Recently I was interviewed on a cable TV show. The questions from the interviewer reminded me that even very well-educated people often have misunderstandings about ADHD.
This is an informational blog for people interested in knowing more about ADHD. Understanding is the key to providing success for people who have trouble meeting their potential.
One question proposed for discussion was:
What is the difference between ADD and ADHD? Many people believe that the older term of ADD meant without hyperactivity, while ADHD meant the symptoms included hyperactivity. The interviewer was surprised that the term ADD (nomenclature from the Diagnostic and Statistical Manual, DSM-V) is no longer used.
All people with Attention Deficit Disorder are now referred to as ADHD, with three subtypes:
1. ADHD predominantly inattentive presentation
2. ADHD predominantly hyperactive/impulsive presentation and
3. ADHD combined presentation. Combined is used when both of the symptom criteria or behaviors for inattentive and hyperactive/impulsive behaviors are observed.
To meet the criteria for ADHD Inattentive Type one must have at least six of the following eight behaviors, for at least six months, that directly impact their social and academic/occupational activities.
Hyperactive and Impulsive also require at least six of the following behaviors, observed by others:
Additional criteria require that these behavioral difficulties:
It is also important that the severity is indicated as mild, moderate or severe, based on the number of symptoms or behaviors that are observed.
ADHD is not about being smart or not smart. In fact most people with ADHD are very creative people.
If you think that you or a loved one may have ADHD, it is a good idea to meet with a professional who specializes in working with people with ADHD, who can offer not just a diagnosis but also education, treatment and strategies to help you understand yourself or you loved one and to navigate your life more successfully. If this is you, please call Weaver Center to set up a consultation.
I am now 66 years old and was diagnosed with dyslexia and attention deficit when I was just 6 years old, at Mass General Hospital in Boston. At that time very little was known about treatments for ADHD and dyslexia. In fact my diagnoses then were “minimal brain damage” and “reading retardation.” They had other terms for my problems with attention, organization, memory, reading, spelling, writing, and math. I was incredibly fortunate to have had the parents that I did, because they are the main reason I am successful today. For over three decades I’ve shared my experiences of growing up with my very intelligent, insightful, loving, and supportive parents and I believe these experiences have helped every student we have worked with.
Today the focus on children with learning differences are their difficulties, their strengths, special education, accommodations, neuropsychological and educational testing, and counseling or therapy to increase their adjustment, coping skills and self-confidence. These are all important things, however, one of the biggest voids in this process can be the lack of emphasis on the importance of parental support and strategies for success. Parental knowledge, understanding, acceptance, love and encouragement in the areas that really matter is the foundation and framework on which all of the above come together in the best way.
Through much of high school I could not read, even though I had daily Orton Gillingham tutoring. I also had individual therapy, therapy with my mother, and active parent involvement in my public school and special education classes throughout all of my school years. I was very hyperactive and always in trouble. I believe I was among the very first to receive Ritalin for my problems. I spent more time in trees than at home or in school. I was fortunate that way.
Here are some of things that my parents did for me and what you may want to consider doing for your child with learning differences.
1. Learn everything you can about your child’s learning differences. My father always said, "The more you understand something the less you react to it." They talked with professionals, with teachers, at the Parent Association Meetings, and received extra discussion about any test results that I received, beginning in first grade. Because they understood so much about me with regard to my problems, they were much more comfortable and much less stressed about the behavior problems, the discouragement, the anxiety and my psychosomatic symptoms [please refer to my autobiography at the Weaver Center website]. They always believed that you move toward problems and take as much time as you can to understand them. They were more able to be kind and gentle with me even though I was a terror [more about that later also]. So parents, learn everything you can, from every source you can, and spend the time to dialogue with people that work with and know your child.
2. Believe in your child! My parents always believed in me even though I never did. While experiencing public failure daily, it is hard to convince a child that they will be successful. My parents always said, "You will be fine… It is just that school was difficult… Life will be less so…” I always heard this when I was crying, so hurt I could barely stand it, yelling and screaming about how stupid I was and how I hated everything. "I hope you will believe that you'll be fine someday, like we do." I remember times when my father and I would drive by a gas station and I would say that maybe I could work at the pumps. My father might say “I'm sure you would be good at it but you might be even better running the gas station.” When I worked on a go-cart and told him maybe I could build go-carts for people, he would respond that “maybe I would like teaching people how to build go-carts.” The expectations were never about doing better in school but taking the examples of my comments in increments to support his belief in me.
