With that lead in and apologies to Monty Python, my Program Ponderings blog is a little different from previous blogs. I am not an educator (although I am a professor in two departments at Western). I have the honor of being the Coordinator of Psychological Services, which is part of Special Education Programs and Services under the umbrella of Program Services. My wife, the English teacher, taught me the adage (quoting from Mark Twain), “Write what you know” so I am writing about what I know.
ADHD has had a chequered history which goes back over a hundred years; yet not everyone believes in the diagnosis of ADHD. Some parents (or teachers) may feel that this is just an excuse for either an unmotivated child or a school system that has not met the child’s needs. The diagnosis has been criticized for being overused although some experts believe that ADHD is under-diagnosed. ADHD is probably the most studied childhood psychiatric disorder with prevalence estimates ranging between 3-7% of all children meeting the criteria (more than twice the number of boys than girls). (For more information see: http://www.cdc.gov/ncbddd/adhd/data.html)
If you don’t like the term wait a few years and it will change! Consider that in 1902 a British doctor first described the symptoms giving them the name “Defect of Moral Control”. He believed that the symptoms of impulsivity and hyperactivity were due to some imperceptible brain damage and hence the term MBD or minimal brain damage or dysfunction gained currency during the last century. The problem was that there was no firm evidence to link the problems observed to any history or physical evidence of brain injury. Fast forward to today and we do have tools to look at brains such as fMRI (functional magnetic resonance imaging) that have shed light on how brains actually work and what may be different about the ADHD brain. More about that later.
In the 1960’s the term “Hyperkinetic Reaction of Childhood” was introduced in the second edition of the Diagnostic and Statistical Manual (DSM-II) used by psychiatrists and psychologists. The symptoms of overactivity, restlessness, distractibility and short attention span were still linked to organic brain damage but the emphasis was placed squarely on the hyperactivity (hyperkinesis).
In DSM-III, the term “Attention Deficit Disorder” was coined and it was recognized that the condition could occur with or without hyperactivity. In 1987, it was changed again to the current term, ADHD. The hyperactive-impulsive (ADHD-H/A) and inattentive (ADHD-I) sub-types were described with some sharing of core symptoms but some differences. The focus was now more on the problem being one of attention rather than overactivity.
This brings us up-to-date although DSM-IV(TR) is now being replaced with DSM-V which will see the light of day probably within a year. The proposed DSM-V criteria for ADHD have changed somewhat in subtle but important ways although the core symptoms: hyperactivity, impulsivity and inattention remain . (See: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=383 ).
The problem with DSM-V, although there are hints to suggest that this is changing, is that the focus is still on the symptoms and not on the underlying processes which are causing the symptoms. Hyperactivity, impulsivity and inattention are the tip of the iceberg. They are the visible by-products of an absence of behaviour that is intentional, goal-directed and purposeful. There is a corresponding absence of thinking that is effortful, organized and reflective. Furthermore, for the person with ADHD, immediate rewards will always trump delayed rewards and there is an absence of the skills relating to delaying gratification. In truth, the “absence” is relative, depending on the severity of the problem and there may be more of a developmental lag. This view of ADHD is supported by recent fMRI findings which link ADHD to the seat of these executive functions in the front

|| click to view video ||
part of the “thinking” brain (particularly, the Dorsolateral Prefrontal Cortex). Dr. Russell Barkley, from whom I have drawn a great deal of my inspiration, has referred to ADHD informally as an “Intention Deficit Disorder” . (click image to watch the video)
Despite all the research and all the recent findings, we still cannot say for sure what causes ADHD in any specific child. Like most other human conditions, there is probably not just one thing at play but a “perfect storm” of determinants which may be a combination of genetic, prenatal, early experiential and proximal environmental conditions. The exact amount that any one of these elements contributes to the problem may differ from child to child. There is also an inter-play between brain structure and function and environmental factors such that we can no longer separate what goes on inside the head from what happens outside the head.
Even among those who accept the reality of ADHD, some have questions and concerns about the use of medications (such as Ritalin) to treat the disorder. Stimulants were first used to treat hyperactive symptoms in 1937 by an American physician, Dr. Charles Bradley. Almost immediately people started to talk about the “paradoxical effects” of giving stimulants to already overactive children , This introduced an unnecessary mystery and also reinforced a complete misunderstanding of the nature of ADHD which has persisted. Ritalin was marketed first in 1956 and remains as one of the oldest psychotropic medications for children still in current use.
There are many new medications, some which offer timed release over the day and others which combine the active methamphetamine and dextroamphetamine ingredients. There are also some which are not stimulants at all but have a different pharmacology, affecting norephephrine levels in the brain rather than the combination of dopamine and norepinephrine levels which the stimulants affect. There is no paradoxical effect. The medications activate the areas of the brain which are responsible for executive functions (the previously mentioned pre-frontal cortex). Although these medications are known to be helpful, they are not the only answer. They may enable a child to benefit from teaching, and create an increased readiness to learn but it is the learning that takes place that is important. Long term studies have shown no long term benefit of stimulant medication on educational outcomes.
So where does this leave us in our quest to help each student, every day, including those with ADHD? We need to support, encourage and of course, at times, provide accommodations for students who face challenges in sustaining focus, organizing their thoughts and who may give up too readily because of the mental effort required. We can coach students to become more organized and there are lots of assistive technology programs that aid the organization of work. The biggest challenge is often in sustaining mental effort without immediate gratification. It’s far easier for a student to fall back to playing fast-moving, instantaneously rewarding game rather than persisting with something that requires sustained mental effort. But there are rewards in putting forward just that little bit of extra effort and persisting just that little bit longer. Students who are able to persist, with or without medication (which is more difficult) will reap the rewards of success in learning. Adolescents and post-adolescents can succeed when they accept their challenges and understand what they need to do to meet these challenges and take control over their lives. There are many examples of successful people with ADHD. You may know one of them. You may be one of them.
To access practical suggestions, every teacher in the Board will have recently received a copy of Making A Difference: An Educator’s Guide to Child and Youth Mental Health Problems. There is a section on Attention Problems (E1). There are many good suggestions in this guide about this and other topics.
If you have any comments or questions, please feel free to respond to this blog and, time permitting, I will try to respond.
P.S. That’s John Cleese at the desk, not me, just in case you were wondering…

Dr. Barrie Evans, C.Psych.
Tags: ADHD, Dr. Barry Evans, Ritalin