_    Why does a stimulant medication "SLOW" down the hyperactivity level of these children (adults) with ADHD and help them "FOCUS" their attention when it makes other children more active? Why does stimulant medication have this paradoxical effect on these children diagnosed with ADHD?

    Here's the core of the metaphor: The stimulant medication essentially speeds up the "lazy" frontal lobes of these ADHD children, providing them with the ability to filter out the extraneous stimuli in a way they could not do without the medication (unless there was an authority figure or structuring device helping them focus). They can now focus on their school work, rather than fidgeting because they feel pressure on their behinds, hear the sneezing, see the notes being passed, are thinking of dinosaurs and how big their teeth are and "ain't they neat they could eat you up so fast" . . . The filter is in place once the proper dose of stimulant medication is achieved.

    This medication has a therapeutic window. Too little, and the effect is poor. Too much, and the child can act dopey. Just right, and they can function much the way normal children do. Give it to children without ADHD and you may see them bouncing off the walls because most of the ADHD meds are stimulants---the opposite of what you’d expect for an already over-stimulated child, which is why the paradoxical effect of calming an over-active child with a stimulant medication is pretty good evidence that something wasn’t working right when the meds were first prescribed.

    It is important for those of us working with these children to report the impact of medication changes to family and physicians working with the children. Just because a child does not respond to a medication or responds too much doesn't mean it's the wrong medication (though it may be). I may just mean that it's not at the right dosage, or that the child may respond better to one of the other options available . . . everyone’s metabolism is different, and essentially, every trial of medications with an individual is an individual experiment. Many respond as the “average” child-patient did to the med-trials; some don’t. Some have very bad responses. The same is true for adults with ADD-ADHD.

    And, yes, as some of you will want to say: these children can often focus without medication when doing something they are highly interested in, just as we all do when something truly catches our attention. Again, the activity, if interesting enough or novel enough will provide a "structure" that normal day-to-day activities don't. It is the "extra energy" coming into the system that I mentioned earlier in this digression.

    One more thought about the ADHD issue comes to mind, this has to do with their behavioral issues more than their ability to focus attention.
    ADHD children have a form of executive dysfunction, which means that the frontal lobes of individuals diagnosed with ADHD are not as effective at monitoring behaviors and controlling impulses as are children (or adults) who don't earn this diagnosis.

    What this means is that many ADHD children who are not on the right dose of the right medication will often blurt out things when we want them to be quite or to conform their behaviors to classroom rules. They don't inhibit the kinds of comments most others do. If the thought comes into their head, it may just jump out of their mouth. While most of us think these things, we can keep the inappropriate comments to ourselves. ADHD children/adults have a very difficult time with this inhibition. They are, the word is, disinhibited compared to the norm.

    Again, the more activity around, the more stimulation they experience, the more difficult it is for them to conform their behaviors to norms that work for others.

    What this does to them as they hit school age is that they often become social outcasts because of their seemingly unsocialized behaviors. This leads them to not liking themselves because others don't like them. They form negative self concepts, and often then begin to act oppositionally, or in ways that reject the opinions of others. It is a vicious cycle of acting out, rejection, acting out, increased rejection, acting out, loss of friendships (except those which are often of the same ilk), and eventually, for many, leads to inappropriate social groups and behaviors that spiral out of control.

    Many ADHD children who are denied effective diagnosis and medical management develop significant behavioral problems in adolescent and adult years including increased substance abuse, impulse control and illegal behavior patterns.

    The research clearly indicates that taking medications earlier in life forestalls this pattern of downward spiraling misbehaviors. Long term outcomes of individuals with this diagnosis who have access to the medication are more positive than outcomes for individuals with the diagnosis who don’t receive this medical intervention. It is important to realize, though, intensive therapeutic interventions can also prove beneficial to both groups . . . though it is generally much more expensive and time-consuming to administer.

    Not understanding this effect and the downward spiral and treating it instead as "willful" behavior is an error that many educators, parents, and authority figures have committed. This lack of understanding is often an integral part of this downward behavioral spiral, and is frequently a potent magnifier of the already harmful impact of the disorder.