3. Focus on the efforts not the results. My parents had a unique approach to helping me with school. I so often failed in the classroom, felt so bad about it, hurt and embarrassed for sure, but mostly felt angry at others because of hating myself. They always said, "Grades and success at school are not that important to us. What is important is that you have a good attitude and work as hard as you can…that's what makes us proud." They often reminded me to volunteer for anything that a teacher might need or want. Clean the blackboard, straighten the chairs, and make blue paper copies (the old days of photocopying). Even though I wanted to always sit in the back of the class and hide as best I could, they always encouraged me to sit up front, which I hated but which teachers seem to like. They kept reinforcing that effort is everything. They knew that as long as I was applying the best effort I could, I was going to do the best I could at whatever schoolwork was required of me. They responded to success and failure the same. Success, that is good you can learn from that. Failure, that is good you can learn from that. One of the things I look back on now is that I did not need to hide all of my failures, or any successes that I had, which I thought might increase the expectations of me if I had any. I could always be open because my parents responded positively with both. I could take the risk of being open with them because I rarely felt the disappointment. I am not exactly sure how they did that but looking back, I can see how important that was to my future. So now, the message to parents is focus on efforts not so much the results.
4. Help your child learn to tell the truth, and understand they don’t have to protect themselves with a lie. I was mad, hurt, and most often in trouble. My parents were not punitive in the standard sense. Their response to all of my wrongdoings was to me "why did I do that?" Most often, I had no idea why. After I calmed down a bit, they would ask, “what do you think about it or what’s your best guess?” This was so hard, as I had preferred to just take a punishment and be done with it. They might ask me to think about it more and just say they were interested and to try to do the best I could to think about how what I did had happened. Because I did not know, I often said what came to mind, which was usually a lie because I was trying to protect myself and explain myself. They said the lying was understandable but it was not good because it would be hard for others to trust me. They encouraged me to think about possible reasons and that I did not need to cover up to protect myself. They were most proud of me when I guessed a possible answer that was a probable one. Interestingly enough, because they always supported telling the truth so well, I learned that protecting myself with a lie was not necessary. To this day I have never needed to lie, always accepted the consequences, have a healthy feeling that I am human and make mistakes, and do not need to feel the hurt of embarrassment for my actions, as I did so often when I was younger. So now, the message to you as parents is to understand that lies serve a purpose that may be understandable but is not very healthy. It is always best to be pleased and proud of the truth, providing your child with an encouraging environment where they will grow to feel that they don’t have to protect themselves with a lie.
5. Focus on the process of being supportive, understanding and taking the time to help your child learn a better way. My father was often working away from home. My parents always said that they agreed to talk with me about anything when they were together. I could talk with either of them anytime I wanted, of course, but often did not. When my father returned and my parents spoke with me, I always predicted it would be a lecture, which I hated. But actually it never was. Whatever the issues that I'd caused problems about with my sister, mother, school, neighbors etc., they both liked to talk with me even though my father and I did most of the speaking, because my mother tended to be less patient and more upset with me. For some reason I always remember them sitting back while they talked and listened. There seem to be no intimidation, and that always surprised me. Of course, they emphasized how my behavior might have affected others. It was clear to me that this is one of the more difficult things to understand at that age. My expression those days was "ready, shoot, aim" or "shoot shoot shoot, no ready, no aim". These of course are expressions of impulsivity, as I rarely thought of anything before I did it. Mostly medicine helps me these days to manage my impulsivity and attention. So my message to you as a parent is to try not to focus so much on the content, details, or even reality of the situation, but on the process of being supportive, understanding and taking the time necessary to help kids learn that what they are doing is understandable but there is a better way.
