How to understand ADHD as the Search for Stimulation

I had just completed my evaluation of 11-year-old Timmy. His parents had brought him to me because of behavior problems and the teacher's complaint that he was "underachieving" in school. Timmy, I explained, has attention deficit hyperactivity disorder, often referred to as "ADHD" or even "ADD." After I inform families of my diagnosis, I welcome their questions and comments. One frequent remark that parents make is, "I don't understand how he has ADHD; he can pay attention when he wants to."

Timmy's parents then gave me examples such as his being able to sit for hours playing computer games or that he can watch television for extended periods. "But he just won't sit and do his homework." From his parents' point of view, Timmy doesn't seem to have a disorder. They see in Timmy a child who just doesn't try to pay attention.

I particularly like parents' questions because they give me an opportunity to educate them as to what ADHD is. Lots of people have only a partial understanding of the disorder. But the better they do understand , the more likely they will be to make appropriate decisions on how to handle a child like Timmy.

The Search for Stimulation
One of the problems in understanding the disorder is the limitations of its name, attention deficit hyperactivity disorder. It's a pretty good name, better than the earlier names we used such as "minimal brain dysfunction" and "hyperkinetic syndrome." "Attention deficit hyperactivity disorder" is a better name because it refers to the difficulty in sustaining attention to tasks, rather than simply the hyperactivity. However, if I were in charge of re-naming ADHD - I would call it the " search for stimulation disorder (SSD)"

The term, "attention deficit hyperactivity disorder," sounds like Timmy has two problems: 1) an inability to pay attention and 2) hyperactivity. Hyperactivity is just one symptom. And as with any disorder people don't necessarily have all the symptoms. Timmy, for example, is not hyperactive.

Secondly and regarding inattentiveness, Timmy's parents do not see him as having difficulty with attention. He seems to them simply to have an attitude problem. He seems not to try hard enough. If he only had a better attitude, they reason, he would do his work and he would not get into so much trouble. They believed he could pay attention "if he wanted to."

Let's look at the problem of Timmy's attention. He has difficulty sticking to tasks such as homework or other relatively tedious chores such as cleaning up his room. But it seemed to Timmy's parents that he just didn't want to do these things, not that he couldn't do them.

His parents are right, partially. Timmy can do things that he is interested in, but he has trouble with tasks that require more sustained effort. It's not because he doesn't care. It's because he needs something he finds interesting or stimulating in order for it to hold his attention.

Timmy searches for stimulation. That often gets him into trouble because he doesn't pay attention when he's supposed to. He turns to look out of the classroom window when he should be listening to the teacher. He gets up out of his seat during the middle of a lesson. He annoys other children when they are trying to listen or do their work.

I'm going to explain what I think ADHD is, just as I explained it to Timmy's parents. Most child psychiatrists, including myself, do not believe the root cause of ADHD is psychological. We believe a dysregulation in the brain produces the disorder. The following is the explanation I gave Timmy's parents. I told them my hypothesis and that no one really knows what causes ADHD. But the hypothesis has considerable explanatory value, and I believe something like it does operate in AD/HD.

"The Invisible Shield"
I describe ADHD as a kind of barrier to the nervous system - an "invisible shield" that prevents normal levels of stimulation from getting through. It’s as though Timmy has a layer around his nervous system that causes normal levels of stimulation to not penetrate. Just as nature hates a vacuum, so, too, the nervous system hates sensory deprivation.

Timmy needs stimulation, and if he doesn't get it, he will seek it out. This would explain Timmy's preference for excitement. Perhaps better put, he has a thirst for any stimulating information or event. He responds to stimulation. He looks out the classroom window not because he's lazy or wants to annoy his teacher and his parents but because he's looking for something to catch his interest. He simply finds school work and chores too boring. He wants to do well. He would like to make his parents proud. But Timmy just can't seem to do it because he has a need for extra stimulation.