    I hope the "metaphor" and "analogy" offered above help you better understand ADD-ADHD.

Biser Rangelov, MA MFC, LPC
Biss-Ann Counseling Services
3001 W. 5th St. Suite 400
Fort Worth, TX 76107
E-mail:[email protected]
Phone: 817.372.1107

_    ADHD is a common mental health disorder for many boys and girls today. For the past six years I provided treatment and skills training for a number of children, adolescent and their parents both in my office and in their natural environment (home, school, and playground). I have heard different misconceptions and false beliefs from parents and teachers due to lack of knowledge and understanding about ADHD, which at times leads to refusal or non-compliance with the treatment. For example, children with ADHD can do math, read, write or control their behavior when a teacher or a parent provides individual attention and a question has been frequently raised as to whether there is “really” a disorder.

    It is very important for the counselor during psycho-education to explain ADHD in understandable layperson language. A while ago, I learned from Dr. Zwingelberg the following metaphor and analogy that I found very useful in helping parents, teachers and school staff members to understand this disorder.

The fact that a child with ADHD can behave and perform more effectively when a teacher stands over them than when they are left to their own direction is NOT a reason to believe that no disorder exists---though this is the argument you will hear from many parents and teachers who disagree with your diagnosis.

    Think of driving an automobile on a freeway when you are very tired. You can fight sleep, but you keep nodding off. This is what it is like having ADD-ADHD. You can fight it, but it takes a lot of effort. Now back to the car. It is two in the morning; you nod off, but awaken yourself, still fighting sleep. You awaken your friend who is sleeping in the passenger seat and say, "I'm falling asleep all the time, talk to me, make noise, help me focus." Your friend does just that. And what happens?

    You find it easier to stay awake and to continue driving without the insistent need to fall asleep. Why? Because you have had an external focus of attention delivered to you. It is as if you have been given extra energy to accomplish your driving task, which in fact you have been given. You now have the energy of another person helping you accomplish the task at hand. You have, essentially, an external conscience, as well.

    This is essentially what happens with ADD-ADHD children given attention by adults or others to help them stay on task and perform, to help their behaviors conform.

    Essentially, and here's the metaphor, ADHD children's frontal lobes are working too slow to filter out extraneous stimuli. As you read this you are likely sitting down. Until you read this next sentence you are unaware of the facts I'll mention in a moment, but the instant I mention them you will note what I say. Your frontal lobes are filtering out extra stimuli at this moment. An ADHD child's (or adult's) frontal lobes are not as effective as yours at doing this.

    Here's what you are filtering . . . as you sit there, reading, you have pressure on your behind. You can feel it now, but until I mentioned it your mind was filtering out the sensation. Now it senses the "feeling" of sitting. You likely also can hear some sounds around you, or smell something, or feel a draft of air, a fan, or even taste something or feel hungry or thirsty or . . . any number of sensual things are occurring that you have weeded out until asked to become aware of them.

    The frontal lobe filters of individuals with ADHD don't filter as effectively. More impulses are coming into their brain and they have to react to them. In a one-on-one situation, such as when a child is tested by a lone psychologist in a quiet office, such stimuli are minimized. When they have an authority figure standing over them, they have extra energy to manage their behaviors . . . much as an individual with kleptomania will not likely steal something when a police officer is standing next to them. This is that external conscience, again.

    In a classroom, or around activity, color, noise, movement, etc., the individual with ADD- ADHD is bombarded with sensory input you and I easily filter out. They struggle with this "filtering" because, essentially, their frontal lobes are working "slower" (part of the metaphor I'm setting up here). This is why it is most difficult for these children to behave in crowded classrooms or where there is a great deal of activity. In class, they hear the pencil sharpener, and must look to see who's there; they hear the sneeze at the back of the room, see the kids passing notes, hear the whispers of kids playing around, are distracted by their own flow of consciousness thoughts . . . and are continually distracted---unlike those with good frontal lobe filters who can weed these things out of their environment and consciousness.

To part II

Biser Rangelov, MA MFC, LPC
Biss-Ann Counseling Services
3001 W. 5th St. Suite 400
Fort Worth, TX 76107
E-mail:[email protected]
Phone: 817.372.1107