6. Notice what your child does well and be sure to let them know what they do well matters to you. My parents always conveyed to me that the things that I could do well were the most important things to them. I do not ever remember having conversations about school other than the pains that I had academically or socially, which were many. They noticed and appreciated that I like to build things, or at least tear them apart. They seem to love that. I had only one friend, and they thought that was great. I spent a lot of time climbing trees and building tree forts (as there was a tremendous amount of scrap wood in my growing neighborhood). I played sports rather poorly when I was younger but somehow they would find the best thing that I did and comment on my success, often using words like "it's amazing how you keep at it… It's really great that you keep going out there and taking it on" [another expression of resilience and persistence that we use so often today]. They talked about how strengths were the best path to the future, and even though they did not seem that important to me, it did to them. This led to the expression of our Center "No one is successful based on their weaknesses...the best way to success is knowing and using your strengths." We often do a strengths inventory with students, asking them to guess how many strengths they have. Often the answers are anywhere from 0 to 10. We then talk and together can usually list 40 to 60 strengths. It’s always very enlightening for kids to know how many strengths they have. Then we make the connection between these strengths to their success in the future.
7. Set clear, consistent limits. My parents set limits that were very clear. Anytime I was physical at home, it meant time spent in my room, and sometimes a lot of time when there was a second or third occurrence. When in trouble with the police, my father, unbeknownst to me, worked with the juvenile officer to have me spend a little time in juvenile hall. If I told a lie, rather than getting angry and punitive, they always discussed how disappointing that was for them. After all their support, disappointment was among the hardest things to hear. Setting limits and having boundaries is very important, but the most important part is to never be angry when you enforce them, if you can avoid it. Be clear and communicate directly (at the time if you can, or later when your child is calmer) why it's important to have clear and strong limits. What I have learned is that getting punishment through limits helped me develop coping strategies. Consistent limits are a really good and important tool to help your child adjust to life that sometimes seems very unfair to them. Then in turn that helps them learn how to adjust and move positively through their problems throughout their life.
Among the most frequent questions asked by students with ADHD and their parents is, “Why is it so hard for me (them) to get to the important things that have to be done?” They often know they are in trouble but do not know why. We hear many derogatory declarations regarding laziness, not seeming to care, hard to get started, hard to finish, and most frequently, working far below potential!
The following is important information for parents, students, teachers and others about the issue of motivation and productivity. These difficulties look motivational but in fact they are neurological, and can be much better addressed with strategies once the challenge and difficulties are better understood.
The most important "treatment" for those with ADHD is understanding why motivation is hard and what to do about it.
People with ADHD actually do not have difficulty with motivation. Look at how they behave, think and organize things that are of high interest to them. Some are up early on Saturday mornings and have difficulty stopping playing a videogame and learning everything they can about it. We often observe over-focus, indicating that those with ADHD may stay with high-interest tasks longer than those without ADHD. Sometimes this confuses people as to why kids that are diagnosed with ADHD are diagnosed that way, considering how over-attentive they tend to be with high-interest tasks.
Therefore, what is the issue about motivation with low-interest tasks such as homework, chores, responsibilities, etc.? Why do kids with attention deficit appear so unmotivated and require so much external motivation, such as yelling, conflict, and behaviors that neither parent nor child want but seemingly can't avoid? I’ve spoken with parents who say, "I'm just not the person that I feel like I am when I'm so mad and disappointed that my child won't move unless I'm yelling at them for things they need to get done around the house."
The understanding is rather simple and the solutions are simple too, although maintaining consistency is crucial and can be difficult for both parent and child.
All humans “get” the things that they are interested in more readily than things that they are not interested in. There is one major difference with a person with ADHD. People with ADHD cannot feel the consequences of their decisions IN THE MOMENT. They usually know the consequences. Just ask, “What is going to happen if you do not do your homework, or your chores, or your room?” So why don't people move and be motivated with that knowledge? Because they do not feel the consequences like those without ADHD. People without ADHD feel the consequences in the moment. They don’t just know them but also feel the anxiety, apprehension, etc., of what will happen if they are not performed in a timely fashion. Therefore, without those of us without ADHD actually initiate, persist and produce to reduce anxiety or the feelings of the consequences. For those of us with ADHD, we do not feel the consequences even though we know them. So the most common response to multiple requests to move is generally, "I have plenty of time, I can do it later, why are you yelling at me?” The responses do not necessarily indicate that they do not want to get things done. They indicate that they do not feel the consequences, so they do not feel the pressure, so they do not move like those of us who do feel the consequences. Therefore, we parents remind and remind because we know that if our kids don’t get started there will be problems.
