A​​n​​ Overview of ADHD Care

by Mark Bertin, M.D.

What is attention deficit hyperactivity disorder (ADHD*)?

ADHD is a developmental delay in a wide range of life management skills including planning and organizing, affecting far more than just attention. ADHD may impact social relations, emotional well-being, academic success, and almost any other area of life, even physical health and self-esteem.  Understanding its full impact in this way allows for practical solutions to ensure that both children and adults living with it thrive.

What causes ADHD?

ADHD is a chronic medical disorder largely determined by genetics. The genetic basis of ADHD is almost as strong as that for height. ADHD has also been related to brain regions responsible for “executive function,” meaning those mental abilities used to coordinate and manage our lives. In fact, most researchers now define ADHD as a disorder of executive function rather than of attention or behavior. Therefore, understanding executive function is the foundation for planning.

What are the components of executive function?

Executive function gives us our ability to manage, coordinate, plan and anticipate, like the conductor of an orchestra, or the CEO of a business.  Executive function is sometimes described as having six components:

• Attention management

The ability to sustain focus when challenged, shift attention, and avoid hyperfocus (become too absorbed) when engaged in an enjoyable task. Difficulties with attention management occur most often when demands are high—but may not for easy, enjoyable tasks. Trouble shifting attention may seem like defiance or ignoring requests, and can lead to challenges that appear oppositional or struggles with transitions and starting new tasks.

• Action management

The ability to control, self-monitor and learn from mistakes. Difficulties can lead to frustrating, unintentional misbehavior.They also can cause children with ADHD to learn more slowly from behavioral interventions than others or to be careless in their work.

• Task management

The ability to organize, plan, prioritize, and manage time.Task management is required for daily routines and responsibilities, and academics such as homework, studying and managing long term projects.These skills are also needed for the self-advocacy and self-management of ADHD. In other words, plans to manage ADHD are often undermined by having ADHD.

• Information management

The ability to remember, organize and retrieve information. Children with ADHD may have trouble organizing their thoughts for speaking and writing, taking notes in school, or keeping track of requests (“Go to your room, get dressed and brush your teeth, please.”)

• Emotional management

The ability to experience emotions without impulsively acting on them. Common ADHD related behaviors include poor frustration tolerance, tantrums, over-reaction and irritability, all of which may impact family and social relations.

• Effort management

The ability to persevere when activities are challenging, to sustain focus and work efficiently. Difficulty with effort management often gets labeled as poor motivation, but frequently stems from ADHD-related issues.

*The term “ADHD with predominantly inattentive symptoms” has replaced “ADD (attention deficit disorder)”

What is the impact of ADHD?

ADHD is not just a school problem.  It effects social and emotional well-being and can strain family relationships. It has been linked to obesity, substance abuse, car accidents and frequent emergency room visits.  Yet when managed appropriately as part of a long-term comprehensive treatment plan, children with ADHD will flourish instead.

How does ADHD change over time?

Executive function matures along a developmental path as the brain matures, until almost thirty years of age. For ADHD, that means that some children outgrow it by adulthood. Others go on to have adult ADHD, the impact of which is greatly lessened when appropriate tools are provided throughout childhood.  As overall demands raise on children, the impact of ADHD may increase as well.

ADHD care consequently requires ongoing guidance that anticipates transitions and proactively builds skills.  We must create a safety net that deals with immediate problems while anticipating hurdles and addressing new challenges as they arise. Because academic and social demands change, plans must evolve as children mature. What works now may not be enough as a new challenge approaches.  Four main areas considered for a typical intervention plan are:

Education

Executive function is a foundation of learning and therefore ADHD can effect all of academics, including reading, writing and math. Children may need help in developing academic skills, controlling behavior in school and managing homework, studying and long-term projects.  Even children receiving good grades may be exhausting or undermining themselves through ineffective strategies. Educational plans should address any needed classroom supports, testing modifications and behavioral interventions, as well as organization, writing and study skills.   Tutoring, behavioral therapy and social skills groups outside of the school setting may also be helpful.

At Home        

Common ADHD-related challenges include morning and bedtime routines, homework, chores, or stressed family relationships, as well as overall behavior and compliance. It is vital to recognize the strain that all of this puts on parents, particularly as ADHD management relies more on adults than children. Structured behavioral plans and parent training benefit both parents and children.

Lifestyle

Adequate sleep, sufficient exercise, and proper nutrition all may improve ADHD symptoms, as may the practice of mindfulness. However, ADHD uniquely bites its own tail – many health routines that help ADHD are harder to sustain if you have it.  Screen time and technology are frequently an excessive draw for individuals with ADHD, pulling them away from healthier activities and potentially worsening ADHD symptoms.

Medical 

Medication recommendations, if necessary, are based on decades of research demonstrating potential benefits. In spite of misleading information often presented as fact, side effects occur no more often than most other pediatric medications. Most importantly, if these medications do not work they can be stopped with no lasting effects.  Medication can be considered when appropriate as one of many options.

Of course, no one plan works for everyone or even for the same child over time.   Plans must be consistently monitored, evaluated and revised. While ADHD may seem like a lot to handle, with persistence and compassion children will thrive.

Mark Bertin, M.D.,is a developmental behavioral pediatrician, an assistant professor of pediatrics at New York Medical College, and the author of The Family ADHD Solution and Mindful Parenting for ADHD.

A PDF version of this article can be found here

Republished with Permission