control is for parents to recruit a 3 person team of teacher-counselor-doctor to come up with treatment plans that the family coordinates for success in grades and relationships.  More on that process to follow.