So once you understand that this apparent motivational problem is not intentional, willful or careless, you can begin to appreciate how difficult it is for your child to get started, continue and complete tasks that are of low interest. Interestingly enough, it is just as hard for people with ADHD to stop doing something of high interest as it is to get started on things of low interest.
What can we do to help bring the consequences into the moment when movement is necessary?
1. Make less interesting tasks more interesting. Setting up rewards does exactly that. Pair high-interest (rewards) with low-interest (starting tasks) to create a "system of rewards." You can see on our website an example of how to set one up. This is referred to as the old grandmother or grandfather principal. If you do this, you’ll get that. Work before rewards (low-interest before high-interest).
2. Set up a competing challenge with him/her using a bit of a David and Goliath model (we refer to this as Cognitive Discrepancy Therapy, which will be discussed more thoroughly in an upcoming blog). For example, you have a youngster give the “ADHD Adversary” a name. It could be Goliath, Darth Vader, Spinach, or anything they view as a challenge for them. This can be fun between parent and child. The child attributes their self-statements to that character or object. So it’s Darth Vader who’s saying, “In a minute, I got plenty of time, one more thing, etc.” The parent’s response is “The best way to fight Darth is to do it now! Don’t let Darth get to you, see if you can prevail. It may be tough but every time you win you develop mental muscle.” In this example, nothing is stated about the consequences because these kids do not get those in the same way that we do. However, giving them a challenge in the moment can be very helpful to them in understanding how Darth can try to prevent them from starting something uninteresting or from breaking away from something very interesting. The competitive way of saying, “Don’t let Darth beat you!”
3. Proximity, consistency, familiarity. If you understand that your child is not moving because they don’t feel the consequences, then one way to destress conflict is to come closer in proximity to your child, still using same volume of voice, but without the anger or frustration that numerous requests often come to. In other words, you are acting loud without being upset. Then both you and the student can laugh about it afterwards because it was a strategy that you know was needed to help them get started.
These approaches come from understanding that the child is not intentionally having trouble moving or being motivated, but it is the nature of their difficulty and they need your help to move. The more consistent you are with these methods, the more mental muscle is developed in the child, lessening conflict, and in the end the child is able to act more motivated.
Remember that having ADHD is a REGULATION deficit not an ATTENTION deficit. With high-interest there is over-attention and with low-interest there is under-attention. People do not have a lot of control over that. Therefore, by definition they need control help from the outside, which can create conflict. By understanding ADHD and implementing helpful strategies, conflict and stress can be reduced, motivation to get moving can be increased, and the home or classroom is a happier place and so is the child, who really does not want to have these difficulties.
It's also good to remember that following their school years there are infinite choices, if their self-esteem remains intact, to be as productive if not more productive than those without ADHD.
One method Dr. Weaver uses to treat his clients with ADHD is Cognitive Dissonance Therapy. This is a simple and elegant therapy that creates a dualism in the client's mind between the disability and the person. Through creating a persona for their disability, people with ADHD are able to view the disability as the antagonist in their life undermining their efforts to be more attentive, organized and productive. Likewise, they create a protagonist to represent their selves fighting to overcome the effects of this disability. For example, people have created antagonists such as Cruella deVille, Darth Vader or Dr. Doom, and protagonists such as Ariel, Yoda or "Eggplant" -- they can be whatever one wants as long as it keeps him or her focused and motivated. The dissonance between the two different identities detaches the problem from the person.
Next, the person begins to recognize the characteristics of their antagonist -- what makes this character so powerful and what negative influences need to be fought with new and effective strategies to change and better control their own behavior -- such as: Darth Vader makes the person sit on the couch when he should be doing homework, and that the antagonist is most powerful when the client is bored. The person with ADHD then develops strategies that the protagonist can use to stop the antagonist, such as to break down a task into tiny tasks and then put all of one's energy into completing each one of those tiny tasks, one at a time. Through the internal conversations that are created because of these two characters, the person with ADHD has an easier time changing and controlling the effects of his disability.
Dr. Weaver teaches Cognitive Dissonance Therapy through one-hour weekly therapy sessions. He says that usually after 4-6 sessions, the client sees improvement in their ability to address and overcome the symptoms of ADHD.