Inattention, Impulsivity, & Hyperactivity (ADHD)

Overview of Inattention, Impulsivity, & Hyperactivity: Sometimes diagnosed as ADHD (attention deficit and hyperactivity disorder) these behaviors, especially in children but also in adults, have gotten a great of public attention over the last 20 years or so, probably because, first of all, they can significantly affect success in school or at work and, second, because the medicines used to treat these behaviors are prescribed so frequently that in nearly every classroom in America, at least one or two student, if not more, will be taking such a medication. Add to this the ambiguous nature of the behaviors (Does my child really have a disorder, or is it just that school is boring because she’s so smart and creative? Is my child’s hyperactivity really a problem, or is it just that “boys will be boys”? Must I medicate my child to make him behave in school, or can I teach him some relaxation skills, put him in a smaller classroom, or change his diet to accomplish the same thing?) and it’s easy to understand why ADHD and the associated treatments are quite controversial.

How do we know if the difficulties we face are mental disorder, or just a result of trying to put square pegs in circular hole? Our society expects a great deal of regimentation and routine from us, especially in a public school or a workplace; for some people, this expectation is irritating but manageable, and for others it may actually feel natural. But for some minority, it appears virtually impossible to follow strict routines, focus on tasks that are not entirely enjoyable or stimulating, and avoid giving in to more natural impulses – to run and play, to talk when one feels like talking, to allow one’s attention to go wherever it goes.

One way to distinguish between a person who is simply too energetic or creative for the regimentation of school or most jobs, on the one hand and, on the other hand, a person with true ADHD, is to discover whether the attention problems and impulsivity occur only in one or two situations, or happen in every circumstance. If a child cannot sit through math class, but has no trouble watching a two hour movie in one sitting, can carry on an intelligent conversation with an adult, and loves to play chess, ADHD is probably not an appropriate diagnosis.  On the other hand, if impulsive, frantic behavior is present at school, at play, out shopping with mom or dad, talking on the phone, at the dinner table, and during bedtime stories, an attention deficit may be present.

The Medical Model and ADHD: Even if ADHD is not diagnosed, difficulties concentrating at school or at work can be very troublesome – no matter if we blame “the system” or the person with the attention deficit. Therapy, with or without medication, can help children and adults learn to stay more focused, manage impulses, and discover what learning and working environments and aids can help increase their attention. A therapist – especially one with a specialization in attention issue or school concerns – can work with parents, teacher, and the child in question to fine tune the learning environment to better suit the child’s learning style and needs. A therapist can also help discover whether attention issues are really the root of the problem, as in many cases learning disabilities, anxiety, anger, problems at home, or other emotional or cognitive challenges can be masked by a child’s acting out. Children can always explain their inner experience to adults; therapy can help uncover the true nature of the child’s inappropriate or troubling behavior.

Diagnostic and Statistical Manual of Mental Disorders (DSM):

DSM-IV Criteria for ADHD

A.   Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.

B.   Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often "on the go" or often acts as if "driven by a motor".
• Often talks excessively.

Impulsivity

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

2. Some symptoms that cause impairment were present before age 7 years.

3. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

4. There must be clear evidence of significant impairment in social, school, or work functioning.

5. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

• ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
• ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 
• ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

Case Examples of Inattention, Impulsivity, & Hyperactivity (ADHD):

Brian, 12, is brought to therapy by his parents who are their wit’s end with Brian’s behavior. He cannot finish his homework, he misbehaves constantly, he is loud, careless, and barely sits still. They want to “try therapy before putting him on medication”. Through play therapy, the therapist begins to uncover some deep anxiety in Brian. The therapist discovers that in class, Brian is actually quite well behaved. He also discovers that Brian’s father is angry quite often, and tends to yell at Brian over even the smallest infractions. The therapist raises the issue with Brian’s parents, and as Brian’s father begins to acknowledge his anger problem, and begins to learn new ways to deal with his son, Brian’s anxiety, and the acting out that results from it, subsides.

Erica, 6, is seen in school by a counselor because she cannot seem to stay focused. While she is very compliant with school rules, she fails to complete any assignments unless closely assisted for the duration of the work. The school counselor recommends her to a psychiatrist who prescribes a medicine, but Erica’s work does not improve. Finally, she is brought to a therapist, who decides to rule out a learning disability. A specialist is brought in and discovers that Erica is dyslexic, which makes her work very difficult. She is taken off her medications, and, instead, a specialized learning plan is created in a collaborative effort between her family, teachers, and school counselor.

Dave, 27, has always had difficulty in school, finding it hard to pay attention for long periods, and always feeling restless. As a professional, the same troubles occur at work, and it is threatening to cost him his job. The therapist teaches some relaxation skills and engages Dave in some techniques for expanding attention span; they help, but are inadequate. A referral to a psychiatrist results in a prescription that helps Dave increase his ability to focus significantly. Dave does not want to stay on this medication forever, though, and continues to work with his therapist to increase his attention span naturally.

Therapy for Inattention, Impulsivity, & Hyperactivity (ADHD): There is a wide range of Psychotherapy Treatment Models or types of therapy used in the treatment of ADHD. Most of these approaches fall into three historic camps of psychology: Psychoanalytic / Psychodynamic approaches; Behaviorism and; Humanism. Regardless of the type of therapy, there are some generally agreed upon elements of healthy therapy which are universal to all forms of psychotherapy. Before beginning therapy for ADHD or any other issue, it is helpful to familiarize oneself with these elements.

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Inattention, Impulsivity, & Hyperactivity (ADHD) Article Summaries