However, if the teacher increases the level of stimulation, it gets through and Timmy can more easily pay attention. The teacher can get his attention in a variety of ways. She can teach in a more dramatic or dynamic manner. She can sit him in the front row and engage him more frequently with eye contact or questions she directs at him. She can even yell at him. Yelling will get his attention. But I don't recommend that one.

An Explanation for the Effectiveness of Stimulant Medication
The fact that stimulant medicines (but not caffeine) such as Adderall can help people with ADHD is itself both interesting and instructive. Stimulants are the most effective medications for the disorder.

Stimulants? Intuitively, we might think that, if we were going to use a medication to help someone with ADHD, we would want to use a tranquilizer, not a stimulant. We might expect a stimulant to make the condition worse since the child is already "hyper.". The clinical fact, however, is that tranquilizers tend to make kids and adults with ADHD more "hyper"; and stimulants make them better. How can we explain this curiosity?

The idea of an invisible barrier around the nervous system might explain this paradoxical finding. A tranquilizer "thickens" that invisible barrier, allowing even less stimulation to get through. Then Timmy feels an even greater craving for stimulation. He might, thus, become more hyperactive or more distractible. I suggest that perhaps stimulants work in ADHD because they don't tranquilize. Instead, they stimulate the nervous system, perhaps leaving Timmy less thirsty for extra stimulation and better able to focus his attention.

Making the Diagnosis
Not all children or adults with inattention have ADHD. I explained to Timmy's parents that ADHD represents a specific disorder. We should not recklessly label people with the diagnosis. ADHD has a "shape", "color", and "feel". The diagnosis is made when someone has several symptoms which meet the diagnostic criteria for the disorder. We do not make the diagnosis simply because of distractibility or hyperactivity.

Role of Physical and Psychological Tests
Timmy's parents asked me about a test for ADHD. I told them we make the diagnosis on the basis of history and clinical observation. Psychological testing and neurological examinations are not necessary in establishing the diagnosis of ADHD. Treatment.

Risks of Not Treating
ADHD prevents kids like Timmy from being able to focus attention on academic work and typically causes significant academic underachievement. Many people do not appreciate how serious a disorder ADHD can be. Frequent complications are academic underachievement and poor self-esteem. 

Furthermore, the impulsivity, short attention span, and overactivity often make the child's behavior unacceptable to peers - resulting in poor socialization and rejection by others because other kids often find it difficult to be with the child or adolescent with ADHD. In late adolescence and in more serious cases, antisocial behavior and an increased risk of developing drug and alcohol abuse follow - partly because of the increased impulsivity of ADHD and partly because the individual is simply not happy.

The Benefits of Medication
50 - 70% of AD/HD children and adults respond with significant clinical benefit to treatment with stimulants. The nature of this improvement can be profound and is often not appreciated by those unfamiliar with the treatment responsiveness of ADHD. These medications often result in functioning at a level better than any the patient has ever experienced before.

Children and adults with ADHD are not "drugged" into compliant, complacent behavior. Numerous studies report stimulants to improve all of the core symptoms of ADHD (the hyperactivity, inattention, and impulsivity). Treated with stimulants they are alert and responsive and have at their disposal greater options for skilled adaptive behavior and greater flexibility for behavioral choices. Left untreated, they may be distracted, impulsive, disorganized, too easily overwhelmed by stresses, and hot tempered.

Non-medication Treatment

Behavior management can be helpful. It is essential to understand, however, that without medication only the environment, not the individual, can be changed. Behavior management means changing the environment so that the inattentive and impulsive individual can function better.

Parent Training for Behavior Management
Sometimes quite helpful, behavior management can be taught to parents in order to enable them to more effectively manage the child's day-to-day behavior. Altogether, however, it should be remembered that behavior management is a way of helping the parents to cope with but not change the underlying behavioral dysfunction caused by ADHD. Behavior management techniques will involve a decreased emphasis on blaming the individual and increased emphasis on changing the child's environment so that the individual can function better within that changed environment. But only medication can change the core dysregulation of the disorder.